Obesity and diabetes are grave international health problems [1, 2] and the economic burden for both patients and national economies is significant [3]. Obesity is a complex condition often involving several other chronic and serious diseases requiring lifelong follow-up [4,5,6]. It often affects whole families and intervention is needed at multiple levels, including social and psychological dimensions. Treatment is therefore complex and time-consuming and poses a challenge for the organisation of health care services [7, 8]. Currently, there is a lack of well-established integrated approaches for prevention and treatment across health care levels.
Treatment offerings
To tackle these challenges, the coordination of services needs to be improved [7, 9, 10]. In Norway, the Coordination Reform was launched in 2010 [11]. Here, as in other countries [12], integrated care is accompanied by goals for moving patients from secondary health care to primary care, increasing focus on prevention and health-promoting activities and patient involvement. Obese and overweight patients with related diseases have traditionally been offered treatment in primary care, but in recent years the number of patients with severe obesity and complications has increased and consequently, so has the number of patients referred to secondary health care. To counter such a development, primary and secondary health care providers should jointly develop integrated care based on an understanding of the disease’s complexity. In addition, knowledge and capacity at the primary health care level must be improved and services targeted at prevention and cure must be made available.
Although health care workers are key players in the effort to stop the obesity trend in the population and to prevent the complications of obesity, international research suggests that obese patients do not receive adequate help for their health problems. Studies have shown that health care providers’ treatment and attitude towards overweight and obese patients are governed by poor knowledge and inconsistencies [13, 14] and have a strong weight bias, indicating stigma [15, 16]. A mapping in Central Norway showed a lack of knowledge and tools for how to treat and prevent overweight and obesity [17]. Less than half of the obese patients who sought medical help for their lifestyle problems were advised to lose weight by their GP [18] or given exercise counselling [19], and while research has shown that such advice and counselling may have an effect on weight loss, it is inadequate [20]. Limited treatment contact is thought to be the main reason why modest weight loss is achieved [20]. There are available treatment guidelines for primary care, but there are currently few sufficiently effective established treatment offerings available to children and adults struggling with overweight and obesity within primary health care [21]. More extensive treatment in primary care is often randomly organised, at times by local enthusiasts. Treatment is difficult to establish in primary care because of the complexity involved in treating obesity, and while GPs are competent to diagnose obesity, there is a general lack in knowledge about treating the disease [13, 14] and available time [20]. Furthermore, considering coordination between primary and secondary health care providers, integrated care for patients with obesity is underdeveloped [4, 14, 22,23,24]. In Norway, obese patients are normally referred to secondary health care when they have a Body Mass Index (BMI) ≥ 40 or BMI ≥ 35 kg/m2 with complications of obesity, while children should have an iso-BMI > 35 or iso-BMI > 30 kg/m2 with complications of obesity [25]. However, until a patient reaches this stage in the development of the disease, few treatments are available, and when a patient is referred to secondary health care, a lack of coordination and cooperation between primary and secondary care leads to treatments that may be limited in scope and time.
Education of GP specialists in the health care system in Norway
The health care system in Norway is primarily a public system organised in two levels. Secondary healthcare services are owned and financed by the Ministry of Health and Care Services and managed through four regional health authorities. The primary care level includes general practitioners (GPs), nursing homes, home care services, maternal and child health centres and out-of-hours services. Primary care is organised and financed by the local authorities (municipalities). Even though GPs are organised as a part of the primary care level, GPs are private contractors and not organised in a shared formal organisation that can instruct GPs or act as a partner on behalf of GPs [26].
The educational program for becoming a GP specialist in Norway includes 1 year of practice at a hospital. Currently, there are no positions targeted at GPs’ educational needs, so a GP seeking specialization must apply for a regular specialist training position at a hospital. In most of these positions, the doctor is enrolled in the rota system. This means that candidates will often spend time in emergency admissions on evening and night shifts that are compensated by time off. This leaves little time to attend in-house patients and perform routine follow-up of patients, both of which are relevant for their practice as GPs.
