In the NHS, the interface between doctors in primary care and those in secondary care has long been a fulcrum, one that determines how effectively and efficiently the wider health service delivers care and meets patient need.

Yet despite its central importance to the day-to-day critical functions of the NHS, the link between primary and secondary care is a complex and evolving relationship, and one that remains beset by a wide variety of structural and cultural challenges.

Many of these challenges and organisational barriers such as patchy communication, a lack of interoperable IT and a mutual misunderstanding among doctors as to the roles and capabilities of their sector counterparts, are long-standing but have undoubtedly been thrown into sharp relief by the pandemic.

Indeed, in addition to the unprecedented demand posed by COVID-19 on all parts of the health service, the past two years have seen sections of the Government and media appear to attempt to stoke division and suspicion between those working in general practice and those in hospital settings.

Efforts towards improving the functioning of the interface through encouraging greater communication, collaborative working and understanding, were already under way prior to the pandemic, but with an elective care backlog of 6.5 million, finding solutions has become more vital than ever.

London GP Farzana Hussain understands only too well the extent to which the whole health service is under pressure and under-staffed and the imperative this creates for resources and referrals to be used carefully.

Based in the borough of Newham, Dr Hussain’s practice is part of the North-East London integrated care system where, like in many other parts of England, the Advice and Guidance triage service is being used to help manage referrals from primary to secondary care.

Introduced as part of NHS England’s elective care recovery programme, Advice and Guidance aims to give doctors in general practice access to digital support from specialists in secondary care.

She says that while she can see the potential in the new system, she feels it is too broad in its scope and does not provide a shared primary and secondary care IT record where hospitals can see all the primary care records.

‘I think the Advice and Guidance system needs a lot more maturity,’ she says. ‘I think it’s a very good idea. But I don’t think we should be mandating it for 12 specialties.

‘If I as the GP, or any of my primary care colleagues, think our patient requires secondary care, we cannot get them referred to a clinic where a consultant or a secondary care team member will see them or phone them; it has to be us emailing to the electronic record system.

‘Some of my issues with that are they don’t have the patient in front of them [and] they can’t look at our EMIS records that we use in general practice. The only information they have is what we are putting in [and] without the whole GP patient record [that] has a huge clinical risk about it.

‘I’m not against the system, I just think that it needs to have a full patient record.’

Dr Hussain adds that, while the backlog and staffing crisis across the whole of the health service are at the root of much of the pressure on the interface, misconceptions about the capabilities and ways of working in each care sector also have the capacity to create barriers.

Based on her own practice’s experience, she says bringing GPs and hospital doctors together through multidisciplinary work is an excellent way to build mutual understanding and collaborative working and promote patient care.

‘I do think that one of the solutions here is to have proper multidisciplinary team working, whether that’s virtual, or whether it is face to face,’ she says.

‘For about six or seven years now in Newham, once every two months we have a meeting with our consultant endocrinologists. [These meetings] started off with discussing cases so that we could reduce referrals, but the knowledge that we’ve got from that relationship works really well.

‘I think we need to be talking to human beings, the consultants or registrars on the other side, and we need to be getting to know them. A primary care network is a great site to do that [as] consultants aren’t going to have time to talk to 46 practices in Newham, but you can do that with nine primary care networks.’

HARKENSEE: Spiralling demand has strained referrals process

Forging bonds between general practice and hospitals through greater cross-working is something paediatric consultant Christian Harkensee is a firm believer in.

Based in Gateshead, Dr Harkensee is closely involved in a programme that provides fellowship posts to GPs from the local area to work in a secondary-care setting.

In doing so, these doctors are able to gain experience in a particular clinical specialty and then take these skills back to primary care following completion of their fellowship.

Dr Harkensee says the initiative is not only effective in countering the ‘siloed thinking’ he believes has traditionally acted as a barrier between primary and secondary care but helps to foster a greater understanding and closer relationship between community and hospital services.

‘[A GP] gaining that experience and expertise, but then also having a leadership in primary care towards their peers and colleagues by training and teaching others [helps] build these connections and expand these connections with secondary care,’ he says.

‘I think these kind of posts should be converted into a more formal programme to which people can apply. They probably should cover most, if not all, specialties [and] become something regular rather than something exceptional and we should have similar posts, for example for secondary-care doctors who want to do the same thing in primary care.’

A consultant in the NHS for almost 12 years, Dr Harkensee says he had seen the spiralling level of demand on primary and secondary care, and how this had strained the referrals process between the two sectors.

‘I think the structural issues with the NHS, in particular the underfunding and understaffing of large parts of it, are what increases these tensions,’ he says.

‘It sometimes feels a little bit like [emergency] departments or specialist clinics function a bit like an overflow of what general practice cannot see. This is not the GPs’ fault; this is just the underfunding and understaffing of the system [and] the pandemic has just exacerbated that.’

Despite the success of initiatives such as his trust’s fellowship programme, Dr Harkensee believes improving interworking between care sectors requires systemic change, such as introducing a shared curriculum at medical school level to foster greater mutual understanding.

Fundamentally, however, change and improvement can only be possible and sustainable through addressing the NHS staffing crisis and through greater resourcing and investment in the health service at a national level.

‘We can’t catch up at the local level what has not been fixed at the centre,’ he says.

‘That really has to come from the top. We can improve it a little bit and it’s important to do that and to change mindsets, but at the same time we need to advocate at a higher level, to say that what we’re doing here without the resources is not sustainable.’

The BMA is working with NHS England to address concerns around Advice and Guidance, in particular to clarify issues around incomplete access to medical information and the implications this has for medico-legal responsibility.

BMA consultants committee member Simon Walsh and his GPs committee counterpart Richard Van Mellaerts have been involved in the association’s negotiations on Advice and Guidance and work concerning the interface.

They say that, while there were many areas ripe for improved integration and interworking between the two sectors of care, GPs and hospital doctors still share the values of ensuring good care and patient experiences.

They add that, despite the huge pressures facing the health service, doctors in primary and secondary care would remain united in their aims and resist attempts to deride and divide the medical profession, such as the attacks on GPs promoted by politicians and sections of the press at the height of the pandemic.

They say: ‘The understanding between clinicians of the challenges we and our counterparts face in the understaffed and underfunded health service, shows there is a strong unity of purpose among members of the medical profession.

‘The past few years have been tough for doctors, and the resultant backlog of elective care is a challenge and one that can only be addressed by a united profession. To that end, we are determined to explore increased ways of working, but we also know that greater integration can only be achieved by addressing the deeper malaise in the NHS.

‘Simply saying primary care needs to do more or secondary needs to do more is not the solution. The solution is a comprehensive workforce strategy that is realistic and addresses the healthcare needs of the population, rather than being constrained by political ambitions.’