Primary and secondary care working together

The BMA is working with NHS England and other organisations to help improve the interface between primary and secondary care.

Location: England Scotland
Audience: All doctors
Updated: Tuesday 4 October 2022
NHS Structure Article Illustration


We have written a report exploring the challenges facing doctors as they deal with the backlog of care built up during the pandemic, and the role of effective collaboration across primary, secondary and community care in tackling this.

Read the report



Working with NHS England and other organisations, the BMA agreed changes to the NHS standard contract for 2017-19, under which clinical commissioning groups (CCGs) commission health services from providers.

There are a number of new requirements which clinicians and managers across the NHS need to be aware of, and which are summarised below.

These are described more fully in the NHS England guidance The interface between primary and secondary care: key messages for NHS clinicians and managers.

National requirements

Managing DNAs and re-referrals

Providers should no longer ask GPs to re-refer DNA appointments.

Managing onward referrals

Clinicians working for the provider should make an onward outpatient referral, without needing to refer back to the GP, where it is directly related to the condition for which the original referral was made, or the patient has an immediate need for investigation or treatment.

Communicating with patients 

Providers should put in place and publicise arrangements for handling patient queries. Providers should communicate the results of investigations and tests to patients directly.

Discharge summaries

Discharge summaries must be sent to the GP within 24 hours after every discharge from inpatient, day case or emergency department care.

Clinic letters following outpatient attendance

Clinic letters should be sent to GPs within 10 days where there is information the GP needs to act on in relation to the patients’ ongoing care. Clinic letters should be sent electronically using standardised clinical headings.


Providers to issue medication following discharge from hospital for a minimum period of seven days (unless a shorter period is clinically appropriate).  

Shared care protocols

Shared care protocols may be agreed locally. Hospitals must only initiate the care under the protocol where the individual GP has accepted clinical responsibility for the patient.

Fit notes

At a suitable point in time, eg on discharge from hospital, clinicians must issue fit notes to patients where appropriate. The note must cover an appropriate period of time.



BMA Scotland and RCGP have produced a set of principles which look at whole system working between primary and secondary care.

It sets out how effective whole systems working is based upon:

  • understanding roles and responsibilities
  • developing high trust relationships
  • adhering to agreed principles
  • parties agreeing to work within these parameters.

Whole system working principles