1 Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination Authors: Rod Sheaff,1 Joyce Halliday,1 John Øvretveit,2 Richard Byng,3 Mark Exworthy,4 Stephen Peckham,5 Sheena Asthana1 1 Plymouth University 2 Karolinska Institutet Stockholm 3 Plymouth University Peninsula Schools of Medicine and Dentistry 4 University of Birmingham 5 University of Kent Address for correspondence: Rod Sheaff 012, 9 Portland Villas Plymouth University Drake Circus Plymouth Devon PL4 8AA UK E-mail: [email protected] Competing interests: None declared. All authors have completed the unified competing interest form at 2 www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1) no financial support for the submitted work from anyone other than their employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work. 3 Abstract 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. 4 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. 5 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. 498 words 6 Table of Contents Abstract................................................................................................................................................3 Table of Contents.................................................................................................................................6 Index of Tables...................................................................................................................................11 Abbreviations.....................................................................................................................................12 Glossary.............................................................................................................................................15 Scientific Summary...........................................................................................................................20 Plain English Summary.....................................................................................................................28 1 The Policy Context..........................................................................................................................29 1.a A tripartite NHS......................................................................................................................29 1.a.i Care integration................................................................................................................30 1.a.ii Fiscal stringency.............................................................................................................31 1.a.iii Provider diversification..................................................................................................31 1.a.iv GPs as commissioner-coordinators................................................................................32 1.b Experiments, initiatives, pilots and mandates.........................................................................33 1.b.i Co-location.......................................................................................................................34 1.b.ii Stronger coordination.....................................................................................................34 1.b.iii London polysystems......................................................................................................35 1.b.iv Integrated Care Pilots: Care networks...........................................................................37 1.b.v A bi-partite system..........................................................................................................38 1.c Internationalisation of the integrated care agenda..................................................................39 1.d What research has so far contributed to altering policy and practice.....................................42 2 Care Coordination and Integration: Process and Structures............................................................43 2.a Continuities of care.................................................................................................................43 2.b The patient: Producing and experiencing continuity of care..................................................45 2.b.i Patients as care coordinators............................................................................................45 2.c Coordination: The production of continuity...........................................................................46 2.c.i Processes and structures for care coordination................................................................46 2.d First-responder provider organisations...................................................................................49 2.d.i Care plans.........................................................................................................................49 2.d.ii Coordination mechanisms within a single organisation.................................................50 2.d.iii Vertical integration.........................................................................................................54 7 2.e Transfer between provider organisations: Care networks.......................................................56 2.e.i Emergent networks...........................................................................................................56 2.e.ii Managed networks..........................................................................................................59 2.e.iii Barriers to care coordination by network.......................................................................62 2.f Continuity, coordination, integration.......................................................................................63