This is a rapid evidence synthesis that explores existing evidence relevant to the closer integration of primary and community services, which will be useful for those responsible for formulating policy in this area. It does not cover the integration of health and social care, as this is a very broad subject which is currently being addressed by the Policy Innovation Research Unit (PIRU) in their evaluation of the Integrated Care Pioneers. The over-arching question that we shall address is as follows:
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?
The evidence synthesis will bring together existing reviews of relevant evidence with some new searches on the topic areas above. This will not be a systematic review; rather we will seek to bring together a disparate range of evidence sources which illuminate this important question. We will ‘snowball’ from reference lists as well as exploring published evidence reviews. Under each of the subheadings above we will address the following sub-questions:
There is a great deal of evidence available about the micro-level aspects of team working. Whilst relevant, understanding the detail and nuances of this evidence is not essential to answering the policy question. However, an overview of the kind of issues that arise in this literature would be valuable. We will therefore provide a brief overview of evidence relating to the following questions:
- What is known about the factors that enable or inhibit effective working across disciplinary boundaries?
- What is known about the factors which affect the effectiveness of teams in general?
- Is there any evidence about the effectiveness of Primary Health Care Teams in particular, with a focus upon their impact on patient outcomes?
Evidence sources and methods:
We will start by scoping review articles which cover the following areas:
- Team working
- Inter-disciplinary working
- Relevant aspects of partnership working
- The outcomes of Primary Health Care Teams
Our synthesis of this evidence will be high-level, brief and interpretive, seeking data ‘saturation’ in terms of the available evidence about effective team working. Preliminary scoping suggests that there is a large volume of evidence in this category, but that it is possible to discern a small number of recurring concepts which we will summarise.
This level highlights aspects of service organisation and delivery. We will explore aspects of the following questions:
- What is known about the effect of co-location of team members on team working?
- What is known about the pros and cons of having a geographical vs practice population base for community nursing services?
- Is there any evidence about the effect of the provision of community services by entities which have different organisational forms on care or care outcomes?
Evidence sources and methods:
We will start with evidence relating to the history of the organisation of community and primary care services in the UK. We will look at historical policy documents such as the Cumberledge report and more recent policy relating to the provision of community services (eg the ‘Transforming Community Services’ programme and policy relating to the development of Community Foundation Trusts). We will perform literature searches on issues relating to co-location of services, focusing upon databases such as Medline, Embase, Social Science Citation Index and the Expanded Academic database. We will look for review articles in this area, including international evidence as well as that from the UK, and will summarise these. Focusing upon delivery mechanisms, we will explore the evidence relating to ‘polyclinics’ and other such attempts to reconfigure services. We will also search the grey literature, looking, for example, for publications advocating particular organisational forms (such as federating GP practices or ‘hub and spoke’ models of service provision). The evidence base informing these publications will be explored.
This level highlights structural aspects of the topic area, focusing upon how system-level factors may help or hinder service delivery.
- What is known about the commissioning of community services?
- Is there any evidence that any particular payment models contribute to desirable service outcomes?
- Is there any evidence relating to ownership of primary and community services, in particular evidence about the effect on services of community care services being owned by either secondary or primary care providers?
Under this heading we will again start with the evidence base said to underpin the most recent reorganisation of community services, ‘Transforming Community Services’. We will run searches using the databases mentioned above to search for any evidence about commissioning/purchasing community services, and also about payment models. In addition, we will explore the historical evidence about attempts by fundholders or Total Purchasing Pilots to commission community services in different ways. We will look at the evidence from the USA about the provision of out of hospital care by organisations such as HMOs, Accountable Care Organisations, and Patient-centred Medical Homes. In each of these areas our initial focus will be upon good quality review articles.