Financial benefits of integration: a case of wishful thinking?BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3661 (Published 03 June 2014) Cite this as: BMJ 2014;348:g3661
The case for integrating care has been compelling. It seems obvious that health and social care services should be working more closely together to provide better care, meet rising demand, and cut costs in wasted or duplicated efforts. It is the much needed shift in care provision that people have been talking about for 20 years. But evidence that integration works is hard to find. Does it justify the time and money being spent?
Integrated care is an imprecise term. It is often used to describe the coordination of existing services, perhaps extending to pooling budgets or sharing staff. But Merav Dover, chief officer for Southwark and Lambeth Integrated Care in south London––says: “Don’t confuse integration with just joining up—it’s a completely different approach and model of care.
“You have to look at your entire services and change them,” says Dover, who works with King’s College Hospital and Maudsley and Guy’s and St Thomas’ foundation trusts, Lambeth and Southwark clinical commissioning groups (CCGs), councils, and general practitioners. “You cannot do this as an add-on. You have to change the way everybody’s working so that it’s mainstream, not an improvement project that is added on. Only when it’s mainstream in that way will we really see the results in the measurements.”
The aim, she says, is to deliver a “social model of care” built around prevention, early intervention, and community services for long term conditions. The government’s Better Care Fund, created to fund integration, has allocated £3.8bn (€4.7bn; $6.4bn) for integrating health and social care in the 2015-16 financial year. Early analysis of the fund’s plans submitted to the Department of Health indicates that councils and CCGs are set to pool around £5.2bn in 2015-16—£3.8bn of Better Care Fund money and £1.4bn from other budgets.
Most people agree that integration will be better for patients. But it is far from clear that investing in integration will save money in the long run.
Last November, when health minister Norman Lamb launched 14 integrated care pioneer schemes, he said: “Through an integrated approach we can achieve better results for patients and make the money go further, whilst making necessary savings.”
Chris Leslie, shadow chief secretary to the Treasury, has described Labour’s “whole person” vision of integrating physical, mental, and social care services as a way to achieve “cashable efficiencies.”
However Chris Ham, chief executive of the King’s Fund, a health think tank, says the optimistic view among politicians of the financial benefits of integration persists “without that being supported by the evidence.”
“I don’t know any evidence of that from any of the evaluations there have been . . . You can certainly reduce waste and take out an amount of inefficiency, but if you’re going to do that you will almost certainly have to find ways of reinvesting what you save into other services to be able to make the changes that integrated care implies.”
Ministers hope that integrated care, and particularly better integration of health and social care, will reduce pressure on hospitals by cutting emergency admissions and speeding up the discharging of patients. But during his first appearance at the health select committee, NHS England chief executive Simon Stevens sounded sceptical about achieving substantial benefits from local schemes being developed under the Better Care Fund. “There are all kinds of ways of doing [integration] which don’t work,” he said.
The chasm between political expectations and reality became clear in March, when a study by the Centre for Health Economics at York University of 38 schemes in eight countries pooling health and social care funds—including 13 in England—found none had shown a sustained reduction in hospital use.1
Senior research fellow Anne Mason, lead author of the study, says: “We have very high expectations of integrated care, and it just seems to make such common sense, but to think that you are then going to save money or reduce secondary care costs is not realistic.”
However, she stresses that the poor results were partly a consequence of the way the data in the original programmes were recorded: “That is partly a measurement problem because they often didn’t follow up the schemes for very long; so we’ve got absence of evidence rather than evidence of absence. But where they did achieve [a change] they often found when they checked back [later] there was no longer any effect.”
Angela Coulter, senior research scientist at Oxford University’s Health Services Research Unit, says that in terms of measured clinical benefits for integration such as better outcomes or reduced time in hospital, “I don’t think there is very much hard evidence . . . We don’t know much at all, not because there aren’t many good examples out there, but because they haven’t been carefully researched.”
Coulter believes claims of substantial improvements in outcomes have often been undermined by the poor quality of research underpinning the numbers: “We have not had an alignment between improvement programmes and good quality, robust research that would stack up clear evidence that this is the way to go.”
