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Narrowing the gap between key decision makers, in real time

We are trialling an innovative virtual ‘drop-in’ patient care service with GPs, aimed at narrowing the gap between primary and secondary care clinicians in a rural, resource scarce region.

Read comments 11
  • Proposal
  • 2022

Meet the team


  • Michelle McKinley Project Lead
  • Patrick Byrne General Practitioner
  • Carmel Darcy Consultant Pharmacist

What is the challenge your project is going to address and how does it connect to the theme?

We are aiming to reduce silo’d working practices by enhancing real-time collaboration, improving efficiency and tailoring patient centred care by making the best use of primary and secondary care insights and expertise, in real time via secure, virtual discussion rooms.  We are particularly focused on supporting the care and treatment needs of older patients with frailty syndromes and multiple long term conditions, who often do not fit into neat and preexisting care pathways.

Since launching this service in November 2021 after a period of codesign between General Practitioners, Practice Managers, Hospital Consultants and Trust Integrated care leads, we have received excellent feedback including:

’it’s existence in itself represents an act of cultural change and commitment to helping break down silo working. This is important’

’Ease and speed of accessibility to expertise…’

’…a sense of collective clinical ownership of patient care.’

This connects strongly with using digital tools to support culture change.

What does your project aim to achieve?

The primary objective is to support high quality clinical care within the community, with minimal disruption and inconvenience to patients by focusing on tailored management plans which embrace the ‘get it right first time’ ethos.

The secondary objective is to support primary and secondary care services in a rural region with serious recruitment and retention challenges in the medical and pharmacy workforce, by fostering true partnership working to achieve positive results for patients, learning and peer support opportunities for primary and secondary care clinicians and reduce practitioner isolation.

How will the project be delivered?

The project is intended to provide a drop in, four times weekly support for all GPs to discuss older patients with multiple long term conditions with an appropriate Specialist, within the region of Fermanagh and West Tyrone, by March 2023.  By demonstrating positive patient outcomes, appropriate balancing measures, a reduction in dependence on unscheduled care pathways and practitioner feedback and learning outcomes, we hope to embed this model as a sustainable method of supporting high quality care.

How is your project going to share learning?

Through webinars, hosting online meetings and written and presentational reports, as well as reporting and governance structures within NHS type services within Northern Ireland’s Health and Care system.

How you can contribute

  • We are seeking encouragement, critique and sense checking of our approach, to consider what areas we need to develop more, how best to track progress and seeking partnerships to cross pollinate learning and development opportunities.

Plan timeline

1 Aug 2022 until May 2023 inclusive


  1. Great to see you are exploring options for bringing specialist input in to the more rural setting


    1. Thanks for the encouragement Louise

  2. This model of collaboration, connection and enhanced relationships supporting care is becoming more well established in children (having been pioneered by Bob Klaber and Mando Watson form Imperial) and many conversations on the applicability to other areas especialy elderly as your project is.

    Pre pandemic we did this in person but now all the MDT is via Teams.  We do run a joint monthly clinic face to face. Here are a couple of links with some more information taht might be helfpul.  Very happy to chat.

    1. Hi Kate

      thanks for these links - have private messaged you to see if we can set up a chat sometime to help us shape and focus on this service.

      Best Wishes


  3. Hi Mark and Emma

    As the theme for this year's Q Exchange is about 'bringing together the worlds and methods of improvement and digital', I was wondering if there is more potential for you to bolster the potential for digital innovations and ways of working in this idea.

    NHSEI's digital playbooks may be a useful source of inspiration - e.g.

    It may also be worth contacting these Q Exchange-funded project from last year to discuss their learning on a project looking to embed a virtual MDTs and

    Best of luck with the idea!


    1. Thanks Jo, Rachel myself and colleagues will take a look at these links - many thanks for flagging them up.

  4. Thank you Mark and Rachel. I really like this as a concept. The opportunity to collaborate, break down  barriers and learn across primary and secondary care. Just a few thoughts.

    1. Although many of the discussions may be informal, would we record outcomes, especially if it changes the patient pathway.

    2. Also how will you know which hospital specialist to involve if it is a drop-in. Is primarily for frailty patients and so Care of Elderly consultant input?

    3. And finally any thoughts about a wider MDT approach within the virtual meeting?

    1. Hi Aklak

      great questions - thank you.

      We do record some outcomes such as relating to whether follow up is needed, whether investigation reports are outstanding, and whether a typed letter from our end is/has been done.

      The Hospital Specialist at present is intended to always be a General Physician or Geriatrician/Older People's Medicine Consultant.  This reduces the number of 'moving parts' for a drop in session though no reason not to widen this in principle to other specialties if the utility/value was there.

      MDT thoughts are in process - once capacity and logistics re availability have been better understood and more of a bedding in period has passed, we are thinking Pharmacy input would be particularly helpful.

      We appreciate you giving your time to encourage us and consider further development considerations.



  5. Hi Mark,

    Can you explain how this works in practice? I've got a bit lost on whether it is a session between GPs and Secondary Care specialists or if patients are involved.

    1. Just adding to my earlier comment Darren.

      In practice four times a week, at times GP colleagues feel are the most convenient, we have drop in virtual sessions to discuss a range of clinical questions for patients within their practice - such as medication advice, arranging investigations or management advice, support with advanced care planning considerations or simply as a ‘second sounding board’ for the existing management plan.

      Some discussions stay recorded only in the patient record, some receive a formal letter summarising the key discussion points, depending on what works best for the GP.

    2. Hi Darren, apols for confusion. It is between GP and Hospital doctor, not involving patients at this stage.


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