Achieving world class outcomes for patients challenges clinicians to ensure all parts of care pathways operate effectively and co-operatively.

Patients rightly expect clinicians to help them navigate their journey effectively. They reasonably expect that clinicians will lead change and work together in their best interests, including across organisational boundaries.

But too often, patients and their carers report less than satisfactory experiences. When they want information or sick notes, it is too often someone else's responsibility. Results are unavailable or locked in a different operating system from the one the clinician uses. Commonly, the clinicians who are guiding their care talk as if they have never actually met each other or as if they do not work to common goals across clinical care settings.

Has this always been the case? Probably to some degree, but I think professional contacts used to be better. Five to 10 years ago, local primary care practitioners would know most of their secondary care colleagues by their first names. GPs would ring and seek advice in the middle of consultations, aware of how and when to access specialists. Patients would pass on the best wishes of one doctor to another and nurses who had trained together would personally co-ordinate patient discharges across ward and community teams.

This all added to patients' sense of security and well-being. In this more intimate NHS, problems were rapidly sorted out and advances in care disseminated through professional peer-to-peer education. Clinical colleagues met at lunchtime and evening meetings spanning primary and secondary care settings. Informality often drove knowledge and improvements in care.


Several factors, not just an expanding NHS, have challenged the personal aspects of clinical relationships. Now is the time to take stock and, with some local commitment and planning, to take action that reconnects clinicians across boundaries to achieve better care outcomes. Patients value continuity of care. They do not necessarily expect this to involve one person heroically travelling the entire care journey with them, but they do have a reasonable expectation that those they meet on the journey will be acquainted and work with each other.

Before the era of primary care trusts and the National Institute for Health and Clinical Excellence, most expert clinical knowledge was based on local service leaders' expertise. It was transferred through talks at meetings that were often supported via pharmaceutical sponsorship. The downside was that when new treatments were launched, pathways relating to their use would dominate much of the postgraduate programme. However, despite this, the treatment of hypertension, cardiac failure, type 2 diabetes, depression, asthma, leg ulcers and medical urology quickly shifted from hospital to primary care settings as a cohort of multi-professional clinicians were rapidly skilled up through active interaction with hospital colleagues. This was arguably more effective in transferring skills than current plans to shift care to community settings. The challenge for PCTs and practice-based commissioning consortia is to rekindle these local learning opportunities and re-engage clinicians on common themes.

In time, prescribing formularies became the norm and contacts with pharmaceutical representatives were discouraged. NICE and PCT-wide guidelines superseded the value of local professionals' opinions and preferred ways of working. However, little or nothing beyond clinical governance sessions have been put in place to maintain the many personal contacts the old ways of working engendered. To compound matters, the new general medical services contract had no requirement that GPs should take part in the previously agreed (and remunerated) 30 hours of education required to receive the postgraduate education allowance. Local postgraduate centres, largely based in hospitals, had serviced this through balanced education programmes involving hospital staff and primary care teams. GP practices also developed their own in-house versions that engaged local specialists, transferring their knowledge and expertise. Both put names to faces and brokered relationships from which patient care ultimately derived great benefit. This contact is now rare, arguably damaging clinical leadership opportunities that exist across organisational boundaries.

The huge NHS investment in acute services expansion increased consultant and other staff numbers. Just at the time when primary care began to look internally for its development of clinical governance, accreditation and skills, the names and faces of those to whom they referred changed dramatically. The new online choice agenda also reduces personal referrals as the application of queuing theory shifts referrals to a specialty rather than an individual specialist. Protocols and guidelines reflected the more nationally agreed approach to standards and much of the previous local flavour and context was lost.

Clinical leadership

Now is time for clinical professionals to challenge this shift. The NHS next stage review emphasises the need for clinical leaders to work across boundaries and make the links that will drive improved quality, safety and outcomes. Patient care is a uniquely human and compassionate process. Clinical leaders across PCTs and provider trusts need to find ways to reconnect and collectively secure the investment and support that allows them to get together and drive change.

The next stage review rightly emphasises the strengths of a clinically led NHS. Service redesign and shifts in care settings can benefit teams across service divides if managed for mutual gain with multi-professional teams working together to optimise their time, skills and inputs into patients care. Good professional relationships help to build skills, transfer knowledge and ensure limitations are recognised. It is not just the responsibility of PCTs or providers to manage this process for us. It is a collective professional responsibility shared by clinical leaders across organisations. Clinical leaders across primary and secondary care must take the initiative to forge these links for the benefit of all.

The highest performing health systems support clinicians to lead where they have the greatest expertise, which is in patient care pathways. Tariffs and a focus on payment for activity can create tensions within the clinical family, which we need to understand and mitigate. It is time to build on the work put into the 18-week pathways and lead a move to invest time and effort in strengthening clinical teams. We should make sure we know who the members of the care team are and the pathways patients travel. If we get this right, it is our patients who will benefit the most.