Primary Care Groups And Trusts Research Articles

Going round in circles? Joint working between primary health and social care

Purpose – The purpose of this paper is to examine research evidence on collaboration between primary and adult social care in strategic, rather than operational, activities at two different time points, following large-scale changes within the health and social care environments; and discuss the prospects for the future. Design/methodology/approach – This paper reports evidence from two substantial longitudinal studies (Dowling and Glendinning, 2003; Checkland et al., 2012) which followed the development of Primary Care Groups and Trusts (PCG/Ts) and Clinical Commissioning Groups (CCGs), respectively. Each used a combination of national surveys and local in-depth case studies to trace the early development of new structures and ways of working following major changes in the NHS and local government. Findings – PCG/Ts had limited success in collaborating with adult social care partners. Health and Well-being Boards offer a new overarching organisational framework for collaborative strategic working between GP-led CCGs and adult social care services. Mandated joint strategic needs assessments also provide a shared framework within which commissioning decisions by both CCGs and social services are made. However, there remains evidence of long-standing barriers, particularly differences in geographic boundaries and in organisational and professional cultures. Research limitations/implications – Evidence from both studies is based on the early years of the respective new organisations; later evidence may have yielded a different picture. Originality/value – This is the first paper reflecting on developments in strategic relations between primary and social care from researchers involved with two longitudinal investigations of the early development of PCG/Ts (1999-2002) and CCGs (2011-ongoing).

A randomized controlled trial of the effect of providing information on accidental injury admissions and their costs to Primary Care Groups and Trusts

Primary Care Groups and Trusts (PCG/Ts) are responsible for improving the health of local populations, but there is little evidence of their strategic involvement in accident prevention. To determine the effect of providing information on local accidental injuries to PCG/Ts on the development of accident prevention strategies. The study is a randomized controlled trial in PCG/Ts in the former Trent Region. Intervention PCG/Ts were sent profiles containing PCG/T specific information on hospital admissions for accidental injury and their costs and on accident prevention interventions. Health promotion leads were surveyed at baseline and three and fifteen months. The primary outcome was whether the PCG/T had a written accident prevention strategy. Secondary outcome measures included other accident prevention activities, prioritization of accident prevention, and knowledge and attitudes towards accident prevention. At three months 38% of PCG/Ts in the intervention arm had a written accident prevention strategy, compared with 42% in the control arm [difference -4%, 95% confidence interval (CI) -31% to 25%]. At fifteen months these values were 55% in the intervention arm and 50% in the control arm (difference 5%, CI -24% to 33%). There were no statistically significant differences between the groups for any outcome measures. Providing profiles containing information on accidental injuries to PCG/Ts did not significantly increase the development of accident prevention strategies, however this study only had sufficient power to detect substantial changes. Larger national studies would be required to detect moderate effects of tailored packages in changing PCG/T behaviour.

Linking research and development in primary care: primary care trusts, primary care research networks and primary care academics

In the UK, primary care groups and trusts (PCG/Ts), also known as primary care organizations (PCOs), are the organizations that will drive forward the primary care development agenda outlined by the government. We undertook a study to investigate the views of PCOs on the place of research in primary care development and their role as participants in the research process. The study population consisted of all PCOs in south London ( n = 23). An initial structured questionnaire explored the organizations’ perceived research needs, the potential of the primary care research community to meet those needs and their current research activity. This was followed by semistructured interviews during which the participants were asked to discuss their views on the place of research in their primary care development agenda and in particular how research might inform the development of clinical skills and services in the short and medium term. The third stage of the project was an action based workshop at which general practitioners (GPs) and primary care nurses developed research questions arising from the earlier stages of the study. The PCOs identified three key areas of research support: public health, health economics and nursing research expertise. Research support was needed to help them identify population health needs and to evaluate new models of care and shifting professional boundaries. In contrast to traditional primary care research, PCOs required rapid delivery of research results, particularly when these were used to inform the commissioning of services. Our study has highlighted that PCOs have a development agenda requiring rigorous research and evaluation to ensure the best outcomes for patients. The differing skills, roles and responsibilities of PCOs, PCRNs and academic departments show how partnerships might develop to further research and development in primary care.

Managing or managed? Experience of general practitioners in English Primary Care Groups and Trusts.

