What can we learn from the evidence to inform the future organisation of general practice in England? What are the challenges of undertaking research in this area?

Problem

Over the past decade new forms of collaborations between GPs for the provision of care have emerged in England. These have largely been driven by GPs themselves. Examples include networks, federations, super-partnerships and multi-site general practice organisations. It has been argued they are better placed than smaller, individual practices to strengthen the workforce, improve quality of care, extend services, and generate efficiencies. Top-down policies are increasingly driving their formation, with a view to creating ‘accountable care’ type organisations through their integration with other health and social care providers. We examined what evidence exists to inform and support the development of GP collaborations in England. This presentation will cover key findings (previously published), but aim to generate discussion about the research challenges encountered.

Approach

We undertook a systematic review of the evidence of the impact of collaboration between three or more GP practices in England on quality of care, costs and the workforce. We also undertook a literature review (non-systematic) to explore the development and impact of initiatives with similarities including clinical networks, GP-led commissioning, out-of-hour cooperatives and integrated care initiatives in England and elsewhere.We searched Embase, HMIC, MEDLINE and SSCI for primary research studies. Further literature was identified through iterative searching of references, websites, and expert recommendation. In reviews of complex evidence, this process of snowball searching has been shown to increase the yield of relevant results. 1,782 publications were screened (1505 from the database search, and 277 from further searching), of these 323 were read in full. Only five studies met the inclusion criteria for the systematic review, the others informed the non-systematic review.

Findings

General practice networks can improve quality in targeted clinical areas using shared clinical guidelines, data entry templates, case discussions, network level incentives, IT-enabled performance dashboards, and network managers. The cost-effectiveness of this is unknown. Large-scale multi-site general practice organisations may be better placed to implement quality improvement processes because of their abilities to assert direction and standardisation. However unintended consequences can arise such as the disenfranchisement of staff.Evidence from other initiatives provided lessons on the advantages and disadvantages of mandated versus voluntary formation, the consequences of different governance structures, ownership models, and organisational size. While expectations placed on larger scale general practice are plausible, evidence indicates that it is not a given that these will be achieved simply because of collaboration or scale. Other factors, such as clinical leadership and adequate resourcing are essential.

Consequences

Evaluation of new collaborations will be vital to better understand what organisational forms of general practice work best, in what settings and why. Questions remain about whether the evolution of collaborations to accountable care organisations will be achievable and deliver on expectations. Significant challenges exist in undertaking research in this area.