Urgent clinical advice
You said... we did
We are committed to strengthening the primary / secondary care interface in order to improve patient quality and experience whilst making the best use of clinical time and resources. We are pleased to share with you the most recent editions of our 'You Said, We Did' bulletin outlining some of the thematic issues we have received and how processes have been improved.
FHFT and primary care interface development collaborative working reference guide
The purpose of the document is to strengthen the interface arrangements across primary and secondary care and in turn optimise patient care. The guide outlines agreed ways of working for the different clinical professionals within primary and secondary care and covers a wide range of interface situations summarised below. Within the document these can be clicked on to take you to the relevant section:
| Referrals, advice and guidance |
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| Prescribing, results and discharge preparation |
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| Further support and guidance / FHFT GP centre |
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- Outpatients – urgent treatment or short courses should be given by a hospital prescription
- Refer to the Frimley Formulary to confirm the “Traffic Light Classification” for the medication and accompanying guidance on appropriate prescribing responsibilities:
- Red = Prescribing remains with the specialist for the duration of treatment. Send information on the medication being prescribed to primary care so that it can be documented in the medical record but retain prescribing within the specialist setting.
- Amber with shared care = The specialist should initiate prescribing. The duration that prescribing will remain with the specialist prior to requesting shared care will be defined in the shared care document available on the Frimley Formulary. Once the criteria for requesting shared care are met then write to primary care to ask if care can be shared. Include a copy of the shared care document in this communication.
- Amber without shared care or Green = Where a service user has a need for the medication to be started within 14 days then prescribe to the service user an adequate quantity of that medication to meet the service user’s immediate clinical needs until primary care receives the relevant clinic letter and can prescribe accordingly. It is recommended that this be at least 14 days. If the medication is prescribed as a course rather than a long-term treatment, then supply the full course.
Where immediate commencement of medication is not required, the specialist will communicate the details to the primary care clinician to action. The prescriber will also reassure the patient that commencing therapy with the medication is not clinically urgent and it may take some time to process the prescription.
Communication to primary care will include the medication (or class of medication) to be prescribed, duration of medication and relevant information to enable safe prescribing. If local practice and protocols require supply for a longer period, this must be honoured unless alternative local arrangements are agreed.
Outpatient prescribing guide - addendum to the FHFT / GP collaborative working reference guide
Background
Most patients with pacemakers do not require ongoing follow-up in the cardiology outpatient service. In addition, the pacing downloads are often performed remotely, with limited patient contact.
This applies only to the finding of AF (atrial fibrillation). Other arrhythmias, including ventricular arrhythmias, will continue to be escalated within the cardiology service. These will continue to be managed with oversight from a cardiology consultant.
Please find below a template letter to the GP/Primary Care Clinician and to the Patient, which has been collaboratively developed and agreed with the Cardiac Network and ICS Clinical Interface Committee (CIC), which includes Primary Care, Secondary care and LMC representatives.
Produced in Collaboration:
Dr Peter Clarkson – Consultant Cardiologist and FPH Lead for Pacing
Dr Sitara Khan – Consultant Cardiologist and FPH Clinical Lead
Dr Nav Chandra - Consultant Cardiologist and Wexham Park Clinical Lead
Dr Dan Mason - Clinical Lead NHS Frimley
Dr Gareth Robinson – Senior Clinical Lead NHS Frimley
Claire Norfolk – Head of Long Term Conditions NHS Frimley
Letter template to the GP/Primary Care Clinician
Dear Dr,
This patient has been found to have atrial fibrillation, as defined by guidelines, on their recent pacemaker check. This check may have been performed remotely.
The burden of AF is x%, the longest episode is x minutes/hours and the highest heart rate during AF is x bpm. The management of this patient is as for any patient with atrial fibrillation, in accordance with guidelines i.e. the presence of a pacemaker does not alter the usual management strategy for AF. We will continue to keep them in pacing clinic for ongoing surveillance of their pacemaker function.
We would be grateful if you could offer them an appointment to review their clinical status, medications and co-morbidities, with a view to initiating anticoagulation and rate control medication as appropriate. We have written separately to the patient and advised them that lifestyle factors such as obesity and excessive alcohol intake are common causative factors for AF. We would also appreciate your help in advising them to address these factors if relevant.
If you feel that the patient would benefit from a review in secondary care with a view to cardioversion or other rhythm-modifying therapy, we will be happy to accept this via a referral to the Arrhythmia service via the general cardiology service on eRS. If you have queries relating to initiating rate-control, please contact us via the Cardiology Advice and Guidance service on eRS.
Thank you.
Your sincerely
The Pacing Team
Frimley Health Foundation Trust
Letter template to the Patient
Dear Mr / Mrs,
We are writing to inform you of the results of your recent pacemaker check, which revealed an irregular heart rhythm called atrial fibrillation (AF). This condition is common with ageing, and many people are unaware that they have it.
