Impediments to change in an Australian trial of coordinated care

Objectives: To identify impediments to change at the local level in an Australian trial of coordinated care. Methods: Qualitative data were collected from in-depth interviews with key stakeholders, analysis of policy and other documents and the observation of trial processes. We developed an analytical framework that included four domains: agreeing trial goals and objectives; overcoming the financial barriers to producing effective care; reducing costs; and improving continuity of care. In each of these domains, we examined the strategies and processes adopted by the trial as well as the perceptions, actions and reactions of the various stakeholders to the evolving model. Results: The trial had mixed success in implementing its key strategies in each of the four domains. Stakeholders did not fully endorse the trial's key goals and strategies, general practitioners were unable to become effective purchasers, increased gatekeeping was never fully realised, cost-saving strategies were not taken up and improvements in continuity of care were impeded by limited provider networks and general practitioner reluctance to collaborate with other providers. Thus the system had some key features of a coordinated care model but none of the qualities that were needed operationalise to them. Conclusions: The trial's approach to coordinating care and its use of market mechanisms to remove the financial barriers to effective care were insufficient for motivating behaviour change in the context of a system that is structured by powerful social processes and relationships.