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Hospital trusts now require ‘designated lead‘ to improve primary-secondary care interface

Every hospital trust will be required to have ‘a designated lead for the primary-secondary care interface’ and integrated care boards (ICBs) asked to ‘regularly review progress’, according to NHS England’s newly published ‘2024/25 priorities and operational planning guidance’.

Delayed since December due to funding discussions, the guidance sets an overall priority for the NHS in England over the next 12 months as the ‘recovery of core services and productivity following the Covid-19 pandemic’ continues.

Introducing the guidance, NHS chief executive Amanda Pritchard said despite ‘increasingly mature partnerships in operation at [integrated care partnership], ICB and place level’ the nation’s ‘ageing population, and growing numbers of patients with multiple and complex conditions’, means the NHS and its partners ‘must continue to adapt so that we can help people to live longer, healthier lives’.

According to the guidance, streamlining the patient pathway by improving the interface between primary and secondary care is ‘an important part of recovery and efficiency across healthcare systems’.

By introducing a designated lead for the primary-secondary care interface, it is hoped that trusts will deliver on the four key areas set out in the access to primary care recovery plan and endorsed by the Academy of Medical Royal Colleges: onward referrals, complete care (fit notes and discharge letters), call and recall and clear points of contact.

Commenting on this interface, David Wiliams, head of policy and strategy at NHS Providers, said his organisation is already ‘seeing the advantages’ of leaders of NHS trusts and local health systems ‘working closely with primary care partners to improve how they cooperate to benefit patients’.

And he said this was ‘playing out in a variety of ways as system working matures and care pathways are being transformed, often at a very local level’.

He added: ‘Designated primary care leads will be welcome support in the drive to achieve closer working, but given the pressure of day-to-day operations, trusts and primary care providers will need national support to focus on the long-term to deliver further improvements.’

Improving care, discharge and waiting times

Improving emergency department waiting times compared to 2023/24 is another core focus of the planning guidance, with a target for A&E staff of a minimum of 78% of patients being seen within four hours in March 2025.

The Royal College of Emergency Medicine (RCEM) had described a previous target of 76% of patients being seen within four hours as ‘unambitious’. On the latest target, RCEM president Dr Adrian Boyle said the ‘small percentage improvements in four-hour access performance are difficult to endorse when there are so many people waiting for 12 hours or longer’.

He also highlighted the incentive scheme for major emergency departments that ‘achieve the greatest level of improvement’ and/or are able to see 80% of patients within four hours outlined in the planning guidance as being ‘potentially divisive’ and uneconomical.

‘We would prefer a quarterly approach to incentivise improved performance, perhaps using the Commissioning Quality Incentive payment system,’ he said.

Dr Boyle did, however, welcome the planning guidance focus on bed occupancy, saying: ‘It is critically important to reduce the dangerous occupancy levels we are currently seeing.’

Dr Boyle noted NHS England data showing that total bed occupancy levels in hospitals across the country reached 95.1% on 20 March 2024.

He said: ‘Overcrowding and patients who are technically ready to go home but haven’t got the right care provision in place, is really adding to the delay problems faced by ambulance staff and we need to ensure that staff in Emergency Departments are able to offer patients the care that they deserve.

“Bed occupancy is still too high and seems to be increasing which is not a good sign that any improvement in that area is forthcoming.’

Nevertheless, the planning guidance outlines an ambition to reduce the number of patients who are still in hospital beyond their discharge-ready date, as well as the length of delay.

It is hoped that continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, admissions avoidance and hospital discharge will also be of benefit, the guidance said.

Other priorities outlined in the planning guidance include reaching a 77% faster diagnosis standard (FDS) target for cancer this year as an interim step toward meeting the target of 80% by March 2026, reducing Category 2 ambulance response times to an average of 30 minutes across 2024/25, as well as improving the working lives of all staff and increasing staff retention and attendance through systematic implementation of all actions and best practice made available through the NHS retention hub.

’Floor not ceiling of ambitions’

Acknowledging that many of these ambitions will be ‘stretching’ and require ‘a relentless focus on improvement, fewer delays and unnecessary processes’, Ms Pritchard said the guidance ‘should be seen as the floor, rather than the ceiling, of our collective ambition to be a better and more responsive employer’.

Royal Colleges and NHS partner organisations have expressed concerns about how this will work in practice.

Looking at the guidance as a whole, Matthew Taylor, chief executive of the NHS Confederation, called the ambitions ‘very challenging for the health service’.

‘We are concerned that the NHS is entering the new financial year in a worse underlying position, with the risk of further strike action over the next six months… compounded by the financial crisis facing many local councils.’

He also criticised the timing of the publication, saying that while the Confederation understood the impact the wider political context is having on long term decision making, ‘we need to get back to a position where the planning guidance is released months and not days ahead of the new financial year’, and that ‘this short-term approach risks holding back the NHS and with it, the wider health and care system’.

Also picking up on the strikes, Sally Warren, director of policy at The King’s Fund, warned that the plan is ‘built upon an assumption that there will be no industrial action throughout the year despite the fact negotiations are still ongoing’.

She added: ’This means it’s quite possible the Government will need to step in to find additional funding if industrial action continues or new pay deals are agreed, assuming it wants the NHS to deliver on the expectations and targets that have been set out.’