Theoretical basis
Mur-Veeman et al. [27] have shown that organizational and financial splits between health care providers, such as those present in Norway between primary and secondary health care, hinder integrated care development and delivery. Organizational divides are closely linked to contradictory interests, separate professional cultures, power relations and mistrust between health care providers. Martinussen [28] has shown that the interaction between GPs and hospital physicians has improvement potential, and weak collaboration between GPs and hospitals has been the focus of several studies [29,30,31]. Delayed or inaccurate communication can have substantial implications for the quality of care, which is especially apparent when patients need lifelong follow-up. Efforts to strengthen integrated care can counteract such inadequate treatment at the interstices between providers. In this paper, integrated care is defined as “[ ] a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors” [32].
There are many strategies available to foster integrated care. It is found that different commitments, goals and tasks can be major obstacles for collaboration between care levels [33]. Thus, defining roles and having a shared purpose is essential to achieve successful interorganizational collaboration [34]. Other approaches include training of medical staff, a focus on how they perform their responsibilities and tasks, and how they work together with colleagues and patients [32]. Face-to-face interaction is well known to foster trust and collaborative relations. This has also earlier been shown to apply to the relationships between GPs and hospital specialists [28, 35]. Networking and collaboration both horizontally and vertically across health care providers promotes integrated care, as well as a “Shared understanding of patient needs, common professional language and criteria, the use of specific, agreed-upon practices and standards throughout the lifecycle of a particular disease or condition…” [32].
Fruitful integration between care levels is dependent on communication between primary and secondary health care providers [36], and this collaboration becomes even more important for patients with multiple complex conditions and needs [37]. Efforts to improve integration should aim to understand the perspectives of clinicians in each setting and implement strategies that engage both groups by way of shared communication through direct access to each other, interpersonal relations, shared electronic medical records and clearly defined accountability [31]. However, organizational and financial splits between these two parts of the health care system impede such collaboration. The lack of a common hierarchy and governance structure necessitates professionals to create combined responsibilities for shared accountability and decision making to deliver integrated care [38]. There is therefore a need for models and methods that may enhance care delivery suited for patients with complex, long term problems that cut across multiple care providers and settings. Such models should combine the clinical expertise of the specialist and the ability of GPs to bridge the gap between medical and social problems [39] to allow for continuity of care over time. The development of agreed care pathways has the potential to align clinical, management and service user interests across primary and secondary care [40] but has been shown to be most effective in contexts where patient care trajectories are predictable [41]. When pathways are more variable, this is a demanding intervention that requires comprehensive and prolonged efforts by health care professionals in the involved organizations [42].
We have witnessed many efforts to foster integrated care in the past decade, and this topic has received substantial political interest [11, 27]. However, there are few reports on how educational programs for care providers can contribute. A noteworthy exception is Hirsh et al. [43], who studied how a clerkship model may provide undergraduate students with training relevant for the continuity of care. Concerning the specialist training of GPs, there are few examples of similar discussions. Surveying former research in the area revealed that specialist training is rarely debated, and when it is, the discussion concerns evaluation forms, attendance and curricula. We did find a few examples of case studies in which GPs visited local hospitals for knowledge exchange [44, 45]. Such cases have been reported as beneficial for integrated care and mutual learning between GPs and hospital staff, but collaboration lasts a short time, does not involve GPs practising at the hospital and does not demand much involvement between GPs and hospital staff. In response to the challenges described above, the Centre for Obesity Research (ObeCe) at St. Olavs Hospital, Trondheim University Hospital wanted to develop an educational program fostering integrated care. Thus, in 2010, an educational program for the specialization of GPs was established at three regional hospitals in Norway to enhance the exchange of knowledge and strengthen coordination between primary and secondary healthcare providers.
The research question addressed in this paper is thus: what are the main outcomes of the educational program relevant for care delivery to obese patients, as experienced by the participants?