This article presents findings from a wider UK Department of Health funded evaluation of English Primary Care Groups (PCGs) and Trusts (PCTs). It presents qualitative research into the experiences of general practitioners (GPs) in these PCG/Ts and explores the extent to which GPs manage, or are managed by, these new organizations. Using the framework of stratification theory, the paper explores whether there is any evidence to suggest PCTs will strengthen collective medical control over resource allocation whilst fending off management control of clinical decision-making. It also examines whether individual GPs not involved at board level feel a loss of control over decisions and their own clinical practice. A stratified random sample of 20 GPs was selected for in-depth interview. The in-depth interviews were designed to capture the full complexity and variety of GPs' experiences that routinely available data could not capture. GPs were anxious that clinical decisions were, or could, be overridden by other concerns such as cost control. The extent to which primary care professionals leading PCGs and PCTs could fend off managerial control was doubted. However, whilst GPs felt under threat, this was more an anticipated threat than a reality. GPs within PCG/Ts seem prepared to accept a degree of standardization if they feel that this is consistent with good clinical care. However, although there was the impression of greater central control, PCGs and PCTs and Government policies did not appear to have made an impression on clinical autonomy.

Joint Working: The Health Service Agenda

The purpose of this article is to examine the policy and practice of collaboration between health and local government from a health servicesperspective. Within this remit, the authors primarily focus on the area of primary care. Four key elements of the post-1997 policy context are discussed: the move from GP fund-holding to Primary Care Groups and Trusts (PCG/Ts); a shift from treating to preventing illness; a drive for implementation by central government; and an emphasis on collaboration. Within this broad context, there are a number of factors which may support enhanced collaboration: the size, scope, responsibilities and budgets of PCG/Ts may well provide an organisational framework which is supportive of joint working. However, the ‘Berlin Wall’ between health and social care has proved to be enduring, and there are aspects of the post-1997 policy context which will continue to inhibit effective joint working, in particular centrally designed performance management systems and the dominance by GPs of PCG/Ts.

Investigating relationships between health need, primary care and social care using routine statistics

Closer integration of primary and social care is central to the agenda of Primary Care Groups and Trusts (PCG/Ts) in England. Relationships between the need for care and primary and social care provision at local levels are investigated using routinely available statistics. Primary care provision is negatively associated with need resulting from material deprivation, but positively associated with older age-related need. Conversely, provision of social care is positively related to need resulting from deprivation but is unrelated to the size of local elderly populations. The ‘inverse care law’ does not capture the complexity of the relationships between need and provision. A lack of boundary coterminosity represents a serious impediment to the goal of establishing integrated health and social care systems for local populations.

Do information systems meet the needs of primary care trusts?

To function effectively, primary care trusts (PCTs) need information from a range of sources. The general practice clinical record is a key source of information for PCTs but has often proved to be of variable quality. PCTs have developed rapidly and now have responsibility for 75% of the healthcare budget. They have a range of information needs that must be met if they are to ensure that healthcare provision meets the needs of patients. Since the abolition of health authorities PCTs have full responsibility for developing practice systems as well as having a key role to play in developing information management and technology (IM&T) within local health economies. The paper describes the problems PCTs face in accessing information to support their core functions and the progress they have made in retrieving data to support service development. It also describes the progress and developments in information and information systems within general practice using data from the National Tracker Survey of Primary Care Groups and Trusts (PCG/Ts). The survey began in 1999 when PCGs were established and has tracked the progress of PCG/Ts over three years. This paper presents the findings from the third survey relating to the development of information to support the needs of PCG/Ts. The findings show that information available to PCG/Ts does not meet their needs in a range of key areas. Many PCG/Ts are collecting data to support the Coronary Heart Disease National Service Framework (CHD NSF) and monitoring some areas of service provision in general practice. The use of information management tools has risen significantly since the second survey and involvement in the Primary Care Information Services (PRIMIS) initiative has more than doubled. The paper concludes that although PCG/Ts and general practices have made substantial progress, there is a long way to go before information providers generate high-quality information to support the needs of PCTs.

Information management and technology (IM&T) in primary care groups and trusts: the gap between national strategy and local implementation

Primary care groups and trusts (PCG/Ts) are key to the successful implementation of the NHS information strategy, Information for Health. This study describes the current levels of IM&T within PCG/Ts and their constituent general practices and examines the ability of PCG/Ts to support the delivery of national targets. Results are derived from the National Tracker Survey of Primary Care Groups and Trusts, which uses a stratified sample of 72 (15%) of PCG/Ts.The findings indicate that although PCG/Ts are beginning to identify their priorities and work on the huge development agenda in primary care, they may have difficulties meeting both local and national targets. PCG/Ts need additional, appropriately skilled staff and better information to support the planning process. They also need access to high quality data from a range of sources to support their key functions. The quality of data currently available to PCG/Ts is generally perceived by IM&T leads as being poor and is seriously hindering progress. The paper concludes that there is a gap between the vision described in the national information strategy and the ability of local organizations to deliver targets. If the national strategy is to be implemented successfully it may need to be adapted in the light of the findings presented.

