Barriers to integration | Source | |
Organisations not committed to change | Integration aborted due to altered service strategy | Campbell, 200418 |
Uncertainties about health service reorganisations | Campbell, 200418 | |
Organisations priortising conflicting interests | Keeping the split of management and commissioning with key issue being access to secondary care and discharge back to primary care maintaining focus on the facilitation (or gatekeeping) of these processes rather than focusing on actually optimising outcomes of care | Agius, 201016 |
Limited resources | Space constraints at the surgeries preventing inclinics | Campbell, 200418 |
Financial constraints | Pinnock, 200923 | |
Increase in workload and shortage of staff | Hull, 2014;22 | |
O’Connor, 201321 | ||
Lack of targeted remuneration and financial incentives | McHugh, 2013;20 | |
O’Connor, 201321 | ||
Poor coordination of finance processes | Inadequate mechanisms for enabling the shift of finance from hospitals to community care | Campbell, 200418 |
Poor exchange of information between professionals | Difficulty to access information from secondary care | Campbell, 200418 |
Single patient record not being used due to technical problems, compatibility problems and governance problems | Featherstone, 201229 | |
Professionals individually negotiating rules for accessing patient records | Featherstone, 201229 | |
Difficult to access specialist advice (GPs not knowing the consultants well enough) | England, 200517 | |
Poor coordination of care | Poor coordination and communication across the interface (eg about non-attendance by follow-up patients; uncertainty when patients would be called or recalled by specialty service) | England, 2005;17 McHugh, 201320 |
No consistent arrangements for discharge from primary to secondary care or shared care services in primary care | Syriogiannis, 201526 | |
Non-person-centered care | Lack of mechanisms to look into patients’ needs and wishes | Hull, 201422 |
Lack of skills in primary care | Paucity of formal training in primary care | England, 2005;17 |
Pinnock, 200923 | ||
Tensions in interprofessional teams | A lack of understanding of the culture of primary care | England, 200517 |
Differences in perception of core safety attributes | Ahmed, 201428 | |
Defensive attitudes | England, 2005;17 | |
Rea, 200727 | ||
Lack of interest in cooperation, entrenched attitudes and antagonism | Pinnock, 200923 | |
Uncertainty over roles and responsibilities | England, 2005;17 | |
Rushfort, 201619 | ||
Enablers of integration | ||
Strong model of care | Intervention based on existing guidelines | Price, 201425 |
Clearly defined structure, defined actions, roles and responsibilities | Price, 2014;25 | |
Campbell, 200418 | ||
Clear and fast routes to secondary care | Bernstein, 201124 | |
New roles to support integration | Named lead (a GP) | Campbell, 200418 |
A GP champion | Bernstein, 201124 | |
Clinical leadership | Campbell, 2004;18 | |
Bernstein, 201124 | ||
Interpractice working | Working with GP consortia | Bernstein, 201124 |
Devolving resource and responsibility to groups of local providers (not individual practice) | Hull, 201422 | |
Bringing clinicians together | Onsite clinics (secondary care and community care and primary care) | Campbell, 200418 |
MDT meetings | Hull, 201422 | |
Rapid access to advice by email or telephone | Hull, 201422 | |
Enhanced self-care | Price, 201425 | |
Follow-up monitoring | Price, 201425 | |
Availability of nursing support | McHugh, 201320 | |
GP education | Bernstein, 201124 | |
Additional resources | Additional financial resources | Campbell, 200418 |
Community practice nurse dedicated time | Campbell, 200418 | |
Fostering and maintaining commitment and enthusiasm for joint working | Knowledge sharing: organisational and professional learning | England, 2005;17Hull, 2014; 22Bernstein, 201124 |
Shared goals and values | England, 200517 | |
Respect for the autonomy of the different groups involved | England, 200517 | |
The surrender of professional territory where necessary | England, 200517 | |
Enabling healthcare professionals to learn about each other’s settings and strengths | England, 200517 | |
Monitoring of care quality and performance | Investment in an IT backbone to support the development of real-time information on clinical performance | Hull, 201422 |
Analysis of key performance indicators with clinical leads working with practice teams to support delivery | Hull, 2014;22 Price, 201425 |
GP = general practitioner; MDT = multidisciplinary team