Health and Social Care Delivery Research (Oct 2023)
Vertical integration of general practices with acute hospitals in England: rapid impact evaluation
Abstract
Background Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1–12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter ‘navigation work’ choosing and accessing health-care provision, with diminishing continuity of care. Limitations In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information. BRACE: The NIHR Birmingham, RAND and Cambridge Rapid Evaluation Centre The NIHR BRACE Rapid Evaluation Centre (National Institute for Health and Care Research Birmingham, RAND and Cambridge Evaluation Centre) is a collaboration between the Health Services Management Centre at the University of Birmingham, the independent research organisation RAND Europe, the Department of Public Health and Primary Care at the University of Cambridge and National Voices. BRACE carries out rapid evaluations of innovations in the organisation and delivery of health and care services. Its work is guided by three overarching principles: Responsiveness. Ready to scope, design, undertake and disseminate evaluation research in a manner that is timely and appropriately rapid, pushing at the boundaries of typical research timescales and approaches, and enabling innovation in evaluative practice. Relevance. Working closely with patients, managers, clinicians and health-care professionals, and others from health and care, in the identification, prioritisation, design, delivery and dissemination of evaluation research in a co-produced and iterative manner. Rigour. All evaluation undertaken by the team is theoretically and methodologically sound, producing highly credible and timely evidence to support planning, action and practice. Plain language summary Our previous evaluation of when National Health Service hospitals take over the running general (medical) practices, based mainly on interviews with National Health Service staff, found that a major aim was to keep open general practices that might otherwise close. The follow-up study reported here looked at wider questions and drew on a wider range of evidence. Does a hospital-run practice affect patients’ satisfaction with their care and how often they go to hospital? Does the arrangement work differently for patients with multiple long-term conditions? To answer these questions, we compiled the first ever list of all the general practices in England run by National Health Service hospitals: they total a little over 1% of all general practices. We found that general practices run by hospitals are not typical. We should not assume that the results found there would be repeated elsewhere if there were to be a widespread move to having hospitals run general practices. Our research drew on 7 years of national data on patients’ use of hospitals and 10 years of findings from the national General Practitioner Patient Survey. We also interviewed patients and staff at three locations in England where hospitals run general practices. Patients’ experience of, and satisfaction with, the care they receive from a general practice is similar whether it is run by a hospital or not. There are modest and temporary (1–2%) reductions in patients’ accident and emergency department and outpatient attendances when a hospital starts running their general practice and larger and more permanent reductions (3–5%) in rates of emergency admissions and readmissions to hospital. Patients with multiple long-term conditions are affected similarly to other patients. The most important condition for success seems to be building and maintaining trust between clinicians and other staff at the hospital and the general practices. Scientific summary Background Within the National Health Service (NHS), acute hospitals do not usually run general (medical) practices. General practitioners (GPs) are contracted by the NHS to provide primary care medical services to the patients registered with them. GPs also act as ‘gatekeepers’, referring patients to other, specialist, NHS services, including those provided by acute hospitals. The large majority of GPs are not employees of the NHS but instead are either contractors to the NHS or are salaried employees of contractor organisations (e.g. partnerships of GPs who hold a contract with the NHS or private companies that do so). Acute trusts are providers of hospital-based, emergency and/or elective specialist health care as well as, in some instances, providers of community health services. In England, acute hospitals are run by publicly owned organisations that are either NHS foundation trusts or NHS trusts, hereafter referred to collectively as trusts. Some acute trusts in England now run general practices, which is a form of vertical integration. This is a relatively new phenomenon in the NHS, occurring since 2015. This kind of integration is distinct from horizontal integration, whereby organisations at similar stages along the patient pathway integrate or even formally merge with one another, such as when one acute hospital trust integrates or merges with another or when one practice integrates or merges with another. Nevertheless, each vertically integrated organisation that includes more than one practice does also include a degree of horizontal integration between the practices that are owned by the same trust. Objectives This report presents the second phase of a two-phase rapid evaluation of when NHS organisations operating acute hospitals have additionally taken over running general practices in locations in the NHS in England. In 2019–20, the phase 1 rapid evaluation investigated the implementation of acute hospitals managing general practices in England and Wales and addressed questions relevant to scaling-up this model of integration in an NHS setting. That qualitative evaluation focused on understanding the rationale for, and the implementation and early impact of, vertical integration. Phase 2 of the study of vertical integration aims to understand the extent of vertical integration that has already taken place throughout the NHS in England, to assess the impact on outcomes from use of the secondary care service, how service delivery has changed or is expected to change, and the patient experience of vertical integration with a particular focus on whether patients with multiple long-term conditions are affected differently from other patients. To meet these aims, the phase 2 rapid evaluation addresses the following research questions: How many general practices have already vertically integrated with NHS organisations running acute hospitals in England; when did that happen, and what are the