Are new ways of working in primary care sustainable? Assessing policy interventions using Normalisation Process Theory

Problem

Primary care policy in the UK continues to focus on the need to re-design services to address increasing patient complexity, increased demand and respond to the recruitment crisis in general practice. While there is much rhetoric, it is unclear to what extent new models of care can be embedded into routine primary care. We aimed to review recent primary care policies focused on new ways of working to assess the extent to which they consider sustainability and normalisation.

Approach

We conducted an analysis of English and Scottish health policies focused on the re-design of primary care services. We searched Department of Health, NHS England, Scottish Government and NHS Scotland sites from 2013 onwards, as well as key organisations such as the Health Foundation, the National Audit Office and the King’s Fund. Initial data extraction identified new models of care, who was involved, potential barriers and facilitators to implementation, resources and monitoring. From this, we applied Normalisation Process Theory (NPT) to explore: (1) if the policy articulated why the described models were ‘new’; (2) if it was clear who should be involved in the delivery; (3) if there was consideration of the impact on current work or resources/training for the new work; (4) how implementation would be monitored and evaluated.

Findings

We identified 23 policies: 15 English, 8 Scottish. Most were produced by Government, NHS England or NHS Scotland. New models of care included Multispecialty providers; Integration of health and social care; New unscheduled care; Pharmacy-led care. Most policies cited aging populations and patient complexity as reasons for change; some also focused on GP workforce shortages and inequalities. Current working relationships were acknowledged, and in some cases seen as crucial for the new intervention. However, linking to new stakeholder groups was also important e.g. local authorities and the third sector, but with no acknowledgement of the time this requires. Resources, particularly new ring-fenced monies, and training were outlined in the policies; however, timescales for implementation were often very short. There was little consideration of the evidence required to assess effectiveness nor how new ways of working would be monitored long-term.

Consequences

There is no shortage of new ways of working in recent primary care policy in England and Scotland. These are, however, high level descriptions and focus on initial implementation, with little consideration of how these models should be embedded and sustained in the longer term. The result is likely to be continued confusion for patients and additional work for primary care staff. The use of a theoretical framework, such as NPT, highlights what policymakers should focus on if they want to ensure the long-term sustainability of new ways of working.