In AF, the heart's upper chambers (the atria) do not contract effectively, which can lead to blood stagnation and an increased risk of clot formation. While AF is not life-threatening, it can raise the risk of stroke, so blood thinners may be advised. Please note that this incidental finding of AF does not reflect any malfunction of the pacemaker; the pacing check indicates no concerns regarding the pacemaker itself.
AF can lead to symptoms such as rapid palpitations; however, many individuals remain asymptomatic. The causes include high blood pressure, heart valve disease, and lifestyle factors such as obesity and alcohol intake beyond the recommended limits.
We will ask your GP practice to arrange a routine appointment (alternatively you can initiate this) so that you can be clinically reviewed, including your medications and any co-existing health conditions. This review will enable your GP to assess your suitability for blood thinners and medication to help control your heart rate. Other treatments for your AF will be considered, and you may be referred to hospital for this.
Please contact your GP practice to discuss your treatment options. If you experience any symptoms related to AF, they can refer you to a cardiologist. For more information, please visit the British Heart Foundation website: Atrial fibrillation (AF) – BHF. Their guidance is summarised below.
Yours sincerely,
The Pacing Team
Frimley Health Foundation Trust
Summary of British Heart Foundation guidance
Atrial fibrillation is a complex heart condition with various causes, including high blood pressure, heart valve disease, cardiomyopathy, and diabetes, among others. It can also arise due to lifestyle factors such as alcohol and caffeine consumption, smoking, and stress. Interestingly, even individuals without any known risk factors may develop this condition, with age being a significant contributing factor.
Managing atrial fibrillation is crucial for maintaining a good quality of life. Emotional support is important, especially as the diagnosis can lead to feelings of stress and anxiety. Resources like the British Heart Foundation’s emotional support hub can provide guidance during these challenging times.
In practical terms, individuals need to be mindful of how atrial fibrillation may affect daily activities, including driving and travelling. Consulting with healthcare professionals can help address any concerns or questions related to their condition.
Effective management also hinges on adhering to prescribed medications and making healthy lifestyle choices. A balanced diet, regular physical activity, quitting smoking, reducing alcohol intake, and effectively managing blood pressure and cholesterol are all essential components of a healthy lifestyle. By focusing on these strategies, those living with atrial fibrillation can achieve a fulfilling life while actively managing their condition.
Intended readership: BOB ICB, Frimley ICB, Maternity Services at RBHFT, BHT, OUHFT, FHFT, GP’s and wider ICS partners including service user representatives.
Position Statement on Interface Between Practices and Maternity Services
"This statement sets out how maternity services and GP practices work together to support women and pregnant people. It aims to provide clarity, avoid duplication, ensure the right care is given by the right person at the right time and improve the experience of care."
Context
This position statement is based on the following context:
1. The NHSE protocol governing the primary-secondary care interface, as reflected in the NHS Standard Hospital contract.
2. Findings of the Ockenden Review that underlined increasing complexity and risk of managing medical conditions in pregnancy and the need for greater specialist medical/obstetric input available to midwives.
3. The need for clinicians within a service to complete an episode of care, using their own organisation’s clinical, supervisory, and administrative resource where needed.
4. Currently, locally, medical records around midwifery care are now separate from GP clinical records systems and not readily accessible when the patient is not in front of the GP, which has implications for safe clinical practice.
5. Recognition that a woman or pregnant person has two clinical services which they can access for pregnancy-related issues – their maternity provider, and their GP practice.
6. Pregnancy itself is not an illness that falls into the definition of GMS essential services.
7. Recognition that midwives are autonomous practitioners that work within the boundaries of midwifery care in line with their Nursing and Midwifery Council Registration and are not prescribers.
8. Recognition that the GP practice continues to provide primary medical services to people who are pregnant.
9. Professional body regulations around good medical practice.
This position statement does not preclude a practice having a bespoke arrangement with their midwife where there is mutual agreement and it is clinically safe to do so.
Recommendations
1. Midwives should oversee the routine antenatal appointments schedule as recommended in NICE guidance and NHS trust clinical guidelines, plus any additional reviews as recommended by them or their medical colleagues in the obstetric service.
2. GP practices should continue to provide primary medical services to any pregnant person, as per the provision of maternity services (s9.7.2, p68) in the General Medical Services (GMS) contract, defined as:
(a) in relation to female patients (other than babies) all primary medical services relating to pregnancy, excluding intra partum care, and.
(b) in relation to babies, any primary medical services necessary in their first 14 days of life.
2.1 The practical application of this is that a GP practice should continue to support any pregnant person, or their newborn presenting to them with a perceived illness, chronic disease, or end of life care. This includes medical conditions related to pregnancy (such as, but not limited to, hyperemesis gravidarum or bleeding in pregnancy). The extent of the care the GP practice is able to offer is primary medical care, and the practice will necessarily need to direct the patient onwards to alternative appropriate services, recognising the increased need for specialist input (such as from the patient’s midwife or obstetric services) during pregnancy.
2.2 Intra-partum care ends on the conclusion of delivery of the baby or the patient’s discharge from secondary care services, whichever is the latter.
