Primary care development

This innovative project set out to identify key areas for small changes that will help bring closer integration and alignment between Solent’s adult community services and primary care.

The programme involved three local GPs spending time observing our community nursing, community independence service and urgent response teams in action. They were able to see first-hand the excellent work delivered by teams, and came away with a deeper understanding of how clinicians in Primary Care can get the best from the services around us.

Following the review, three key workstreams were identified (SBAR, Multidisciplinary team meetings and communication) and working groups were set up to drive the work forward. The continued work of these workstreams can be seen more in the dropdown boxes below.  

We have also published a short evaluation report to share the findings from this work, and we are keen for this to be shared as widely as possible. The outcomes, resources and learning from this work can be translated across services and geographies.

SBAR ('Situation', 'Background', 'Assessment', 'Recommendation'), is a structured communication tool which supports structured handover of relevant information and referrals quickly. Whilst it has been used within the Trust for many years, its use has been sporadic and with varying effectiveness. The Trust understands the value in this tool when used effectively, and as such, our team has developed training for Community Teams and Primary Care to enable them to use the tool effectively. We are currently carrying out an impact review of the use of SBAR across our community nursing teams, and hope to spread this work across the Trust and to our partners.

The training packages can be accessed through the NHS England Learning Hub. The Primary Care version can also be viewed through Vimeo.

We recognise the importance of Multi-Disciplinary Team meetings (MDTs), especially to support the most complex patients we care for.

Complex Care MDTs

Our Trust runs weekly ‘Complex Care MDTs’ in each of the three localities within Southampton city, which bring together a range of health and care professionals. Through the work of the Southampton Primary Care Review Programme, we were able to streamline this process, including referral criteria and using SBAR as the basis for patient discussion.

We have actively sought ways to improve GP representation at these meetings; any GPs with patients on the list to be discussed are now emailed 2 days before the meeting to invite them to attend. We also welcome GPs to refer patients into our Complex Care MDT meetings, even if they are not previously known to the service. Patients are prioritised for discussion if there is representation from the relevant primary care setting. To refer patients to Complex Care MDT, please email the relevant email address and provide a referral in the format of SBAR. We have also produced a flyer with more information.

East locality (meetings are on Tuesdays, 09:30-10:30)

West locality (meetings are on Wednesdays, 09:00-10:00)

Central locality (meetings are on Thursdays, 09:00-10:00)

MDT Mapping

As part of the Southampton Primary Care Review Programme, we also carried out a mapping exercise and produced a mapping spreadsheet to show all the MDTs running across Southampton city; those run by our Trust, as well as those run by GP practices or at PCN level. We are keen to fill in the gaps, so please contact us if your information needs updating.

The team recognises that effective communication is key to ensuring good relationship between services. We aim to share information through the ICB’s communication channels. In 2024, we put together a series of articles, showcasing the learning from the Primary Care Review Programme. You can access these articles here.

We are also in the process of scoping for a Trust-wide communications guidance, to help guide the communication of routine and urgent information (both patient information and other information) between our services and Primary Care.

When we speak to our Primary Care colleagues, we often receive feedback such as GPs not knowing who they community nurses are, or not knowing how to refer into a particular service.

We have produced three ‘Padlets’, which give a visual ‘Who’s who’ of each of the three community nursing and CIS locality teams within Southampton. They can be accessed below:

• Central locality 'Who's Who' Padlet
• East locality 'Who's Who' Padlet
• West locality 'Who's Who' Padlet

We have also produced a ‘Snapshot Directory’ of Adult Services in Southampton, which local GPs and their teams can use to understand more about the breadth of services we provide, how to refer in, and key contact information.

In late 2023, a shared care clinic was set up in Solent GP Practice once a week, for patients across the Central PCN in Southampton. The clinic aimed to upskill practice nurses, build relationships and improve integration between services. The clinic enabled 6-8 patients each week to be seen for care of PICC lines, catheter care, nephrostomy care and rocket drain care. We have produced a good news story to showcase this innovative project. Our community nursing service is keen to extend the project to other PCNs; if this is of interest, please get in touch with us.

Hampshire and Isle of Wight Integrated Care Board (ICB) stood up a transformation programme which focuses on primary and local care; addressing same day access, urgent care response, integrated neighbourhood working (INW), proactive case management, virtual wards, and telemedicine, asking for local place systems to develop their own local operating model to meet the needs of their communities.

In April 2024, a Southampton INW Task and Finish Group (TFG) was set up to provide a means of driving the programme forward. The group has brought colleagues together from Health and Social Care, Public Health, alongside the Project Lead and Coordinator, who have formed new relationships and links and will continue to develop, provide direction, and support the programme as it evolves. The group’s purpose is to develop and mobilise integrated neighbourhood working models which meet the need of the local population. The programme has been codesigned to enable partnership working to flourish across services, organisations and community groups within areas loosely defined by each of the Primary Care Network footprints. The TFG provides regular progress reports to Southampton & Local Care group (PLC), whose members are from Southampton health, care, and voluntary sector, to inform progress and enable them to uphold their responsibilities in providing oversight and accountability of the programme.

As part of our project journey so far, we have spent a great deal of time researching and developing documents that we felt would be useful put together on Padlet, to share with others to aid with INW thinking. You can view this Padlet here.