Vertical integration – the way forward?

Is ‘vertical integration‘ the way forward for general practice? Andrew Paterson, PCC associate, looks at the pros and cons

The secretary of state for health has recently announced the new priorities for the upcoming integrated care systems in relation to delivering health and social care. These include prevention (public health and primary care), personalisation (patient-centered) and performance priorities (measurement and accountability). While the new health and social care bill is being drawn up into an act, and law, primary care contracts themselves will be nearing their review period at the end of 2023-24; this gives an opportunity for both commissioning teams and GPs/front line staff to test new models that can cater for the ever-changing health care needs of the new, post-pandemic, patient population groups. 

Vertical integration model

As part of this review of primary care, one such model that is being discussed and tested successfully is vertical integration (related distantly to the former PACS-based model). In health and social care, vertical integration (VI) refers to the co-ordination of primary, secondary and tertiary health care services within a tiered service delivery system. Having corporate and experienced teams managing NHS hospitals take over the operation of GP practices means that patients can continue to consult a range of health care professionals at the local practice rather than seeking healthcare elsewhere. In several places in the UK GP practices are now being run by NHS hospitals, enabling some GP practices to continue which would otherwise have closed, according to a new study by the National Institute for Health Research which was undertaken by researchers at the University of Birmingham and RAND Europe. Part of the on-going review is looking at how to better integrate GPs with hospitals and incentivise a link-up with trusts; this would include ‘academy-style’ hospitals that are similar to the Wolverhampton model.  

Benefits/opportunities of vertical integration

• Successful vertical integration can lead to improvement in the continuity of care for each patient across the various tiers of health care delivery – for example, care necessary after a hospital stay should be provided by a primary care facility; in a successfully vertically integrated system, a patient’s primary care provider would be in communication with the hospital team caring for their patient and would receive all the necessary documentation from the hospital or post-acute facility stay, including discharge plans. 
• VI could offer solutions for some primary care challenges such as rising demand and a high number of staff nearing retirement.
• Work activities can become equitable for all, and hours invested would be paid appropriately. 
• Historically, GP practice staff have had restricted career development opportunities; this model of working at scale with a larger workforce and patient numbers can offer broader career opportunities.
• VI can bring GP practice staff within the scope of NHS pensions, improved salary and redundancy packages, sickness benefits, cover arrangements and other corporate advantages available to trust-based staff.
• In today’s workforce having the opportunity for a more flexible, work-life balance is becoming an increasing priority. This new VI model could help to reduce some of the current burdens in primary care, through streamlining some non-value-based functions.
• Front line clinical and patient-focused time can increase if the VI model can subsume back-office administration, HR, finance, estates and other non-clinical maintenance and support function roles.
• Anecdotal information has suggested that GP’s working lives have been broadly positive under VI model.
• GPs also have access to professionalised governance, which supports things such as CQC processes, complaints and incidents, while patients have access to more services from their practices.
• Practice staff can have access to high quality training and personal development packages which are more often lacking in a traditional smaller practice. 
• Practices can improve their outcomes by ‘piggybacking’ on the trust’s intelligence and data-driven teams for population health management focus style patient prioritisation.
• There is protection of employment for staff, and access to unions and basic employment rights.
• There is a good relationship between GPs and the trust where it is working.

Challenges to consider 

• There has been no extensive independent evaluation of outcomes for such an approach in the UK, but models do exist, and work well, where they have been implemented elsewhere (such as in USA, Canada, Australia). This can be developed, and one can learn from local UK models where these have been implemented in the past few years.
• There is limited evidence to date as to improvements in patient satisfaction, GP workload reduction or better health outcomes – this must be built-in and captured at every stage in the first few years of implementation.
• There is also a question of choice being limited for patients if most practices are run in this way – and more so, if the same trust also offers the acute or community care in the locality.
• Some patients prefer smaller, boutique-style, local practices closer to their homes and workplaces, and shy away from large healthcare providers (although this can be mitigated by having local branch practices in the traditional sense). 
• Loss of autonomy has been noted by some GPs who have described feeling more like locums or salaried GPs, although this can be averted by including willing or experienced GP reps on trust boards which will only improve their influence on combined pathways.
• For commissioners, there is a concern that a two-tier service could develop in locations where patients at trust practices get priority access.
• It has also been pointed out that, once a practice joins, it is difficult to leave – partly because staff move onto different terms and conditions.

PCC is experienced in implementing models such as these through our activity supporting working at scale, including the development of GP Federations and working across community and acute trusts. If you would like to know more see www.pcc-cic.org.uk or contact [email protected] PCC is a not-for-profit social enterprise that provides trusted, practical support to health and social care including training, development and advisory services.