Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK; Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK.
Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK.
Health Policy. 2019 Jan;123(1):51-61. doi: 10.1016/j.healthpol.2018.10.017. Epub 2018 Nov 10.
Policymakers in England are increasingly encouraging the formation of 'large-scale' general practice provider collaborations with the expectation that this will help deliver better quality services and generate economies of scale. However, solid evidence that these expectations will be met is limited. This paper reviews evidence from other inter-organisational healthcare collaborations with similarities in their development or anticipated impact to identify lessons. Medline. SSCI, Embase and HMIC database searches identified a range of initiatives which could provide transferable evidence. Iterative searching was undertaken to identify further relevant evidence. Thematic analysis was used to identify areas to consider in the development of large-scale general practice providers. Framework analysis was used to identify challenges which may affect the ability of such providers to achieve their anticipated impact. A narrative approach was used to synthesise the evidence. Trade-offs exist in 'scaling-up' between mandated and voluntary collaboration; networks versus single organisations; small versus large collaborations; and different types of governance structures in terms of sustainability and performance. While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size. Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.
英格兰的政策制定者越来越鼓励形成“大规模”的一般实践提供商合作，期望这将有助于提供更高质量的服务并产生规模经济。然而，这些期望将得到满足的可靠证据有限。本文回顾了其他具有相似发展或预期影响的组织间医疗保健合作的证据，以确定经验教训。Medline、SSCI、Embase 和 HMIC 数据库搜索确定了一系列可以提供可转移证据的举措。进行了迭代搜索以确定更多相关证据。主题分析用于确定在开发大规模一般实践提供商时需要考虑的领域。框架分析用于确定可能影响此类提供商实现预期影响的能力的挑战。采用叙述方法综合证据。在强制性和自愿性合作之间、网络与单一组织之间、小合作与大合作之间以及可持续性和绩效方面的不同治理结构之间，“规模化”存在权衡。虽然积极的影响似乎是合理的，但有证据表明，临床结果或患者体验不一定会改善，也不一定会因组织规模的扩大而实现成本节约。由于影响和潜在的意外后果尚不清楚，政策制定者谨慎行事并通过正在进行的评估获得信息是明智的。