It is, however, inherently difficult to show improved outcomes: “For example, some of these projects aim to reduce emergency admissions or reduce costs. Many of them are focused on the most vulnerable groups with the highest needs, and it is going to be very difficult to demonstrate reductions in cost, or greater cost effectiveness.”
The south London scheme claims its older people’s programme could save 23 500 hospital bed days by 2015-16, but Dover admits that effects such as reductions in emergency admissions are difficult to prove. “What we have done with very small numbers is to demonstrate the difference that could be made if we do things at scale—and that’s what we are about to do.”
Discerning clinical benefits is further complicated by integration schemes being bolted onto the end of months or years of poorly coordinated care. That makes it difficult to disentangle the effects of different parts of the care system, or to provide data that are of use in determining what the benefits to patients and the health service would be if whole populations were provided with integrated care.
Results “very much depend on the baseline level of care that they are getting, and that is very variable within as well as across countries,” says Mason.
Identifying clinical or financial benefits is made more difficult by one of the most striking features of integration schemes—they uncover substantial unmet need.
This is typified by a project recently launched in Swansea to improve the identification and treatment of heart failure. After years of little change, the number of heart failure patients jumped from 2150 to 2400 between 2013 and 2014 (box).2
Swansea heart failure project2
Although the Swansea project is focused on heart failure, it is integrated with care for other conditions. Improvements include better medicines management for patients with both heart and renal failure, and having seven nurses in the community who are experts in managing chronic conditions and are trained to identify a range of long term illnesses.
Kathryn Roberts, British Heart Foundation heart failure coordinator for the programme, says: “The chronic illness nurses are well trained, and they are able to treat the patient holistically, because we know heart failure rarely happens on its own.
“The cost of the nurses could be deemed expensive because they are highly trained, but you need that level of knowledge and skills to deliver effective care.”
The work in Southwark and Lambeth, which includes inviting older people for a “holistic health assessment” to identify problems earlier, has uncovered extensive need for social support. Integrated care managers are improving coordination between health and social care so that, for example, health professionals can make social workers aware of nutritional problems. The managers also provide a point of contact for patients so they know there is somewhere they can go to discuss a problem.
Dover says: “We are uncovering a number of social factors—enormous loneliness, people who are fearful to leave their houses, people who are not really moving and their muscles are wasting so they are at a really high risk of falling, people whose nutrition is poor, whose medicine cabinets are overflowing.”
Politicians tend to have a simplistic interpretation of the relation between social care and health care—if you have more of the former you will need less of the latter. But as a Mason puts it: “Social care is a complement, not a substitute.”
While it is true that, for example, ensuring elderly people are feeding themselves properly will help reduce falls, there is not a simple substitution of food and nutrition support for an emergency admission.
Benefits for patients
So if integration does not cut spending, and improved health outcomes are difficult to demonstrate, what is the point of doing it?
Ham highlights a more subtle financial benefit than savings—the ability to reform the way care is provided without ramping up costs: “I would cite the evidence from the turnaround of the [United States] Veterans Health Administration in the 1990s, which clearly shows improvements in the quality of care and clinical outcomes in a number of disease areas, and there was a significant shift from hospital-based care to care outside hospitals, and all that was without a substantial increase in the overall budget.”3 4
So integration offers a care system under financial stress a route from hospital based care to community based support for long term conditions.
Alongside the possibility of reforming care pathways without big cost increases, integration is essential if the rhetoric of patient centred care is to be turned into a reality.
Ham says: “A core aspect of integration is how to integrate care around individual patients, their carers and their relatives—how do you coordinate care to make sure it really is joined up and sees them as a whole person rather than someone with a particular disease? If you don’t do that we are not going to be able to deliver the outcomes and responsiveness that patients need and have every right to expect.”
Anand Chitnis, chair and clinical lead for Solihull CCG, says integrating services enables patients with long term conditions to make sense of their illness and care and take responsibility for what they need to do: “[As a patient] I have to make sense of what could happen, what will happen, what will make a difference. I need to be able to work out what the doctor will need to do and what I will need to do.