3. Where a pregnant woman or person presents to their midwife rather than their GP practice with a pregnancy-related issue, the midwife should be able to manage that presentation, using their own clinical, supervisory, and administrative hierarchy within their employing organisation where required.
4. In pregnancies that are complex and outside the scope of a midwife, referrals to obstetric and/or specialist secondary care may be required. With regards onward referrals:
4.1 If the presenting problem is related to that which the service is supporting the woman or pregnant person for, that service should manage and prescribe if treatment is required or refer directly onwards to the most appropriate clinical pathway. (For example, where a midwife suspects their patient has gestational diabetes, they can refer that patient into the relevant diabetes clinic).
4.2 Regardless of whether the presenting problem is related to that which the service is supporting the pregnant person for, if it is urgent, the service should refer onwards to the most appropriate clinical pathway.
4.3 If it is unrelated and routine, the service can direct the patient to contact their GP practice for the practice’s own assessment and decision-making.
4.4 Where there are direct access arrangements for midwives, these should be used where the midwife thinks it appropriate (such as referring a pregnant woman or person with depression into the perinatal mental health service).
5. The requester of a test is responsible for ordering the tests they desire, responding to those results, and informing the patient. In practice, this means that the clinician can order the tests they desire, receive those results, interpret them, action them where required, and inform the patient of the results, using their own clinical, supervisory, and administrative hierarchy within their employing organisation where required.
6. Routine prescribing requests are managed in the usual way, by asking the GP practice to prescribe by way of an agreed formal communication which acts as a handover of that aspect of care, and the request is consistent with local formulary guidance (e.g. traffic light system). A routine medication request without clinical details is not sufficient. There is a 2-week window for GPs to respond to routine requests for prescriptions in line with the nationally recognised standard https://
7. In line with completing an episode of care, prescriptions used in routine midwifery care should be available for midwives to request, using their own clinical, supervisory, and administrative hierarchy within their employing organisation where required. The LMC supports the use of Patient Group Directions (PGDs) for midwives, signed off by midwifery services, in these circumstances.
Glossary of Terms
"PGDs (Patient Group Directions) are legal frameworks that allow certain health professionals to supply or administer specific medicines without a prescription."
Position Statement on Interface Between Practices and Maternity Services
Key Points
Management involves:
- Identifying patients with AF and assessing for associated cardiac symptoms such as heart failure, angina, or dyspnoea.
- Optimising heart rate control prior to surgery, aiming for a resting heart rate of less than110 bpm.
- Reviewing anticoagulation therapy. Patients taking DOACs or warfarin may need to have these medications withheld before surgery (refer to local anticoagulation guidelines).
- Liaising with the GP if AF is newly diagnosed or if further optimisation or assessment of thromboembolic risk is required prior to surgery.
The most common presentation is a patient with known chronic AF, usually elderly, asymptomatic and on appropriate anticoagulation. In such cases, no additional intervention is usually needed beyond appropriate perioperative management of anticoagulants.
For patients requiring urgent or emergency surgery, any decision to delay the procedure should involve careful evaluation of the risks and benefits of postponement
Abbreviations
AF - Atrial Fibrillation
HR - Heart Rate
IHD - Ischaemic Heart Disease
LMWH - Low Molecular Weight Heparin
NICE - National Institute for Health and Care Excellence
NOAC / DOAC - Non-Vitamin K Antagonist Oral Anticoagulants / Direct Oral Anticoagulant
Causes
- Atrial Fibrillation (AF) is a common condition in elderly patients and often encountered in the peri-operative context.
- Existing or newly diagnosed AF is associated with increased perioperative morbidity and mortality.
- The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age50–59 years to almost 9% at age 80–89 years.
- AF in younger age groups (< 50 years). Specific causes and risk factors (outlined below)should be sought/investigated and treated.
- IHD, valvular pathology, heart failure, hyperthyroidism, sepsis drugs such as caffeine, alcohol, cocaine
Confirm Diagnosis and Baseline Assessment
- Obtain a history and assess for cardiac symptoms; dyspnoea, palpitations, syncope/dizziness, chest discomfort, reduced exercise tolerance, stroke/TIA.
- Record routine observations.
- ECG to confirm the presence of AF (Patients will have an absence of P waves and the QRS complexes occur in an irregularly irregular pattern).
- Blood tests to include: FBC, U&Es, clotting profile.
Suitability for Elective Surgery
The patient should have a HR <110 bpm prior to elective surgery with a target of < 90bpm for optimal control. A rapid rate can lead to decompensation and symptoms of heart failure.
Stable AF
- Patients with known AF and a HR < 110 bpm are suitable to proceed with surgery.
Poorly Controlled AF with a HR > 110 or New-Onset AF
- Discuss with the surgical team and refer the patient back for review by the GP as soon as is reasonable.
- The preoperative assessment team is responsible for sending this letter using the online incidental AF template.
- Surgery may need to be postponed, depending on the urgency. This decision should involve both the anaesthetic and surgical teams.
Further Cardiac Assessment:
- If cardiac imaging is required (e.g. Echo) to assess fitness for surgery, it should be requested via Epic.
