Enablers and barriers to coalface primary care reform in England: a qualitative study.

Background: Since the Declaration of Alma-Ata in 1978 (1) global health policy has prioritised primary and integrated care reform to better manage chronic illness, improve health access, and prevent disease.(2) Yet internationally primary care, like the health systems it struggles to support, is currently far from strengthened; and is increasingly challenged by chronic underfunding, lack of recognition, and a diminishing and demoralised workforce.(3,4) AIM: To better understand the policy barriers responsible for the current status from the perspective of general practice in England DESIGN & SETTING: Key Informant Interviews with 12 general practice policy or practice leaders identified from publicly-available position statements, publications or innovative programs in UK primary care reform over the past decade METHOD: A qualitative deductive approach using thematic analysis to analyse informant data to understand historical barriers and explore enablers for future reform.

Results: The analysis resulted in eight main themes. 1. Dynamics of power and autonomy 2. Under-investment in primary care 3. Aligning policy and implementation 4. Navigating complexity and change 5. Building trust through relationships and leadership 6. The revolving door of policy and leadership 7. Valuing the workforce: A key to morale and retention 8. Strategic communication and media engagement CONCLUSION: Better-targeted funding reform, more effective systems integration building on general practice and community service strengths, and better valuing the complex role of the primary care sector as central to a high-functioning health system, were seen as key to the future. Participants also called for more effective policy input from those skilled in the delivery of care, and the capacity for earned autonomy and flexibility to deliver care relevant to individual community need. Action to address these opportunities is pressing, as finalisation of the 10 Year Health Plan and more-immediate NHS restructure rapidly gathers momentum.