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NIHR Signal Ways of integrating care that better coordinate services may benefit patients

Published on 11 December 2018

doi: 10.3310/signal-000693

New integrated care models can increase patient satisfaction, perceived quality of care and improve access to services. It is less clear whether there may be effects on hospital admissions, appointments or healthcare costs. Strong leadership and patient engagement are among factors influencing successful implementation.

The NHS is undergoing reconfiguration to better coordinate services around patients. This NIHR-funded review looked at the international literature to understand how new care models may affect patients, providers and systems. It included a qualitative review of attitudes, barriers and enablers of integration. Nearly half of the 267 studies came from the UK. Most investigated integrated care pathways, often as part of a multicomponent intervention including multidisciplinary teams and some form of case management. Most studies focused on older people.

The complexity and variability of interventions across the literature make it difficult to understand the effect of specific changes. Most studies were at risk of bias, with few comparison studies as these are often not appropriate for organisational research.

The review finds some positives, but overall highlights the complexity of implementing and assessing new models of care.

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Why was this study needed?

The 2014 NHS Five Year Forward View emphasised the need for health and social care services that are coordinated around the patient, rather than being single, unconnected episodes of care. They outlined models for service reconfiguration, including Primary and Acute Care Systems (PACS), integrating secondary, primary and community services; and Multispecialty Community Providers (MCPs), integrating out-of-hospital care. Fifty vanguard sites have taken the lead in developing these models since 2014, with annual funding of over £100 million. Compared with 2014/15, PACS and MCP vanguards have seen lower growth in emergency hospital admissions (1.1% and 1.9%, respectively) compared with the rest of England (3.2%).

However, studies by The King’s Fund and others have highlighted challenges when implementing change, such as difficulties in engaging care providers or clarifying roles and responsibilities. This has led to variability in implementation. It is also unclear whether integrated care influences patient outcomes.

What did this study do?

This systematic review identified 267 pieces of literature from the UK and economically-similar countries, published from 2006 onwards, which analysed and described new models of integrated care. Almost half of the studies (118) came from the UK: 54 were interventional and 64 were qualitative.

The majority of UK (and international) studies examined integrated care pathways, followed by multidisciplinary teams and case management. Interventions had four main elements of focus: patient care, service reconfiguration, workforce changes, or financial or governance aspects.

The researchers used a logic model framework to examine what the benefits of integration might be and the mechanisms for achieving these outcomes.

Many initiatives were complex and only briefly described. All UK studies had potential for bias. Only 16 had high quality comparison design: two were randomised, and participants or assessors unaware of allocation in only four and five studies, respectively. However, this perhaps reflects the difficulties of evaluating complex system changes.

What did it find?

  • Quality of care. Nine of 12 UK interventional studies and four of seven qualitative studies found that integrated care, delivered across variable conditions and services, improved patient satisfaction. Four studies assessing staff-perceived quality of care all reported that this improved.
    There was similarly strong evidence of improved patient satisfaction and perceived quality of care from systematic reviews. All 10 UK studies assessing waiting times (for example, for admission or appointments) consistently reported that this had improved, and all six studies reporting access to services similarly found improvements. There was some evidence from three UK studies that integrated care increased likelihood of meeting patient preferences (specifically about place of death in end-of-life care).
  • Effect on resources. Fifteen of 21 UK studies found that integrated care reduced length of hospital stay. Four of these studies were high quality and most related to community-dwelling older adults. All six studies assessing number of outpatient appointments reported a reduction. Findings were more mixed for scheduled and unscheduled admissions, readmissions, emergency department attendance, frequency of clinician contact, or number of GP appointments. International studies similarly found inconsistent or limited evidence for resource use.
  • System impact. There was no clear evidence that integrated care reduced healthcare costs. Of 12 UK studies assessing overall cost of healthcare provision, only five found a reduction (of which one was qualitative), one showed it increased costs, and the remainder found no change. Three UK studies assessing secondary care costs provided found some evidence for a reduction, but three of four studies assessing community care studies found that costs increased. Systematic reviews and international studies similarly found inconsistent evidence on healthcare costs.
  • Factors influencing implementation. Common workforce-related barriers to implementation reported across UK studies were established hierarchies, professional identity and organisational culture, and difficulties with changed boundaries of professional roles.
    Studies emphasised that training in the new model was essential, in addition to communication between staff with a better understanding of different roles.
    Effective leadership (for example, local champions), clear vision and effective IT systems were among those highlighted as strong enabling factors.
    Many studies also emphasised the importance of patient involvement when developing and implementing new care models.

