Editorial Thursday 22 March 2012: DH integrated care pilots evaluation suggests mixed results

The DH has published the evaluation it commissioned from RAND / Ernst & Young of the integrated care projects pilots.

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You will remember that celebrity nonentity Minister Who? himself attempted to tell the health select committee that Care Trusts (which arose from the integrated care concept had been ""an interesting experiment (that) didn't really get out of the lab".

The analysis is fascinating, and it doesn't find that the pilots were a failure.

I reproduce the executive summary below.

● While much of the wider literature focuses on ‘models’ of integrated care, we found that Integrated Care Pilots (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.

● 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. A range of other improvements in care were reported by pilots following local evaluations. We have reported these but they lie beyond the scope of the national evaluation.

● Patients did not, in general, share the sense of improvement. This could have been:
because the process changes reflected the priorities and values of staff (a so-called professionalisation of services);
because the benefits had not yet become apparent to service users (‘too early to tell’);
because of poor implementation; or
because the interventions were an ineffective way to improve patient experience.

We believe that the lack of improvement in patient experience was in part 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.

● 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.

● 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).

● Can the approach to integrated care found in these pilots improve quality of care? We conclude that it can if well led and managed, and tailored to local circumstances and patient needs. Improvements are not likely to be evident in the short term.

● Can the approaches to integrated care found in these pilots save money? Our conclusions concur with those of Ovretveit (Ovretveit J. Does Clinical Coordination Improve Quality and Save Money? London: Health Foundation, 2011) – not in the short term and certainly not inevitably. However, we found evidence that the case management approaches used in the pilots could lead to an overall reduction in secondary care costs.

● Echoing the views of Powell Davies and colleagues (Powell Davies G, Harris M, Perkins D, Roland M, Williams A, Larsen K, et al. Coordination of Care within Primary Health Care and with Other Sectors: A Systematic Review. Sydney: Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, UNSW 2006), it is noted that the most likely improvements following integrated care activities are in healthcare processes. They are less likely to be apparent in patient experience or in reduced costs.

Important limitations to our findings
● The ICPs stated that they enjoyed considerable support from their status as DH pilots, and, in addition, they were provided with project management support and formative feedback from the evaluation team. For these reasons we should be careful about assuming that lessons learned from the evaluation would apply to establishing integrated care more widely.

● The pilots built on existing practices, then learned, adapted and abandoned some things and seized new opportunities. Any before-and-after study is limited by the emergent and changing character of the interventions.

● Much of the qualitative data used here was sourced from interviews, surveys and structured feedback from the sites. It is inevitable that such data will be subjective and, on occasion, may be designed to present the best impression, though we do not believe this was generally the case.

● The reduction in secondary care costs that we demonstrated in case management sites needs to be balanced against the cost of delivering new services in the community, which were not measured in this study.

● The quantitative evaluation was limited to survey data from staff and service users and comparison of outcomes with data from matched controls. Attribution of changes (or lack of them) to the intervention is less secure in this design than, say, a randomised controlled trial.

What results mean for decision-makers
● The scale and complexity of delivering integrated care activities can easily overwhelm even strong leadership and competent project management. While it may seem obvious in theory that integrating activities should be scaled to match local capacity, this was not always the case in practice. In some cases, enthusiastic local leadership produced expectations that were difficult to realise in practice. Changes to practice often took much longer to achieve than anticipated.

● The focus on the needs and preferences of end users can easily be lost in the challenging task of building the organisational platform for integration and in organising new methods of delivering professional care. Using performance metrics focused on the end user and strengthening the user voice in the platform for integration might avoid this.

● When developing integrating activities there is no one approach that suits all occasions, and local circumstances and path dependencies will be crucial in shaping the pace and direction of change. Integration is not a matter of following pre-given steps or a particular model of delivery, but often involves finding multiple creative ways of reorganising work in new organisational settings to reduce waste and duplication, deliver more preventive care, target resources more effectively or improve the quality of care.

● Similarly, although the needs of the individual ICPs were due to local circumstances, there were some very common challenges reported, similar to those of more general organisational change (see Chapter 7). Individual organisations looking to implement service integration initiatives should take time up front to prepare for these challenges and create back-up plans to address them. We also recommend that the NHS as a whole should work to enable local, transitional changes (e.g., through giving organisations temporary relief from regulations restricting health or social care staff employment, or competition regulations, where strong cases are made).

● Of the approaches used in these 16 pilots, the case management focus adopted by six sites looked to be the most promising in terms of reducing secondary care costs. However, the reductions in costs were in elective admissions and outpatient attendance, rather than in emergency admissions as had been anticipated.

● General conclusions about integration are limited by the nature of these particular interventions, especially their focus on integrating community-based care as opposed to, for example, integration between primary and secondary care (which was the focus of only a minority of pilots).

● Although there are no pre-given steps, we believe that there is a common set of questions that should be asked when delivering more integrated care. These questions are identified in our proposed structured approach to planning and decision-making, which is summarised in our ‘route map’.