At present, it seems hard to imagine a time when the covid-19 pandemic will be over, but when it eventually is, there will be an opportunity to cement many of the positive innovations made over the past year. We will also need to deal with the major problems the pandemic has created and the pressures on general practice that predated the current crisis.  

One area where there is an opportunity to accelerate work already going on is around outpatients and specialist referrals. Here there is scope for a more fundamental re-examination of the model, which avoids the missed opportunity of just replacing face-to-face consultations with phone, web, and virtual clinics, and instead changes the relationship between hospitals and primary care well beyond just improved communication. 

For years, both primary and secondary care have bemoaned the growing separation of the two sectors. Rebuilding these relationships is particularly valuable in specialties that deal with long term conditions or provide longitudinal care for patients. Obvious areas include diabetes, respiratory medicine, paediatrics, geriatric medicine and cardiology. Incorporating mental health would also be beneficial. 

Some models (such as Consultant Connect) that connect GPs to a wider group of consultants are useful, but may prevent the development of relationships that create trust, an understanding of mutual strengths and weaknesses, and attitudes to risk. These advantages may be easier to achieve if Primary Care Networks (PCNs), or a group of them, had named consultants, specialist nurses and others involved in long-term conditions care that directly relate to them. 

Models where specialists work closely with GPs and specialist nurses have been around for some time. In 2014, The King’s Fund described a number of successful models that changed the way that specialists work. These involved a strong emphasis on education and training, and involved the specialists in a population-wide approach to improve the overall health of the area they served and get a better understanding of it. 

Other specialties that deal with more episodic care (such as ear, nose, and throat), or where there are fewer referrals from primary care, will still benefit from being part of a system to provide timely advice and support. These specialists will relate to more than one PCN, but it may be beneficial to consider a named consultant to provide the interface.  

The traditional model of a referral letter being written by the GP to a hospital specialist, and a patient then being seen has already changed in many places. In Sheffield’s CASES model, non-urgent referrals for selected specialties go to GPs with a special interest in that area, who provide advice or support to the patient with the help of a specialist consultant mentor, which in some cases obviates the need for referral to hospital. In the referral and advice service in Tower Hamlets, e-referrals are seen by consultants who have the option to respond in a number of different ways. These include providing advice in the notes, speaking to the patient by phone, discussing the case with the GP, or calling the patient in. GPs can ask for the patient to be given advice or booked into a virtual clinic. 

These approaches require a well-defined pathway, which include identifying any investigations required, ensuring that the objective of the referral is clear, and that a holistic view of the patient is available. Often a multitude of individual and non-standard forms have got in the way of such holistic care.  

The opportunity for GPs to have a direct discussion with a specialist for cases that are particularly challenging, but where a referral may not be necessary, can also be useful. This way of working needs to offer flexible options, support dialogue between clinicians, and provide a clear statement of the interaction’s purpose. These types of models also reduce the need for other routine outpatient activity such as annual follow-ups.  

Feeding back the questions and issues that have been raised in these different models, or running regular case presentations, are also an important contribution to professional development. 

The ability for the specialist to review the GP record and to directly write to GPs, where appropriate, could greatly assist. At the very least a system that allows notes from consultants to be viewed from within the GP system without a separate login would be beneficial. Here there remain some information governance obstacles to be overcome.

A longstanding concern has been the growing tendency for GPs to be sent long “to-do” lists by hospitals. Not only is this likely to be an inefficient form of task-shifting, it can lead to GPs taking responsibility for drugs and tests that are unfamiliar to them. Developing a more rational distribution of work, and reducing “hand-offs,” would be an important goal of the new approach. It might increase work for hospitals, but could also impose more discipline in decision-making if the work cannot be simply handed over.

There is already broad agreement about the need to move away from paying hospitals for activity in a number of areas. The King’s Fund case studies of specialists working in new ways with primary care showed that such models generally reduced outpatient referrals, attendances and follow-up, and could also lead to a significant fall in emergency admissions. The hospital’s costs probably changed little—staff time was simply used differently. There has not been systematic research on the impact on workload, but from the examples we have seen, there is no evidence it has increased. The changes seem more related to reducing work that adds little value.  

New contracting and payment models will be needed to support moving away from paying hospitals on the basis of the numbers of patients seen, but perhaps the most significant shift is for consultants and their teams to see themselves as jointly responsible for thinking about the whole population—including the missing patients and those at risk, rather than just the care of those who are referred. This implies joint accountability for the PCN and the hospital staff for the health of the children, people with long-term conditions, frail older people and others that they look after.

There are many practical issues to sort out, and the shortage of spare time in primary and secondary care is an obstacle, as these changes need to be clinically led. One might wonder if time that has been dedicated to the more transactional components of commissioning might be better spent on improvement activities such as these. The challenge of a new cohort of patients with complex multi-system problems after covid-19 makes it even more urgent.  

Nigel Edwards, CEO of the Nuffield Trust.

Competing interests: none declared.

The author wishes to acknowledge the contribution to this article from Michelle Drage, Elliott Singer and Lisa Harrod-Rothwell from Londonwide LMCs and from Donal O’Donoghue from the Royal College of Physicians, who also contributed to the article and who has since very sadly died from covid-19.