Introduction This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. Methods The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). Results The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. Conclusion Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.

ObjectiveTo examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.DesignMultisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.ParticipantsPrimary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.SettingThree ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.ResultsCommissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.ConclusionsCommissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.

A greater number of primary health services that collaborate with specialist services, including nurse-led clinics, may facilitate health care for persons who are homeless, reducing the burden on acute services.

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SUMMARYThis paper examines the experience of developing primary care organizations (PCOs) in New Zealand and England, exploring how far these new institutional forms have been able to 'tip the balance' of their host health system in favour of primary care. The original objectives for establishing PCOs in the two countries are assessed using published research evidence on the impact of PCOs covering: efficiency and cost containment; the development of clinical engagement and leadership; the development of primary care; and the purchasing of secondary and referred services. It is concluded that in both countries, progress has been made in aligning more closely the individual focus of general practice with the population perspective of the wider public health system. The New Zealand approach of using non-governmental PCOs is judged consistent with harnessing the professional culture of general practice towards community-based public health. By contrast, English primary care trusts (PCTs) are at risk of becoming remote from their origins as purchasers in primary care and general practice, unless the re-introduction of practice-level purchasing can provide GPs with new enthusiasm for local planning and service development.

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