Primary Secondary care interface project

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About

The primary-secondary care interface has long been identified by RCGP Scotland as an area of high risk to patients. It is widely accepted that healthcare provided at the interface between primary and secondary care can be dysfunctional. This leads to a disrupted patient journey and healthcare that is unsafe and inefficient. This dysfunction disproportionately effects disadvantaged groups. 

Since 2018, RCGP Scotland has received funding from the Scottish Government to support the establishment and development of dedicated primary-secondary care Interface Groups in each Health Board. 

The project has aimed to support Interface Groups across Scotland by:

  • Meeting with interface representatives from each of the Scottish Health Boards to learn about different approaches to, and experiences of, Interface Group working. 
  • Co-creating a Gold Standard Model that provides guidance on the principles and recommended structure that underpin a successful and effective Interface Group.
  • Creating networking opportunities between Groups, like webinars and an Interface Group Forum in 2024, to facilitate the sharing of learning and experience amongst themselves and with Health Boards who do not currently have a dedicated Interface Group.
  • Providing resources and templates that support the establishment and ongoing work of Interface Groups, such as how to set up work shadowing opportunities.
  • Work closely with the Centre for Sustainable Delivery (CfSD) to ensure relevant pathway development work includes input from both primary and secondary care

To find out more about the project, listen to our discussion with Dr Chris Provan on RCGP Scotland's Podcast - Generally Speaking. The episode covers the problems that exist around the interface, the RCGP Scotland's work on this to date, the potential of Interface Groups to improve the current system and the work that is already being done across Health Boards in Scotland at the moment. The episode is now live on Spotify and Apple Podcasts.

You can find more details about support and upcoming events in the ‘Ongoing support for Interface Groups’ section below.

The impact of Interface Groups and interface-related projects

There is a high volume of interactions between clinical teams at the primary-secondary care interface. Improvements at this point in the system have the potential to improve the experience for many patients. Interface Groups provide a whole system approach to healthcare delivery and often facilitate organisational improvement and innovation at the interface. Bringing senior primary and secondary care clinicians together with the aim of improving the patient journey can help to realise benefits in patient safety, organisational efficiency and healthcare inequalities. 

Interface Groups provide a mechanism for dealing with issues, whether they relate to the admission, referral and discharge of patients or to problems in communication, prescribing or uncertainty around clinician roles at the interface. Through Interface Groups, these problems can be effectively managed and solutions embedded. 

Case study: Innovating at the interface in NHS Lothian

Within Lothian, the Lothian Interface Group (LIG) played a key role in building momentum and securing support for a pilot to trial a new cluster interface model in medical paediatrics. The pilot has significantly improved referral pathways, reduced referral rates and waiting times alongside enhanced experience for both clinicians and families.

Read the full case study here
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Establishing an interface group

If you’re working to establish an Interface Group, this guidance brings together the key information, tools and templates to streamline the process and help you build strong foundations for a well run and sustainable group.

Gold Standard Model for Primary–Secondary Care Interface Group working in Scotland

The aim of an Interface Group should be clear: to improve the patient journey. Each Interface Group must have organisational recognition by the Health Board. It should be embedded within existing Health Board governance structures and should be the recognised place to bring operational issues at the interface. Examples of interface areas include:

  • Patient discharge from hospital
  • Referrals from primary care
  • Communication between primary and secondary care
  • Investigation or result handling across the interface
  • Primary care role in the provision of care
  • Prescribing across the interface
  • Significant/adverse event analysis relating to the interface
  • GP Quality Cluster work 
  • Inequitable healthcare

Interface Groups should have senior representation from primary and secondary care and from Health Board management. Exact group make-up should be determined at a Health Board level.
Interface Groups should develop terms of reference with a shared vision and direction.

It should include:

  • The route for escalation of an issue if the Interface Group is unable to reach consensus. This should fit into existing organisational and governance structures.
  • Clear and transparent mechanisms by which the group operates. For example, there should be clear pathways to raise issues, record outcomes, and communicate Interface Group decisions. 

Interface Groups should:

  • have a culture that is collaborative and focused on outcomes that keep the lived experience of patients and carers at the centre of the process.
  • be accessible and visible throughout the organisation with transparent information on who is in the group, how others can feed in, and where to find information about outputs.
  • encourage innovation focused on improving patient care at the interface.