The relationship between size and performance of primary care organisations in England.

To examine the relationship between the size and performance of primary care organisations, the effect of and the reasons for mergers. Data on size, proxy measures of performance and merger intentions for 71 organisations were extracted from telephone and mail surveys of primary care groups and trusts (PCG/Ts). Of the 22 performance measures examined, only two were significantly associated with size, and over half were not associated with any of the potential explanatory variables. Most organisations (70%) were planning mergers. If all planned mergers take place, the mean size of primary care organisations will double to nearly 200000. The main reasons for mergers were to make better use of resources and for PCGs to become PCTs. There is little evidence that the performance or efficiency of a primary care organisation is associated with its size. Optimal size may differ for different functions. Mergers are seen as a way of increasing management capacity and may reflect the desire of managers to manage large organisations. There is a risk that larger primary care organisations will recreate hierarchies and lose local ownership and participation.

Is GP Restratification Beginning in England?

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs’ professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners’ income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group’s strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form.

User involvement in clinical governance.

To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation. Qualitative data comprising semi-structured interviews, reviews of documentary evidence and relevant literature. Twelve PCGs/PCTs in England purposively selected to provide variation in size, rurality and group or trust status. Key stakeholders including Lay Board members (n = 12), Chief Executives (CEs) (n = 12), Clinical Governance Leads (CG leads) (n = 14), Mental Health Leads (MH leads) (n = 9), Board Chairs (n = 2) and one Executive Committee Lead. Despite an acknowledgement of an organizational commitment to lay involvement, in practice very little has occurred. The role of lay Board members in setting priorities and implementing and monitoring clinical governance remains low. Beyond Board level, involvement of users, patients of GP practices and the general public is patchy and superficial. The PCGs/PCTs continue to rely heavily on Community Health Councils (CHCs) as a conduit or substitute for user involvement; although their abolition is planned, their role to be fulfilled by new organizations called Voices, which will have an expanded remit in addition to replacing CHCs. Clarity is required about the role of lay members in the committees and subcommittees of PCGs and PCTs. Involvement of the wider public should spring naturally from the questions under consideration, rather than be regarded as an end in itself.

Primary care groups and trusts: a threat or an opportunity for the development of community-based nursing in England.

To examine the role of Primary Care Groups and Trusts (PCG/T) in relation to nurses working in general practice and community health services. Over the past two decades there have been rapid changes in the numbers and roles of nurses working in primary care and community based settings. The establishment of Primary Care Groups offers health care professionals, including nurses, the chance to develop local primary care services and to integrate community and primary care nursing. These developments may offer opportunities or pose threats to nursing staff. Data are drawn from a longitudinal study of a randomly selected sample of Primary Care Groups in England (n = 72). In a second survey of Groups carried out in autumn/winter 2000, Primary Care Group chairs and chief officers were interviewed by telephone. Response rates were 97% for both chairs and chief officers (69 of each). Chairs indicated that in most areas Primary Care Groups were consulting with local nurses to develop policy. Fifty-seven (85%) reported that investment in nursing staff and nursing services was a high priority in their area. Twenty-eight (41%) indicated that nurse-led services designed to increase patient access had already been established in their area, and 20 (29%) were planning new nurse-led services. Many developments had been initiated by Primary Care Groups. Initiatives to integrate community and general practice based staff were underway in most areas. Primary Care Groups and Trusts are initiating changes in general practice and community based services which are likely to have long-term and important implications for nurses in terms of their roles, conditions of work and future careers. It is important that nurses are consulted and are involved in developing and implementing policy change.

Primary health and social care services in the UK: progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the state's objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older people's services.

Impact on health authorities of the introduction of primary care groups and trusts.

