Evidence on Integrated Care
EVIDENCE ON INTEGRATED CARE FOR WCHW.
1. Kings Fund: Lessons from the Integrated Care Pilots 2012.
- Most unexpected result was a significant increase in emergency admissions (9% in the 6 sites that focused on case management). “To reduce emergency admission for higher-risk individuals would require a complex and sophisticated multi-disciplinary team of specialists to manage their needs in the community”.
+Good result was that outpatient and elective admissions were significantly reduced and saw a 9% reduction in secondary care costs in the pilot sites doing case management.
2. DOH Independent Study of 16 Integrated Care Pilots
Key messages from this evaluation
Integrated care comes in many shapes and sizes
●While much of the wider literature focuses on ‘models’ of integrated care, we found that ICPs developed and implemented a loose collection of ‘integrating activities’ based on local circumstances. Despite the variations across the pilots, a number of aims were shared: bringing care closer to the service user; providing service users with a greater sense of continuity of care; identifying and supporting those with greatest needs; providing more preventive care; and reducing the amount of care provided unnecessarily in hospital settings.
●Most pilots concentrated on horizontal integration – e.g., integration between community-based services such as general practices, community nursing services and social services rather than vertical integration – e.g., between primary care and secondary care. Staff reported improvements in care, most of which were process-related.
●Integrated care led to process improvements such as an increase in the use of care plans and the development of new roles for care staff. Staff believed that these process improvements were leading to improvements in care, even if some of the improvements were not yet apparent. ●
● Patients did not appear to share the sense of improvement
This could have been because the process changes reflected the priorities and values of staff (a so-called ‘professionalization’ of services); the benefits had not yet become apparent to service users (‘too early to tell’) ; poor implementation; or the interventions were an ineffective way to improve patient experience.
●We believe that the lack of improvement in patient experience was partly due to professional rather than user-driven change, partly because it was too early to identify impact within the timescale of the pilots, and partly because, despite having project management skills and effective leadership, some pilots found the complex changes they set for themselves were harder to deliver than anticipated.
●We also speculate that some service users (especially older patients) were attached to the ‘pre-pilot’ ways of delivering care, although we recognise this may change over time. It is possible to reduce utilisation and associated costs of hospital care, but it seems to be very hard to reduce emergency admissions .
●A key aim of many pilots was to reduce hospital utilisation. We found no evidence of a general reduction in emergency admissions but there were reductions in planned admissions and in outpatient attendance. We speculate that among the patients in our pilots some may have been attached to the pre-pilot ways of delivering care, although we recognise this may change over time.
●The costs of implementing change were varied and individual to each pilot. We found no overall significant changes in the costs of secondary care utilisation, but for case management sites there was a net reduction in combined inpatient and outpatient costs (reduced costs for elective admissions and outpatient attendance exceeding increased costs for emergency admissions).
- Most pilots concentrated on horizontal integration e.g between community and social services, not vertical, between primary and secondary care.
- Can integrated care improve the quality of care? Yes, if well led and managed but “are not likely to be evident in the short term”.
- Can integrated care save money?” Not in the short term and not inevitably”.
3. The Nuffield Trust: An overview of integrated care in the NHS : 2011
198 0 s
• coordinated working
• shared planning
• coordinated care
• care programmes
• case/care management
19 9 0 s
• inter-agency working
• intermediate care
• shared protocols
• managed care
• disease management
• inter-professional working
• whole systems working
• integrated delivery networks
• patient-centred care
• shared decision-making
• integrated care pathways
COMPETITION AND CHOICE
Discussions about integrated care have raised concerns over the role of markets and competition in health care, with initiatives to encourage competition across hospitals and greater patient choice potentially making vertical and horizontal integration more difficult to achieve. For instance, at its worst, integration can be interpreted as a takeover bid ‘in which the interests of the smaller or less powerful group are completely submerged’ (Jones, 1972: p345), raising questions over contestability.
Questions remain over the role of competition in facilitating or impeding integrated working. Take the example of an emerging integrated care system in Trafford, where preserving choice between providers at different parts of the pathway is a major challenge in the face of current policy on choice and competition (Ham and Smith, 2010; Shaw and Levenson, forthcoming). The predominant focus in Trafford is to provide integrated services for the local community.
