Improving the primary and secondary care interface at Greenwich and Bexley

Overview

Greenwich and Bexley Interface Forum was set up in April 2024 to tackle interface challenges between primary, community and secondary care, reduce GP workload and improve patient care continuity. Membership was expanded to include community services and hospice care to address interface issues across all care settings. 

What the organisations faced

GPs and hospital colleagues alike in Greenwich and Bexley were facing increased administrative burden, unnecessary workload transfer and delays in patient care due to unclear responsibilities between care settings. Common issues included:

• inappropriate requests from hospitals for onward referrals and fit notes

• delays in discharge summaries affecting continuity of care

• lack of clarity on prescribing responsibilities and patient recalls

These challenges risked inefficiencies and delayed treatment for patients.

Improvement

Colleagues from Greenwich and Bexley general practices, NHS Lewisham and Greenwich Trust (LGT) and NHS South East London (SEL) ICS’s Greenwich and Bexley teams formed a primary and secondary care interface forum in April 2024 to tackle these challenges, with a pledge to place robust interface arrangements at the heart of everything the forum does.

Greenwich and Bexley Interface Forum agreed on priorities beyond the four NHS England pillars and focused on improving coordination across urgent, elective and community care with a number of key initiatives: 

• Clarifying responsibilities: Introducing an ‘inappropriate requests’ letter to reduce unnecessary GP workload and prevent delays in patient pathways.

• Improving discharge processes: Working with hospital teams to identify and resolve delays in discharge summaries.

• Expanding collaboration: Including community services such as Oxleas NHS Foundation Trust, the local hospice and GP federation to strengthen coordination across care settings.

• Integrated urgent care pathways: Developing an ‘integrated neighbourhood team’ approach to urgent (same day) care pathways and interfaces across A&E, same day emergency care (SDEC), urgent treatment centre (UTC), emergency 111, virtual wards, GP access, and high intensity users (HIU)s. 

• Elective recovery support: Preparing to support elective recovery, including through advice and guidance and Consultant Connect. 

• Reducing repeat referrals: Extending the number of specialties and duration of patient initiated follow up (PIFU) to reduce the need for patients to go back to their GP for re-referral

• Shared care prescribing: Agreeing processes for management of Attention Deficit Hyperactivity Disorder (ADHD), gender identity clinic requests, and enabling community midwives to prescribe iron. 

• Addressing ad hoc requests: Supporting self-administration of insulin, catheter care passports, memory clinic liaison team, and disjointed dementia diagnosis and care interfaces. 

• Building relationships: Hosting social events to strengthen positive primary, community and secondary care relationships and share learning on topics such as health inequalities. 

Outcomes

Onward referrals, fit notes, and recall

Following nine months of collaborative work in Greenwich and Bexley between local GPs (including clinical leads and LMCs), hospital and ICB leads, an inappropriate requests letter was launched in February 2025 and shared widely with practices. The letter has been added to the local online document repository for general practices, with the aim of  to reducing the number of inappropriate requests from secondary to primary care for onward referrals, recall and fit notes, as well as inappropriate prescribing, test result follow up, and individual funding request (IFR) requests. 

In the first five months, an average of 20 letters per month were issued to challenge inappropriate requests from secondary care, such as onward referrals and fit notes. This reduced avoidable GP workload and prevented delays in patient pathways. Early hospital feedback also found that the letters created a learning opportunity for clinicians, clarifying responsibilities and awareness of pathways.

A thematic analysis is planned once 12 months of data is available, which will inform education for local clinicians on pathway optimisation. Further work also includes mapping which south-east London trusts have electronic systems for arranging recalls beyond one year. This will help confirm when hospitals can manage recalls directly, reducing unnecessary steps for GPs.

Discharge summaries and outpatient letters 

Delayed discharge summaries were identified as a problem within Queen Elizabeth Hospital due to communication issues between doctors and nurses about when discharge summaries could be sent. Following targeted internal engagement and process changes,  delays were reduced by 50 per cent, ensuring GPs received timely information to support patient follow up. Work is now focused on improving the quality and clarity of discharge summaries across south-east London, so actions for the GP are consistently clear.

Lessons learned

The forum is now focusing on improvements that will benefit secondary care priorities, including elective recovery and managing urgent care demand – supporting the 10 Year Health Plan’s aim to shift care closer to home. 

They recognise that organisational changes within the ICB and hospital trust could delay their progress in creating and testing innovative solutions. To mitigate this, they are developing a strong, evidence-based case for primary, community and secondary care interfaces to be central to integrated neighbourhood development. 

Their focus remains on creating integrated pathways and neighbourhood teams that deliver holistic care, reduce inefficiencies and ensure patients experience seamless transitions between primary, community and secondary care.