Lessons from the integrated care pilots

Last month the Department of Health published the findings of a two-year independent study of 16 integrated care pilots. The pilots were established following Lord Darzi’s recommendations on the need to explore different ways of providing integrated care to drive improvements in the quality and cost-effectiveness of patient care. Experimentation was encouraged, so the 16 initiatives varied greatly in the populations and/or the diseases and conditions they sought to influence and in the way organisations and teams were developed.

It is fair to say that the collective results of these pilots have been mixed. While the staff generally reported positive experiences in terms of things such as improved teamworking and greater job interest, and they thought that quality of care to their patients had improved, this was not necessarily reflected in the experiences of the patients and service users themselves. Although patients reported receiving care plans more frequently and most felt that care was being better co-ordinated after a discharge from hospital, people found it significantly more difficult to see a doctor or nurse of their choice, were less involved in decisions about their care, and were listened to less frequently.

What these findings imply is actually a common problem in integrated care – the process of ‘doing’ the integration can often become the priority and the emphasis on the care experience gets lost in the process. This problem needs to be ‘red flagged’. As our recent work on the experiences of older patients in hospital and of people with long-term physical and mental health needs highlights, continuity of care and personal relationships affect people’s life chances. Recent research from Canada has demonstrated how measuring user experiences can predict the extent to which care is well co-ordinated and the subsequent impact on people’s care outcomes.

A key lesson from the integrated care pilots is that the experiences of patients and service users must be captured and acted on. This would help ensure that new approaches to care – which might involve shaking up the way patients interact with care professionals – focus on developing continuity of care with service users. It is for these reasons that The King’s Fund recently called for the use of patient experience measures to drive forward the integrated care agenda.

Perhaps the most unexpected result from the pilots was a significant increase in emergency admissions (9% in the six sites that focused on case management). At first glance this seems counter-intuitive, but if you are focusing on those at most risk of a hospital admission due to their serious ill-health, the chances are that you will see an increase in emergency admissions as patients are appropriately admitted for specialist care. To reduce emergency admissions for higher-risk individuals would require a complex and sophisticated multidisciplinary team of specialists to manage their needs in the community, something that existing nurse-led teams cannot offer.

However, outpatient attendances and elective admissions were significantly reduced – by 22% and 21% respectively. This suggests that patients needing ongoing care and support can be effectively managed in the community. Indeed, overall, there was a 9% reduction in total secondary care costs in the pilot sites doing case management, even with the spike in emergencies. This, at least, proves that case management can be effective in controlling non-emergency admissions and containing costs.

It is a shame that no data was collected on care outcomes, clinical effectiveness or mortality (though the varied nature of the pilots probably precluded this type of analysis). In future we need to ensure that the ‘triple aim’ goals of integrated care are being met: positive user experiences, better care outcomes, and improved cost-effectiveness.

As part of a broader programme of work on integrated care, we are currently recruiting case sites that have demonstrated such successes for a project looking at care co-ordination for people with complex chronic conditions.

Comments

I have been involved in a number of attempts at integrated working for over 10 years both in the Community and in Emergency Care settings. I have always felt that combining skills both interprofessionally and interagency is a very powerful resource for our patients, however I feel that we have only scratched the surface of what could be achieved. On a number of occasions when we have just started to achieve something very effective a change of management has meant the undoing of years of good work on the ground. There are many elements of the move towards integrated care that feel very much two steps forward one back. However I am currently working for a Community Trust providing Prevention of Admission work and Complex Discharge Planning in an Acute Trust hospital and sharing an office with Adult Services staff, so we are heading in the right direction. Despite this each day is a battle to get the needs of our patients met effectively.

I will be following your Integrated Care discussion with interest as I believe this is the way forward for effective provision of care and maximum use of our dwindling resources.

I have read many of the helpful information on your web site can you tell me which hospitals were part of the integrated care pilot .Thanks Louise

Lessons we can draw from these pilots are firstly that its clear that patients' and carers' views and aims are key to developing more effective services, especially for older people with multiple long term conditions. Hearing their voice is a challenge as they dont come to focus groups or meetings as they tend to be housebound but we need to ensure we hear them.
Secondly, integration of community health and social care services without engagement of primary care (GPs) or secondary care (acute hospitals) is not especially likely to impact on secondary care usage.
I remain optimistic that there can be an impact on non-elective secondary care usage if we can move services like comprehensive geriatric assessment to where the patients (people) are (in their own homes) rather than waiting for them to come to the front door of the hospital.

I was iniitally disappointed not to see greater impact from integrated healthcare, but your comments on reduced secondary care costs are encouraging. Certainly from both a primary and secondary care perspective fragmented care remains a constant concern with pockets of active improvement as a result of Clinical Commissioning. There is a great opportunity to work across organisational silos with both then Health and Wellbeing boards and Local Education and Training Boards. A much more effective use of easy access feedback from clinician users and patients which indicates trends to local lead clinicians for each bundle of care seems a practical way forward.

This is a very helpful summary. What is clear is that we need a set of measures of effectiveness of integrated care which include patient experience, and that we need to be tracking and owning those within any service and modifying our interventions if they are not improving. The question is not whether integrated care is the right thing to do, but what approaches to integrated care get the right results from everyone's perspective. Complex interventions need ongoing modification based on tracking results of a broad set of outcomes.

As you know Northern Ireland has an 'integrated' health and social care sysem. It is generally hailed as a good model, however despite our 'integrated' system we have similar problems in terms of co-ordination, professional boundaries and different budgets heads etc.