The University of Manchester Research
Moving Services out of hospital: Joining up General
Practice and community services?
Link to publication record in Manchester Research Explorer
Citation for published version (APA):
Bramwell, D., Checkland, K., Allen, P., & Peckham, S. (2014). Moving Services out of hospital: Joining up General
Practice and community services? Policy Research Unit in Commissioning and the Healthcare System Manchester
Centre for Health Economics.
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Download date:25. Aug. 2022
Moving Services out of hospital: Joining up General Practice
and community services?
August 2014
Research Team:
Dr Donna Bramwell
1
Dr Kath Checkland
1
Dr Pauline Allen
2
Professor Stephen Peckham
3
Disclaimer: This research is funded by the Department of Health via the Policy Research
Programme. The views expressed are those of the researchers and not necessarily those of
the Department of Health.
1
University of Manchester, Oxford Road, Manchester
2
London School of Hygiene and Tropical Medicine
3
University of Kent, Canterbury
2
Glossary
ACO - Accountable Care Organisation
CCGs - Clinical Commissioning Groups
CFTs - Community Foundation Trusts
CHS - Community Health Services
CN - Community Nurse
CQC - Care Quality Commission
DH - Department of Health
DN - District Nurse
FTs - Foundation Trusts
GP - General Practitioner
LTCs - Long-term Conditions
NHSE - NHS England
PbR - Payment by results
PC - Primary Care
PCTs - Primary Care Trusts
PHCT(s) - Primary Health Care Team (s)
PRUComm - Policy Research Unit in Commissioning and the Healthcare System
RCTs - Randomised Controlled Trials
TCS - Transforming Community Services
YoC - Year of Care
3
Executive Summary
Introduction
Closer collaboration between primary care and community health services is a clear objective
of the most recent NHS reforms. Currently, there is much emphasis on integrating healthcare
services and in particular, moving care closer to home and out of the acute care setting by
utilising Community Services and Primary Care.
This report summarises the findings of a rapid review undertaken by PRUComm of the
available evidence of what factors should be taken into account in planning for the closer
working of primary and community health/care services in order to increase the scope of
services provided outside of hospitals. We synthesised the findings of recent reviews of the
published literature seeking to examine evidence relevant to answering the question:
What factors should be taken into account in planning for the greater integration of
primary and community care services in order to increase the scope of services
provided outside hospitals?
We examined evidence focused at three different levels:
Micro-level – factors affecting the effectiveness of multidisciplinary team-working
Meso-level- the impact of service organisation and delivery issues, including population
coverage and service location
Macro-level – structural issues, such as ownership models and financing
Methods
We undertook an extensive review of available evidence at each of these levels, which
explored both published research and grey literatures, including reports and policy documents.
In areas with extensive research evidence, we focused upon review articles; in areas with less
evidence we highlight opinion pieces, showing clearly where evidence does or does not exist to
validate claims made.
Micro-level factors
There is an extensive literature which focuses upon the factors which affect the ‘effectiveness’
of multidisciplinary teams. However, much of this literature fails to clearly define what is
meant by ‘effectiveness’ in this context, with many articles using measures of process (such as
collaboration and innovation within teams) rather than outcomes. However, there is
reasonable consensus about the following:
Good communication between team members is a consistent underlying enabling
factor, with shared IT and record systems important
Structural aspects of teams which have been shown to affect performance (such as
team size and shared interdisciplinary training programmes) probably act via
improving or impeding communication
Clear agreed goals are important in enabling collaboration within teams
Good leadership, with a strong commitment to partnership working is facilitative
4
Clear linkage between good team processes and concrete outcomes (such as reduction
in admissions) is lacking. However, teams with a good internal ‘climate’ who work
happily together are likely to provide higher quality care, and this in turn is likely to
feedback to improve team climate.
There is no good evidence about the optimum size or skill mix of multidisciplinary
teams required to provide care for a given size of population
Meso-level factors
The current organisation of CHS in England means that community nursing services and GP
practices generally cover different populations, with community nursing services generally
covering geographically located populations which cut across practice boundaries.
This model developed historically based upon opinion rather than evidence, with
advocates arguing it provided greater autonomy for nurses, less professional isolation,
more equitable services and better coverage for sickness. Opponents argue that
having nurses covering a different population from that covered by their Primary
Healthcare Team colleagues is inefficient, inhibits team working and prevents good
communication. There is little good evidence to back up either of these positions.
Many community nursing teams currently occupy different premises than their GP
colleagues. There is some evidence that co-location of teams facilitates
communication and improves service delivery, but these benefits do not flow
automatically.
New models of care such as the federation of GP practices into larger groups covering
the same population as a neighbourhood nursing team have been advocated and
proponents of this model offer compelling case studies to back up their claims.
However, there is no good research evidence to back these up, and it remains unclear
what the important ingredients of a successful model might be
The London ‘polysystems’ initiative is largely regarded as having been unsuccessful, in
part because community services were not well integrated into the model from the
start.
Alternative models of care provision based upon care co-ordination around the patient
rather than structural integration of teams have been shown to improve patient
experience, but they do not seem to reduce admissions or save money
Macro-level factors
The financing and ownership of community health services has changed a number of times
since the inception of the NHS. Originally the responsibility of Local Authorities, in 1974 they
were transferred to District Health Authorities alongside acute care. In the 1990s they were
established as standalone organisations, before being brought into Primary Care Trusts in the
early 2000s. In 2008 PCTs were required to divest themselves of their provider role, and
community services were transferred to a number of different organisations. Some were set
up as standalone Community Trusts, whilst others have been taken over by Acute Foundation
Trusts and some have set themselves up as Third Sector organisations (TSOs). Some types of
community services traditionally provided by PCTs (eg podiatry, physiotherapy etc) have, in
some cases, been transferred to different providers than the community nursing services.