When is a polyclinic not a polyclinic?

Multilevel Determinants of Common Mental Disorders in Migrant and Non-Migrant Wives in Tajikistan

The purpose of this study was to investigate common mental disorders among Tajik migrant and non-migrant wives in a primary care center. Using a cross sectional design, quantitative surveys using standard questionnaires were administered to 300 married Tajik women aged 18-45 in Dushanbe. Descriptive and multivariate analyses described the demographic and mental health patterns, and comparison of key sub-groups, using Chi-square, T-test and regression. 26% of women in primary care had moderate or severe depression, 17% had moderate or severe anxiety and 20% had moderate or severe PTSD. Lifetime physical or emotional abuse was reported in 22% and women with lifetime physical or emotional abuse had higher depression, anxiety and PTSD scores. Significant multivariate associations predicted the following risk factors: for depression (R²=.40): higher number of people you live with, older age of woman, and migrant husband; for anxiety (R²=.41):more direct trauma and older age of woman; for PTSD (R² =.48):lower number of people you live with, more direct trauma, older age of woman, highernumber of children, non-migrant husband, and lifetime emotional or physical abuse. Mental health interventions are needed in primary care settings for women with common mental disorders, including those exposed to trauma and migration.

Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

Background

An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.

Objectives

To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.

Methods

Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.

Results

Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.

Conclusions

On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Experience of continuity of care of patients with multiple long-term conditions in England

Objectives:

To examine patients’ experiences of continuity of care in the context of different long-term conditions and models of care, and to explore implications for the future organization care of long-term conditions.

Methods:

Qualitative semi-structured interviews were carried out with 33 patients recruited from seven general practices in South London. Patients were selected who had one or more of the following long-term conditions: arthritis, coronary heart disease, stroke, hypercholesterolaemia, hypertension, diabetes mellitus or chronic obstructive pulmonary disease.

Results:

Multiple morbidity was frequent and experiences of continuity were framed within patients’ wider experiences of health care rather than the context of a particular diagnosis. Positive experiences of relational continuity were strongly associated with long-term GP-led or specialist-led care. Management continuity was experienced in the context of shared care in terms of transitions between professionals or organizations. Access and flexibility issues were identified as important barriers or facilitators of continuity.

Conclusions:

Across a range of long-term conditions, patients’ experiences of health care can be understood in terms of nuanced understandings of relational and management continuity. Continuity experiences, meanings and expectations, as well as barriers and facilitators, are influenced by the model of care rather than type of condition.

Will polyclinics deliver real benefits for patients? Yes

Government proposalstoestablish polyclinics are intended to reshape NHS services. Michael Dixon believes they will deliver more patient centred care, but Stewart Kay (doi: 10.1136/bmj.a130)thinks they are an unnecessary change