The previous section has outlined reviews of the effects of integrated care and highlighted the inconsistency in the evidence. The reviews have been international in scope. Although that brings major benefits in terms of the size and scope of the evidence, it does lead to additional complications in interpretation. Integrated care may have different meanings in different health systems, and the comparator conditions may also vary widely. It is generally accepted that context is an important moderator of the effects of complex interventions,26–28 and the context in which integrated care is introduced may also be very different.25This section has a focus on empirical evaluations conducted in the UK.
The Evercare evaluation29explored the case management of older people at high risk of emergency hospital admission. Although not a formal integrated care intervention, it shares a number of features in terms of the eligible population and the nature of the intervention. Evaluation showed no effects on admissions or other outcomes, although the service was popular with patients and carers.30
The Partnerships for Older People Projects involved a wide range of community- and hospital-facing services, with a significant focus on prevention. Evaluation using data from the British Household Panel Survey suggested some improvements in quality of life, although the comparator was not particularly strong in methodological terms. Although overall analyses31suggested that the investment led to savings, more detailed analyses32of a subgroup of services found no evidence of reductions in hospital admissions, and even
suggested some increases.
An early pilot scheme in England33involved the establishment of 16 ICPs. It should be noted that although these were all introduced into a single health-care system, the pilots did vary, being based on local
circumstances in which the care included in the‘integration’project was dependent on the local context. Overall, the evaluation found that there was an increase in emergency admissions in the pilot areas and there was mixed evidence about whether or not the ICPs were able to reduce costs. Among the 16 ICPs, case management was perceived to be the best option for reducing secondary care costs (a net reduction in combined inpatient and outpatient costs were reported). Such comparisons lack the rigour of randomisation. The findings were also difficult to interpret as the key outcomes that the services were trying to change (emergency admissions) showed increases in activity, whereas reductions occurred in untargeted elective services. Assessments of patients were also conducted as part of the evaluation of the ICPs. Patients reported that they were more likely to be told that they had a care plan, to feel clear about follow-up arrangements and to know whom to contact, and were less likely to report problems with medication. All of these are relevant outcomes of an integrated care initiative. However, somewhat surprisingly, they also reported being less likely to see the health professional of their choice, being less involved in decisions about their care and being less likely to report that their preferences had been taken
into account. Again, all these are relevant outcomes for a person-centred integrated care service. The fact that patients reported reductions in some patient experience measures and improvements in others highlights the difficulties of improving outcomes in this area.33
The North West London Integrated Care Pilot was a large-scale programme that had an initial focus on people with diabetes mellitus and patients aged>75 years. The intervention involved information technology to support case finding and multidisciplinary groups (MDGs) to deliver care planning. Although implementation was generally successful (albeit somewhat delayed) and there were some impacts on process of care (including rates of care planning), a matched controls analysis of effects showed no impact on emergency admissions, although the analysis was judged to be preliminary.34,35
There was also a call for‘ambitious and visionary’local areas to become integrated care pioneers, with 14 sites starting in one wave in 2013 and another 11 sites starting in a second wave in 2015.36Pioneers were tasked with the conventional outcomes of integration initiatives (improved patient experience, outcomes and financial efficiency), with expert support and some very limited additional funding. Early results from the pioneers (largely on the basis of interviews and self-reports from stakeholders) found a common focus on a particular cohort (older, multimorbid or frail patients) and a wide range of potential interventions (including interventions focused on those in need, as well as longer-term prevention work).
Early evaluation has identified a number of barriers to and facilitators of progress, leading to slow
progress and a reining in of ambitions concerning any rapid demonstration of improved outcomes. Patient experience was judged to be the area in which initial gains were most likely to be made. The authors of the report into the pioneers highlighted the‘integration paradox’, whereby financial and other service pressures both increase the pressure for integration (to manage those pressures) and act as a barrier to its effective implementation.37
In some ways, the evidence from the UK studies is less positive than the international literature. Although some positive impacts have been observed, these have been matched by some negative findings (including increases in admissions and reductions in some aspects of patient experience). It is not clear why this should be. The UK has a fairly strong primary care system with which patients are generally highly satisfied.38It is possible that changes that lead to disruption in existing arrangements can cause difficulties for patients, even if the intention is to improve integration.
Integration remains a cornerstone of current health policy, but evidence concerning the benefits of integration, optimal methods of achieving it and the factors that influence success is still limited. The identification of models of integration in the UK that are feasible, sustainable and cost-effective remains a priority.
In that context, the National Institute for Health Research (NIHR) Health Services and Delivery Research (HSDR) programme advertised a call for‘ambitious research studies assessing the cost-effectiveness of new and innovative models of care or clinical pathways for people with long term conditions. The aim is to generate high-impact research which will provide commissioners and providers with useful evidence when re-designing services’.39
The Salford Integrated Care Programme (SICP) was judged to be‘a new and innovative model of care . . . for people with long term conditions’.39The aims of the SICP were to improve integration of care to provide better health and social care outcomes, improved experience for services users and carers, and reduced health and social care costs.
assess the clinical effectiveness and cost-effectiveness of the SICP, with the following research questions.
1. How do key stakeholders (commissioners, strategic partners) view the SICP, what do they expect from it and how is it aligned with their objectives and incentives?
2. What is the process of implementation of two key aspects of the SICP [the MDGs and the integrated contact centre (ICC)]?
1. What is the impact of the MDGs on the outcomes and costs of people with long-term conditions? 2. What is the impact of health coaching in the ICC on the outcomes and costs of people with
Salford Integrated Care Programme:
The setting was Salford in the north-west of England. At the time of CLASSIC, the population of Salford was 234,916 (of whom 34,000 were aged≥65 years). There are comparatively high levels of deprivation (Salford is one of the 20 local authorities with the highest proportion of areas in the most deprived decile) and illness (22.8% living with a long-term illness, compared with a national rate of 17.9%) (SICP
unpublished internal briefing document).
The health and social care system in Salford is largely coterminous, with one local government partner (Salford City Council), a single health commissioner [Salford Clinical Commissioning Group (CCG)], a mental health provider (Greater Manchester West) and a provider of acute and community services (Salford Royal Foundation Trust). Salford contains 52 general practices in eight neighbourhoods.