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The interface between primary and secondary care

Patient hands

The BMA is working with NHS England and other organisations to help improve the interface between primary and secondary care.

Good organisation of care across the interface is crucial for ensuring patients receive high-quality care, and in making the best use of clinical time and NHS resources in all settings.

We will continue to update our resources and guidance area, which includes the latest prescribing guidance for all professionals involved in commissioning and prescribing across primary, secondary and tertiary care.

Latest guidance and resources


What you need to know

Working with NHS England and other organisations, the BMA agreed changes to the NHS Standard Contract for 2017-19, under which clinical commissioning groups (CCGs) commission health services from providers.

There are a number of new requirements which clinicians and managers across the NHS need to be aware of, and which are summarised below. These are described more fully in the Key Messages guidance, which the BMA has produced in partnership with other relevant organisations.

Key national requirements


Let us know - what support do you need to meet the requirements?

While changes to ways of working can take time to embed, what should Trusts be doing to help doctors in secondary care meet the new requirements described above?

For example, could the requirements be explained during doctors’ inductions? Are there practical problems that need addressing, such as the availability of forms on wards or the IT systems used?

Any feedback you are able to share, whether an example of good practice or a problem that needs addressing, will help us inform discussions with NHS England and ensure doctors across primary and secondary care get the support they need.

Contact us


Essential information

  • Key national requirements

    • Managing DNAs and re-referrals
      Providers should no longer ask GPs to re-refer DNA appointments.

    • Managing onward referrals
      Clinicians working for the provider should make an onward outpatient referral, without needing to refer back to the GP, where it is directly related to the condition for which the original referral was made, or the patient has an immediate need for investigation or treatment.

    • Communicating with patients and responding to patient queries
      Providers should put in place and publicise arrangements for handling patient queries; providers should communicate the results of investigations and tests to patients directly.

    • Discharge summaries
      Discharge summaries must be sent to the GP within 24 hours after every discharge from inpatient, day case or A&E care.

    • Clinic letters following outpatient attendance
      Clinic letters should be sent to GPs within 10 days (7 days from April 2018) where there is information the GP needs to act on in relation to the patients’ ongoing care; clinic letters should be sent electronically using standardised clinical headings (by October 2018).

    • Medication
      Providers to issue medication following discharge from hospital for a minimum period of seven days (unless a shorter period is clinically appropriate) and following a clinic attendance where a patient has an immediate clinical need, for a locally agreed period of time. More information on prescribing is available here.

    • Shared care protocols
      Shared care protocols may be agreed locally, but hospitals must only initiate the care under the protocol where the individual GP has confirmed willingness to accept clinical responsibility for the particular patient in question.

    • Fit notes
      At a suitable point in time (on discharge from hospital or at clinic), clinicians must issue fit notes to patients where appropriate, the provider organisation must enable this, and the notes must cover an appropriate period of time.


  • Resources and guidance

    NHS e-Referral Service: a guide for secondary care doctors - This guidance is for secondary care clinicians to consider when implementing e-RS.

    NHS e-Referral Service: a guide for GPs - We have worked with NHS England and NHS Digital to produce joint guidance for GPs to understand the most effective way of using e-RS.

    Onward referrals - This guidance is for secondary care clinicians explaining when patients can be referred onward without referral back to the GP

    Key messages for NHS clinicians and managers – a short guide describing the key national requirements which doctors need to be aware of.

    Patient leaflet – explains what patients can expect to happen if they are referred by their GP to see a specialist or consultant in a hospital or community setting.

    Template letters for GPs – templates to support GPs and LMCs in reporting problems to Trusts and CCGs.

    Improving how secondary care and general practice work together – a joint letter from NHS England and NHS Improvement issued to Trusts and CCGs.

    Responsibility for prescribing between Primary & Secondary/Tertiary Care – guidance on prescribing and principles for shared care.

    2017-19 NHS Standard Contract provisions across primary and secondary care: implementation toolkit for local systems - practical ways in which organisations can collaborate locally to implement provisions relating to primary and secondary care