Understanding stakeholder perspectives on the organisation of primary care: the mediating role of the public in community governance.

HV Social pathology. Social and public welfare;R Medicine (General);RA0421 Public health. Hygiene. Preventive Medicine

O'Dowd, John James Mallon ; Hanlon, Philip

University:University of Glasgow

Department:Institute of Health and Wellbeing

关键词: primary care, public health, organisation, models, governance, community governance, general practice;   

Others  :  http://theses.gla.ac.uk/4547/1/2013o%27dowdmd_Redacted.pdf

来源: University of Glasgow

【 摘 要 】

Aim and ObjectivesThe overall aim of this work was to explore the current organisation of general medical services in Scotland, and by doing so, to create evidence which would identify a more effective and acceptable organisational model for the future delivery of primary care (general medical services) within the Scottish context.There were three research objectives: to improve understanding of the views of the public in relation to the organisation of general practice (general medical services) within the wider context of primary care within Scotland; to improve understanding of the views of professionals working within primary care in relation to the organisation of primary care; and to identify and refine models of primary care, and then to test these models of primary care against the status quo with primary care staff and with representatives of the public.MethodsMixed methods were used to answer the research questions. These included group-work with members of the public in order to identify their priorities for the future of primary care;and semi-structured interviews with a purposive sample of primary care staff which combined members of the core practice team with Community Health Partnership and Health Board managers. Two alternative models for the provision of primary care general medical services were identified by combining the findings from the public and primary care staff with the literature. The two alternative models were then explored by public representatives and primary care staff using mixed methods which combined scoring of the models with deliberative discussion.Results Work with the public identified a number of specific priorities. The most important priorities included: quality of care; access to care; and holism. A number of other issues such as a desire for involvement in their own care and the importance of access were also identified. Equity was also acknowledged as being important. There was general agreement between the public and primary care staff in terms of priorities, although staff were resistant to an increased role for the public in overseeing the organisation of practices. Staff and the public agreed on the high levels of variability in general medical practice and the public were concerned about low levels of holism. Staff and managers described an emerging sense of confusion about the roles of general practice. Practice staff had very negative views of Community Health Partnerships and Health Boards in terms of governance, and there was a lack of leadership and direction across primary care. There was evidence of low levels of trust between practice staff and CHP/Board managers. Skillmix was seen as desirable, though some saw it as a means to cost reduction. The independence of practices within the NHS was overwhelmingly supported by staff, who felt that this was preferable to the difficulties encountered in the directly employed and managed system. Practice ownership and the issue of profit was contested with a number of staff being uncomfortable with the idea, but there was a recognition that removing this driver might have negative consequences. There was ambivalence about the move to a wider model of health and the impact of integration with other sectors which was seen negatively by practice staff.Two alternative models were identified: a local contract model and a social enterprise model. These were tested by public representatives and primary care staff against the status quo. The public scored the local contract more highly on the domains of patient influence on service organisation, and on patient and carer involvement in their care. The public representatives scored the social enterprise model significantly more highly than the local contract model and the status quo. The primary care group did not score the novel models significantly higher than the status quo. The staff group were concerned about proposals to increase the involvement of the public in the organisation of services. ConclusionsThe work builds on that of others who have identified the public’s priorities for primary care. It suggests that holism, patient influence in service organisation and equity are important priorities. The work with primary care staff confirms work by others relating to difficulties with the governance of primary care. Alternative independent models of provision were advanced which might address some of the current difficulties in general medical services. The author proposes that user involvement should form an important part of primary care governance, bringing together conflicting perspectives of CHP/Board managers and practice staff. The public’s main role in governance is to mediate between the positions taken by health professionals and managers, creating a shared perspective which is acceptable to the public. Furthermore, the concept of conditional trust and the emergence of new forms of professionalism which foster interdisciplinary working are proposed as potential solutions to the current impasse.