- For new-onset AF, a routine referral to the arrhythmia clinic should also be made via Epic via the pre-op team.
- All results should be shared with the patient’s GP to ensure appropriate follow-up and coordination of care.
Urgent or Unstable Cases do not discharge:
- Patients with AF and HR > 140 bpm or any signs of cardiovascular decompensation (e.g., hypotension, chest pain, syncope) require urgent inpatient review.
- These patients are not suitable for discharge and should be escalated immediately for medical assessment.
Urgent Review Pathway at FPH and WPH:
- Can be arranged via the Ambulatory Care Unit (ACU)
- Pre op team can contact the nurse in charge of ACU
- If space available, patient may be transferred for urgent optimisation.
- If patient is unstable or haemodynamically compromised escalate for urgent review via 2222NEWS pathway
Emergency Surgery
- Time-critical surgery may proceed with intra-operative management, this requires anaesthetic/surgical evaluation given risk of intraoperative instability.
- Assess for and correct common reversible causes: Sepsis, hypovolaemia, hypoxia, electrolyte imbalances (Mg2+ and K+).
- Acutely decompensated patients may require electrical or chemical cardioversion (refer to ALS adult tachycardia guidelines)
Anticoagulation
- DOACs should be stopped preoperatively. Refer to trust guideline for the Management of Anticoagulated Patients Undergoing Elective Surgery or Invasive Procedures Bridging with LMWH:
- See separate preoperative anticoagulation guidelines.
- Patients with high CHA₂DS₂-VASc score (>4) or those with a history of mechanical heart valve should be considered for bridging.
- Bridging is not usually required in isolated AF.
- Initiation of anticoagulation post-op:
- Directed by the surgical team. Resume anticoagulation promptly post-op when safe (i.e. when risk of surgical bleeding is assessed to be acceptably low)
- New-onset AF during/after non-cardiac surgery. ESC guidance recommends anticoagulation as per CHA₂DS₂-VASc.
- Refer to NICE guidelines for specific timing and renal impairment considerations.
Communication
To GP if:
- AF is newly diagnosed.
- Intervention undertaken (e.g. referral, treatment started DOAC/beta-blocker).
- Surgery postponed.
- To other specialists via epic referral pathway as appropriate.
Summary
- Stable, Known AF:
- Patients with pre-existing AF and a resting heart rate < 110 bpm are generally suitable to proceed with surgery.
- These patients will require guidance on withholding anticoagulation preoperatively.
- Poorly Controlled or Symptomatic AF:
- Patients with HR > 110 bpm or symptoms (e.g. chest discomfort, palpitations, dyspnoea) may require optimisation before elective surgery.
- They should be referred to their GP for review by GP as soon as is reasonable for optimisation.
- Newly Diagnosed AF:
- Newly identified AF during preoperative assessment should be communicated to both the patient and their GP.
- Surgery may need to be postponed, depending on the urgency of surgery and the severity of symptoms and clinical findings.
Pre-Operative Management of Atrial Fibrillation for Elective Surgery
| PRIMARY & SECONDARY CARE INTERFACE DEVELOPMENT - PRIORITIES 25/26 |
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| PRIORITY AREA 1: IMPROVE QUALITY & EFFICIENCY OF DISCHARGES (Nat. (PCARP) & Local Priority) (this continues to be a high priority for the Trust & Meds reconciliation QI is a ‘quality account’ for 25/26, with Exec level oversight) |
| 1.1. Continue to undertake meds safety QIs – with a further focus on end-to-end medicines reconciliation process improvements (Lead: AD, EF) |
| 1.2. Continue regular quality of discharge audits (quarterly): (lead GS) & Increased surveillance via PALS (lead EF) (through the Discharge Improvement meeting & Safer discharge prog). |
| 1.3. Embed the CIC developed ‘Discharges - Working with our partners’ education packs within resident doctor inductions & training (Lead GR, LA, SG) |
| 1.4. Complete “GP to action” (“Actions required of General Practice (GP)” and “Actions required of FHFT”) section in all discharges including maternity, ED & SDEC areas and OP correspondence ((Nat Req.) (when the pause on further rollout is lifted). Currently live in OP correspondence. (Lead: SG, GR) |
| 1.5. Finalise review of agreeing specific timescales for where follow up bloods post-discharge should take place e.g. less than x day requirements will be managed by secondary care, otherwise in primary care (Lead: LA, SG) |
| 1.6. Ensure robust processes for FHFT to onward referral from FHFT care to other acute / specialist providers; including FHFT to the SABP memory clinic (Lead: LA, GR) |
| 1.7. Continue to focus on reducing the number of duplicate discharge letters and ensuring amended discharges are clearly marked (e.g. using the .addend Epic process) (Lead: GS, TBC governance). |
| PRIORITY AREA 2: STRENGTHEN DIGITAL INTERFACES BETWEEN PRIMARY & SECONDARY CARE & COMMUNITY SERVICES (Local Priority) |
| 2.1. Roll out ReSPECT forms electronically to PC (via Docman) these will be sent separately to the discharge summary (but at the same time) (Lead: LA, FHFT)- June 25 (after Epic upgrade) |
| 2.2. Roll out electronic EMED3 (Fit notes) on Epic to GPs (via Docman) [Nat. Priority - Level 2] (Lead: GS, FHFT)- next project after ReSPECT form- June onwards |
| 2.3. Roll out sending ENDOSCOPY reports electronically to PC (via Docman) instead of posting results (Lead: AS, FHFT) |
| 2.4. Progress Epic care link single sign on (SSO) with EMIS (Lead NG, FHFT & KB ICB) |
| 2.5. BSPS to continue the roll-out of I-refer and Universal ICE Programme (SB, BSPS) |