However, with current policy emphasising choice for patients from any willing provider (Department of Health, 2010), similar integrated care systems or organisations may need to create access to alternative providers outside of the immediate network, in order to satisfy wider policy requirements for choice and competition (Lewis and others, 2010).
Emerging evidence indicates that integrated care provides opportunities for improving quality and increasing efficiency of care (see above), both of which are key elements of current policy. To achieve this, a balance is necessary between the need for competition in some areas of care and collaboration in others.
NB. It is only possible to improve what you measure.
“There is a shortfall in evidence of the impact of integrated care. What evidence there is tends to be drawn from a limited range of settings and initiatives, which focus on structures and processes, and involve limited assessment of outcomes or costs. Further work is urgently needed to identify what integrated care initiatives work best for whom, and in what circumstances. As integration is an ongoing process, evaluation can facilitate continual refinement.”
Find out more online at: www.nuffieldtrust.org.uk/integ
4. The Reconfiguration of Clinical services 2014: The Kings Fund
What were the key drivers of clinical service change?
As part of our broader NIHR research, we investigated the drivers of clinical service change. Earlier analysis by The King’s Fund (Imison 2011) argued that workforce, quality, cost and access are the key interlinked factors that need to be taken into account when reconfiguring services, and that the challenge is arriving at a configuration that optimises all four elements. A striking finding from our research was that cost and workforce far outweighed the other two factors in driving service change. Finance featured in 62 proposals (57 per cent of the total), while workforce featured in 53 (49%). 24 reconfiguration proposals (22%) were driven by both workforce and finance.
THE PROCESS OF CHANGE
Many of the reconfigurations reviewed by NCAT encountered public or clinical opposition. For patients and the public, the perceived risks from service reconfiguration frequently outweigh the proposed benefits. The evidence from local media coverage and campaign websites showed that campaigners were often concerned that the proposed changes would reduce access to services, increase waiting times in A&E departments, or that downgrading ‘anchor’ services such as A&E or maternity would lead to further closures over time. Even the successfully implemented reconfigurations had faced public and political opposition, including use of social media, petitions, rallies and public meetings. These campaigns were often supported by local MPs and councillors. Overall, 40 per cent of proposals were not implemented as planned; some proposals were revised over a number of years, and had more than one visit by NCAT.
Fulop et al (2012) have rightly argued that reconfiguration issues cannot be solved by ‘calculations of optimal design’, particularly given the political nature of service change. That being said, we would argue that where evidence does exist, it should be taken into account. The current approach and deficit of evidence can result in change that is not only resented by local communities but does not achieve its original ambitions. There are very few evaluations of significant service change, but those that do exist suggest that reconfiguration has often not achieved the desired results (Spurgeon et al2010; Raftery and Harris 2005) – a finding that mirrors the evidence from the merger literature (Gaynor et al 2012).
What evidence is available to guide service change?
Our evidence review confirms longstanding concerns (Posnett 2002 ; Edwards and Harrison 1999) about the quality of evidence to guide the reconfiguration of clinical services. We found particular gaps around the impact of service change on finance.
For hospital services, this evidence was almost entirely lacking, as large-scale reconfigurations are hardly ever tracked and evaluated. For community and mental health services, the evidence suggests that community-based alternatives may improve quality but are unlikely to deliver significant net savings. This is particularly worrying given assumptions – in many of the proposals reviewed by NCAT (Imison et al forthcoming) and by national bodies (Monitor 2013) – that service reconfiguration will deliver substantial savings.
Nursing shortages are likely to play an increasingly important part in
reconfiguration decisions. Community nursing numbers have fallen at a time when they should be increasing, thus creating an obstacle to new models of community-based care.
The most recent substantive piece of policy on hospital configuration was Keeping the NHS local – a new direction of travel (Department of Health 2003b). This guidance aimed to stem the tide of hospital and A&E closures.
