The general practice perspective on barriers to integration between primary and social care: a London, United Kingdom-based qualitative interview study

Abstract

ObjectiveThere is an ongoing challenge of effective integration between primary and social care in the United Kingdom; current systems have led to fragmentation of services preventing holistic patient-centred care for vulnerable populations. To improve clinical outcomes and achieve financial efficiencies, the barriers to integration need to be identified and addressed. This study aims to explore the unique perspectives of frontline staff (general practitioners and practice managers) towards these barriers to integration.DesignQualitative study using semistructured interviews and thematic analysis to obtain results.SettingGeneral practices within London.Participants18 general practitioners (GPs) and 7 practice managers (PMs) based in London with experience of working with social care.ResultsThe study identified three overarching themes where frontline staff believed problems exist: accessing social services, interprofessional relationships and infrastructure. Issues with contacting staff from other sectors creates delays in referrals for patient care and perpetuates existing logistical challenges. Likewise, professionals noted a hostile working culture between sectors that has resulted in silo working mentalities. In addition to staff being overworked as well as often inefficient multidisciplinary team meetings, poor relationships across sectors cause a diffusion of responsibility, impacting the speed with which patient requests are responded to. Furthermore, participants identified that a lack of interoperability between information systems, lack of pooled budgets and misaligned incentives between managerial staff compound the infrastructural divide between both sectors.ConclusionIn this study, primary care staff identify intangible barriers to integration such as poor interprofessional relationships, in addition to more well-described structural issues such as insufficient funding and difficulty accessing social care. Participants believe that educating the next generation of medical professionals may lead to the development of collaborative, instead of siloed, working cultures and that change is needed at both an interpersonal and institutional level to successfully integrate care.

“They created a team of almost entirely the people who work and are like them”: A qualitative study of organisational culture and racialised inequalities among healthcare staff

“…Our study supports existing strategic-level recommendations to promote systems-change, including sustained strategies transparently linked to senior-level accountability targeting organisational, workplace inter-and intra-personal levels (Naqvi et al, 2019;West et al, 2015). This necessitates buy-in from all leadership levels, openly prioritising workforce diversity, and resourcing specific initiatives to increase inclusion (Priest et al, 2015;West et al, 2015).…”

Identifying and understanding the factors that influence the functioning of integrated healthcare systems in the NHS: a systematic literature review

“…This demands a mutual understanding of and commitment to the vision across the organisations involved 24. Differences in geographical boundaries, communication boundaries, status inequalities, professional cultures, working practices and priorities can lead to divides between staff from different organisations, creating conflict and a ‘blame culture’ that stifles ongoing integrated working 25–29. Fostering an ethos of learning and self-reflection was also shown to yield positive outcomes as staff continue to work together long term 26 28 30…”

“…Furthermore, integrating services often requires increased workloads at the start and overworking staff can reduce motivation to collaborate with other sectors, yielding high staff turnover and poorer outcomes. Therefore, managing the workload of staff is key in both the initial stages of implementation and the ongoing functioning of IHSs 25 27…”

“…These include: interprofessional teamwork involving both top-down and bottom-up communication,24 25 35 the formation of good working relationships built on trust,26 35 36 and the presence of shared information technology platforms between organisations to enable easy data sharing 20 21 24–26 31 37 38. The lack of ongoing planned communication between members of partnering organisations leads to contact often being limited to emails with minimal face-to-face interaction, and was often cited as a barrier to long-term collaboration 27…”

“…Economic factors, such as the reluctance of commissioning organisations to pool budgets, and low levels of funding and staff, often with inadequate training, were cited as barriers to planning and implementing integrated care in 61% of articles,30 32 33 and the need to devise long-term plans with an appropriate level of funding was expressed as vital to preserve the ongoing functioning of IHSs 18 27. Providing a manageable caseload without overstretching human resources is also a crucial success factor for the long-term functioning of IHSs,33 as it was in the case of Coastal Locality in Torbay and South 35.…”