Health Services Management Centre, University of Birmingham, Birmingham, UK.
Health Economics Research Centre (HERC), Nuffield Department of Population Health, University of Oxford, Oxford, UK.
BMJ Open. 2022 Jan 11;12(1):e053222. doi: 10.1136/bmjopen-2021-053222.
To understand the rationale, implementation and early impact of vertical integration between primary care medical practices and the organisations running acute hospitals in the National Health Service in England and Wales.
A qualitative, cross-comparative case study evaluation at two sites in England and one in Wales, consisting of interviews with stakeholders at the sites, alongside observations of strategic meetings and analysis of key documents.
We interviewed 52 stakeholders across the three sites in the second half of 2019 and observed four meetings from late 2019 to early 2020 (further observation was prevented by the onset of the COVID-19 pandemic). The single most important driver of vertical integration was found to be to maintain primary care local to where patients live and thereby manage demand pressure on acute hospital services, especially emergency care. The opportunities created by maintaining local primary care providers-to develop patient services in primary care settings and better integrate them with secondary care-were exploited to differing degrees across the sites. There were notable differences between sites in operational and management arrangements, and in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial.
Vertical integration is a valuable option when primary care practices are at risk of closing, and may be a route to better integration of patient care. But it is not the only route and vertical integration is not attractive to all primary care physicians. A future evaluation of vertical integration is intended; of patients' experience and of the impact on secondary care service utilisation.
了解英格兰和威尔士国民保健制度中初级保健医疗实践与运营急症医院的组织之间垂直整合的基本原理、实施情况和早期影响。
在英格兰的两个地点和威尔士的一个地点进行定性、交叉案例研究评估，包括对现场利益相关者的访谈，以及对战略会议的观察和关键文件的分析。
我们在 2019 年下半年对三个地点的 52 名利益相关者进行了访谈，并观察了从 2019 年底到 2020 年初的四次会议（由于 COVID-19 大流行的爆发，进一步的观察被阻止）。发现垂直整合的唯一最重要的驱动力是将初级保健保持在患者居住的当地，从而管理对急性医院服务的需求压力，特别是急诊服务。通过维持当地初级保健提供者来开发初级保健环境中的患者服务并更好地将其与二级保健相结合的机会，在不同程度上被利用。在运营和管理安排以及组织和临床整合方面，各地点之间存在显著差异。组织更紧密的整合归因于当地初级保健和二级保健之间先前的良好关系，以及对当地卫生经济范围内综合工作的历史规划和准备。当地利益相关者认为，垂直整合对卫生系统成本的净影响是有利的。
当初级保健实践面临关闭风险时，垂直整合是一种有价值的选择，并且可能是更好地整合患者护理的途径。但它不是唯一的途径，并非所有初级保健医生都对垂直整合感兴趣。打算对垂直整合进行未来评估；评估患者的体验以及对二级保健服务利用的影响。
