Dr Andrew Foster: Introducing the Nottingham & Notts Primary-Secondary Care Interface Partnership

The Primary Secondary Care interface group has been working since 2021 to improve the way that staff at Nottingham University Hospitals and those working in General Practice work together.

Their focus is to improve patient care and clinical outcomes by strengthening relationships between these two groups of staff by building and trust and taking real action to change behaviours and processes that can complicate patient care and damage this partnership.

The group has delivered tangible changes, and the work of the group has been recognised locally and nationally with other organisations learning from their experience and working to create similar projects.

Key Achievements

The group has generated around 90 projects aimed at improving the interface between primary and secondary care. As a result, many of those things which have historically caused additional work and frustration should now happen much less often. Notable examples include:

Hospital discharge summary audit – Over 7,000 discharge summaries have been audited to understand the type and scale of inappropriate transfer of work from secondary to primary care.
Co-produced presentation outlining five asks that improve patient experience at the interface

The Five Asks Scheme

1. Communicate clearly and concisely. Where actions are required by the patient or GP, make this clear and easy to identify in all correspondence.
2. Refer a patient to another speciality within NUH where this relates to the original problem, or a directly related medical condition, rather than asking the GP.
3. Follow up the results of tests NUH have undertaken, informing the patient and completing any actions, as required.
4. Issue a fit note, wherever appropriate for the full duration needed.
5. Provide patients with prescriptions for new or altered medications when seeing them in an NUH outpatient setting

Primary Care Presence in NUH Inductions – GPs now participate in junior doctor and consultant inductions, providing insights into the Primary Care perspective and fostering a culture of collaboration from the outset of their careers.
Jointly agreed letter templates regarding inappropriate request to GPs – Templates agreed with and supported by NUH leadership to support General Practice to correct unsuitable demands.
Primary-Secondary Interface event June 2024 – Attended by GPs and Consultants and supported NUH and the LMC to increase engagement with the work of improving relationships.
NUH Fix It WhatsApp Group –
No more “repeat chest Xray in 6 weeks” – An often-cited frustration in General Practice. Hospital staff now take responsibility for arranging repeat chest x-rays following discharge.

The Interface Group categorize their wide-ranging activity across six domains (Culture & Relationships, Continuous Improvement, Clinical Integration, Digital Integration, Training and Development and Communications) and have a pipeline of future improvement plans.

How the Primary Secondary Care Interface Group began and evolved

The relationship between Secondary Care clinicians and General Practice is complicated. Many have felt historical frictions worsen in recent years as demands on the system have increased and technology, standardised communication proformas and referral triage processes have increased the distance between the two sectors.

This interface work began in late 2021, as both General Practice and NUH were facing huge pressures due to the COVID19 pandemic. All Nottingham based clinicians share the care of a population experiencing broad challenges including; access to care, worsening outcomes, and health inequalities. The system faces large backlogs of pent-up demand and long waiting lists, a workforce exhausted by pandemic pressures, and significant financial pressures.

A group of NUH consultants, staff and leaders from General Practice began meeting to explore how the two sectors could collaborate and work more effectively together to meet these challenges.

Early discussions in the interface group identified the sense of a deepening “them and us” culture. Initial meetings allowed clinicians from both sectors to express their struggles candidly and acknowledge that they were facing similar and connected issues. This transparency has been crucial in the developing of relationships, trust and a culture of collaboration.

There was a shared recognition that both primary and secondary care were struggling with similar challenges. They became focussed on finding solutions that benefit both sectors and also securing a smoother journey through the system and better outcomes for patients.

Principles

· *Don’t duplicate* work that is already being undertaken elsewhere in the system	· Seek to *satisfy the needs of our patients at their first presentation* to healthcare services, whenever possible
· Be *open, honest & respectful* to each other, recognising that we are all doing our best to meet the needs of our population	· *Don’t try to solve everything.* Take action that will make a difference to someone: · What we can do in days and weeks rather than in months or years · Doing something is better than nothing · Not everything we try will work
· *Don’t ask someone to do something that you should be doing yourself*	· Developing an understanding of *‘this patient needs’* and being able to respond regardless of the care setting

Key principals keep the group’s work focussed on delivering meaningful change

A focus on early quick wins allowed the group to build momentum, grow and become an established fixture within the system. The group has expanded to include representatives from NUH clinical and organisational leadership, Nottingham City and South Notts Place Based Partnerships, the ICB Clinical Design Authority and Nottinghamshire LMC.

Representatives from NUH departments and other parts of the system attend meetings to discuss specific issues relating to their part in the interface between primary and secondary care. They meet weekly to discuss challenges and to address issues.

People involved

Nottingham City PBP – Dr Husein Mawji, Dr Andrew Foster, Claire Matthews.

