Phase segregation and crystallization in a

Before proceeding, it should be clarified that the focus is whether and/or to what extent interventions are (likely to be) effective in causing a shift of the balance between primary and hospital care to happen, not whether and/or to what extent a shift in the balance is effective for a secondary purpose. It is obvious that this strict criterion would exclude a broad range of relevant studies focusing on strengthening primary care without incorporating analysis of hospital care.

Findings from a systematic review in several high-income countries suggest that a range of interventions could contribute to shifting the balance between hospitals and primary care providers (as defined in this thesis): assessment of elderly people before case management, disease management (especially in relation to long-term conditions), early supported discharge with community-based rehabilitation for stroke and other patients, rehabilitation in the community for a range of conditions, care at home and hospital at home interventions (Johnston et al., 2008). Indeed, various interventions and policy approaches are possible in shifting the balance towards primary care. The remainder of this sub-section focuses on gatekeeping because of the claims made about its potential contributions and the need to keep the review manageable.

Gatekeeping has been defined as an arrangement between primary care providers

and specialists which involves a generalist (primary care doctors, family medicine doctors, general practitioners, etc.) who acts as a gatekeeper for specialist care and coordinates care for patients, i.e. that in order to access specialist care patients have to be referred by a primary care practitioner, and is supposed to work as a mechanism to enhance greater efficiency in use of health care resources (Starfield, 1994). Historically, gatekeeping probably emerged in two ways: first employed by health insurers to approve sickness claims, and then to excess restriction of access to hospital care financially or administratively (Stone, 1978). The search on gatekeeping identified a recent systematic review (Garrido, Zentner, & Busse, 2011) considered by independent assessors at Centre for Reviews and Dissemination (2011) to be of good quality, which has provided a summary of empirical studies about gatekeeping before 2010. For years between 2010 and 2016 (September), the review here included another publication from Egypt (Ward, 2010), covering three indicators: visits to primary care providers, visits to specialists, expenditures for ambulatory specialist care.

One study (Ferris, Perrin, et al., 2001) included in the systematic review was dropped due to severe selection bias³. Only three studies in the systematic review were thus suitable for comparison and provided limited information. A US study by Escarce et al. (2001) reported an additional 50.9% of primary care visits on average in insurance plans with gatekeeping compared to a plan without such requirements.

Schwenkglenks et al. (2006) reported, based on a study in Switzerland, no change in primary care visits after introducing gatekeeping. While Escarce et al. (2001) reported a 77.4% reduction of visits to specialists in gatekeeping plans, a German study by Ose et al. (2008) reported little effect of gatekeeping in reducing specialist care

3 In the study of Ferris, Perrin, et al. (2001), beneficiaries were allowed to choose between plans requiring gatekeeping and without such requirement. As the author acknowledged, the reduction of utilisation and expenditures care in both primary care and specialist care was likely mainly due to selection bias since beneficiaries who expected lower utilisation of care tended to opt for the gatekeeping plan.

-a gatekeeping scheme saw a decrease of 4% of visits to specialists per year on average, while the reduction was 5.8% in a comparison group without gatekeeping. Using a survey from a pilot district with gatekeeping and a control district without gatekeeping, Ward (2010) reported about 63% reduction in visits to hospital outpatient departments, with 10.75% increase in visits to primary care facilities (in contrast to a decrease of 29% in a comparison area without gatekeeping).

Gatekeeping studies identified here could be generally categorized into three groups. The first group focused on gatekeeping as a feature of managed care, and mainly corresponds to the rise and fall of the managed care movement mainly in the US but also in other countries without gatekeeping policies such as Germany and Switzerland between 1980s and early 2000s (e.g. Ferris, Chang, et al. (2001) and Perneger, Etter, and Rougemont (1996)). The second group of studies were in countries with previously strict gatekeeping policies trying to respond to greater calls for choice, particularly in the case of National Health Service Scotland (Perneger et al., 1996).

The study from Egypt (Ward, 2010) was the only study in the third group, addressing the challenge of hospital-centred care in developing countries.

In the Chinese literature, despite repeated reports showing a large proportion of cases could be treated more cost-effectively at lower levels of care (Lei et al., 1996;

Wang, Gusmano, & Cao, 2011a; Xu, Diwan, & Bogg, 2007), studies about the effectiveness of interventions aimed at shifting the balance between primary and hospital care were rare. The only article included was of low quality. Guo, Liang, and Jin (2012), pooled two cross-sectional surveys of residents in the catchment of a community health centre in Beijing that had implemented a payment reform which replaced fee-for-service with global budget, rendering budget independent from providing services. Without using a control group, the study found that the proportions of patients visiting primary care facilities for initial contact rose from 32.6% at baseline to 61%. The quality of the study was further compromised by not providing sufficient

details of methods.

2.5.2 Issues of complexity in shifting the balance between hospitals and primary