A new reported entitled ‘Medical Evolution’ has been published today by think tank Policy Exchange, centring around a cross-party call for a proactive approach and highlighting the role of digital in managing the interface between GPs and hospitals.
The report, co-authored by Dr David Landau and Dr Sean Phillips, states that a “well-functioning interface enables the efficient coordination of care between providers and acts as a fair means of managing demands and costs”. However, issues have “become increasingly pronounced in recent years, with the interface too often functioning poorly, with delay, frustration and clinical compromise resulting”.
It points to recent polling from Healthwatch England which indicates that a fifth of patients referred by a GP for consultant-led care “end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted”.
As such, the report estimates that at least 15 million GP appointments per year are “dedicated exclusively to managing issues with the breakdown of this interface”. It also estimates that a further 150,000 people could be on a ‘hidden’ waiting list, where patients have been referred to a GP for further treatment but are not included on official lists.
Medical Evolution makes a number of recommendations, including the overarching recommendation the Department of Health and Social Care and NHS England should establish an interface improvement initiative. This would see a joint committee of officials overseeing the implementation of national and system-level interface initiatives along with identifying national-level high-impact measures which could improve interface working.
Firstly, the report says that communication capabilities should be improved so that clinicians correspond with each other and their patients seamlessly. This should include making the e-Referral Service “a more open and innovative platform,” the authors say, adding that NHSE should focus on “creating an effective ‘data layer’ from which applications can more seamlessly ‘plug and play’, enabling providers to be effectively reimbursed”. Primary and secondary care providers and tech suppliers should also focus on improving the application layers so that they can become more user-friendly.
In addition, the Digital Care Services catalogue should be “adapted to encourage greater innovation in the delivery of digital communication capabilities for interface working”. As a minimum, this should include enabling clinician-to-patient and clinician-to-clinician messaging, reminder scheduling, image sharing and video consultation capabilities. Hospital staff should be able to book patients directly for investigations across relevant primary care and community provider setting, and the catalogue services should integrate with NHS Service Finder “to ensure seamless and direct clinician-clinician communication”.
Alongside this, the NHS App and provider websites should be enhanced “to provide more effective ‘back channels’ for clinicians to be able to communicate,” the report continues, with NHS trust websites to include more effective directories of services.
Another recommendation is to “commit to boost transparency for patients as their care is managed across the interface by enabling patients to ‘track’ who is responsible for their care“. This should include additions to the My Planned Care platform, as an example, to allow patients to see the contact information for those responsible for their care once they have been referred, and this information should be updated in real-time. “This should be regarded as a means of improving how the NHS explains to patients where they are in the process too,” the authors write. “This has particular relevance for people at risk of digital exclusion who may not be able to ‘self-track’ in the way envisaged above.”
The report recommends that the NHS as a whole should be supported to implement the Booking and Referral Standard, and all trusts should be encouraged to adopt The Professional Records Standards Body e-Discharge Standard, which “enables hospitals to safely transfer standardised clinical information using headings and coded data onto GP IT systems when a patient is discharged”.
A further recommendation is to compile and publish ‘incomplete referral data’ at national, ICS and trust levels. This should be published on a monthly basis, the report specifies, to enable improved monitoring of pathways and better target support – therefore reducing the prevalence of the hidden waiting lists.
The authors encourage the introduction of new incentives to enable greater uptake of clinical decision support systems across general practice, with effective integration with electronic patient records required to enable this, alongside closer collaboration with Royal Colleges and other key stakeholders to define best practice.
“Beyond measures taken at a national level, changes are required at all levels in the NHS system,” the report states. At system level, one recommendation is for integrated care systems to work with the NHS Business Authority to “enable greater use of joint prescribing budgets to enable hospital staff to issue prescriptions directly (particularly in cases where a consultant has a detailed understanding of relevant medication).” As such, the authors note, changes to the Electronic Prescription Service should be made to support this.
At neighbourhood and place level, the report says, Shared Referral Pathways should become commonplace across the NHS. It points to the successful example of the cardiology department at Mid Yorkshire Hospitals NHS Trust, “which proactively pools primary and secondary expertise as well as information (reflected in joined-up records and information for the patient)”, stating that this “should become the default approach as a means of ensuring shared responsibility for patient care.”
Trusts should work with primary care teams in order to reduce the information gap, the report continues, highlighting the importance of leveraging automated processes and ensuring staff focus on producing timely discharge reports within 24 hours.
Dr David Landau, report author and senior fellow at policy exchange, said that “for too long the interface has been neglected as a key site of activity, and not proactively managed. Policy Exchange’s proposals look to ensure more people can access specialist support with a shorter wait and closer to home.”
Labour MP and qualified pharmacist, Taiwo Owatemi MP, commented that “the interface between primary and secondary care is becoming increasingly complex, and requires a dedicated approach… the proposals [here] which look to minimise patient risk at discharge from hospital have particular significance for me.”
From former health minister Lord Bethell: “This is a significant and wide-ranging report from Policy Exchange. I fully support their call for a patient-centred approach to service re-design and the development of a ‘patient tracker’, building on the ‘My Planned Care’ platform which would put more information in the hands of service users.”