Aligning secondary care work appropriately: Secondary Care Hub model

Across a number of specialties in NHS Grampian, there had been an increasing expectation that some tests requested by secondary care would be undertaken in general practice with the associated clinical and administrative workload attached. 

This had developed without a consistent or agreed approach, leading to variation in practice and uncertainty for both clinicians and patients. In many cases, this had developed pragmatically in response to service pressures and evolving pathways, rather than through a single agreed approach.

Clinical Interface Group (CIG) discussions identified several issues, including:

• Uncertainty around which tests were most appropriate to undertake at the point of GP consultation
• Variation between specialties in what was expected from general practice
• Additional activity without consistent agreement or system-wide clarity
• Delays for patients where referral or investigation pathways were unclear 

This led to inefficiency, inconsistency, and frustration across both primary and secondary care.

The CIG supported a structured programme of work using a short life working group to take this forward. This included:

• Bringing together primary care, secondary care and operational colleagues through a focused working group
• Using utilisation data to understand demand and where pressures were sitting across the system
• Designing a hub model and spreading activity across the geography to improve access and resilience
• Clarifying roles so investigations are undertaken at the most appropriate point in the pathway and results go directly to the clinician who needs them
• Expanding the model to support additional activity, including ECGs as part of annual psychiatric medication reviews as an example
• Developing the approach jointly over time, testing and refining it in practice 

This work has been developed alongside Community Treatment and Care services, with a shared ambition to create a more integrated model. While a fully aligned service delivery approach has not yet been achieved due to a number of complexities, including funding, this remains an important direction for improving efficiency and patient experience. 

In reality, this has been a gradual shift and has looked different across specialties, but taking a consistent approach has helped move things in the right direction. The focus throughout was on developing a model that worked for both primary and secondary care, rather than prioritising one part of the system over another.

In practice, this is starting to give patients a more streamlined and consistent experience:

• Results being directly reviewed by the clinician responsible for that aspect of care
• Reduced need for multiple steps before referral
• More direct and coordinated investigation pathways
• Greater consistency in how patients are managed across specialties
• Reduced delays caused by unclear or variable secondary care requirements 

Outcome

• Development of a secondary care hub model to coordinate investigations
• Greater consistency in how and when secondary care requested testing is undertaken in the community
• Improved clarity in roles and responsibilities across the interface
• A model that can continue to evolve as services align 

Key Learning

• Short life working groups enable focused progress on complex interface issues
• Use of data supports more effective system design
• Joint development over time is critical to embedding change
• Alignment of funding and service models is essential for full integration 

For more information on this case study, please contact scotland.interface@rcgp.org.uk