| 2.6. Support consistent visibility of Clinician name and role in Primary and Secondary Care correspondence (FHFT: TS & ICB: AT) |
| 2.7. Support national work to develop an Electronic Prescribing System (EPS) on Epic for FHFT to provide direct prescribing to community pharmacists (Subject to national and system funding – awaiting Red Tape Challenge details). |
| PRIORITY AREA 3: IMPROVE THE QUALITY & CONSISTENCY OF REFERRALS & A&G USE - ensuring patients are being managed in the most appropriate setting - supporting optimal patient care including prioritisation of patients requiring specialist care, and supporting efficient triaging and onward care (including straight to test) |
| 3.1. Run a ‘Planned Care summit’ to determine priorities & continue with pathway & transformational developments (ZZ, ICB EL Lead). |
| 3.2. Seek to review and resolve where appropriate and feasible commissioning gaps across the interface - ICB team to identify/support review of commissioning gaps e.g. Low CLL/MGUS (ICB Primary Care Lead, AT). |
| 3.3. Optimise DXS to provide high quality decision support for referrals / A&G requests (Lead: ZZ ICB Elective Care Led & DXS team) • Ensure forms/pathways are fit for purpose and work for Primary and Secondary care. • Ensure DXS referral forms are available for all key specialties with agreed minimum data sets (MDS) (including EBIs/PA) • Work with the LMC to ensure forms / MDS are understood and adopted throughout Primary Care. • Increase uptake of DXS with an integrated dashboard to understand patterns re: referrals, returned referrals, A&G and DXS use etc. - work with outlier practices and specialities. |
| 3.4. Review and implement Direct Access to Diagnostics in response to GIRFT and National GPDA guidelines (+ linked to UICE & I-refer development) (Lead: HL Diagnostic Programme Lead). |
| 3.5. Ensure there is a clear and robust Prior approval / IFR / Clinical policies implementation process across the Primary and Secondary Care interface (Lead: ZZ, ICB EL Lead). |
| PRIORITY AREA 4: GOLDEN THREAD - STRENGTHEN RELATIONSHIPS & UNDERSTANDING ACROSS PRIMARY & SECONDARY CARE |
| 4.1. Review the Primary and Secondary Care Collaborative working guide and create a summary document (to complement the education slides and reference guide) (Lead: SG, FHFT & AT ICB) |
| 4.2. Continue to strengthen interface connections with Education Events in Primary Care (Lead: ICB Training Hub) |
| 4.3. Continue to strengthen the Clinical Lead Evenings (Lead: ICB Training Hub) |
| 4.4. Review other ideas and take forward as required e.g. ‘Meet the Team’/ ‘Working Well with our Partners’ workshop, exploring the feasibility of shadowing (Lead: AT & ICB Training Hub) |
| 4.5. Focused relationship support, troubleshooting & understanding with specific specialties or practice teams. Agreed to focus on UEC/ ED / GP interfaces at discharge re: language and expectations on discharge (Lead: LA, GR) |
| PRIMARY & SECONDARY CARE INTERFACE DEVELOPMENT - NATIONAL & LOCAL PRIORITIES 25/26- Year End Summary | |||
| NATIONAL & LOCAL INTERFACE PRIORITIES | ACTION FOR 25/26 | RAG | 25/26 Year End Summary |
| 1. IMPROVE QUALITY & EFFICIENCY OF DISCHARGES (National & Local Priorities) | |||
| IMPROVE QUALITY & EFFICIENCY OF DISCHARGES (National (PCARP) & Local Priority) – (this continues to be a high priority area for the Trust and as such is a ‘quality account’ for 25/26 with Exec level oversight) | 1. Continue to undertake meds safety QIs – with a further focus on end-to-end medicines reconciliation process improvements |
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The trust baselined performance against national medicines reconciliation standard compliance and discharge medication incident monitoring. Two workshops took place with approx. 70 colleagues inc. resident doctors, pharmacists, ward nurses, discharge lounge and in-reach specialists and senior clinical leaders. These workshops identified multiple opportunities to improve our medicines pathway, which would directly impact the safety of our discharge medication processes. Key improvements include: 1. Discharge summaries are marked as ‘DRAFT’ until pharmacy checks are complete. Nursing staff remove ‘DRAFT’ before sending to GPs and patients, ensuring medication accuracy. (This applies to all inpatient areas except SDEC and DSU discharges where pharmacy checks aren’t required due to the short duration of stay) 2. Mandatory Nurse Actions: A new mandatory element requires nurses to confirm they have handed over and discussed medications with patients, aiming to improve the effectiveness of medication handover. 3. Medicine Reconciliation on Admission guidelines: developed and shared with all clinical teams. There has also been a focus on identifying patients on admission who have key time critical medications such as those for Parkinsons and Epilepsy. 4. Safe Prescribing Training Programme Development: intended to rolled out in '26 by the pharmacist education team. The programme would cover safe prescribing practices for all prescribers entering the organisation, including non-medical prescribers and doctors at all levels (face-to-face and recorded sessions). This will be led by the Chief Pharmacist - providing updates to the Quality Assurance Committee. |