What does current guidance say on this issue?

The NHS Five Year Forward View (2014) highlighted the need for services to be integrated around patients. In addition to PACs and MCPs as previously described, three other vanguard types have been introduced:

  • Acute Care Collaborations, linking hospitals to improve their clinical and financial stability
  • Urgent and Emergency Care services, to better integrate A&E, GP out-of-hours, urgent care centres and ambulance services
  • Enhanced Health in Care Homes, providing older adults with coordinated health, care and rehabilitation services

NICE guidance is available in specific areas, including the organisation of emergency care services, transition between hospital and community, and comprehensive care for frail older adults.

There are different contexts in Wales, Scotland and Northern Ireland which have had a longer experience of integrated care across different health sectors and across health and social care settings.

What are the implications?

It is promising to find strong evidence that integrated care models can improve patient satisfaction and perceived quality of care. However, on the whole, the complexity of interventions make it difficult to conclude the effects on individual people’s health, and healthcare systems and resources.

The challenges of implementing and evaluating new care models may be worthy of further evaluation.

Different elements are considered in this international review, from multidisciplinary teams to shared budgets and services. As the authors suggest, further study needs to identify the specific elements of new care models that affect outcomes.

Citation and Funding

Baxter S, Johnson M, Chambers D et al. Understanding new models of integrated care in developed countries: a systematic review. Health Serv Deliv Res. 2018;6(29).

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 15/77/10).

Bibliography

The King’s Fund. Integrated care in Scotland, Northern Ireland and Wales. London: The King’s Fund; 2013.

NHS England. NHS Five Year Forward View. London: NHS England; 2014.

NHS England. Next steps on the NHS Five Year Forward View. London: NHS England; 2017.

NHS England. Models of care. London: NHS England; 2016.

Why was this study needed?

The 2014 NHS Five Year Forward View emphasised the need for health and social care services that are coordinated around the patient, rather than being single, unconnected episodes of care. They outlined models for service reconfiguration, including Primary and Acute Care Systems (PACS), integrating secondary, primary and community services; and Multispecialty Community Providers (MCPs), integrating out-of-hospital care. Fifty vanguard sites have taken the lead in developing these models since 2014, with annual funding of over £100 million. Compared with 2014/15, PACS and MCP vanguards have seen lower growth in emergency hospital admissions (1.1% and 1.9%, respectively) compared with the rest of England (3.2%).

However, studies by The King’s Fund and others have highlighted challenges when implementing change, such as difficulties in engaging care providers or clarifying roles and responsibilities. This has led to variability in implementation. It is also unclear whether integrated care influences patient outcomes.

What did this study do?

This systematic review identified 267 pieces of literature from the UK and economically-similar countries, published from 2006 onwards, which analysed and described new models of integrated care. Almost half of the studies (118) came from the UK: 54 were interventional and 64 were qualitative.

The majority of UK (and international) studies examined integrated care pathways, followed by multidisciplinary teams and case management. Interventions had four main elements of focus: patient care, service reconfiguration, workforce changes, or financial or governance aspects.

The researchers used a logic model framework to examine what the benefits of integration might be and the mechanisms for achieving these outcomes.

Many initiatives were complex and only briefly described. All UK studies had potential for bias. Only 16 had high quality comparison design: two were randomised, and participants or assessors unaware of allocation in only four and five studies, respectively. However, this perhaps reflects the difficulties of evaluating complex system changes.

What did it find?