Interface Group Leads and supporting administration should be resourced to ensure there is time for groups to meet and action research and improvements.

 

Working together as an Interface Group

Strong working relationships are central to how Interface Groups operate. Bringing together colleagues from different disciplines and parts of the NHS naturally means a range of perspectives and ways of working. Many established Interface Groups have developed approaches that help them collaborate effectively and build constructive relationships across the interface.

The resources below offer practical guidance to help your Interface Group work well together and learn from the experience of others.

Case study: Using standardised templates to streamline work

NHS Highlands Interface Group has standardised how work is submitted to the group by introducing an SBAR (Situation, Background, Assessment, Recommendation) template for submissions. Anyone wishing to raise an issue or propose a piece of work is asked to complete the SBAR template to clearly outline the problem and what they'd like the Interface Group to consider in 500 words.

Read the full case study and access the SBAR template
A GP wearing a pink hijab talks with a couple during a GP appointment.

Work shadowing provides an opportunity to improve the relationships, communication and joint working between primary and secondary care, through better understanding of each other’s roles, remits and challenges. You may find the resources below useful for arranging work shadowing in your area.

Since 2024, RCGP Scotland have facilitated tailored coaching sessions for three Interface Groups, focusing on strengthening professional relationships and supporting groups to develop a clear, shared direction. Feedback from participating groups has been highly positive, with many noting the significant benefits of coaching.

  •  “I feel the interface group has hugely benefitted from the coaching. I am clearer about the reasons others value it, we have made efforts to be more organised and formalised and this is leading to improvements through output of meaningful work, and clinical engagement… has improved.”
  • “The coaching felt like a breakthrough moment – having a neutral respectful person, was helpful for people to reflect on. It's been really helpful as a catalyst to bring people together.”


If you’re interested in receiving coaching for your Interface Group, please contact Scotland.interface@rcgp.org.uk

Delivering as an Interface Group

Interface Groups play an important role in shaping improvements, contributing to efficient delivery and better patient outcomes. Even small changes build over time to create lasting impact.

The ‘Please Write to Me’ guidance, which endorses secondary care writing directly to patients, as well as GPs, is an example of an existing tool that can improve communication at the interface and can be adopted by other Groups.

The case study library

The case study library hosts a variety of examples of what Interface Groups have achieved across Scotland. They illustrate the range of ways in which groups can influence service improvement and support change, with templates available to support work across the Interface.

Access the case study library here
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Ongoing support for Interface Groups

We aim to support Interface Groups to continue developing and work well together, both within individual groups and collectively across Scotland. You can find more information about upcoming events and the range of support available below. If there are any other resources or support you would find helpful, please get in touch by emailing scotland.interface@rcgp.org.uk

We host webinars to support Interface Groups to undertake improvements, with a particular focus on health equity. Previous webinar topics have covered health inequalities and ‘Missingness’. 

Future webinars will be listed on the events page of the RCGP website. Please email Scotland.interface@rcgp.org.uk to register your interest in being informed of upcoming Interface webinars, or to access webinar recordings.

Interface Groups can apply for funded professional coaching. This tailored support offers dedicated time and expert facilitation to help your group strengthen relationships, build a clearer shared purpose and improve how you work together. 
If you’re interested in learning more or receiving coaching for your Interface Group, please contact scotland.interface@rcgp.org.uk 

There will be another in-person networking event for Interface Group Leads and those working on Interface-related projects in 2026/27, building on the success of our Interface Forum event in 2024 and the interface webinars in 2025 and 2026. 

This event will facilitate the sharing of best practice, showcasing successful outcomes of successful work as well as enabling discussions around overcoming barriers and encouraging individuals to network from across Health Boards. 

Further details on the previous event can be found in the event report. Please email Scotland.interface@rcgp.org.uk if you’d like access to presentation recordings and running slides from the event.

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Further reading and resources

This section contains links to further reading and resources that relate to interface working across Scotland, the rest of the UK and internationally.

Contact us

If you are a part of an Interface Group in Scotland or are interested in setting up an Interface Group in your Health Board please get in touch. Contact us at: scotland.interface@rcgp.org.uk.