Vertical integration of general practices with acute hospitals in England: rapid impact evaluation

Sidhu M, Saunders CL, Davies C, McKenna G, Wu F, Litchfield I, Olumogba F, Sussex J
Record ID 32018005226
Authors' objectives: Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Within the National Health Service (NHS), acute hospitals do not usually run general (medical) practices. General practitioners (GPs) are contracted by the NHS to provide primary care medical services to the patients registered with them. GPs also act as ‘gatekeepers’, referring patients to other, specialist, NHS services, including those provided by acute hospitals. The large majority of GPs are not employees of the NHS but instead are either contractors to the NHS or are salaried employees of contractor organisations (e.g. partnerships of GPs who hold a contract with the NHS or private companies that do so). Acute trusts are providers of hospital-based, emergency and/or elective specialist health care as well as, in some instances, providers of community health services. In England, acute hospitals are run by publicly owned organisations that are either NHS foundation trusts or NHS trusts, hereafter referred to collectively as trusts. Some acute trusts in England now run general practices, which is a form of vertical integration. This is a relatively new phenomenon in the NHS, occurring since 2015. This kind of integration is distinct from horizontal integration, whereby organisations at similar stages along the patient pathway integrate or even formally merge with one another, such as when one acute hospital trust integrates or merges with another or when one practice integrates or merges with another. Nevertheless, each vertically integrated organisation that includes more than one practice does also include a degree of horizontal integration between the practices that are owned by the same trust. This report presents the second phase of a two-phase rapid evaluation of when NHS organisations operating acute hospitals have additionally taken over running general practices in locations in the NHS in England. In 2019–20, the phase 1 rapid evaluation investigated the implementation of acute hospitals managing general practices in England and Wales and addressed questions relevant to scaling-up this model of integration in an NHS setting. That qualitative evaluation focused on understanding the rationale for, and the implementation and early impact of, vertical integration. Phase 2 of the study of vertical integration aims to understand the extent of vertical integration that has already taken place throughout the NHS in England, to assess the impact on outcomes from use of the secondary care service, how service delivery has changed or is expected to change, and the patient experience of vertical integration with a particular focus on whether patients with multiple long-term conditions are affected differently from other patients. To meet these aims, the phase 2 rapid evaluation addresses the following research questions: How many general practices have already vertically integrated with NHS organisations running acute hospitals in England; when did that happen, and what are the characteristics of those practices where vertical integration has taken place? What impact is vertical integration having the use of on secondary care? Does this impact differ for people with multiple long-term conditions compared with other patients without long-term conditions or living with a single condition? What impact is vertical integration having on the patient journey with regard to access to and overall experience of care? How does the experience differ for people with multiple long-term conditions compared with those living with no or one long-term condition? Addressing these questions informs the refinement and validation of a theory of change for vertical integration between acute hospitals and general practices, developed in the phase 1 evaluation, describing the desired outcomes and the mechanisms by which these are expected to be achieved.
Authors' results and conclusions: At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1–12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p 
Authors' methods: Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Our overall approach was a mixed-methods rapid evaluation comprising four work packages (WPs).
Project Status: Completed
Year Published: 2023
URL for additional information: English
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • Delivery of Health Care
  • Delivery of Health Care, Integrated
  • Hospitals
  • General Practice
Organisation Name: NIHR Health Services and Delivery Research programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
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