Outcomes of the program
The educational program incorporated several strategies earlier identified as beneficial for fostering integrated care in three important domains: organisational, service delivery and clinical practice [
32]. Central to the development of integrated care is vertical integration between primary and secondary health care through
formal and informal relations, networks and collaboration, which breaches the organizational divide between the two systems [
27]. High quality service delivery hinges on the
knowledge and competence of medical staff both at the primary and secondary health care levels, and is not only related to the specific disease(s), but also to care delivery [
32]. In the clinical domain, a shared understanding of patient needs and use of
shared practices and standards between providers is essential [
37]. Interviews with personnel involved in the program indicate that the program showed results in these directions, even though there were also shortcomings. For example, the interviewed GPs did not know whom to approach in their respective municipalities to realize new ideas and changes in care delivery.
The educational program has been shown to be able to foster relations between hospital staff and GPs, which are lacking in the existent health care system. This is important for a patient group that will continuously be in need for care to avoid serious complications and that has the risk of becoming revolving-door patients due to a fragmented and poorly integrated health care system. As Tricco et al. found [
50], multidisciplinary care is needed for chronic patients with complex conditions, and improving care for this group is effective at reducing readmissions. Care needs to be provided in a continuous interplay between primary and secondary care by health professionals who have defined roles and responsibilities and a shared purpose [
31,
33,
34]. This corresponds to earlier recommendations for care delivery for patients with complex care needs [
37], that shows that their need for care is best met by close interaction and collaboration between primary and secondary health care providers.
The educational program contributes to integrated care for obese patients by combining the expertise of specialists from the hospital with the broader and more holistic experience and competence of GPs [
39]. Obesity is a condition that requires caregivers to bridge medical and social problems. With the increased prevalence of complex conditions, hospitals cannot simply discharge patients to primary health care without themselves offering to share their knowledge and expertise. Secondary health care has experienced a strong increase in referrals for patients suffering from obesity and related conditions. To reduce this burden, secondary health care providers need to engage with care givers in primary care to strengthen their ability and capacity to treat this patient group. Also, medical staff at secondary health care institutions need to gain an understanding of how obesity and subsequent treatment are intertwined with broader issues such as work, family life and social problems, as well as the framework conditions of the patients’ local communities. A Cochrane review [
51] concluded that audit and feedback strategies can be important to improve professional practice, but this improvement depend on how the feedback is provided and by whom. Creating a learning environment, as in this educational program where health professionals openly discuss practices and alternative approaches, can thus be a potential strategy for enhancing quality of care.
Through collaboration and direct dialogue, the GPs and specialists involved in the educational program create and shape shared understanding and practices. Patient’s awareness of such dialogues between the GP and specialists from the hospital has earlier been suggested to strengthen patients’ sense of security [
52]. Collaboration between caregivers from primary and secondary health care services is important both for the quality of care that is given to this patient group and to ensure continuity of care. Other strategies, such as developing agreed care pathways, could provide stronger alignment between primary and secondary health care providers, but it might also demand much efforts and prolonged engagement to implement [
42], especially when patient pathways are variable [
41], as in the case of obesity.
The educational model thus promises to compensate for some of the problems of the current organization of the health care system [
27]. The artificial division between clinical specialists at hospitals and GPs in primary care has earlier been shown to lead to weak communication, which affects the continuity and quality of care [
28‐
31]. A doctoral thesis concluded that integration depends on the collaborative partners’ ability to develop all-embracing objectives and view their services and work as a part of the total chain of care. Integration depends on sufficient communication and interorganisational teamwork, a learning environment, common perspectives and clarified roles [
36]. Through developing relations, enhancing knowledge and competence and shared understanding and practices, the educational program studied here promises to breach obstacles to continuity of care for patients suffering from obesity. There are many different strategies that have been shown to be conducive to enhancing quality of care, both within and across primary and secondary care. However, as Grol and Grimshaw [
53] argue, approaches should be fit for purpose and adapted to the barriers and facilitators to change in each situation. The approach chosen here answered a perceived need to strengthen knowledge in primary care. The program continues and is now in use at several departments at St. Olavs Hospital. It should be considered a step towards strengthening integrated care between primary and secondary care.
In Central Norway, since 2010, the educational program has gradually been instituted as a permanent program that is offered to a number of departments at St. Olavs Hospital. As of today, 35 GPs have been employed at seven different departments (Department of Ophthalmology, Department of Ear, Nose and Throat, Head and Neck Surgery, Child Department, Department of Endocrinology, Department of Neurology, Department of Clinical Pharmacology and Department of Gynaecology) at St. Olavs Hospital, Trondheim University Hospital, and in three different departments (Department of Geriatrics, Child Department and Department of Surgery) at Namsos Hospital. According to the Director of Integrated Healthcare at St. Olavs, the experiences from these departments are univocally positive (Personal communication, email to author BK, 6.1.2018). In sum, these experiences reflect this study’s findings. The departments found it useful to interact with GPs to learn more about the expertise in general practice and the GPs increased their knowledge, which in turn was transferred to their colleagues in primary care. Increased knowledge and competence in primary care resulted in fewer referrals to the hospital. Finally, the capacities of the different departments at the hospital increased with the aid of the GPs.
The educational program did not seek to alter the organizational divides between primary and secondary care, but focused on strengthening connectivity and collaboration across these divides by involving GPs in secondary care for a defined time period. According to the informants, this had positive impacts for both primary and secondary care, as discussed above. This was considered a necessary first step to demonstrate the usefulness and feasibility of the program, considering the large number (47) of municipalities in this region, all with highly diversified tasks and structures. An important lesson learnt from this program is that while obesity and diabetes are a growing concern in Norwegian municipalities, it is important to designate funding of assigned positions directed towards such illnesses as a cost-sharing scheme across several municipalities. The continuation of the program now (2018) shows that groups of municipalities are engaging with secondary health care providers to incorporate the increased knowledge and experience of the GPs in municipal structures.
Limitations and future research
The empirical basis for this article is limited, with 13 respondents and one case, although it was carried out in three hospitals. The results are indicative of how such an educational program may contribute to integrated care, but a more extensive program and more studies are needed to reach findings that can be considered representative. The strength of the study is its reporting of a novel model that may foster integrated care and strengthen the expertise of primary care while reducing the burden on the acute sector.
Revising educational programs in line with the model described here may be an affordable and feasible approach to dealing with some of the organizational splits between health care providers. The costs of the program were limited to salary expenses for the participating GPs, and their work at the hospital contributed financially to the respective departments. However, further research should also assess the costs of the intervention and compare these to other strategies for integration. Nevertheless, there is a need for more systematic knowledge of how educational programs may contribute to integrated care and how such programs may have long-term effects on the collaboration between primary and secondary health care providers. Further research should study the effects of such programs, and especially seek to assess how patients experience strengthened interactions and collaboration between GPs and hospital staff.