Healthcare
If you’re working in primary care, you’ll likely be familiar with the term ‘workload dump’. The inappropriate transfer of work has plagued the system for many years now. As a result, the primary-secondary care interface continues to be identified as a key priority for improvement.
Certainly, we need only look to its recurring presence in national directives. 2023’s primary care recovery plan detailed an aim to cut bureaucracy by reducing time GP practices spend liaising with hospitals as well as associated administrative work with other providers. And most recently, NHS planning guidance has called on trusts to select a designated lead to improve working with primary care while asking ICB boards to regularly review improvement.
But what progress has been made? Here, we take a closer look at the problem, current approaches to address it and possible ways it could be solved in the future.
Last year, it was reported that practices spent up to 20% of their time dealing with lower-value administrative work arising from the primary-secondary care interface.
While locally, an LMC report suggested between 30% to 40% of GP time is being wasted on interface problems. This is said to cost the region around 98,000 appointments and four million pounds a year. At a national level? The Policy Exchange estimates 15 million GP appointments are lost annually due to the breakdown between primary and secondary care.
With such figures, it’s no wonder this issue continues to rear its head on annual NHS to-do lists. It has rightly been identified as a potential ‘quick win’ that could provide some much needed breathing room for practices struggling with current demand pressures. Furthermore, it not only promises significant capacity gains, but also improved patient experience and cost savings.
So what’s causing these issues?
An LMC survey of general practice staff found the most commonly cited source of interface difficulties to be acute providers (92%) followed by mental health (81%) and community providers (71%).
Invariably, communication has also been cited as a key driver. Scenarios abound where patients are not made aware of test results or clinical letters take too long to arrive. For GPs, this makes management of discharged patients challenging to say the least.
It becomes even more difficult when patients have been prescribed new medication. The management of complex patients is said to “take a long time to unravel.” And additional problems present around clinical investigations, whereby GPs are tasked with multiple follow-up actions to complete. From onward referrals through to following-up blood tests and issuing fit notes.
An online editorial recently summarised:
“Increasingly complex patients are discharged from secondary care follow up earlier, which leads to more tasks, more appointments and more work in a general practice already under pressure.”
On the flipside, GPs are finding referrals rejected inappropriately or in some cases entering a ‘black hole’. Indeed, a poll by Healthwatch reported how one in five patients seeking specialist care experienced a ‘referral black hole’, either being referred to the wrong service, having a referral appointment cancelled, being taken off a waiting list or not hearing anything about their referral. This of course inevitably leads to the proverbial bounce back to general practice as well.
In response, the GP recovery plan has identified four focus areas in line with findings from the Academy of Medical Royal Colleges. These are also included in 24/25 operational planning guidance and are summarised here.
Onward referrals: Where a patient is referred to secondary care and requires another referral, secondary care providers should make onward referrals rather than sending them back to general practice.
Complete care: Upon discharge or after outpatient appointments, patients should receive ‘everything they need’ such as fit notes and discharge letters. Regarding the latter, these should include actions for general practice such as medication changes.
Call and recall: Trusts should have call and recall systems in place for patients, follow up tests and appointments. This is to remove the need for practices to contact secondary care providers on behalf of patients.
Clear points of contact: To improve communication between primary and secondary care, ICBs are required to establish single routes that enable rapid and prompt response to any issues or requests, e.g. guidance and advice on referrals
The RCGP has made similar recommendations to improve the primary-secondary care interface which cuts across many of these areas and has developed resources such as template letters primary care providers can send to ICBs to initiate conversations around interface issues. The BMA has also issued guidance and templates for pushback of inappropriate requests.
So is the situation improving? If recent reports are anything to go by, many of these areas unfortunately remain persistent problems for practices.
There have been anecdotal reports from GPs which suggest onward referral is still an issue according to Pulse. Furthermore, some ICBs report that secondary care providers have not prioritised workstreams from the Primary Care Recovery Plan. Available capacity within secondary care and a national focus on elective recovery have been cited as barriers. There is also said to be a perception that this remains ‘an issue facing primary care’ rather than a system one.
One GP summed up the experience as:
“They understand that patients might suffer as a result, but as long as the witness to and brunt of that suffering is the GP, that’s fine.”
A range of initiatives have been suggested to improve the current situation. From models of outpatient transformation through to strategies to improve collaboration.
A newly published evidence brief by the Health Equity Evidence Centre makes recommendations to address health inequalities arising out of the primary-secondary outpatient interface.
These include building in support mechanisms for attendance at specialist appointments, use of care coordinators for system navigation and inclusive communication. Flexibility of appointments is also highlighted (face-to-face and remote) alongside use of targeted appointment reminders. In cases of DNA, further appointments should be offered rather than asking practices to re-refer.
The BJGP has identified how common problem touchpoints arise when patients move from general practice to specialist care and back, and re-emphasise the importance of ‘good hospital discharge summaries’ which, when done correctly, can reduce harm and provide an important handover document. Furthermore, to facilitate better collaboration and communication, the system must look at ways to build relationships and simply get doctors ‘in the same room.’
Shared educational events or workplace swaps could present a viable solution. Indeed, in regards to the latter, both the RCGP and BMA have noted that hospital health professionals should spend a year in general practice as part of their training to build shared understanding.
Echoing the focus on collaboration, the NHS Confederation has launched a programme to improve working between primary and secondary care. Four key ingredients are cited as essential for this purpose:
Some examples have also been shared which illustrate the potential of optimal interface working. One GP practice has established an urgent treatment centre (UTC) in collaboration with community services, out-of-hours providers, acute trusts and the integrated care board.
In this model, the team set up a GP at the emergency department to initially test whether patients could be seen at a UTC instead. They then looked into hybrid models of employment to provide alternative care options. Full shared care records are in place as well as access to the same IT systems.
Learnings include the need to build mutual trust and understanding through regular conversations. This includes visiting respective places of work to establish respect and common ground. To instil confidence in change, the programme has also featured small incremental shifts in practice and use of evidence to show impact throughout the project’s journey.
Other key components cited include transparency around available funding, how it should be invested and the benefits it can bring. Additionally, a go/no go approach on major decisions across the interface, where individuals are invited to vote has helped to keep the project moving. Results from the programme include 1000 fewer diagnostics via the emergency department equating to a potential saving of around £20,000 per month.
While examples are also emerging of trusts managing APMS GP contracts which may point to some alternative ways to deliver primary care. Such models are said to have provided opportunities for integration while relieving administrative burden and freeing up GP time.
Although interface issues will not be solved overnight, their prominence is growing and with it, calls for action. Of course, immediate demand pressures will continue to pose an obstacle to finding the time ‘to do the work’ required to fully mitigate ‘workload dump’. However, until the issue is properly addressed, it will paradoxically continue to feed the supply-demand mismatch.
Recent initiatives rightly recognise that this is a two-way relationship and the problem will not be solved in silos. There is no silver bullet but collective action and co-creation of solutions together will likely be the path that bears most fruit in the years to come.
Suvera is a CQC-registered digital healthcare provider specialising in complex, chronic care. Our virtual clinics support practices, PCNs and ICBs to manage patients living with hypertension, asthma, COPD and diabetes. From patient outreach to condition review and prescribing, we can help mitigate primary-secondary care interface issues and deliver:
If you need support, contact our team on partnerships@suvera.co.uk or book a meeting here.
Discover how we saved Shrewsbury PCN over 4,839 hours in appointments and approximately £345,000 in our film.