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The organisation of care for people with multimorbidity in general practice: An exploratory case study of service delivery
[Thesis]. Manchester, UK: The University of Manchester; 2015.
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Abstract
This thesis explores the provision of services for people with multimorbidity in general practice. It considers 3 broad research questions: how services are organised; why they are configured in this way; and the impact this organisation has on service delivery. At present, there is no formalised system for managing multimorbidity in general practice. Current arrangements reflect the wider organisation of care for chronic conditions which typically involves managing individual chronic conditions. The needs of people with multimorbidity are often complex and require a number of services from several providers. Coordinating these services is challenging, not least because of the fragmented system within which professionals and providers are situated. Different clinical, managerial and funding arrangements complicate this situation, creating as it does a number of parallel work streams. Effective healthcare for people with multimorbidity requires different providers to work collaboratively to promote linkage across professional and service boundaries. Information flows and administration play an important role in promoting continuity and coordination within and across work streams that span primary, secondary and tertiary care. In some instances, inefficiencies in services can be linked to the lack of integrative working between the clinical and administrative aspects of care. At present, fragmented systems are perpetuated by the lack of a whole systems approach that would align clinical, managerial and financial aspects of service provision across organisations. This thesis demonstrates that, services in general practice are increasingly determined by factors external to it. Most notably the division of care across multiple providers and the financial and contractual arrangements which require an organisation of services that promotes a division of labour and a routinsation, aimed at optimising the daily through put of patients. If the present and future needs of people with multimorbidity are to be effectively met, changes to the way services are provided in general practice must be considered as part of a whole system of healthcare, whereby collaborations between different professionals and services are intentionally organised and actively managed. Although the evidence base for managing multimorbidity is limited, there is a growing recognition that in terms of improving outcomes for people with multimorbidity, improving clinical care alone is not as effective as simultaneously improving the organisation or design of services across the whole system of provision.
Layman's Abstract
This thesis explores the provision of services for people with multimorbidity in general practice. It considers 3 broad research questions: how services are organised; why they are configured in this way; and the impact this organisation has on service delivery. At present, there is no formalised system for managing multimorbidity in general practice. Current arrangements reflect the wider organisation of care for chronic conditions which typically involves managing individual chronic conditions. The needs of people with multimorbidity are often complex and require a number of services from several providers. Coordinating these services is challenging, not least because of the fragmented system within which professionals and providers are situated. Different clinical, managerial and funding arrangements complicate this situation, creating as it does a number of parallel work streams. Effective healthcare for people with multimorbidity requires different providers to work collaboratively to promote linkage across professional and service boundaries. Information flows and administration play an important role in promoting continuity and coordination within and across work streams that span primary, secondary and tertiary care. In some instances, inefficiencies in services can be linked to the lack of integrative working between the clinical and administrative aspects of care. At present, fragmented systems are perpetuated by the lack of a whole systems approach that would align clinical, managerial and financial aspects of service provision across organisations. This thesis demonstrates that, services in general practice are increasingly determined by factors external to it. Most notably the division of care across multiple providers and the financial and contractual arrangements which require an organisation of services that promotes a division of labour and a routinsation, aimed at optimising the daily through put of patients. If the present and future needs of people with multimorbidity are to be effectively met, changes to the way services are provided in general practice must be considered as part of a whole system of healthcare, whereby collaborations between different professionals and services are intentionally organised and actively managed. Although the evidence base for managing multimorbidity is limited, there is a growing recognition that in terms of improving outcomes for people with multimorbidity, improving clinical care alone is not as effective as simultaneously improving the organisation or design of services across the whole system of provision.