Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation

Background: Vertical integration refers to merging organisations that operate at different stages along the patient pathway. An organisation running an acute hospital and also operating primary care medical practices (general medical practitioner practices, ‘GP practices’) is an example of vertical integration. Evidence is limited concerning the advantages and disadvantages of different arrangements for implementing vertical integration, their rationale and their impact.
Objectives: To understand the rationale for and early impact of vertical integration in the National Health Service (NHS) in England and Wales. To develop a theory of change for vertical integration.
Design: A rapid, qualitative, cross-comparative case study evaluation, at three sites, in England (two) and Wales (one), comprised of three work packages: 1) rapid review of literature, telephone scoping interviews, and stakeholder workshop; 2) interviews with stakeholders across case study sites, alongside observations of strategic meetings and analysis of key documents from the sites; and 3) development of a theory of change for each site and for vertical integration overall.
Results: We interviewed 52 stakeholders across the three case study sites. Gaining access to and arranging and completing non-participant observations proved difficult. The single most important driver of vertical integration proved to be the maintenance of primary care local to where patients live. Vertical integration of GP practices with organisations running acute hospitals has been adopted in some locations in England and Wales to address the staffing, workload and financial difficulties faced by some GP practices. The opportunities created by vertical integration’s successful continuation of primary care – namely, to develop patient services in primary care settings and better integrate them with secondary care – were exploited to differing degrees across the three sites. There were notable differences between the sites 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.
Limitations: Across all three case study sites, the study team was unable to complete the desired number of non-participant observations. The pace of data collection during early interviews and documentary analysis varied. Due to the circumstances of the Covid-19 pandemic during project write-up, the team was unable to undertake site specific workshops during data analysis and an overall workshop with policy experts.
Conclusions: The main impact of vertical integration was to sustain primary medical care delivery to local populations in the face of difficulties with recruiting and retaining staff, and in the context of rising demand for care. This was reported to enable continued patient access to local primary care and associated improvements in the management of patient demand.
Future work: Evaluating the patient experience of vertical integration, effectiveness of vertical integration in terms of impact on secondary care service utilisation (accident and emergency attendances, emergency admissions and length of stay) and patient access (GP and practice nurse appointments) to primary care.
Study registration: Ethical approval from the University of Birmingham Research Ethics Committee (ERN_13-1085AP35).
Funding: The National Institute for Health Research Health Services and Delivery Research programme (16/138/31 – Birmingham, RAND and Cambridge Evaluation Centre).