The mindset that ‘biggest is best’ that has underpinned many of the changes in the NHS in the last few decades, needs to change. The continued concentration of acute hospital services without sustaining local access runs the danger of making services increasingly remote from many local communities. With new resources now available, new evidence emerging that ‘small can work’ and new models of care being developed, it is time to challenge the biggest is best philosophy.
(Department of Health 2003b, p 3)
It set out a future for small hospitals as part of a wider whole system of care (see Figure 2 below). Since then, the focus of government guidance has been the process of change rather than the model of care. The most recent guidance (Strategy Unit NHS England 2013) reiterates the four key tests for any proposal, originally set out by David Nicholson (2010). These are:
1. Strong public and patient engagement
2. Consistency with current and prospective need for choice
3. A clear clinical evidence base
4. Support for proposals from clinical commissioners.
As our report highlights, meeting the third of these tests is far from straightforward.
A+E: Page 23:
Average distance from (next) nearest hospital with A&E:
26.8km (trusts with turnover of less than £200 million)
23km (trusts with turnover of between £200 million and £300 million)
21km (trusts with turnover of more than £300 million)
45 sites are located more than 30km from the next nearest A&E
5 sites are more than 60km away (Monitor 2014)
A few studies suggest that greater distance to hospital is associated with an increased risk of mortality once illness severity has been taken into account. Nicholl et al (2007) found a 1 per cent increase in mortality risk for each 10km increase in distance, an effect that was amplified in people with respiratory distress.
Some authors have described a ‘distance decay’ effect under which distance from hospital services reduces patients’ utilisation of them (services are taken less often or later). This impact is disproportionately felt by those with low incomes, poor access to transport, and by elderly people and people with disabilities (Mungall 2005).
P27: The 2014/15 to 2018/19 planning guidance encourages a new model of primary and community care that reduces emergency admissions to hospital. The latest Better Care Fund planning guidance assumes that new, more integrated models of care should deliver a reduction in overall emergency admissions (NHS England and Local Government Association 2014).
The areas with the highest bed use had excessive lengths of stay for patients for whom hospital was the transition between home and supported living (Imison et al 2012). National audit data (based on returns from 50 per cent of clinical commissioning groups) suggest that intermediate care capacity needs to approximately double to meet potential demand.
The average investment in 2012/13 in health-based intermediate care was £1.9 million per 100,000 weighted population, and re-ablement services £0.7 million per 100,000 weighted population – but with wide variation.
SUMMARY OF EVIDENCE
A significant proportion of hospital beds are occupied by frail older people and people with long-term conditions who would be more appropriately cared for in the community. For some conditions, admissions can be avoided with more proactive care, and in many cases, length of stay could be reduced if there were more services to support rehabilitation and discharge. This would deliver a much better patient experience.
However, there is a lot of evidence to suggest that it can be hard for community-based initiatives, including changes to primary care, to significantly reduce hospital admissions.
Delivering improvement seems to require new ways of working across a system, including within hospitals, supported by good continuity of primary care. Even with successful implementation, there is little evidence to suggest that more community-based models of care will generate significant savings. Future workforce projections also present challenges to community-based models of care.
Page 29: Community-based alternatives sometimes have poorer outcomes than hospital-based care (Roland and Abel 2012). Further, home-based telehealth, as implemented in the Whole System Demonstrator sites, did not improve the quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease (COPD), diabetes or heart failure over a 12-month period . (Cartwright et al 2013)
• Systematic reviews and national evaluations are generally consistent in their finding that shifting care out of the acute setting and into the community does not lead to significant reductions in health care costs. (Edwards 2009).
• Evaluations of integrated care programmes have not demonstrated overall changes to secondary care costs. (Bardsley et al 2013
Page 31: An economic evaluation in a pragmatic, cluster RCT showed that telehealth interventions were not a cost-effective addition to standard care for people with long-term conditions (Henderson et al 2013).
• There is conflicting evidence on the impact of telecare and telemedicine. Telemedicine was found to reduce unplanned admissions for heart disease, diabetes, hypertension, and unplanned admissions among older people (Purdy et al 2012). Other studies found that telecare did not reduce admissions for people with COPD, diabetes, or heart failure (Bardsley et al 2013)