NUH – Dr Mark Simmonds, Dr Alun Harcombe, Dr John Walsh, Tim Guyler, Simon Gascoigne, Kelly Jandrell, John Peach.

Research – Dr Nick Boddy.

ICB – Dr Stephen Shortt, Dr Nicola Jay.

South Notts PBP – Dr Jill Langridge, Dr Aamer Ali, Jacki Moss.

Clinical Design Authority – Dr Jeremy Griffiths.

Local Medical Committee – Dr James Hopkinson, Dr Jen Moss-Langfield.

Regular membership includes individuals with the ability to influence their organisations

A culture of open, honest, informal communication and relationship-building enables an agile approach to making decision and taking action. The work is supported by the NUH integration team who support the structure and governance of the group. This has been essential to balance the open and informal atmosphere with an ability to be organised and impactful.

Primary/Secondary Roadmap

The group has delivered multiple milestones since 2021, these include:

September 2021	Primary/Secondary Care Interface Group established to support the recovery of Long Term Conditions management
October 2021	Explored initial areas of focus including UEC attends and Spirometry
August 2022	Primary Care video incorporated into Junior Doctors Induction
September 2022	Shared Learning Programme commenced (3 year multi disciplinary rolling training programme jointly provided by NUH Heads of Service and Primary Care
November 2022	1^st Primary/Secondary Care Working Group with NUH CEO and Primary Care Representatives
November 2022	Spirometry Pilot Launch
November 2022	Flu outreach pilot commenced providing opportunistic vaccinations to patients attending routine hospital appointments
January 2023	Established a Written Communications Sub Group to look at clinic letters/discharge letters/waiting list communications/TTO audit
January 2023	NUH CEO writes to all GP practices to share the Trust’s first People First Report
May 2023	2^nd Primary/Secondary Care Working Group with NUH CEO and Primary Care representatives
August 2023	Written Communications Group engagement with 45 specialties to feedback issues raised by interface group and identify opportunities for improvement
September 2023	Audit of 7,000 TTOs to review what is being asked of GPs
October 2023	Reinforcement of clinical and professional behaviours enabling improvement of the interface
November 2023	Primary/Secondary Care update to NUH Trust Leadership Board
December 2023	NUH Fix IT Pilot commenced
January 2024	Primary/Secondary Care Interface Update to NUH Trust Board
January 2024	Echo on ICE business case approval
January 2024	GP/Consultant Twinning Scheme – 20 NUH Consultants and 20 GPs shadowing one another to gain broader understanding of each other’s environments
May 2024	Primary/Secondary Care Working Group meeting with NUH CEO and Primary Care Representatives
May 2024	NUH Chief Executive writes to all GP practices
May 2024	Raising the profile of this work locally and nationally through various routes including ICB, NHS England and NHS Confederation
July 2024	Primary/Secondary Care Engagement Event

Learning from the Interface Group

The impact of this work has led to increased interest from clinical specialties keen to engage with the interface group. There have been discussions exploring the establishment of groups to improve the interface between other system partners such as Nottinghamshire Healthcare Trust and East Midlands Ambulance Service. The initiative has gained recognition at a national level, with group leaders being asked to share learning from the Nottingham experience through the NHS Confederation.

Key learning points

Building Relationships and Trust: Regular informal meetings where leaders create an open and safe culture enabling representatives from both sectors to engage in candid discussion about mutual concerns.

Adaptability and Flexibility: Being open to change and to challenge established norms, behaviours and embedded processes.

Audit activity and use data: The group audited over 7,000 discharge summaries from NUH to understand the type and scale of work transfer from secondary to primary care, such as requesting further tests and referrals. This evidence added credibility to calls to change processes and behaviours.

Commitment from senior leaders: Senior clinical and executive leaders from both sectors champion the work of the group with colleagues. Leaders need to have sufficient credibility and influence with colleagues to make the argument for change.

Support with governance and structure: To ensure that meetings are productive and actions are completed. The NUH interface team provide project management to ensure that projects are delivered and meetings function effectively.

How to feedback clinical issues to NUH

What already exists?

Via E-Healthscope
Emailing the dedicated inbox: nuhnt.gp.feedback@nhs.net

What is on the horizon?

Implementation of the Five Asks Scheme template letters – available on F12/Ardens [expected November]

For more information, to learn how to get involved, or to suggest an issue for the group to address, please email nuhnt.integrationteamnuh

Dr Andrew Foster

GP Partner, Parkside Medical Practice

Deputy Clinical Director, Nottingham City Place Based Partnership

Director, Nottingham City General Practice Alliance

Celebrating success of primary / secondary care collaboration

More than 80 projects aimed at improving the way primary and secondary care work together have now been completed, with lots more on the way.

