GPs need to play a stronger role in coordinating care for people with long-term or chronic conditions, The King’s Fund has urged.

Limited engagement by GPs reduced both the effectiveness of and the number of referrals across five successful care coordination programmes which the Fund analyses in a new study, it says.

And despite attempts to address this – including financial incentives and information sessions – only one of the five sites studied managed to achieve the desired level of GP engagement.

The report brings together key findings of a two-year project looking at effective strategies for delivering coordinated care for people with long-term and complex needs.  The five programmes – Midhurst Macmillan Community Specialist Palliative Care Service, Oxleas Advanced Dementia Service, the Sandwell Esteem Team (mental health), community virtual wards in South Devon and Torbay and community resource teams in Pembrokeshire – were selected because of their success in moving towards meeting the “triple aim” challenge of improved care experiences, better care outcomes and more cost-effective service delivery.

But the researchers say they found a “chronic” lack of evaluation on which to judge programme performance, and stress the need for more measurement, evaluation and reflection.

The primary purpose of care coordination should be to improve care quality and it should be driven at a local level, says the Fund, which reports that its analysis shows that: 

• care coordination programmes can take some years to mature and build the necessary legitimacy and capability to become accepted;

• successful approaches to care coordination cannot simply be transported “en bloc” – understanding the local context is key;

• scaling-up operations by building a number of locality-based approaches under the direction of umbrella organizations could have more impact on costs:

• weak links with secondary care must be addressed to improve transitions from hospital to home, reduce readmission rates and secure faster access to specialist knowledge; and

• models of care coordination are likely to be more effective when they operate as “fully integrated” provider teams with a degree of operational autonomy.

Commenting on the findings, King’s Fund assistant director of policy Richard Humphries said this first-of-a-kind comparison of five local success stories shows it is rarely easy to build an effective system of joined-up care.

“Common challenges include the need to strengthen engagement with local GPs and build better links with secondary care, as well as difficulties in securing long-term funding,” he noted.