The National Tracker Survey of Primary Care Groups (PCGs) and Trusts (PCTs) in the UK has provided evidence about how PCGs and Health Authorities managed the transition to PCTs. This was a major challenge for both organizations. Devolution of responsibilities was dependent on the capacity and readiness of PCGs to take on their new roles. The development of good working relationships between the principal parties was critical to this process. Health Authorities started to let go and all put in place basic mechanisms for holding PCGs to account in their first year. However, a number of PCGs regarded their Health Authority as authoritarian. Most Health Authorities were found to have started to provide information to support PCGs in their core functions, but resources were frequently problematic. It will be important for Health Authorities and PCG/Ts to negotiate a shared view of their respective roles and responsibilities. The future role of Health Authorities in providing strategic leadership for their local health economies was not sufficiently well defined or understood.

Are primary care groups and trusts consulting local communities?

Primary care groups and trusts (PCG/Ts) in the English NHS were established in 1999 and have responsibility for providing and commissioning health-care for around 100 000 people. PCG/Ts are dominated by health professionals, but are responsible for representing the interests of the local community. This paper assesses how they have informed and consulted local communities and the perceived impact of this consultation on decision-making. The paper uses evidence from the National Tracker Survey of PCG/Ts, a longitudinal survey of 72 (15%) of the PCG/Ts in England, using data from telephone interviews with chairs and chief officers, and postal questionnaires to lay board members and representatives of Community Health Councils (CHCs). Eighty-one per cent of PCG/Ts had public involvement working groups. Methods of consulting the community included consulting CHCs (87%), holding public meetings (75%) and consulting local patient groups (67%). Only 31% of chairs felt they were effective at consulting. Ninety-two per cent of CHC representatives attended all board meetings. Most CHC representatives reported that there had been little or no consultation with the CHC in areas such as commissioning, service development or clinical governance. Only 14% of CHC representatives rated PCG/T consultation with the public as effective. Eighty-seven per cent said that local communities were largely unaware of the existence of PCG/Ts, and 70% commented on the weaknesses in PCG/T efforts at public consultation. Public participation is being taken seriously by PCG/Ts, but most are struggling to develop effective ways of involving local communities. Efforts to involve the public may become little more than token gestures. The proposed abolition of CHCs may make it more difficult for PCG/Ts to obtain a lay perspective. Effective consultation requires the development of new methods and adequate resources, but a stronger lay voice in the governance structures of PCG/Ts is needed.

Management in primary care groups and trusts

Primary Care Groups and Trusts (PCG/Ts) are central to the British Government's plans to modernise the NHS. To fulfil their functions they will require sufficient numbers of skilled managers supported by an adequately resourced staffing infrastructure. However, this paper indicates that managers believe there is a serious gap between the expectation that PCG/Ts will play a central role in NHS modernisation and the managerial capacity required for the accomplishment of their objectives.

Needs of older people in the community: issues for PCGs and PCTs.

National policy (Department of Health, 1997, 2000) is directing care provision to being appropriate to meet people's needs; to be effective; evidence-based; efficient and economic. Primary care groups (PCGs) and trusts (PCTs) have been identified as being the organizations to deliver such care. Since the introduction of the NHS and Community Care Act 1990, certain issues have been highlighted as having implications for the provision of an 'ideal' service for older people on the community. These issues focus around three main areas: assessment of need; working in partnership and quality of service provision. This article discusses these issues and their implications for PCGs/PCTs in relation to supporting older people in the community.

Did Health Improvement Programmes improve in their first two years?

Objective This study sought to track the development of Health Improvement Programmes (HImPs) from 1999 to 2000. Design A documentary analysis of pairs of HImPs produced by 26 health authorities in 1999 and 2000. Method A structured analytic tool was devised, based on government guidance on the content of HImPs. Results HImPs have become longer, and include more priorities. Health promotion and public health priorities are less commonly chosen than those with a disease focus, particularly those in 'Saving Lives: Our Healthier Nation'. There has been a decrease in the quantity of supporting data provided (health needs assessment, financial resources, existing services), and the role of Primary Care Groups and Trusts (PCG/Ts) is not given central emphasis. There is an increase in target-setting and in clarification about roles and responsibilities among partners, and commitment to the principle of public consultation about the local National Health Service (NHS). Conclusion Although the scope of HImPs has broadened, and some components are now presented in more detail, it is not clear that these documents embody more achievable strategies. With so many priorities requiring attention, it seems likely that politically important issues (such as waiting lists) will take precedence over the promotion of population health.

The health improvement role for primary care

Primary Care Groups and Trusts (PCG/Ts) are required to improve the health of their populations. How are they going about this? This survey of 72 PCGs found that most are embracing national priorities, assessing local health needs, and contributing to Health Improvement Programmes (HImPs). Although their focus is still on health care rather than on health, most are establishing partnerships with other agencies with a role in improving health.