Better integration between consultants in departments across Nottingham University Hospitals (NUH) and GP Practices in South Notts and Nottingham City is helping to reduce unnecessary workload shift and improve communication and understanding between primary and secondary care.

Last month, consultants, GPs and other health partners came together for an event hosted by Notts LMC to celebrate the success of the integration work to date, raise awareness and hear the audience’s views about how further improvements can be made.

Working together helped build mutual trust between consultants and GPs, giving each a greater understanding about the daily challenges they faced and how small changes could make a huge difference to the efficiency and effectiveness of each other’s daily work.

Quick wins

The integration work first started informally in September 2021 during the Covid-19 pandemic. From an initial focus on ‘quick wins’, such as simplifying communication and greater use of internal hospital referrals. the project has grown considerably. There are now weekly meetings involving NUH, GPs, Notts LMC and the Place-based Partnerships (PBPs), in addition to task and finish groups tackling specific issues and active, live problem-solving.

The work here in Nottingham is ahead of the game compared to many Trusts around the country with the volume of collaborative work ongoing with primary care.

So much so, it is being held up as an exemplar nationally.

In May, Husein Mawji, GP & Clinical Director, Nottingham City PBP and Mark Simmonds, NUH Deputy Medical Director were invited to present details about the integration work through the NHS Confederation. This has already prompted numerous contacts from colleagues from NHS trusts across the country eager to find out more.

For more information, contact Kelly Jandrell, Integration Project Lead at NUH at kelly.jandrell@nhs.net

South Notts Community Voices event – young people

As a Place-Based Partnership, we’re really keen to hear what’s important to young people to help them keep healthy and well so we worked with our District and Borough Youth Council members to design an event for young people.

So on Saturday 2 July we held our very first Community Voices engagement event for young people at Nottingham Arena, with all the young people who joined us to share their views being treated to an ice skating session with their parents at the close of the event.

Pictures of young people at the Community Voices event — Some of the young people who joined us at our Community Voices event at Nottingham Arena

It was a really fun, action-packed morning with lots of discussion about what the young people loved about the area they live in terms of health and wellbeing opportunities (tops) and what they didn’t like (pants). You can see the washing line of feedback in the pictures above.

We also talked about how they keep healthy and mentally well and what support needed to be available. Finally they had to draw their ideal place (blindfolded!) which certainly made for some interesting presentations.

Look out for the more, including feedback and evaluation in an upcoming newsletter.

Partnership working supports vulnerable people in Gedling

Elected Members have raised just over £10,000 to provide food for vulnerable families and children in the Borough.

Gedling Borough Council’s Humanitarian Team have been leading the Council’s response and recovery work during the pandemic with a specific focus on assisting vulnerable or isolated residents. A number of projects are currently underway with partner organisations to provide support and address inequality including:

Partnering with Rushcliffe CVS to offer a South Nottinghamshire Volunteer Befriending Service where volunteers make regular friendly telephone calls to people in the borough who’re lonely or isolated.
Work with Jigsaw Homes to deliver ‘One Step at a Time’, a project to help local residents who are lonely or isolated and who may be feeling apprehensive about getting out and about. Volunteers are supporting Jigsaw Homes tenants to improve their mobility by walking short distances with them in their local area and improving their confidence by chatting to them. Pilots of One Step at a Time are also being delivered in other areas of the County.
Coordination of meetings every three weeks with representatives from Jigsaw Homes, the CCG, South Notts Integrated Care Partnership, Rushcliffe CVS and Age UK to ensure mutual collaboration and strong operational coordination between commissioned social prescribing services and public sector partners during the winter months.
A project to enhance and promote the role of local NHS Volunteers Responders in partnership with Notts County Council and Nottingham CVS. Funding has been awarded to enable us to assess the impact of the scheme locally and to use the learning to inform future collaborative VCS work.
Virtual engagement with stakeholder groups to inform response and recovery initiatives including Gedling Seniors Council and Youth Council, Faith Leaders and Food Bank contacts. Some of the outcomes of this work include a consultation with Young People to shape services and activities in the borough, and the promotion and signup of schools and Youth Clubs to the charity Kids Against Plastic, run by two pupils at Redhill Academy.

In addition to the Council’s work to support health and well-being, Elected Members had raised just over £10,000 to provide food for vulnerable families and children in the Borough.

The Humanitarian Team lead worked with the County Council’s Children’s Services, ABL Health, Gedling Play Forum, GBC Customer Services, the Richard Herrod Centre Hub and Church and Food Bank Leaders Group to identify and provide healthy, festive food parcels to the 600 most vulnerable families in the Borough in the week leading up to Christmas.

