Background
In many countries, increasing demand for the provision of high quality health care services combined with constraints on health care funding are driving health care systems to seek suitable alternatives to high cost specialist care. Health care systems with better developed primary care tend to have lower health care costs [
1], and stronger primary health care is associated with lower all-cause mortality, as well as cause-specific premature mortality, including cardiovascular diseases [
2,
3].
In economically developed countries, cardiovascular disorders account for substantial proportions of health care expenditure [
4‐
6]. Higher costs for secondary care services in comparison with the management of problems in primary care [
3], difficulties in accessing specialist services, including long waiting times for specialist consultations [
7], fragmented care due to lack of communication across the health care system [
8] as well as a small number of conditions that do not have clearly defined pathways or responsible health care providers, strongly support the shift of services from secondary to primary care [
3].
In England, the increasing use of primary care is evident from the rise in the total number of GP consultations per person per year - from 3.9 in 1995 to 5.4 in 2007 [
9]. The ageing population, combined with the longevity of many people who develop chronic health conditions that require specialised care, also result in an increasing need for specialist consultations, total outpatient appointments rising from around 55 million in 2007/8 to 90 million in 2011/12 [
10].
In consequence, due to increasing demand for consultations and investigations, health care systems are struggling to provide required services within reasonable time limits [
7]. Expanding secondary care services in proportion to increasing demand is not the ideal solution, as increasing the capacity and availability of hospital appointments, although tending to increase costs, does not automatically lead to improved access for all patient groups. Paradoxically, increased access to health care services has been shown to stimulate increased demand [
11‐
14]. Major re-structuring of primary care services is being considered, or is underway, in several countries, partly in order to increase capacity for managing chronic conditions. For example, federations or other forms of practice networking are emerging in England, with similar developments in New Zealand and Canada [
15]. The patient centred medical home movement is extending in the United States [
16].
But is the direct transfer of patients with complex chronic conditions from secondary to primary care a sensible policy? In this paper we argue, having searched for evidence on approaches to shifting care for some people with cardiovascular problems from secondary to primary care, that a collaborative, multidisciplinary approach is required to achieve high quality outcomes from cardiovascular care in the community. To identify relevant evidence, we referred to articles we had already identified and drew on a search of the following bibliographic databases for papers reporting studies of any design that addressed our question: Medline, Social care online, Current controlled trials metaregister, ASSIA (Proquest), Cochrane, HMIC, Biomed central, Google, Europe PMC, HTA, NIHR portfolio database. The searched included articles published 1994–2014. Keywords used for the search were: 'heart failure', 'heart', 'cardiac', cardiovascular', 'chronic cardiovascular conditions', 'multidisciplinary', 'collaborative', 'models of care', 'service'.
Summary
Current research supports the idea of the management of certain chronic health conditions in primary care based on the integration of GPs and specialists into multidisciplinary teams, availability of reliable evidence about cost-effectiveness, health care outcomes, patient preference and incentives for GPs. Evaluation of such schemes is mandatory, however, to ensure that the expected benefits do materialise.
Acknowledgement
Authors would like to thank Ms Rita Bola for her contribution to the literature search.
The preparation of this publication was funded, as part of the project, by Leicester city Primary Care Trust, grant No RM62G0520. The funder had no role in the design or interpretation of the materials or in the writing of the manuscript.
Competing interests
The authors declare that they have no competing interests.
Authors’ contribution
JK has been involved in searching the literature, data analysis, drafting and reviewing of the manuscript. EP and RB have been involved in searching the literature, analysis and comparison of the data, drafting and critically revising the manuscript. CK have been involved in searching the literature and critically revising the manuscript. All authors read and approved the final manuscript.