First reported 1 Nov 2013•Latest report 23 Sep 2025
Definition
What this concern includes
Includes failures in coordination, communication, clinical-information access or information sharing specifically between primary care and secondary care providers where the deficiency can impair safe patient care, including inaccessible records, unshared messages, unclear interaction arrangements and inadequate coordination of mental-health or other clinical care.
Not included
Excludes failures confined to communication within primary care or within secondary care when the cross-interface condition is not identified.
Excludes generic inter-agency or inter-service communication failures without a primary-to-secondary healthcare interface.
Excludes deficiencies in the underlying clinical assessment, treatment or referral decision when coordination and information sharing between primary and secondary care operated reliably.
Excludes failures belonging to a more specific named pathway or system, such as radiology follow-up, mental-health referrals or electronic-record authentication, when that narrower concern is the supported boundary.
Reports
18
Distinct published reports
Individual concerns
22
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
28
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England7
National Institute for Health and Care Excellence4
Department of Health and Social Care3
Essex Partnership University NHS Foundation Trust2
Surrey and Borders Partnership NHS Foundation Trust2
Aneurin Bevan University LHB1
Ascribe Limited1
Avon and Wiltshire Mental Health Partnership NHS Trust1
BrisDoc Healthcare Services Limited1
Bristol NHS Foundation Trust1
Cornwall Health Limited1
Cornwall Partnership NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Esher Green Surgery1
Farnham Medical Centre1
NHS trust10
Executive non-departmental public body9
Healthcare site5
Integrated care board4
Ministerial department3
Local health board2
Private limited company2
Company1
English county council1
Health-system partnership1
Independent healthcare provider1
Multi-service care provider1
Police force1
Social-care provider1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Wiltshire and Swindon
Concerns raised1
Systemic failure in communication between mental health and primary care
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Use DocMan instead of email for DWF Hub referral-outcome communication with GPs, except when the referrer explicitly requests email.
Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Evaluate the DWF Hub’s DocMan process and use Trust governance processes to decide whether to adopt it across the other Hub teams.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Review AMHT communication practice, identify available changes and assess which options could strengthen controls against GPs missing important communications.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Discuss AMHT communication practices with teams to identify whether improvements are needed.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
DocMan is considered effective, timely and secure for communication between Oxfordshire Talking Therapies and GPs.
Stated by Oxford Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust will not change AMHT communication practices until it understands available options, utility and potential consequences.
Stated by Oxford Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised2
Insufficient coordination and communication between primary and secondary care providers
Failure of primary and secondary care providers to access each other’s electronic medical records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Work with the ICB to find a solution to the Practice’s clinical estate constraints affecting interaction with GPiMHS staff.
Stated by Esher Green SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 16 January 2025.
Action
Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
Stated by Esher Green SurgeryStated plannedThe respondent said that this action was planned when they made their response on 16 January 2025.
Action
Continue timely verbal communication with GPiMHS staff about at-risk patients and confirm those communications by email.
Stated by Esher Green SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 16 January 2025.
Action
Raise staff awareness within the Practice of the agreed communication measures.
Stated by Esher Green SurgeryStated completedThe respondent said that this action was complete when they made their response on 16 January 2025.
Action
Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
Stated by Esher Green SurgeryStated completedThe respondent said that this action was complete when they made their response on 16 January 2025.
Action
Provide live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.
Stated by Surrey Heartlands ICBStated completedThe respondent said that this action was complete when they made their response on 16 January 2025.
Action
Implement a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.
Stated by Surrey Heartlands ICBStated plannedThe respondent said that this action was planned when they made their response on 16 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The practice cannot independently improve communication across Surrey; practice-level action will not address the wider issue without a uniform SABP approach.
Stated by Esher Green SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Fully utilised clinical space and Surrey-wide space pressures make regular in-person GPiMHS interaction unlikely, so email and telephone should be prioritised.
Stated by Esher Green SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing practice email arrangements are considered sufficient to mitigate urgent and non-urgent communication risks between GPimhs staff and practices.
Stated by Surrey Heartlands ICBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Electronic record connectivity is a commissioning responsibility for the Surrey-wide ICB, not an individual GP practice.
Stated by Esher Green SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Surrey Care Record access is considered sufficient to resolve the risk of GPimhs staff lacking necessary GP record information.
Stated by Surrey Heartlands ICBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised2
Inaccessibility of primary care records to secondary mental health services
Lack of a unified record-keeping system for sharing patient information
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Achieve national read-only interoperability between Shared Care Records across England.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England is best placed to address the absence of a unified record-keeping system across NHS providers.
Stated by Surrey and Borders Partnership NHS Foundation Trust and Surrey County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Inadequate communication with primary and secondary care providers
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Deliver enhanced care-coordination training to all community mental-health staff and maintain it pending the new Community Framework.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
Action
Deploy mental-health clinicians within Essex Primary Care Networks to improve communication between primary and secondary care providers.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
Action
Transform community mental health pathways and establish integrated models across primary care networks in line with published guidance.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
Action
Establish specialist mental health provision for people sleeping rough in high-need areas, including a site in Southend, Essex.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
Action
Publish a refreshed suicide-prevention consensus statement and accompanying guidance supporting frontline information-sharing when someone is at risk of suicide.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 17 April 2026.
Gwent
Concerns raised2
Failure of communication and collaboration between primary and secondary care
Failure to directly contact the responsible medical team to address significant concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Provide access to a medical consultant for clinical advice through the Flow Centre telephone line.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Launch direct-access telephone advice lines for urgent and outpatient queries through Consultant Connect.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Create a bypass-number directory enabling hospital teams to contact GP surgeries directly when immediately necessary.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Operate a Medical Examiner service with multidisciplinary panel review, including Primary Care input, to identify and review interface issues.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Send GPs weekly updates from the Deputy Medical Director about key information and changes to Secondary Care Services.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Provide GPs with intranet access to information on pathways, Secondary Care Services and advice lines.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Explore primary–secondary care communication options, identify case-specific barriers, address them, and ensure clinical staff know the available routes.
Stated by The Richmond ClinicStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Continue cooperating with and positively engaging in the Health Board’s programme to facilitate primary–secondary care communication.
Stated by The Richmond ClinicStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
For community patients, the registered GP and Primary Care team have overall responsibility for medical care coordination.
Stated by Aneurin Bevan University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing clinical systems, letters, directories and switchboards provide GPs with sufficient access to hospital records, clinicians and support.
Stated by Aneurin Bevan University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Northamptonshire
Concerns raised1
Failure of primary and secondary care electronic patient systems to share allergy information
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Wiltshire and Swindon
Concerns raised1
Failure to share relevant physical healthcare check results between primary and secondary healthcare providers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to seek early guidance from the prescribing secondary care physician
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised1
Lack of access to relevant records across healthcare providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing secure RiO access arrangements are considered sufficient for sharing health records with other agencies.
Stated by Cornwall Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures in coordination, communication, clinical-information access or information sharing specifically between primary care and secondary care providers where the deficiency can impair safe patient care, including inaccessible records, unshared messages, unclear interaction arrangements and inadequate coordination of mental-health or other clinical care.