characteristics of those practices where vertical integration has taken place? What impact is vertical integration having the use of on secondary care? Does this impact differ for people with multiple long-term conditions compared with other patients without long-term conditions or living with a single condition? What impact is vertical integration having on the patient journey with regard to access to and overall experience of care? How does the experience differ for people with multiple long-term conditions compared with those living with no or one long-term condition? Addressing these questions informs the refinement and validation of a theory of change for vertical integration between acute hospitals and general practices, developed in the phase 1 evaluation, describing the desired outcomes and the mechanisms by which these are expected to be achieved. Methods Our overall approach was a mixed-methods rapid evaluation comprising four work packages (WPs). Work package 1: understanding the current scale of vertical integration in England Work package (WP) 1 details the extent of vertical integration in England through desk-based analysis of secondary care statutory financial reporting, primary care GP workforce data and GP contracting data. There is triangulation of practices where vertical integration has been identified. The following statistics describing the characteristics of the vertically integrated practices are presented: number of acute hospital trusts (including those providing community health services) managing general practices; the number of general practices managed by the acute hospital trust; practice sizes in terms of patient population, patient demographics and workforce descriptors. Work package 2: development of a statistical analysis plan As part of WP2, the study team identified appropriate counterfactual or control sites and an appropriate approach to coding multiple long-term conditions as part of the detailed plan of analysis. In addition, this WP addresses several methodological questions, including how to deal analytically with general practices that have merged during the study time frame and how to consider and incorporate the impact of COVID-19 on our analyses of the use of secondary care. Work package 3: quantitative analysis of the impact of vertical integration on secondary care utilisation As part of WP3, we assessed the impact of vertical integration on a sample of practices for the use of secondary care service both overall and more specifically for people with multiple long-term conditions. We examined the following outcomes at different intervals over a 4-year period: outpatient attendances, accident and emergency department (A&E) attendances, all inpatient admissions, emergency inpatient admissions, inpatient admissions for ambulatory care sensitive conditions (ACSC), bed days, readmission within 30 days of discharge; for the identified practices and their controls before and after the identified practices were vertically integrated. We also report the financial implications in terms of an overall change in the cost per use of secondary care for vertically integrated practices. Additionally in this WP, we analysed data from 10 years of national General Practitioner Patient Survey returns to compare trends in patient experience of care at general practices that vertically integrated with patients at practices undergoing other organisational changes and with practices remaining stable organisationally throughout the relevant period. Work package 4: staff and patient experiences of care delivery and provision across three purposively selected case study sites We completed focus groups and interviews across three case study sites with key service managers and clinicians from the acute hospital, community care and general practices, and primary qualitative research via interviews, capturing the views of patients from integrated general practices, to understand their experiences of accessing services in areas where vertical integration is present. Study team members met with the BRACE patient and public involvement (PPI) panel and discussed the ‘what’ questions (what is important to find out/know about) and the ‘how’ questions (how best to gather this information). Members of the PPI panel took part in two workshops (May and November 2022). To aid the process of analysing and interpreting data, the research team held bimonthly meetings during the project and also held three data analysis workshops between September and November 2022 to develop interpretation of findings and refine the overall theory of change. Results The scale of vertical integration in the National Health Service in England As of March 2021, we identified 26 trusts in vertically integrated organisations, running a total of 85 general practices (i.e. with unique practice codes) across a total of 116 general practice sites (as some practices work from multiple locations). The mean number of practices run by each trust was 3.3 (range 1–12) with community trusts running slightly fewer practices than acute trusts: means of 3.0 and 3.5 respectively. However, the median number of practices is higher per community trust than per acute trust (medians are 3.0 practices per community trust and 2.0 practices per acute trust). Vertically integrated general practices are smaller than other practices on average, with a median list size of 6794 patients (mean 8902) at vertically integrated practices against a median list size of 8028 patients (mean 9245) at other practices. There is not much difference in size between practices integrated with acute trusts and those integrated with community trusts, although the latter are slightly larger in terms of median patient list sizes as of March 2021. Vertically integrated practices are very slightly more likely to be in the most deprived decile when compared with non-vertically integrated practices (16–15%, respectively). Vertically integrated practices are considerably more likely to be on alternative provider medical services (APMS) contracts than are other practices: only 2% of other practices have APMS contracts but 14% vertically integrated practices do. Three-quarters (75%) of practices that are not vertically integrated achieved a Quality and Outcomes Framework (QOF) score within 25% of the total quality points achievable. The performance of vertically integrated practices, as measured by QOF scores, was weaker: only 59% of the vertically integrated practices achieved QOF scores of at least 75% of the possible maximum. Vertically integrated practices also employ fewer GPs, in line with their smaller patient list sizes: a median of 3.6 full-time