Primary care transformation – achievable aim or a unicorn in disguise?

Problem

Health systems across many countries are attempting to address issues of access, demand and cost containment by reforming or developing primary care, as re-affirmed in the Astana Declaration. Increasingly, re-design is badged as ‘primary care transformation’. However, what does that mean? Is policy clear about which aspects of a health system should be targeted and can research evidence inform that re-design? As part of a programme of work evaluating primary care transformation in Scotland, we aimed to analyse the research and policy evidence to understand; (1) what is primary care transformation; (2) what areas of delivery does it address; and (3) what are the enablers and barriers of primary care transformation.

Approach

Systematic scoping review of research literature focused on primary care transformation from 1996 to 2018, which included new models of care, new ways of working, and service integration. Papers included had to report on reviews or syntheses of data across multiple sites. The policy review focused on the UK; we searched Department of Health, NHS England, Scottish Government and NHS Scotland sites from 2013 onwards, as well as key organisations such as the Health Foundation, and the National Audit Office. Analysis used the Framework approach and was underpinned by Normalisation Process Theory to explore how ‘primary care transformation’ is understood, who is involved, what resources are required and how it is evaluated.

Findings

We screened 404 papers, including 18 full text papers and 15 policy documents. There was no agreed definition of ‘primary care transformation’ although it was generally described as ‘profound’ and/or ‘significant’ change from usual ways of working. Staff roles and relationships; increasing the patient-centeredness of services; and changing payment systems (especially in systems funded by insurance systems) were all areas targeted. Transformation often relied on new uses of IT, but this was often as much a barrier as an enabler. High level commitment to change, team working, adequate and sustainable resourcing were key facilitators. Conversely, resistance from staff, lack of time and sustainable resourcing were barriers. National policy highlighted new ways of working and the importance of IT in achieving transformational change, but with little in the way of strategies to achieve these aims or consideration of the resources or time required.

Consequences

Internationally, Governments are looking to primary care to meet the needs of ageing and increasingly multimorbid, complex patient populations. Transforming care is referred to as a mantra. However, to date, the evidence of what works, in what contexts is not well incorporated into policy and there is often a lack of recognition of the resources required for sustainable change. Researchers and policymakers need to work more closely together to align research evidence with policy needs.