Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

The practice of commissioning healthcare from a private provider: learning from an in-depth case study

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background By 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’). Objectives To: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers. Design Mixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically. Results In the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners. Conclusions Commissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other. Funding The National Institute for Health Research Health Services and Delivery Research programme

General practitioner provision of preventive child health care: analysis of routine consultation data

<b>Background</b> GPs contribute to preventive child health care in various ways, including provision of child health surveillance (CHS) reviews, opportunistic preventive care, and more intensive support to vulnerable children. The number of CHS reviews offered in Scotland was reduced from 2005. This study aimed to quantify GPs’ provision of different types of preventive care to pre-school children before and after the changes to the CHS system.<p></p> <b>Methods</b> GP consultation rates with children aged 0–4 years were examined for the 2½ years before and after the changes to the CHS system using routinely available data from 30 practices in Scotland. Consultations for CHS reviews; other aspects of preventive care; and all reasons were considered.<p></p> <b>Results:</b> Prior to the changes to the CHS system, GPs often contributed to CHS reviews at 6–8 weeks and 8–9 and 39–42 months. Following the changes, GP provision of the 6–8 week review continued but other reviews essentially ceased. Few additional consultations with pre-school children are recorded as involving other aspects of preventive care, and the changes to CHS have had no impact on this. In the 2½ years before and after the changes, consultations recorded as involving any form of preventive care accounted for 11% and 7.5% respectively of all consultations with children aged 0–4 years, with the decline due to reductions in CHS reviews.<p></p> <b>Conclusions:</b> Effective preventive care through the early years can help children secure good health and developmental outcomes. GPs are well placed to contribute to the provision of such care. Consultations focused on preventive care form a small minority of GPs’ contacts with pre-school children, however, particularly since the reduction in the number of CHS reviews

Principles for research on ethnicity and health: the Leeds consensus statement

Background: There is substantial evidence that health and health-care experiences vary along ethnic lines and the need to understand and tackle ethnic health inequalities has repeatedly been highlighted. Research into ethnicity and health raises ethical, theoretical and methodological issues and, as the volume of research in this area grows, so too do concerns regarding its scientific rigour and reporting, and its contribution to reducing inequalities. Guidance may be helpful in encouraging researchers to adopt standard practices in the design, conduct and reporting of research. However, past efforts at introducing such guidance have had limited impact on research practice, and the diversity of disciplinary perspectives on the key challenges and solutions may undermine attempts to derive and promote guiding principles. Methods: A consensus building Delphi exercise—the first of its kind in this area of research practice—was undertaken with leading academics, practitioners and policymakers from a broad range of disciplinary backgrounds to assess whether consensus on key principles could be achieved. Results: Ten key principles for conducting research on ethnicity and health emerged, covering: the aims of research in this field; how such research should be framed and focused; key design-related considerations; and the direction of future research. Despite some areas of dispute, participants were united by a common concern that the generation and application of research evidence should contribute to better health-care experiences and health outcomes for minority ethnic people. Conclusion: The principles provide a strong foundation to guide future ethnicity-related research and build a broader international consensus

Hybrid manager-professionals' identity work : the maintenance and hybridization of medical professionalism in managerial contexts

We examine the ‘identity work’ of manager–professional ‘hybrids’, specifically medical professionals in managerial roles in the British National Health Service, to maintain and hybridize their professional identity and wider professionalism in organizational and policy contexts affected by managerialist ideas. Empirically, we differentiate between ‘incidental hybrids’, who represent and protect traditional institutionalized professionalism while temporarily in hybrid roles, and ‘willing hybrids’, who developed hybrid professional–managerial identities during formative identity work or later in reaction to potential professional identity violations. Questions about willing hybrids' professional identities led them to challenge and disrupt institutionalized professionalism, and use and integrate professionalism and managerialism, creating more legitimate hybrid professionalism in their managerial context. By aligning professionalism with their personal identity, and regulating and auditing other professionals, willing hybrids also position hybrids collectively as elite within their profession

Impact of Scottish vocational qualifications on residential child care : have they fulfilled the promise?

This article will present findings from a doctoral study exploring the impact of 'SVQ Care: Promoting Independence (level III)' within children's homes. The study focuses on the extent to which SVQs enhance practice and their function within a 'learning society'. A total of 30 staff were selected from seven children's homes in two different local authority social work departments in Scotland. Each member of staff was interviewed on four separate occasions over a period of 9 months. Interviews were structured using a combination of repertory grids and questions. Particular focus was given to the assessment process, the extent to which SVQs enhance practice and the learning experiences of staff. The findings suggest that there are considerable deficiencies both in terms of the SVQ format and the way in which children's homes are structured for the assessment of competence. Rather than address the history of failure within residential care, it appears that SVQs have enabled the status quo to be maintained whilst creating an 'illusion' of change within a learning society