| 2. Continue regular quality of discharge audits (quarterly) and increased surveillance (Lead: GS & EF, through the Discharge Improvement meeting & Safer discharge prog). | Green | Regular audits took place, Chief Clinical Information Officer (Graham Smith) presented outcomes of the audits at the Clinical Effectiveness and Audit committee. Where relevant outcomes have feed into the above work programme and the bi-wkly discharge quality meeting. Assurance and Benchmarking: The audit results provided assurance and indicated that FHFT was not an outlier in MedRec benchmarking, while recognising that improvements were still needed. Audit results are sent to clinical governance meetings to highlight the importance of medication safety and ongoing improvement efforts. | |
| 3. Embed the CIC developed ‘Discharges - Working with our partners’ education packs within inductions & clinical education sessions. | Green | Key messages within the 'FHFT and GP Collaborative Working Reference guide' were re-iterated through our co-produced doctor training slides. These were successfully delivered to resident doctors in March 2025, Jan and Feb 2026. It has been agreed to replicate training regularly through bi-monthly CMO meetings and education half days with Divisional Clinical Medical Directors. | |
| 4. Embed “GP to action” (“Actions required of General Practice (GP)” and “Actions required of FHFT”) section in all discharges including maternity, ED & SDEC areas and OP correspondence (Nat Req.) (when the pause on further rollout is lifted). Currently live in IP correspondence. | Amber | Currently live in IP correspondence. On hold in maternity, ED & SDEC areas and OP correspondence - this was a national metric and not deemed a high priority locally. August 2025: Internal communication has been drafted, ready to be rolled if required. Carry forward to 26/27 if prioritised. | |
| 5. Complete proposal for establishing clear timescales for post-discharge follow-up blood tests; for example, requirements for tests within fewer than 'x' days will be managed by FHFT, while others will be overseen by primary care. Current guidance only asks that requests to PC have realistic timescales. | Amber | Proposal paper drafted and discussed with Cos/Clinical Director's Meeting. To finalise draft with FHFT's new divisional structures and share with CIC/GP Leads in 2026/27. Carry forward to 26/27 if prioritised. | |
| 6. Ensure robust processes for FHFT to onward referral from FHFT care to the SABP memory clinic | Green | Complete - June 2025: SABP Memory clinic referral process now live in Epic. Communication sent internally to all teams and documented within the YSWD. | |
| 7. Continue to focus on ensuring amended discharges are clearly marked (using the .addend Epic process) | Green | ||
| Improvements include: 1. Discharge/Medicine Reconciliation workshops took place in July and Aug - the '.addend' process was identified as one area to provide further education. 2. The Clinical Effectiveness and Audit committee shared a key message to all areas reminding them of the correct process to follow and its importance. 3. Further trust-wide communications shared on .addend process. 4. Changes to the discharge process have been implemented including the introduction of new digital milestones to ensure the correct sequence of actions take place to reduce the risk of multiple discharges being sent e.g. doctors complete bed reconciliation, pharmacy screens, supply is given, and nurses generate discharge summaries after these steps. 5. Duplicates report shared with Clinical Digital Divisional Leads to drive forward further improvements in 26/27 |
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| 2. STRENGTHEN DIGITAL INTERFACES BETWEEN PRIMARY & SECONDARY CARE (Local Priority) | |||
| STRENGTHEN DIGITAL INTERFACES BETWEEN PRIMARY & SECONDARY CARE & COMMUNITY SERVICES (Local Priority) | 1. Roll out ReSPECT forms electronically to PC (via Docman) these will be sent separately to the discharge summary (but at the same time) June 25 (after Epic upgrade) | Amber | FHFT have been working with Manchester and Epic on a technical solution to send attachments via Docman. A workaround solution has been developed and is hoped to be rolled out in Q1 26/27 (to carry forward to 26/27). |
| 2. Roll out electronic EMED3 (Fit notes) on Epic to GPs (via Docman) [Nat. Priority - Level 2]- next project after ReSPECT form- June onwards | Amber |
Once a digital solution has been found for sending ReSPECT form attachments via Docman (above) the same process will be applied for DWP compliant Fit Note sending. In parallel, a proposed Fit Note guidance table is being reviewed by clinical teams which will form part of the SOP/Clinical Guidelines (to carry forward to 26/27) |
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| 3. Roll out sending ENDOSCOPY reports electronically to PC (via Docman) instead of posting results
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Green | Complete - Build complete in EPIC (Sept '25). Testing with 7 practices in Frimley North, South & Bucks (started in Oct 25). Successfully rolled out to all practices: 01.12.25. | |
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Amber | 1. SSO via NHS mail - Implemented April 2026 (interim step) for all practices. Next step is to offer this out to other NHS trusts and organisations. 2. Contextual Launch via Emis- costs have been provided and will be reviewed by ICB and FHFT (to carry forward to 26/27 - if prioritised) Other Epic Care Link (ECL) access work programmes include: 3. Enabling radiology requesting via ECL from non-ICE providers - Enabled for SABP (Oct) extending to Military sites, private Dentists. 4. Enabling Health Visitors access to ECL - 160 active users over 8 organisations , increasing access to sensitive records held in Epic 5. Military practices are not on Docman so receive FHFT correspondence via the post. In March '26, 5 practices (Sandhurst, Pirbright, Minley, Aldershot, and Odiham) have had Epic Care Link enabled have had Epic Care Link enabled to see their patient records. 6. Notification of discharge functionality - Activation of an optional functionality for all practices - this allows practices to be notified when patients are discharged following emergency/inpatient episode. |
