Primary care development

Is there a disconnect between Primary Care and the community teams in your area? Are siloed ways of working getting in the way of joined-up, person-centred care? Do teams struggle to understand each other's roles, pressures, and ways of working?

In Southampton, GPs and HIOWH's adult community teams faced these very barriers to effective collaboration. Without shared understanding, efforts to integrate care were often limited or inconsistent. 

To address this, we launched an innovative project focussed on building closer integration through shared learning, observation and "walking in each others' shoes". This hands-on approach fostered mutual understanding and strengthened relationships between Primary Care and our community services - paving the way for more mature, effective collaboration.

The impact has been practical as well as cultural. From co-developing tools around the SBAR Communication Tool to improving Complex Care MDTs and communication, the project has delivered tangible outputs and laid the groundwork for scalable, system-wide improvements in integrated care.  

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.

Do you receive referrals or emails that lack clarity about the issues or what's being requested? Are you frustrated by incomplete patient information or unclear handovers? Do you wish communication was more effective?

Southampton GPs and community nurses recognised these were consistent problems and started a project to implement and embed SBAR. SBAR is a proven communication tool which can be used in handovers, MDT meetings, and urgent situations. When consistently used, SBAR improves safety, strengthens teamwork, and leads to faster, more effective decision-making.

How could it help your practice? Have a look at the specifically designed learning programme we have produced (see link in section below), and in 30 minutes, you and your team can become an 'SBAR team'.

More about SBAR

SBAR ('Situation', 'Background', 'Assessment', 'Recommendation'), is a structured communication tool which supports structured handover of relevant information and referrals quickly - to communicate with confidence. 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.

To support the use of SBAR and unify our resources, we have consulted with our Working Group and colleagues in Community Nursing and CIS, and agreed on the strapline: SBAR: Communicate with confidence. 

We have put together the following resources to support you to use SBAR in your practice:

• SBAR training packages - each package consists of a video, an infographic and a self-reflection worksheet. The training packages can be accessed through the NHS England Learning Hub. The Primary Care version can also be viewed through Vimeo.
• 'SBAR of an SBAR' - we have written an 150 word summary of SBAR in the format of SBAR, to demonstrate SBAR in practice. This is a single A4 sheet, which would be ideal as a poster and for sharing on social media.
• Impact evaluation report 2-page PDF showcasing the impact of SBAR on teams within the Trust, and the impacts you will see if you implement SBAR in your practices and with your teams.
• Blog post - we have written an easy-read blog post summarising our SBAR impact evaluation and call to action.
• 'Call to action' flyer / poster - we have produced a flyer / poster to highlight key actions to take regarding implementing and using SBAR.
• SBAR image / graphic - this image summarises what SBAR stands for. It can be used as a poster, and is also ideal for sharing on social media.

Do you struggle with lack of engagement from community teams and community partners in your MDT meetings? Do you want to engage with Primary Care in your MDT meetings but don't know where to start? Are you spending excess admin time managing the paperwork resulting from your MDT meetings?

Southampton community teams experienced these very challenges in the management of their Complex Care MDT and launched a project to streamline the Complex Care MDT process.

By streamlining the Complex Care MDT processes (including updating referral criteria, creating new recording templates based around SBAR, and engaging with Primary Care), it made it easier to influence care planning for complex patients - saving time, improving outcomes, reducing duplication, and improving collaborative working.

Complex Care MDTs

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

We recently completed an impact evaluation of these CCMDT meetings. Over one year, 1168 patients were referred into CCMDT (averaging 7.5 patients per week per locality). The evaluation has demonstrated the impact that CCMDT is having on patient care, such as improved coordination and continuity of care, improved patient engagement and health outcomes, and helping to establish efficient, sustainable care. 

Primary Care MDT meetings

Several of our community teams are also involved in supporting practice-level and PCN-level MDT meetings. One really successful practice-level MDT with excellent engagement is Stoneham Lane Surgery. We have produced to Good News Story to showcase the successes of this MDT meeting, including what's working well, why it matter for GPs and a call to action.

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.

Do you find it challenging to communicate effectively with Primary Care services? Are you looking for better ways to share learning and key messages?

The faced similar challenges across our Primary Care Review Programme. Our workstreams were generating valuable insights, but without a clear strategy for communication, this learning wasn't always reaching Primary Care teams effectively or consistently. To address this, we've been using variety of methods to showcase learning and improve communication, such as regular articles in the ICB's weekly newsletter, social media updates, and internal communications with staff. We're now going further by developing clear communications guidance to support more consistent, streamlined and effective information-sharing with Primary Care, both for routine updates and urgent situations. This is helping us strengthen collaboration, reduce confusion, and ensure the right messages reach the right people at the right time.

Communication through the ICB's channels

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.

Engagement meetings with PCNs

All Southampton PCNs and Practices were contacted in Autumn 2024 to offer the opportunity to meet with their locality community teams (Community Nursing and CIS). The aim of these sessions was to build relationship and to hear from practices and PCNs about challenges, opportunities and priorities, especially with a focus on shared care of frail patients. Meetings were held between Dec 2024 and Feb 2025 with Central PCN, North PCN, SeaCity PCN, West PCN and Woolston & Townhill (SPOFS Neighbourhood). A summary PDF has been produced, showing the key themes and actions from these meetings.

Development of communications guidance

We are in the process of developing guidance for how routine vs urgent communication (both patient information and other information) is made between our services and Primary Care. 

Who's Who Visuals

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 a visual 'Who's Who' of each of the community nursing and CIS locality teams within Southampton. They can be accessed below:

• East locality 'Who's Who'
• West locality 'Who's Who'

The Central locality 'Who's Who' is currently in development.

If you would like to create a 'Who's Who' for your team, you can use Canva or Padlet to do this. For those wishing to use Padlet, we have created a Who's Who Padlet 'How to Guide'. If you require any further information, please email Annemarie.

Directory of Adult Services in Southampton

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. This information is updated quarterly.

Are your community services under pressure from rising demand for complex care? Are practice nurses you are linked in with looking for more support and opportunities to upskill? Is there a lack of integration between community and primary care services in your area?

In Southampton Central PCN, we were facing these very challenges. Patients who were not housebound still require complex treatments such as PICC line care, nephrostomy and catheter management, placing strain on community services and highlighting gaps in collaboration. 

To tackle this, in August 2023, we launched a weekly shared treatment clinic at Solent GP Practice for non-housebound patients. Run jointly by community nursing and practice nurses, the clinic not only delivered essential complex care but also provided hands-on learning opportunities to upskill practice nurses and improve integration between services.

The results? Reduced pressure on community teams, improved patient experience, and stronger collaborative working. Following this success, we're now exploring how the model could be expanded to other PCNs across the Trust's footprint.

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 help drive the programme forward. The group included colleagues from Health and Social Care, Public Health, alongside the Project Lead and Coordinator. The group’s purpose is to develop and mobilise integrated neighbourhood working models which meet the need of the local population. The INW programme has been co-designed to enable partnership working within areas loosely defined by each of the PCN footprints. The TFG provides regular progress reports to the 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.

INW Padlet

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.

INW Hubs

We have created a logo for use by the INW Hubs in Southampton, in variety of colourways. These are available below, all as PNG files on transparent background. Please select the option you would like to view and download (please note these are password protected, so please contact Annemarie Aburrow, Primary Care Engagement Coordinator for the password):

• Logo with blue rim and colourful people
• Logo in all blue
• Logo with green rim and colourful people
• Logo in all green
• Logo with red rim and colourful people
• Logo in all red