Large-scale general practice in England: what can we learn from the literature?

Traditional general practice is changing. Three-quarters of practices are now working collaboratively in larger-scale organisations – albeit with varying degrees of ambition and organisational integration. Policy-makers and practitioners have high hopes for these organisations and their potential to transform services both within primary care and beyond. But can we be confident that they can live up to these expectations? This report presents findings of an extensive literature review on the subject of large-scale general practice, and contributes to a stream of work by the Nuffield Trust in this area, details of which can be found at: www.nuffieldtrust.org.uk/large-scale-general-practice

Why do evaluations of integrated care not produce the results we expect?

A number of evaluations of models of integrated care have not produced the expected result of reduced hospital admissions, and in some cases have even found people receiving integrated care services using hospitals more than matched controls. We tested three hypotheses for these surprising results with a group of 50 integrated care experts in a seminar: (1) problems with the model; (2) problems of implementation; and (3) problems of evaluation. Our group of experts did not rule out any of these hypotheses and came up with some advice as to manage these issues. For example, model designers should rigorously test the underlying logic; commissioners should seek out advice from experts and patients/professionals; and evaluators should choose outcomes wisely, use mixed methods approaches, and provide regular feedback loops to implementation sites. Evaluating integrated care is a skilled task that requires multiple approaches in terms of the design and implementation of the models. National research funders or other appropriate bodies might consider developing an advisory service to provide support to local systems planning evaluations

Children and young people's experiences of cancer care: a qualitative research study using participatory methods.

BACKGROUND: Little is known about whether children's cancer services actually meet children's needs, as the majority of previous research has sought the views of parents as proxies. OBJECTIVES: To explore children's and young peoples' views of cancer care and to present a conceptual model of communication and information sharing. SETTINGS: Three Principal Cancer Treatment centres in the United Kingdom. PARTICIPANTS: Thirty-eight participants at different stages of the cancer journey (e.g. on treatment, near end of treatment, up to 18 months following treatment) were grouped for data collection by age: young children (4-5 years), older children (6-12 years) and young people (13-19 years). METHODS: Data were collected concurrently over 6 months using age-appropriate, participatory-based techniques. Techniques included play and puppets, the draw and write method, interviews and an activities day. RESULTS: Some findings confirmed previously reported issues, such as, young children's inabilities to voice their preferences, and the importance of familiar environments and parental support for all ages. New findings suggested children worry about the permanence of symptoms, and older children are unhappy about their parents leading communications with health professionals. As communication and information sharing featured as an area in which children's and young people's preferences changed most dramatically, we propose a conceptual model of communication roles of patients, their parents, and health professionals to illuminate communication patterns. The model suggests children (aged 4-12 years) reside in the background of information sharing with health professionals until they gain autonomy as young people (around age 13). They then move into the foreground, and their parents transition into a supportive background role. Reviewing this model may help younger children realise their abilities to voice their preferences and older children to move into the foreground. Parents and professionals, in turn, can learn to develop in their supportive background roles. We encourage further testing of the model to define roles within relevant contexts. CONCLUSIONS: Overall, this study offers a perspective on the needs and preferences of children and young people receiving cancer care. Differences across ages were more striking with reference to preferences for communication. These differences are highly relevant to the way we communicate information to children and young people

Is bigger better? Lessons for large-scale general practice

The study examined the factors affecting their evolution and their impact on quality, staff and patient experience

Practical approaches to seeking assent from children.

AIM: To describe and evaluate two approaches--a storyboard and a wordsearch--that the authors used with children aged four to 12 years to obtain assent. BACKGROUND: The assent process is vital in helping children to understand the elements of a research project and to make a choice of whether or not to participate. However, the methods for obtaining assent are not well documented. DATA SOURCES: Two researchers' thematic reviews of the primary researcher's field notes, taken during a study of eating problems during chemotherapy. DISCUSSION: The assent process appeared to be an enjoyable, positive experience for many children. They appeared to understand what participation entailed--that it was voluntary and that they had a choice. CONCLUSION: When using child-centred techniques, children are aware of what being in a research study will mean to them. IMPLICATIONS FOR PRACTICE: Researchers can be confident in gaining assent from children as young as five years

Lessons for ‘large-scale’ general practice provider organisations in England from other inter-organisational healthcare collaborations

Policymakers in England are increasingly encouraging the formation of 'large-scale' general practice provider collaborations with the expectation that this will help deliver better quality services and generate economies of scale. However, solid evidence that these expectations will be met is limited. This paper reviews evidence from other inter-organisational healthcare collaborations with similarities in their development or anticipated impact to identify lessons. Medline. SSCI, Embase and HMIC database searches identified a range of initiatives which could provide transferable evidence. Iterative searching was undertaken to identify further relevant evidence. Thematic analysis was used to identify areas to consider in the development of large-scale general practice providers. Framework analysis was used to identify challenges which may affect the ability of such providers to achieve their anticipated impact. A narrative approach was used to synthesise the evidence. Trade-offs exist in 'scaling-up' between mandated and voluntary collaboration; networks versus single organisations; small versus large collaborations; and different types of governance structures in terms of sustainability and performance. While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size. Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation

Practical approaches to seeking assent from children.

AIM: To describe and evaluate two approaches--a storyboard and a wordsearch--that the authors used with children aged four to 12 years to obtain assent. BACKGROUND: The assent process is vital in helping children to understand the elements of a research project and to make a choice of whether or not to participate. However, the methods for obtaining assent are not well documented. DATA SOURCES: Two researchers' thematic reviews of the primary researcher's field notes, taken during a study of eating problems during chemotherapy. DISCUSSION: The assent process appeared to be an enjoyable, positive experience for many children. They appeared to understand what participation entailed--that it was voluntary and that they had a choice. CONCLUSION: When using child-centred techniques, children are aware of what being in a research study will mean to them. IMPLICATIONS FOR PRACTICE: Researchers can be confident in gaining assent from children as young as five years

Talking with children with cancer about their disease and treatment: an ethnographic study of everyday practice

Purpose/objective Bluebond-Langner's highly influential ethnographic study in the 1970s was the first of its kind to detail the everyday experiences of patients and their families during childhood cancer. The landscape of care and treatment is now very different, with families having a realistic expectation of cure, despite the continuing arduous nature of the treatment: our current study takes place in a very different medical and cultural context. As part of our on-going research programme to explore communication patterns, this study looks at the work of newly diagnosed children with leukaemia. We sought to enrich our understanding of the complicated context-related factors facilitating or barring successful communication