Interface Working – Improving Care For Patients And Increasing Efficiency Across The System
Page Contents
Published Primary/Secondary Care interface documents for your area
What This Means in Practice for GPs and Practice Teams
Core Principles of Effective Interface Working
What This Means for Primary Care
Introduction
Delivering high-quality patient care relies on smooth and consistent collaboration across the healthcare system. Interface working – the point where care moves from one part of the system to another – is often where delays, confusion or duplicated effort can occur. Improving these transitions means better outcomes for patients, improved safety, and reduced frustration for both staff and services.
BUT…for GPs and Practice teams it can sometimes feel like you coming up against a brick wall when trying to refer a patient. The plethora of guidelines and pathways that you are supposed to follow make it seem impossible to find the right place for a patient.
Across Wessex and our neighbouring systems, considerable effort is being invested in improving communication, clarifying responsibilities and developing shared expectations across pathways. These developments support the wider ambitions of Integrated Care Systems and contribute to more sustainable, efficient and rewarding clinical practice for all professionals involved in a patient’s care.
The Government has renewed its pledge to cut NHS bureaucracy as part of its 10-year plan, including for GPs. This is known as “Getting It Right First Time” – or GIRFT
GIRFT guidance is useful : Bridging-the-interface-checklist-July-2025.pdf
Improved communication at the interface of healthcare organisations is essential for effective clinical care. To support this, GIRFT has produced two guides:
- Bridging the interface between primary and secondary care, mental health and community services.
- Clinical operational standards supporting emergency care pathways.
Here is a link to a new document published by the Academy of Royal Medical Colleges. This document sets out, in very simple terms, some ingrained historical myths held within secondary and primary care, along with the reality (or myth-buster) and how the myths can be challenged at a local level. This document can be helpful (alongside your local interface document) to challenge any behaviours seen in colleagues working outside primary care Escape_The_Tape.
Published Primary/Secondary Care interface documents for your area
Dorset Memorandum of Understanding (2024)
Dorset MOU Primary, Community, Secondary care
A clinically led agreement focused on improving trust, communication and pathway clarity across health sectors, ensuring the patient remains central.
BSW Excellence in Partnership Working
Primary and Secondary Care Excellence in Partnership Working
Provides clear expectations for communication, investigations, prescribing and use of referral pathways, helping align processes across the system.
Hampshire & Isle of Wight Way (2025)
The_Hampshire_and_Isle_of_Wight_Way_2025.pdf
Sets out practical principles such as responsibility for results, clarity of onward referral and ensuring patients fully understand their care and what will happen next.
Frimley Interface Standards
FHFT_and_primary_care_collaborative_working_reference_guide_2023.pdf
A slightly earlier example of an interface document that sets out detailed expectations for primary and secondary care.
| The documents are co-written by GPs with ICBs and secondary care colleagues and are designed to be a reference point to underline how primary and secondary care should interact. If you come across areas where you feel these guidelines on fair play are not being followed you can reference these details to colleagues and feedback to your ICB using your feedback tool. |
What This Means in Practice for GPs and Practice Teams
For general practice, improving interface working does not mean taking on more tasks – rather, it means ensuring that patients receive the right care from the right professional at the right time. When something is asked of primary care that would be more appropriately managed in secondary or community services, it is important to clarify expectations and work collaboratively to direct the task to the appropriate team.
Primary care teams should feel confident referencing the locally agreed system documents – such as the Dorset Memorandum of Understanding, the BSW Excellence in Partnership Working guidance and the Hampshire & Isle of Wight Way – when discussing responsibility for tasks. These shared agreements provide a professional, system-wide framework for decision-making and help ensure patients experience seamless care without unnecessary delays.
Using these documents is not about “pushing back” on colleagues, but about ensuring:
- Patients aren’t passed between parts of the system without clear ownership
- Work sits where it is most clinically appropriate
- Communication remains consistent, safe and efficient
- Avoidable repetition and administrative burden is reduced for everyone
Where something is more appropriately handled by secondary care – for example, arranging a test, issuing a first prescription or following up a result – the GP practice can refer to the relevant guidance, and work with secondary care colleagues to agree the most suitable way forward.
Why Interface Working Matters
All parts of the NHS are working under sustained pressure. When different sectors coordinate effectively:
- Patients experience fewer handover delays
- Staff spend less time solving administrative problems
- Pathways are clearer, safer and easier to navigate
- Resources are used more efficiently
Despite strong collaborative intent, siloed working can still occur. Improving mutual understanding across services helps smooth institutional boundaries and ensures care is designed around what matters most to patients and their families.
Core Principles of Effective Interface Working
Across multiple regional documents, a consistent set of principles emerges. These are not rules but shared professional expectations that support safe and constructive cross-organisational working.
- Keep the patient at the centre
Every decision, communication and handover should prioritise patient experience, safety and clarity. Patients should:
- Understand what the plan is
- Know what to expect next and roughly when
- Know who to contact if concerns arise
- Clinicians should, wherever possible, complete actions themselves
If a clinician identifies the need for tests, treatment, or referral, it is usually most efficient and safest for them to take ownership of arranging it. This avoids unnecessary steps and ensures patients experience continuous care.
- The requester retains responsibility for results
When a test is ordered, the team requesting it should receive, interpret and act on the results unless a shared-care arrangement is already agreed. This supports clinical safety and prevents important information falling between services.
- Clear, timely and structured communication
Discharge letters, outpatient summaries and care updates should spell out:
- What was done
- What has changed
- What follow-up is planned
- Whether any action is expected from another service
Where this information is consistent and well structured, patients and professionals alike benefit.
- Mutual respect and collaborative relationships
These principles work best when all services recognise one another’s pressures, expertise and limitations. Assuming good intent, communicating openly, and building constructive relationships are key to improving system-wide working and staff wellbeing.
What This Means for Primary Care
For GPs and practice teams, local guidance highlights the importance of:
- Clear referral letters that explain the reason and the clinical question
- Considering local pathways, advice & guidance services and appropriate pre-referral investigations
- Helping patients prepare for planned procedures, including optimisation of long-term conditions and supporting them to “wait well”
While patients remain under primary care while awaiting appointments, clear communication from secondary care – particularly around prescriptions, investigations and expected timelines – supports safe ongoing management.
What This Means for Secondary and Community Providers
Local system agreements also encourage hospital and community colleagues to:
- Arrange investigations, first prescriptions and onward referrals directly when appropriate
- Provide fit notes when needed, and for a realistic duration
- Ensure follow-up is organised for patients who leave hospital unexpectedly or decline admission
- Make clear what actions (if any) are expected of primary care
This avoids unnecessary duplication and ensures patients experience continuous, coordinated care.