Dr Matthew Lewis explains how the approach at his trust is improving the quality of patient referrals, and communication between primary and seconday care clinicians.

Relationships between general practitioners and consultants have become more distant in recent years, perhaps because of increasing numbers of doctors in both sectors, pressure of time, loss of shared educational forums and the tendency to un-named referrals.

At the same time, the number of patients referred with gastrointestinal disorders is rising, which places a significant burden on waiting lists. At times of financial constraint, it is essential to ensure good communication between GPs and hospital specialists so that patients are only referred when necessary.

The need is identified as:

  • More effective interface between primary and secondary care
  • Reduced referrals to secondary care
  • Improved working practices to ensure correct referral practices

Sandwell and West Birmingham Hospitals Trust is engaged in a process which aims to reconstruct patient pathways within our locality, but this depends on close links to improve the flow of patients between primary and secondary care.

Existing routes of communication have either been slow (letters: dictated, typed and delivered by post), awkward (telephone: difficulties negotiating consultant secretaries or practice switchboards) or untimely (mobile phones: access to letters, notes and computer records are not always possible).

Previously we considered email processes to exchange information but it was not possible to share patient specific data because of concerns over confidentiality.

The problem:

  • Limited communication between consultants and GPs
  • Existing means of communication are sub-optimal
  • Previous email systems lacked security

However, when our trust adopted NHSmail, which offers much greater security, as the standard email platform, we decided to revisit the use of email as a means of dialogue between GPs and consultants.

The first decision was to create a shared (generic) email address so that the service could be covered by any member of the team, even if some people were on leave. Consultants access this email address through the web version of NHSmail, using their password to log on to their personal email address and, from there, to the generic site.

Four consultants review the emails during the week, on a 1 in 4 rota, aiming to give an initial response within 24-48 hours; conversations lasting over a week can be picked up by the next consultant. We are willing to accept enquiries about specific patients (if NHS or local identification number is included) or we can give general advice about un-named patients.

At the end of the email conversation, our secretaries upload the email trail onto the electronic patient record, where it can be viewed in the same way as the typed letters.

The solution:

  • Generic departmental email address
  • Emails checked and replies sent within 48 hours
  • All correspondence uploaded to EPR if patient has hospital ID

This initiative was launched with three large local practices and once the process was shown to be successful, it was extended to all the GPs in our referral area. We now offer two separate email addresses for GPs to contact us on each of our sites at Birmingham City Hospital and Sandwell General Hospital. Feedback from GPs has been excellent.


  • Small amount of consultant time reviewing emails
  • Potential reduction in paid activity through diminished referrals
  • But no set-up charges and system functioning fully within days

The consultants have found that checking emails comfortably fits in to the working day and is often quicker than trying to speak to GPs over the telephone. It is expected that the number of referrals to our trust will fall as a result of this initiative (with more GPs receiving advice through the email system) but this acceptable in the short-term as it fits in with our commitments through Right Care Right Here; in the longer term, it is hoped that our share of the local referrals will be maintained as a result of better contact with GPs.

An alternative approach is available through NHS Choose and Book but this is limited to a single question and response before the conversation is terminated and therefore lacks the flexibility that is needed to develop a useful clinical conversation.


  • Improved relations with GPs
  • Excellent feedback from users
  • No discernable impact on referrals after nine months

We consider that this model of secure email communication through NHSmail has the potential to enhance working relations between primary and secondary care clinicians, improve the appropriateness of hospital referrals and deliver more cost-effective healthcare for patients in a number of specialities.

Find out more:

Written evidence from the British Society for Gastroenterology.


Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice

Right care right here