The Challenge
Across Suffolk and North East Essex, clinicians working in both primary and secondary care had been raising consistent concerns about how services connect, and the ongoing challenge of reconnecting the primary and secondary care interface in day to day practice.
Advice and guidance pathways varied, referrals were not always clear, and discharge communication could lack key information. This often meant time spent navigating processes or following up across organisations, which would result in delays, duplication or uncertainty about next steps.
These challenges were widely recognised across the system, however, progress in addressing them had been limited. Conversations were happening, but they were not consistently translating into coordinated action.
The Approach
Suffolk and North East Essex (SNEE) Integrated Care Board partnered with Xytal to design and deliver a leadership programme focused on improving the primary and secondary care interface.
The programme aimed to strengthen relationships across the interface while equipping clinicians and system leaders with the skills and confidence to lead practical improvement.
Participants from across primary care, acute services and the wider system came together to work on shared challenges. The programme combined leadership development with continuous improvement methods, including action learning, collaborative problem solving and structured reflection.
A key feature of the programme was the use of an accountability chain, supporting participants to move from identifying problems to testing and sustaining change in practice.
Turning Insight Into Action
Participants worked in small groups to tackle specific challenges that affect the interface between services. Each group focused on a clearly defined issue and used a structured improvement approach based on the DMAIS model.
- Define: The teams begin by identifying the problem and understanding why it matters.
- Measure: Baseline data is collected to understand the current process and variation.
- Analyse: Teams explore the root causes behind the issue.
- Implement: Practical changes are tested within services.
- Sustain: The focus then moves to embedding improvements so that they become part of everyday practice.
Ten improvement projects were developed across the programme, each focused on a specific challenge at the interface.
Work included improving discharge communication for mental health inpatients, reducing variation in advice and guidance response times across specialties, and reviewing inappropriate urine samples sent to microbiology, where seventy two per cent were found to lack sufficient clinical information. Other projects explored access to community services and ways to strengthen collaboration around primary care mental health support.
These projects were supported through structured improvement methods, enabling participants to analyse current processes, test changes and begin embedding improvements within their local services.
The closing session
The programme concluded with a final session in March, bringing participants together to share their work and reflect on their learning.
A central part of the day was the poster conference, where each group presented their project using the DMAIS framework. Participants moved between groups, discussing the work, asking questions and sharing insights.
The session also focused on sustaining improvement and continuing leadership development beyond the programme. There was a strong sense of momentum throughout the day, with participants building on each other’s ideas and recognising the progress that had been made.
Feedback And Learning
Feedback from participants highlighted a shift not only in how they work with others, but in how they approach leadership and problem solving in practice.
- Participants valued the opportunity to connect with colleagues across the system and work more closely across organisational boundaries.
“The programme has been a great opportunity to meet a range of new colleagues and develop relationships across the system, as well as helping me to understand some important areas of challenge and improvement.”
- They also described the importance of structured reflection and peer support in helping them develop their approach to improvement.
“Coaching and action learning sets have been most valuable part for me, giving space for reflection and to learn the power of letting the team find the solutions within a supportive environment”
- There was a noticeable change in how participants viewed their role as leaders, with increased confidence to step forward and support system level change.
“Permission to be a leader rather than a manager. To support a culture for system change in my role.”
- Participants also described making practical changes in how they approach leadership and collaboration in their day to day work.
“More collaborative approach to problem solving”
“Resisting the urge to fix things immediately. Giving the team chance to find the solutions themselves”
“I will be more confident approaching colleagues across organisations. I will also feel more confident working closer with colleagues in other more senior roles and professions.”
These shifts reflect a broader move towards more collaborative, confident and system focused leadership across the interface.
Early impact
Participants reported improved collaboration across the primary and secondary care interface and greater clarity in how services connect. Improvement work is contributing to more consistent communication, better use of pathways and a clearer understanding of demand across services.
Providing structure, support and space for clinicians to work together enables shared challenges to be addressed in a coordinated way. Progress depends not only on process change, but on relationships, confidence and shared ownership across the system.
