GPs need to play a stronger role in coordinating care for people with longterm or chronic conditions, according to a new report from The King’s Fund.

Co-ordinated Care for People with Complex Chronic Conditions, funded by Aetna and the Aetna Foundation in the United States, compares five UK-based case studies with a proven track record in providing care coordination in primary and community care settings. It identifies the critical success factors that enable effective care co-ordination and how these might be transferrable to different settings, in the United Kingdom and elsewhere. 

Across all of the five case study sites, limited engagement from GPs reduced the effectiveness of care coordination and the number of referrals into the programmes. Despite attempts to address this, including financial incentives and information sessions, only one of the sites had managed to achieve the desired level of engagement with GPs.

The findings follow recent calls by the Health Secretary for general practice to improve the co-ordination of care for vulnerable older people, including proposals to allocate a named clinician to oversee their care.

The report concluded that the primary purpose of good care co-ordination should be to improve quality of care, rather than just to reduce costs, and that good care co-ordination should be driven at a local, rather than a system, level. The report also found a chronic lack of evaluation on which to judge the performance of care co-ordination programmes and recommended that there should be more measurement, evaluation, and reflection on performance.
Other key lessons from the report include:

  • care co-ordination programmes can take some years to mature and to build the necessary legitimacy and capability to become accepted
  • successful approaches to care co-ordination cannot simply be transported ‘en bloc’ – understanding the local context is the key to transferring lessons from one setting to another
  • there is potential to scale up operations by building a number of locality-based approaches under the direction of umbrella organisations – this might have more impact on reducing costs
  • weak links with secondary care need to be addressed to improve transitions from hospital to home, reduce readmission rates and secure faster access to specialist knowledge 
  • models of care co-ordination are likely to be more effective when they operate as ‘fully integrated’ provider teams with a degree of operational autonomy.

Richard Humphries, Assistant Director of Policy, The King’s Fund said: “The importance of coordinating care has risen rapidly up the policy agenda. Our comparison of these five local success stories – the first analysis of its kind – shows that it is rarely easy to build an effective system of joined-up care. Common challenges include the need to strengthen engagement with local GPs and build better links with secondary care, as well as difficulties in securing long-term funding.

“Our report offers some important lessons to those commissioning or delivering co-ordinated care about how they can apply the principles of these successful models, particularly the need to target specific local communities, and greater importance  to be placed on monitoring and measuring the impact of care co-ordination. We hope that this learning will be used to inform the work of the government’s integrated care pioneer areas which are due to be announced imminently.”