Background: Poor communication to GPs at hospital discharge threatens patient safety and continuity of care, with reliance on discharge summaries that are commonly written by the most junior doctors. Previous quality improvement efforts have largely focused on adherence to standardised templates, with limited success. A lack of understanding has been identified as a cause of the issue's resistance to decades of improvement work. Aim: To understand the system of communication to GPs at hospital discharge, with a view to identifying potential routes to improvement. Design & setting: A qualitative exploration of the secondary-to-primary care communication system surrounding a large UK hospital. Method: A systems approach, recently defined for the healthcare domain, was used to structure and thematically analyse interviews (n = 18) of clinical and administrative staff from both sides of the primary-secondary care interface, and a subsequent focus group. Results: The largely one-way communication system structure and the low level of hospital stakeholder insight into recipient GP needs emerged as consistent hindrances to system performance. More open lines of communication and shared records might enable greater collaboration to share feedback and resolve informational deficits. Teaching sessions and assessments for medical students and junior doctors led by GPs could help to instil the importance of detail and nuance when using standardised communication templates.

Objectives To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement. Design Systematic review with meta-analyses. Methods Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs - heterogeneity was assessed using I 2 statistics. Results Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I 2 =91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I 2 =97%). Conclusions This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed. PROSPERO registration number CRD42017065920.