The impact of vertical integration of health services across England and Wales

Vertical integration is a valuable option to consider when GP practices look likely to fail due to recruitment and financial difficulties, but it is not an option that should be imposed from the top down.

What is the issue?

The long-term sustainability of primary care in the UK has become an increasing focus of concern in the face of growing patient demand and shortages of primary care physicians: GPs. In several locations across England and Wales, NHS organisations responsible for managing acute hospitals have also taken over the running of primary care medical practices. This is an example of vertical integration, in which organisations merge at different stages along the patient pathway. There is limited evidence concerning the reasons behind vertical integration, how it can be implemented, and its advantages and disadvantages.

RAND Europe, with our partners at the BRACE centre, was commissioned by the National Institute for Health Research to evaluate what has led to this kind of vertical integration in England and Wales, how it has been implemented, and with what consequences.

How did we help?

The researchers conducted an evaluation at three sites where vertical integration has taken place. The evaluation involved scoping work (literature, interviews and a design workshop with stakeholders), a large number of in-depth interviews, observations of meetings, and development of a theory of change for each case study and for vertical integration overall. Analysis of the data collected helped our researchers to understand the rationales for vertical integration; barriers and enablers to its implementation; and early indications of likely impacts of vertical integration.

What did we find?

The overall theory of change for the vertical integration is summarised below:

• Rationale: to sustain primary care by supporting local practices, thereby protecting patient access and avoiding the closure of GP practices
• Priorities: to improve recruitment and retention in primary care and address the growing workload
• Inputs: financial investment to recruit locums and improve estates management, as well as development of multidisciplinary teams of health care professionals, and reorganisation of back office functions
• Processes: development of shared back office function, integrated governance and development of training opportunities for all types of practice staff
• Outcomes: better recruitment and retention of primary care staff; a more flexible, upskilled workforce; and the opportunity for GP practices to remain open
• Impact: sustained patient access to primary care locally and increased opportunities for innovative patient care in future.

What are the implications for policy and practice?

Vertical integration is a valuable option to consider when GP practices look likely to fail due to recruitment and financial difficulties. But it is not an option that should be imposed from the top down; many GPs evidently do not wish to join such arrangements. Vertical integration may be a route to better integration of primary and secondary care for patients, but it is not the only option.

There was a lack of evidence on the outcomes and effectiveness of vertical integration, particularly in respect to cost-effectiveness and patient care. The researchers plan to return to the question of costs and savings, patient experiences and outcomes in a future evaluation of vertical integration.