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Green |
Ongoing - programme led by BSPS rather than FHFT - Regular BSPS progress updates are provided monthly at ICS CIC meeting and monthly Primary Care Managers meetings, GP briefings etc. The team also have GP pilot sites involved. |
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| 6. Support consistent visibility of Clinician name and role in Primary and Secondary Care correspondence. | Green | Further communication sent out to all operational teams July 2025 - asked Primary care to proactively feedback any examples where this is still not happening. There was also a request for Primary Care to do the same. DXS referral forms are being updated to request this detail as they get refreshed etc. |
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| 7. Support national work to develop an Electronic Prescribing System (EPS) on Epic for FHFT to provide direct prescribing to community pharmacists (Subject to national and system funding – awaiting Red Tape Challenge details). | Q1 25/26 |
Epic provides structured medical information and we have protocols in place for Inpatient and outpatient prescribing (see section 4). Epic is working with neighbouring Trusts to develop an EPS. Once this is available it will be considered by the Frimley system. To note, Frimley South community services (FHFT and HRCG) use EMIS and therefore if the staff are prescribers they can send the prescription to community pharmacists electronically and wouldn't require an EPS. Also, in Frimley North they have a similar digital solution (where there is a prescriber). Epic have confirmed the national build is ongoing, likely timescale quarter 3 2027, once the build is complete, costs would be reviewed by FHFT with the view to seek to roll out across the organisation (to put in 27/28 plan). FHFT and ICB will provide updates on national progress during 26/27 through the CP updates. |
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| 3. IMPROVE THE QUALITY & CONSISTENCY OF REFERRALS & A&G USE (Local Priority) – FOR ICB TO OVERSEE AND SUPPORT | |||
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IMPROVE THE QUALITY & CONSISTENCY OF REFERRALS & A&G USE - ensuring patients are being managed in the most appropriate setting - supporting optimal patient care including prioritisation of patients requiring specialist care, and supporting efficient triaging and onward care (including straight to test) |
1. Run Planned Care summit to determine priorities and continue with pathway & transformational developments. |
Green | ICB Led - Planned care summit was organised to increase viability of the various changes happening across the system to ensure increasing alignment of initiatives. See Elective transformation Programme for further details |
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2. Seek to review and resolve where appropriate and feasible commissioning gaps across the interface - ICB team to identify/support review of commissioning gaps e.g. Low CLL/MGUS. |
Amber | ICB Led - With the publication of the NHS blue print for ICBs and regions, there is lack of clarity on the resources to be available in the interface with acute, community and MH services. The current level of input from the ICB will be retained until future functions and structure of the new TV ICB is established - August 2026 | |
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3. Optimise DXS to provide high quality decision support for referrals / A&G requests
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Amber | ICB Led - On-going work to maintain DXS for primary care and use it to host clinical guidance, pathways and referral forms. | |
| 4. Review and implement Direct Access to Diagnostics in response to GIRFT and National GPDA guidelines (+ linked to UICE & I-refer development) | Amber | 1. Update provided at CIC on the 12.09.2025 2. Radiology and ICB Diagnostic Leads met with GPs leads in late 25/26 to discuss GP direct access (GPDA) pathways to prioritise reviewing (over and above the national GPDA/CDC priority areas). These were: CT Chest, CT KUB, Brain imaging etc. Further meeting arranged with Frimley North GPs in May 2026. 3. Trust CDC and GPDA Clinical Lead appointed (Sri Iyengar) who will work with GPs and ICB Lead to drive this work programme forward in 26/27. |
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| 5. Ensure there is a clear and robust Prior approval / IFR / Clinical policies implementation process across the Primary and Secondary Care interface | Green | ICB Led - Updates provided at CIC and through communications (including the latest YSWD). ICB developed a new website policy area. DXS updates undertaken and ongoing. Further communications shared with FHFT and ICB colleagues in April 2026 (re: ICB transition arrangements). | |
| 4. GOLDEN THREAD - STRENGTHEN RELATIONSHIPS & UNDERSTANDING ACROSS PRIMARY AND SECONDARY CARE | |||
| GOLDEN THREAD – continue to strengthen relationships and understanding across primary and secondary care |
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Green | Key messages within the 'FHFT and GP collaborative working reference guide' were re-iterated through our co-produced doctor training slides which have been rolled out. Where new interface issues have arisen - interface agreements have been developed and agreed and have formed part of the Addendum which can be found on the FHFT GP centre interface developments section e.g. community midwifery prescribing, management of incidental AF findings following Pre-op appointment and Pacemaker checks. |
