The dimensions and determinants of integration in primary care
The NHS has been going through a period of institutional change. New models of health care services have emerged that revolve around integration of primary care providers. The study of integration is important because it influences the performance of NHS organisations. This thesis explores the contribution of industrial economies to eliciting dimensions and determinants of integration in primary care within the context of local health care co-operatives (LHCCs) in Scotland. A definition and taxonomy of integration in primary care was constructed based on a review of the economics and health care literature. Hypotheses about the determinants of integration in primary care were derived from neo-classical economics, new institutional economics, and evolutionary economics. Data were taken from self-administered questionnaire surveys of all Scottish LHCCs, LHCC practices, and non-participating practices. They were then analysed using descriptive, statistical, and regression techniques. LHCC integration was not homogeneous across Scotland. Dimensions of LHCC integration did not develop at the same pace across LHCCs. Some LHCCs had achieved a higher extent of LHCC integration along a number of dimensions than others. LHCC integration was influenced by determinants derived from industrial economics and concerns derived from the health care literature. Area, population, and GP characteristics, and other NHS organisations did not affect LHCC integration. The thesis developed a theoretical framework firmly rooted in economic theory and the health care literature, and applied it to LHCCs in a systematic way. This has provided an insight into the attitude and behaviour of primary care providers towards integration in primary care. Additional work needs to be carried out on the likely implications of integration in primary care on incentives, behaviour, efficiency, and equity in the NHS Scotland.