Shifting Services from Secondary to Primary Care: Stakeholders' Views of the Barriers

Objectives: To identify the barriers to shifting services from secondary to primary care perceived by the involved stakeholders. Methods: Forty-five semi-structured interviews with stakeholders from primary care, acute and community hospitals, purchasers (health authorities) and other agencies involved in two contrasting initiatives to shift services. Results: Stakeholders perceived similar barriers in the two initiatives: disinvesting from existing providers; lack of information on activity and costs; uncertainty over the quality of the proposed alternative service; concern about an increasing workload in primary care; diversity of views within primary care; difficulties in communication between the many agencies involved; and lack of leadership by purchasers. Conclusions: Service shifts which involve disinvestment from existing providers and collaboration between agencies with different views and interests will inevitably face a range of barriers. Attempts to shift services by disinvesting from secondary care are likely to encounter the greatest difficulties. Attempts to shift without concomitant disinvestment may also be slow because of the difficulties of multi-agency collaboration. Frustration will be reduced if those involved have a realistic understanding of the difficulties rather than being surprised and overwhelmed by them.