Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination 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 co-ordination 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; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the 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 inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did 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 a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner 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 co-ordination 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. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

Groundwork for primary care in Slovakia: report from an EC/Phare project.

The report opens with a description of reforms and problems in the Slovak health care, including an international comparison of the position of primary care physicians. Project activities in four areas are explained. In the financial area a new payment system for primary care doctors was developed. In the area of pharmaceutical cost containment the focus was on the prescription of cheaper drugs and on possibilities of more rational prescribing of drugs. With respect to quality of care a peer review group was created that developed a professional guideline. Finally, data were collected for feed back to the various activities and for making a start with research. In a separate chapter a systematic evaluation of the project was reported. The final chapter deals with conclusions and recommendations

Science in practice: can health care reform projects in Central and Eastern Europe be evaluated systematically?

Since the beginning of the 1990s, health care reform projects have taken place in many of the former Communist countries, but these projects are rarely evaluated systematically. Evaluation, however, is an important tool for increasing their rationality and continuity. The aim of this paper is to identify the difficulties in the efforts towards systematic evaluation and draw lessons for the future. For this aim, the requirements for a more rigorous, controlled evaluation are compared with our experiences of evaluating a health care reform project in the Slovak republic. From this comparison a number of discrepancies arise: it was difficult to set clear and realistic goals at the start of the project; the outcomes of the project could not always be measured, nor could 'the process' always be distinguished from the outcomes. Systematic evaluation was further hampered by an insufficient degree of structuration of the project, in advance and during the implementation, and by the absence of a tradition and infrastructure for data collection. On the basis of the experiences and relevant literature, recommendations for future evaluations are formulated. The main lesson is that, given the context, often it will not be possible to use an ambitious evaluation, and concessions need to be made. At the same time, continuous efforts towards more systematic evaluation procedures should be made, but it is wise and more sustainable to do this in an incremental way. (aut.ref.

Unity or diversity?: task profiles of general practitioners in Central and Eastern Europe.

The countries of Central and Eastern Europe, where - until the end of the 1980s - the Semashko health care system prevailed, are often perceived as a homogeneous group. If this highly centralized system, with its tight state control, together with the 'equalizing' influence of communism, has led to a uniformity in the provision of health services, this could be reflected in the service profiles of general practitioners (GPs). The aim of this paper was to find out whether this picture is justified and investigate differences between the former communist countries. Methods: in 1993 and 1994, standardized questionnaires were sent to (mostly random) samples of GPs (7,233 in total) in 30 European countries. Four areas of service provision were measure: the GPs' position in first contact with health problems and their involvement in the application of medical techniques, disease management and preventive medicine. Variation patterns and mean scores were analyzed by way of multilevel analysis. Results: There is no more uniformity in Central and Eastern Europe than in Western Europe. In Eastern Europe there are in fact considerable differences: GPs in former Yugoslavia have the most comprehensive service profile, whereas the lowest scores were found among doctors in the former Soviet Union. The countries which had a social insurance system before the Second World War, such as the Czech republic en Hungary, are situated in between. Conclusions: There are distinctive national differences in GPs' task profiles in Central and Eastern Europe, which provide clues for the country-specific design and implementation of primary care-oriented reforms. (aut. ref.