Background:

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives:

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design:

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures:

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources:

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods:

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results:

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations:

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions:

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work:

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration:

This study is registered as PROSPERO CRD42016039552.

Funding:

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

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 15/77/15. The contractual start date was in June 2016. The final report began editorial review in June 2017 and was accepted for publication in December 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Alison Turner reports membership of the National Institute for Health Research (NIHR) Dissemination Centre Advisory Group. The Strategy Unit (NHS Midlands and Lancashire Commissioning Support Unit) was commissioned to support the Dudley Multispecialty Community Provider (MCP) vanguard, and Alison Turner has been involved in providing evidence analysis in support of the local evaluation of the vanguard. Abeda Mulla reports membership of the NIHR Health Services and Delivery Research (HSDR) Prioritisation Panel (researcher led); The Strategy Unit was commissioned by the Dudley Clinical Commissioning Group (CCG) to deliver a primary care development programme, and Abeda Mulla is involved in providing general practices with service improvement and change support, and evaluating the programme workstreams. The Strategy Unit was also commissioned by NHS England to conduct a rapid research study in the context of General Practitioner (GP) Access, and Abeda Mulla was the technical lead for the project, overseeing all aspects of the analysis and writing the report. Andrew Booth reports being a principal investigator on a NIHR HSDR Evidence Synthesis Centre contract and membership of the NIHR Complex Reviews Research Support Unit Funding Board. Shiona Aldridge works for The Strategy Unit, which was commissioned by NHS England to conduct a rapid research study in the context of GP Access, and she was involved in undertaking the qualitative analysis; she was also involved in providing evidence analysis in support of the local evaluation of the Dudley MCP vanguard. Sharon Stevens reports being involved in providing evidence analysis in support of the local evaluation of the Dudley MCP vanguard and undertaking the evidence review for the NHS England-funded review of managing access in English general practice. Mahmoda Begum reports that, in relation to The Strategy Unit being commissioned by the Dudley CCG to deliver a primary care development programme, she is involved in providing general practices with service improvement and change support, and evaluating the programme workstreams; she was also involved in undertaking the qualitative interviewing and analysis for the NHS England-funded review of managing access in English general practice. Anam Malik reports that, in relation to The Strategy Unit being commissioned by the Dudley CCG to deliver a primary care development programme, she is involved in providing general practices with service improvement and change support, and evaluating the programme workstreams; she was also involved in undertaking the qualitative interviewing and analysis for the NHS England-funded review of managing access in English general practice.