The aim of our NIHR-funded project was to explore the relationship between the organisation of primary (health and social) care services and the care experience of frail older people with multiple, complex needs. We chose five areas in England where care was organised differently, one of which was in the West Midlands. In each area we spoke to older people (66 in total) who had multiple chronic conditions and were receiving services from two or more providers. We also looked at their medical records in the GP surgery and spoke to those responsible for providing their health and social care.
Our patients (average age 78) were typically frail. Many had experienced deteriorating health in the last year and mobility was a particular problem. Despite the range of mechanisms introduced to try and overcome organisational barriers they, and their service providers, reported remarkably similar problems.
Patients valued continuity, particularly contact with a regular GP – but this was not easy, nor was it often possible to discuss all their health-related concerns, obtain regular review or follow-up on discharge. Care plans were very limited, transfer of information imperfect (discrepant IT systems were still evident and many practitioners continued to rely heavily on paper records) and, faced with multiple care coordinators, many felt they themselves had the best overview of their care. It also remained difficult to be seen in the community and patients often understated problems such as pain, impaired mobility and fear of falling, meaning that many had problems accessing help, particularly attending repeat appointments.
Organisations were responding to these challenges in broadly similar ways. We found an increasing number of special initiatives, dedicated posts and multi-disciplinary care teams focusing on frail older people. In all five of our study sites, formally managed care networks had been established to improve care across organisational boundaries. These were typically aimed at admission avoidance and facilitated discharge, together with better long-term condition management. These were good at working flexibly (e.g. adding in new services for small care groups in the short term) but often limited by: incomplete information, referral and financial flows across organisational boundaries; capacity mismatches; and conflicting financial incentives and managerial targets.
Caseloads were also becoming increasingly stratified. All our community health services identified case managers for patients with complex, long-term conditions. Yet, despite their complex co-morbidities, few of our patients had access to this support or indeed a designated care co-coordinator.
Differences between our case study sites often appeared to reflect variations between GP practices rather than system-level differences. For example, levels of community support, onward referral, home visits and care co-ordination by GPs tended to be higher in practices that either still operated patient lists or where the patient was predominantly seeing the same doctor. This suggested continuity of contact may produce higher quality of care, enabling a more complete assessment of need and more wide-ranging support. In contrast, differences in ownership affected the range of services to which patients had direct access; GPs’ managerial responsibilities (relevant to care coordination because of their impact on GP workload); and the scope for doctors to develop special interests.
Our research team comprised: Rod Sheaff,1 Joyce Halliday,1 John Øvretveit,2 Richard Byng,3 Mark Exworthy,4 Stephen Peckham,5 Sheena Asthana1
1 Plymouth University
2 Karolinska Institutet Stockholm
5 University of Kent
Our research was funded by the National Institute for Health Research - Service Delivery & Organisation Programme (Project Reference Number 09/1801/1063)
If you want to find out more our full report will soon be available in the Health Services and Delivery Research Journal: http://www.journalslibrary.nihr.ac.uk/hsdr
Or contact the Project Lead Rod Sheaff: Rod.firstname.lastname@example.org (01752) 586652