Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation

M. Sidhu, Jack Pollard, J. Sussex
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引用次数: 5

Abstract

Vertical integration refers to merging organisations that operate at different stages along the patient pathway. An organisation running an acute hospital and also operating primary care medical practices (i.e. general medical practitioner practices, also known as ‘general practices’) is an example of vertical integration. Evidence is limited concerning the advantages and disadvantages of different arrangements for implementing vertical integration, their rationale and their impact. Our aim was to (1) understand the rationale for, and early impact of, vertical integration in the NHS in England and Wales and (2) develop a theory of change for vertical integration. We carried out a rapid qualitative cross-comparative case study evaluation at three sites in England (n = 2) and Wales (n = 1), which comprised three work packages: (1) a rapid review of literature, telephone scoping interviews and a stakeholder workshop; (2) interviews with stakeholders across case study sites, alongside observations of strategic meetings and analysis of key documents from the sites; and (3) development of a theory of change for each site and for vertical integration overall. We interviewed 52 stakeholders across the three case study sites; however, gaining access to and arranging and completing non-participant observations proved difficult. The single most important driver of vertical integration proved to be the maintenance of primary care local to where patients live. Vertical integration of general practices with organisations running acute hospitals has been adopted in some locations in England and Wales to address the staffing, workload and financial difficulties faced by some general practices. The opportunities created by vertical integration’s successful continuation of primary care, namely to develop patient services in primary care settings and better integrate them with secondary care, were exploited to differing degrees across the three sites. There were notable differences between the sites in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial. Across all three case study sites, the study team was unable to complete the desired number of non-participant observations. The pace of data collection during early interviews and documentary analysis varied. Owing to the circumstances of the COVID-19 pandemic during project write-up, the team was unable to undertake site-specific workshops during data analysis and an overall workshop with policy experts. The main impact of vertical integration was to sustain primary medical care delivery to local populations in the face of difficulties with recruiting and retaining staff, and in the context of rising demand for care. This was reported to enable continued patient access to local primary care and associated improvements in the management of patient demand. The patient experience of vertical integration, effectiveness of vertical integration in terms of impact on secondary care service utilisation (e.g. accident and emergency attendances, emergency admissions and length of stay) and patient access (e.g. general practitioner and practice nurse appointments) to primary care requires further evaluation. This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 17. See the NIHR Journals Library website for further project information.
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英格兰和威尔士全科医生与急性病医院的垂直整合:快速评估
垂直整合是指合并在患者路径不同阶段运作的组织。经营急性医院并经营初级保健医疗实践(即全科医生实践,也称为“全科实践”)的组织是垂直整合的一个例子。关于实施垂直一体化的不同安排的优缺点、其理由及其影响的证据有限。我们的目标是(1)了解英格兰和威尔士NHS垂直整合的基本原理和早期影响,以及(2)发展垂直整合的变革理论。我们在英格兰的三个地点(n = 2) 和威尔士(n = 1) ,包括三个工作包:(1)文献快速审查、电话范围访谈和利益攸关方研讨会;(2) 对案例研究地点的利益相关者进行访谈,同时对战略会议进行观察,并对各地点的关键文件进行分析;以及(3)为每个地点和整个垂直一体化发展变化理论。我们采访了三个案例研究地点的52位利益相关者;然而,获取、安排和完成非参与者的观察证明是困难的。事实证明,垂直整合最重要的驱动因素是维持患者所在地的初级保健。英格兰和威尔士的一些地方已经采用了全科医学与经营急性医院的组织的垂直整合,以解决一些全科医学面临的人员配备、工作量和财务困难。垂直整合成功延续初级保健所创造的机会,即在初级保健环境中发展患者服务,并将其更好地与二级保健相结合,在三个地点得到了不同程度的利用。在组织和临床整合方面,各站点之间存在显著差异。更紧密的组织整合归功于当地初级和二级护理之间以前的良好关系,以及当地卫生经济一体化工作的历史规划和准备。当地利益相关者认为,垂直一体化对卫生系统成本的净影响是有益的。在所有三个案例研究地点,研究团队都无法完成所需数量的非参与者观察。早期访谈和文献分析期间的数据收集速度各不相同。由于新冠肺炎疫情在项目编写期间的情况,该团队无法在数据分析期间举办现场研讨会,也无法与政策专家举办全面研讨会。纵向一体化的主要影响是,在招聘和留住工作人员遇到困难以及护理需求不断增加的情况下,维持向当地人口提供初级医疗服务。据报道,这使患者能够继续获得当地初级保健,并改善患者需求管理。垂直整合的患者体验、垂直整合对二级护理服务利用的影响(如事故和急诊就诊、急诊入院和住院时间)以及患者获得初级护理的机会(如全科医生和执业护士预约)的有效性需要进一步评估。该项目由国家卫生与护理研究所(NIHR)卫生与社会护理提供研究计划资助,并将在《卫生与社会保健提供研究》上全文发表;第10卷,第17期。有关更多项目信息,请访问NIHR期刊图书馆网站。
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