A directory of services and organisations offering support in Gedling is available on the Council’s website and you can also email volunteer@gedling.gov.uk for more information about any of the projects listed. The team regularly produce a Community and Health and Wellbeing newsletter. Please email the team if you would like to be added to the mailing list.

Local GP invites South Notts residents to discuss health and care priorities at partnership’s ‘Community Voices’ event

Dr Nicole Atkinson, Clinical Lead for South Nottinghamshire Integrated Care Partnership (ICP) covering Broxtowe, Gedling, Hucknall and Rushcliffe, is inviting people who live in those areas to join her at a digital event to discuss priorities for health and care in the area.

The event, which will take place on Zoom between 3pm and 5pm on Thursday 1 October, will be led by Dr Atkinson, who also works as a GP in Eastwood

The South Nottinghamshire ICP works across health and care organisations, local councils and communities to support the integration of services and help local people live happier, healthier lives.

Interested residents and health and care workers in the area can sign up at: https://south-notts-icp-community-voices.eventbrite.co.uk

Alongside Dr Atkinson, there will be a presentation from Dr Tim Heywood, Broxtowe GP and Clinical Director of Nottingham West Primary Care Network.

People attending the event will be asked for their views on the Partnership’s key priorities for the next year, which are:

Ageing well
Care navigation (the patient journey through health and social care)
Mental health
Health and wellbeing
Community engagement

Dr Atkinson says: “This event is a fantastic opportunity to get involved with the development of integrated services in South Nottinghamshire. I’m really excited to talk about our priorities with local residents and start involving them in our work.

“There has already been a lot of really innovative work that has started here in South Nottinghamshire that has improved services for patients, which has then gone on to be rolled out across other areas. We want to build on those successes and involve local communities to help drive further innovation.

“We really want to engage people so they are genuinely involved in how their local services develop and how we join up care. So, if you have the time and you want to get involved, I look forward to talking to you.”

People who are interested in finding out more about the Partnership and getting involved with shaping services can sign up at: https://south-notts-icp-community-voices.eventbrite.co.uk

Zoom instructions

Event agenda

Community Voices breakout rooms

People who are interested in finding out more about the Partnership and getting involved with shaping services can sign up here.

Dr Aamer Ali joins the South Notts ICP Clinical Leadership team

We’re delighted to announce Dr Aamer Ali has joined the clinical leadership team for the South Nottinghamshire Integrated Care Partnership.

Working alongside ICP Clinical Lead, Dr Nicole Atkinson, Aamer will bring his considerable experience of both working with elderly patients and driving integrated working to this new position.

Aamer is a Consultant Geriatrician at Nottingham’s Queens Medical Centre, with interface and front door frailty as his main area of clinical practice.

He is also the Clinical Director of Integrated Medical Services, and his expertise and experience from more than 12 years working with commissioners and providers will be invaluable in influencing the direction of travel towards improvement for services for older people across South Nottinghamshire.

This role is a perfect fit for Aamer, who has a history of working with teams across the South Nottinghamshire patch. He says: “I have worked closely with South Notts teams, most notably on GPs supporting the Health Care of Older People wards in QMC and development of the community geriatrics project including care home vanguard.”

Aamer runs an outpatient clinic in falls and bone health, along with a virtual clinic for the community falls and bone health team. He also provides mentoring and the educational lead role for the community falls team as well.

He is also a lead in the elective Orthopaedics SCOPES service and is working with the End Of Life Care team in Nottingham.

With his wealth of skills and experience, Aamer will bring strategic oversight to the ICP’s older people’s strategy and hopes his expertise can help shape the development of the ICP’s plans.

Aamer explains: “I have co-authored the NUH Dementia Strategy and sit on both the ICS’s dementia and end-of-life groups, while I also developed the ‘front door’ frailty team that has been working for many years in the emergency department.

“All these projects have given me a broad knowledge, understanding and expertise in older people and older people’s services, particularly working with them when they are in vulnerable states and when they are admitted in crisis.

“I think that it’s really important that I share that expertise and use it to make a difference to community teams. We have talked about transformation for a long time but I have felt that real transformation hasn’t taken place yet.

“I would like to think that, as a hospital doctor bringing this perspective to a community setting, I may be able to influence decisions which result in significant change in elderly people’s services, working with the community services to develop a countywide strategy.”

Born in Lahore, the City of Gardens, Aamer graduated in Pakistan before coming to the UK in 1996, where he trained locally as a geriatrician. A father of three, he has a Level 2 in British Sign Language ( aspiring to level 3) and a love of Indian classical music.

Dr Nicole Atkinson says: “I’m delighted that Aamer has joined the clinical team. His knowledge and expertise will be key to helping us deliver improved integrated care for our older people, and ultimately support them to live happier, healthier lives in South Nottinghamshire.”