equivalent GPs compared with 4.3 in other practices (in England, the number of patients per doctor (trainee and fully qualified) at general practices was 1700 in October 2022). The numbers for acute and community trusts’ practices are very similar. Impact on use of secondary care services We find that vertical integration is associated with statistically significant, modest reductions in rates of A&E attendances: a 2% reduction [incidence rate ratio 0.98, 95% confidence interval (CI) 0.96 to 0.99; p < 0.0001]; outpatient attendances: a 1% reduction (incidence rate ratio 0.99, 95% CI 0.99 to 1.00; p = 0.0061), emergency admissions and emergency readmissions: a 3% reduction in the rate of emergency inpatient admissions (incidence rate ratio 0.97, 95% CI 0.95 to 0.99; p = 0.0062) and a 5% reduction in the rate of emergency readmissions (incidence rate ratio 0.95, 95% CI 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ACSC over a 4-year period. The falls in A&E and outpatient attendance rates are temporary, as these rates resume growing at faster rates than for practices that did not vertically integrate and held general medical services contracts throughout the study period. We found little difference between the impact of vertical integration of general practices with acute hospital trusts and vertical integration with community trusts; except that in the 2 years following vertical integration, outpatient attendances increase faster in practices that have merged with an acute hospital trust than in practices merging with a community trust. We found no evidence that the impact of vertical integration is different for people living with multiple long-term health conditions compared with people with a single or no long-term health conditions. For the 39 vertically integrated practices included in our financial implications analysis, the total estimated annualised hospital cost saving amounts to £1.9–6.7 million. Staff and patient experiences of care delivery and provision Through quantitative analysis of national General Practitioner Patient Survey (GPPS) data over 10 years, we found that after practices become vertically integrated, continuity (ability to make an appointment with a preferred GP) becomes differentially poorer by 6.6% points (p = 0.0001). Analysis of GPPS data also shows that horizontal mergers between practices have minimal impact on patient experience, while practices switching to an APMS contract reveal slightly worsening patient experience for continuity, access and satisfaction. Analysis of focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that vertical integration remains one model of integrated care that can help general practices remain open. Vertical integration between acute trusts and general practices is supported by the introduction of novel ways of clinically integrating care across primary, community and secondary care to meet the needs of all patients locally, but specifically those at risk, have complex and/or multiple long-term conditions. Health service improvements driven by local acute trusts in collaboration with clinicians in general practice may use vertically integrated practices to test services before encouraging wider local roll out to non-vertically integrated practices. Notably, health service improvements are introduced following a significant period of cultural interchange; that is, colleagues from acute and primary care understanding each other’s ways of working, challenges to delivering provision and aligning back-office functions. Second, health service improvements were not only between primary and acute care but also between primary and community care, with clinicians from community and acute care becoming more embedded in providing services in general practice. Finally, patients with multiple long-term conditions encounter significant ‘navigation work’ choosing and accessing health provision, with diminishing continuity of care with the onset and scaling up of multidisciplinary team working. However, this holds true for both vertically integrated and non-vertically integrated general practices. Conclusions Vertical integration can benefit particular general practices and trusts, but our analysis does not indicate a case for its widespread roll-out. There are implications for policy and practice. For vertical integration to be successful, there is a need for an initial period of trust and relationship building as part of the cultural transformation for both primary and secondary care. Practitioners and managers in vertically integrated arrangements should consider how changes in the provision of care can help to reduce the extent of ‘navigation’ and ‘illness work’ that patients have to undertake, which are greatest for those living with multiple long-term conditions. The effects of vertical integration take time to build up and initial impacts may not last; hence, patience is needed to allow vertical integration to develop where it is attempted. There are also implications for future research. We have not yet evaluated whether vertical integration improves recruitment and retention of primary care staff; nor the extent (if any) of economies of scale in provision of back-office functions. Our quantitative analysis of hospital utilisation data showed that initial reductions in A&E and outpatient attendances following vertical integration of a general practice with a trust did not appear to last; although reductions did persist for emergency inpatient admissions and readmissions. We followed up for 2 years after vertical integration, but even for that modest a follow-up period our sample of practices that could be analysed was merely 39. Further quantitative follow-up in future would not only permit investigation of the longer-term impact of vertical integration on hospital usage but would also enable more certain and precise estimation of the magnitudes of any effects. More extensive interviewing of patients and their carers would provide better evidence about patient experiences of navigating care as part of vertically integrated models of care compared with care outside vertical integration models, including patients with multiple long-term conditions. Finally, further qualitative research with primary and secondary care clinicians, service managers and other staff, could improve understanding of the rationale and drivers for service level improvements, the indicators that would represent effective integration between primary, community and secondary care and how agendas to meet local needs can best be agreed and addressed. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.
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