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

Vertical integration is a valuable option to consider in some locations, particularly 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 a modest but growing number of locations in England and Wales, NHS organisations responsible for managing acute hospitals and other secondary health care provision 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 impacts.

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?

We undertook two phases of evaluation. In phase one, the researchers conducted an evaluation at two case study sites in England and one in Wales. 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.

In phase two, which focused on England, we identified all of the locations where vertical integration has been implemented. We then analysed statistically the impact of vertical integration on patients’ use of hospital care, both emergency and elective activity, and on patients’ experience of primary care as reported in the national General Practice Patient Survey. We also conducted interviews and focus groups with patients and staff across three case study sites to explore the impact of vertical integration on patient experience of care overall.

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.

Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach: the places where vertical integration has occurred are not typical of the country as a whole.

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.