“The medical model is, ‘you have a long-term condition, I will treat you and give you drugs.’ That doesn’t make sense to patients in the same way. They are confused, and as a result they have lost control and aren’t making decisions . . . I think integrated care is the answer.”
Keeping the patient at the forefront of integration is essential; otherwise services might feel integrated only to staff. Coulter says: “A worry I have is that many integrated care projects lead to much nicer, cosier conversations between professionals but that doesn’t lead through to any difference for patients, and patients’ experiences and outcomes must be the ultimate test. For people with long term conditions we are not looking for cures, we are looking for improvements in their health status and quality of life.”
As increasing amounts of money and time are invested in integrated care, its development requires better research into costs, outcomes, and patients’ experiences. But strengthening the research foundations will be hard (box).
Need for better research
Mason stresses that the quality of research is crucial: “A very simplistic before and after comparison is not going to be informative, and the anecdotal reports—you can almost ignore them. You need to look at the evidence very critically.
“What needs to be done in Britain is that instead of everyone doing their own thing, we measure things systematically [with] a common set of data. Once you’ve got a common dataset you can get at what the issues are.”
But integrated care involves numerous interventions, so it is difficult to identify and measure specific outcomes. Mason compares this with the relatively straightforward testing of drugs.
“Unless you do randomised, controlled trials you’re never really going to get any reliable results because this is a complex intervention with so much happening, and if you are not trying to assess things in a controlled way you won’t be able to measure things with any sort of precision,” he says.
More than most clinical research, the results from integration projects can be skewed by factors such as governance and team culture. Turning diagrams about information flows and decision making into a new way of working, underpinned by changes in culture and values and a more sophisticated understanding of the patient, requires a wide range of skills and highly effective leadership across all the organisations involved.
“A lot of the difference between successful evaluations and unsuccessful ones relates to the skills that are used around the implementation. I suspect one of the reasons you get negative reports is that those implementation skills weren’t in place,” says Ham.
In the NHS, the effectiveness of integration programmes can be undermined by a payment system that often discourages joined-up working, while the divide between health and social care budgets makes it difficult to share risks and benefits.
Dover stresses the importance of getting the right financial systems in place: “It will require integrated commissioning—so we’re looking to pool budgets across health and social care and payment systems which incentivise prevention not treatment.”
Long term studies of integrated care have an additional problem—with so many different aspects to the care, it will change over time as practice develops: “With a complex intervention it is evolving as you go, and that means you’re trying to measure a moving target. Mason says: “So although integrated care sounds a simple and obvious thing, it is actually much more difficult than a drug if you’re going to try to assess it.”
There is increasing emphasis on measuring patients’ experiences and quality of life.5 While these should be a key measure of success, Mason says: “They are fraught with difficulties in getting people to measure things in a valid way. We’ve got a long way to go in measuring these things.”
Dover believes patients’ experiences must be central to measuring benefits: “We need to measure value in terms of people’s experience of the care, the clinical outcomes and the money that we are spending. We can’t get any one of those three out of balance.” Others have pointed out that these results are often not used to modify practice.6
Ham stresses that while the case for integrated care is sometimes difficult, the case for fragmented care is impossible.
“The evidence base is mixed, but there are a sufficient number of studies that show benefits from integrated care. We should move on from a debate about whether the evidence is good enough to how do we make sure we act on the evidence and realise the benefits more widely,” Ham says.
If health and care services do not pursue integration, “patients will continue to experience disjointed and fragmented care too often; that in turn means there will be mistakes. There will be significant waste in the way we use NHS resources and we will have to keep building a model of care which is too reliant on acute hospital provision because we are not able to invest in the out of hospital services that might enable us to make the shift in care we’ve all been talking about for the last 20 years.
“Integration is about how you make the changes that can ensure the sustainability of the NHS, both financially and clinically. That is the prize to be won.”
Cite this as: BMJ 2014;348:g3661
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.