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Green |
ICB led - Regular, joint FHFT/GP Education / PLT setting meeting continues - sharing 'hot topics', gaps in education and forward plan etc. Protected Learning Time programme for East Berks will continue with some changes to the organisation with PCNs taking more of a role going forward. On 26/27 priorities plan to review and re-establish structures following ICB transitions |
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| 3. Continue to strengthen the Clinical Lead Evenings (ICB Training Hub) | Amber | ICB led - On hold, seeking clarity re: future plans with ICB re-structures | |
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Amber | ICB led - On hold, seeking clarity re: future plans with ICB re-structures | |
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Green | ED/UEC Areas Joint work initiated with ED and UEC areas - using GP feedback to support a deeper dive into language used on discharges etc. * Regular meetings set up with ED and UEC to provide regular feedback/themes received from primary care via the Primary Care Engagement team. * ED team reviewing DXS Referral form and Pathway * Emergency Care teams ongoing training sessions established (monthly) SHO's every other week where discharge education pack (created at CIC) is shared. * Project initiated by ED at Wexham to promote initial contact with speciality prior to sending a patient to ED. Feedback is being provided on a monthly basis directly to practices. This work programme will continue in 26/27 Cardiology Further work on the FHFT Cardiology - GP interface (following 24/25 priorities). This includes: New FHFT Cardiologist appointment to work with GPs. He's now visited all 16 PCNs which have included education sessions tailored to topics requested by the practices. FPH Clinical Lead (Sitara Khan) and the South team have also been to the Frimley South PLTs in Feb 2026 (12, 24 &26th) and WXP Clinical Lead (Navin Chandra) is delivering a face-to-face session on 12/05 in Bracknell and a virtual session on 10/11 for RBWM. |
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FHFT & GP Interface development priorities for 2024/25 - year end summary report
FHFT & GP Interface development priorities for 2025/26 - year end summary report
The below table shows the main ways FHFT communicates key messages with primary care and then re-iterates these messages in other forums (depending on the relevance and importance).
| Key message communication channel from FHFT to PC (decision based on impact / urgency) |
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|---|---|---|---|---|---|
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High impact / urgent
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Medium - high impact / less urgent
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| FRIMLEY ICS SYSTEM COMMAND CENTRE (SCC) EMAIL COMMUNICATION | FRIMLEY ICS GP/ PRIMARY CARE BI-WEEKLY BULLETIN | ||||
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Key messages are then repeated further through the following channels and meetings
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| Included in additional communication channels: | |||||
| Monthly comms summary email - to all clinical managerial leads and LMC |
ICS CIC - key topics and monthly comms summary is a standing agenda item |
ICS admin MS Teams channel - key / relevant topics |
Monthly GP briefing slides and / or via presenters | If appropriate, Meds Optimisation Bulletin or Training Hub Bulletin | |
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| Monthly primary care managers meeting (standing agenda item) | Primary care admin support webinars | ISC clinical speciality delivery groups and operational groups | Frimley training hub - monthly group to support agenda setting | ||
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| DXS | FHFT GP centre website | 'You said We did' | FHFT and PC collaborative working reference guide | ||
Note - If a communication is Place-specific but not high enough importance/impact for the SCC route AND the item has missed the cut off for the weekly GP bulletin (above) – the communication will be sent via the ICB primary care managers to disseminate to their practices. This should be requested rarely, and we would request confirmation of receipt of the email and distribution of the communication.
* The GP / PC bulletin and SCC are also shared with Buckinghamshire practices via the Buckinghamshire management / communication structures
Frimley ICB primary care bulletin
All GP / primary care bulletins can be found at: NHS Frimley - GP bulletin archive. The bulletin is managed by Frimley ICB but includes key messages from FHFT to primary care.
If you have any questions relating to any of the material in this email or have any suggestions for how we could improve this, please email: frimleyicb.
For any patient-specific clinical concerns, please contact the relevant service directly; contact details to the clinical admin teams can be found on the GP Centre website via the following link: https://
If you are unable to reach the service, please escalate your concern to the PALS team:
• Frimley Park Hospital PALS: fhft.
• Heatherwood and Wexham Park Hospitals PALS: fhft.
For thematic or process related issues, please contact the FHFT Interface development support team (fhft.