  • Quality of care. Nine of 12 UK interventional studies and four of seven qualitative studies found that integrated care, delivered across variable conditions and services, improved patient satisfaction. Four studies assessing staff-perceived quality of care all reported that this improved.
    There was similarly strong evidence of improved patient satisfaction and perceived quality of care from systematic reviews. All 10 UK studies assessing waiting times (for example, for admission or appointments) consistently reported that this had improved, and all six studies reporting access to services similarly found improvements. There was some evidence from three UK studies that integrated care increased likelihood of meeting patient preferences (specifically about place of death in end-of-life care).
  • Effect on resources. Fifteen of 21 UK studies found that integrated care reduced length of hospital stay. Four of these studies were high quality and most related to community-dwelling older adults. All six studies assessing number of outpatient appointments reported a reduction. Findings were more mixed for scheduled and unscheduled admissions, readmissions, emergency department attendance, frequency of clinician contact, or number of GP appointments. International studies similarly found inconsistent or limited evidence for resource use.
  • System impact. There was no clear evidence that integrated care reduced healthcare costs. Of 12 UK studies assessing overall cost of healthcare provision, only five found a reduction (of which one was qualitative), one showed it increased costs, and the remainder found no change. Three UK studies assessing secondary care costs provided found some evidence for a reduction, but three of four studies assessing community care studies found that costs increased. Systematic reviews and international studies similarly found inconsistent evidence on healthcare costs.
  • Factors influencing implementation. Common workforce-related barriers to implementation reported across UK studies were established hierarchies, professional identity and organisational culture, and difficulties with changed boundaries of professional roles.
    Studies emphasised that training in the new model was essential, in addition to communication between staff with a better understanding of different roles.
    Effective leadership (for example, local champions), clear vision and effective IT systems were among those highlighted as strong enabling factors.
    Many studies also emphasised the importance of patient involvement when developing and implementing new care models.

What does current guidance say on this issue?

The NHS Five Year Forward View (2014) highlighted the need for services to be integrated around patients. In addition to PACs and MCPs as previously described, three other vanguard types have been introduced:

  • Acute Care Collaborations, linking hospitals to improve their clinical and financial stability
  • Urgent and Emergency Care services, to better integrate A&E, GP out-of-hours, urgent care centres and ambulance services
  • Enhanced Health in Care Homes, providing older adults with coordinated health, care and rehabilitation services

NICE guidance is available in specific areas, including the organisation of emergency care services, transition between hospital and community, and comprehensive care for frail older adults.

There are different contexts in Wales, Scotland and Northern Ireland which have had a longer experience of integrated care across different health sectors and across health and social care settings.

What are the implications?

It is promising to find strong evidence that integrated care models can improve patient satisfaction and perceived quality of care. However, on the whole, the complexity of interventions make it difficult to conclude the effects on individual people’s health, and healthcare systems and resources.

The challenges of implementing and evaluating new care models may be worthy of further evaluation.

Different elements are considered in this international review, from multidisciplinary teams to shared budgets and services. As the authors suggest, further study needs to identify the specific elements of new care models that affect outcomes.

Citation and Funding

Baxter S, Johnson M, Chambers D et al. Understanding new models of integrated care in developed countries: a systematic review. Health Serv Deliv Res. 2018;6(29).

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 15/77/10).

Bibliography

The King’s Fund. Integrated care in Scotland, Northern Ireland and Wales. London: The King’s Fund; 2013.

NHS England. NHS Five Year Forward View. London: NHS England; 2014.

NHS England. Next steps on the NHS Five Year Forward View. London: NHS England; 2017.

NHS England. Models of care. London: NHS England; 2016.

Understanding new models of integrated care in developed countries: a systematic review

Published on 24 August 2018

Baxter S, Johnson M, Chambers D, Sutton A, Goyder E & Booth A.

Health Services and Delivery Research Volume 6 Issue 29 , 2018

Background The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care. Objectives The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes. Design The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings. Setting Any setting. Participants Patients receiving a health-care service and/or staff delivering services. Interventions Changes to service delivery that increase integration and co-ordination of health and health-related services. Main outcome measures Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff. Study design Empirical work of a quantitative or qualitative design. Data sources We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review. Review methods The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence. Results We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs. Limitations Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness. Conclusions There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models. Future work Links between elements of new models and outcomes require further study, together with research in a wider variety of populations. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

Integrated care is seen by all national governments in the UK as a potential solution to the challenges of rising demand and poor patient experience when people require support across service boundaries. There is no doubt that fragmentation in care is a problem, but it’s less clear what is a reasonable expectation of impact from the possible approaches and how to best implement them.

This literature review sets out what we know to date and, just as important, the boundaries of our knowledge. We can say with some confidence that models which work across a system can improve patient experience and access to care but not yet that they influence the use of resources or overall costs. Common interventions such as multi-disciplinary teams and case management are most effective when introduced as components of a larger programme.

The review also highlights that positive impact is dependent on the implementation process overcoming numerous barriers. It confirms previous research that transformation requires engaging the workforce, addressing incompatible systems, and meaningful involvement of patients and communities.

Integrated care is not quick, or cheap, but the review finds sufficient evidence that it is a goal worth pursuing.

Dr Robin Miller, Deputy Director, Health Services Management Centre, University of Birmingham

The commentator declares no conflicting interests