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Integrated Care: What can the evidence tell us?Naomi FulopKing’s College LondonNovember 2008

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Acknowledgements

NHS Confed publication: Building integrated care(with Nigel Edwards and Alice Mowlam, 2005)

Background literature review (with Alice Mowlam, 2005)

Review of relevant evidence for Integrated Care Pilots prospectus (with Angus Ramsay, 2008)

Health warning

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Defining integration (again)

Economic approaches- markets vs. hierarchies vs. networks- transaction cost economics

(Williamson, 1975)

Organisational theory - integration/differentiation in organisationaldesign

- degree of co-ordination among unitswithin organisations

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Integrated health care

‘Integrated care is a concept bringing together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency’

(WHO, 2002)

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Need for integrated health care“The current care systems cannot do the job.Trying harder will not work, changing systems of care will.”

Need systems of care in which “clinician andinstitutions… collaborate and communicate toensure appropriate exchange of information andco-ordination of care”

(Institute of Medicine, Crossing the Quality Chasm, 2001)

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Continuum of configurations of health care

--------------------------------------------------------->autonomy co-ordination integration

(Source: Grone and Garcia-Barber, 2002)

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Types of organisational integration

Vertical- combination of firms at different stages of the

production process, with a single firm producing the goods or services that either suppliers or customers could provide

Horizontal- combination of two or more firms producing similar

goods or services.

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Drivers of vertical integration

Improve quality of care, esp for long term conditions

Savings in transaction costs (esp where integration of payer and provider)

Economies of scale and scope Managerial control

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Types of vertical integration

where agencies involved at different stages of the care pathway are part of a single organisation

where payer and provider agencies are part of a single organisation

networks/virtual integration

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Typologies of integration (1)

(Shortell, 1996, 2000)

Functional + Physician = Clinical

Integration of support, functions eg. Finance, HR, IT etc

Clinician alignment with aims of delivery system

Extent to which patient care services are co-ordinated across people, functions, activities and sites over time

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Typologies of integration (2)

Denis et al add: Normative integration – role of values Systemic integration – coherence of rules and

priorities

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How integration can occur

Three possible directions: Hospital trusts expand outwards and downwards Primary care trusts expanding outwards and

upwards Formation of new organisations of delivery

(Feachem and Sekhri, 2005)

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Nature of the evidence

Limited – a lot on processes, less on outcomes Quite a lot from US More recently, evidence from other more

comparable health care systems Little large scale evaluation Evaluation of ‘boutique’ pilots (Ouwens et al, 2005)

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Summary of evidence (1) Summary of the impact of integration of payment and provision Most evidence from US (e.g. Burns and Pauly, 2002; Enthoven and Tollen, 2004) , but

also Italy, Canada and UK (Johri et al, 2003)

Perceived improved partnerships increased focus on case management and use of IT systems

important some increases in capacity are reported, but not quantified mixed evidence on admissions and lengths of stay (e.g. Evercare in

England) mixed evidence on costs, with little information available from the

NHS domain; and inconsistent information internationally.

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Summary of evidence (2) Summary of the impact of integration of provision Evidence from US, UK, Sweden and the Netherlands (eg. Ouwens et al, 2005)

Models from England – Care Trusts, Unique Care Some evidence of strengthened partnerships organisational integration being hampered by lack of coordination at

national policy level some reports of improved capacity, e.g. personnel improved focus on governance and adherence to guidelines little evidence of impact on health outcomes limited evidence of impact on cost

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Summary of evidence (3) Summary of the impact of networks e.g. managed clinical networks in Scotland, Chains of

Care in Sweden mixed evidence: while some cases show improved

communication across organisations and with patients, others show key personnel resistant to role changes;

some evidence of improvements in care provision, but few statistically significant; and

little evidence of improvements in costs or health outcomes.

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Lessons

Lesson 1. Integrate for the right reasons Objectives of integration need to be made explicit Is it to improve quality of care, reduce costs,

both? Can objectives be achieved in other ways? Are new services related to core business? –

unrelated diversification may not create real value (Burns and Pauly, 2002)

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Lessons Lesson 2. Don’t necessarily start by integrating

organisations Integration that focuses mainly on bringing organisations

together is unlikely to create improvements in care for patients.

Some evidence that more successful integration can be achieved through formal and informal clinical integration (King et al, 2001)

Excessive focus on patient pathways might lead to a loss of the benefits of overall service coordination, e.g. in managing co-morbidities.

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Lessons Lesson 3. Ensure local contexts are supportive of

integrationKey contextual elements: a culture of quality improvement a history of trust between partner organisations existent multidisciplinary teams local leaders who are supportive of integration personnel who are open to collaboration and innovation effective and complementary communications and IT

systems.

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Lessons

Lesson 4. Be aware of local cultural differences

significant challenge of bringing together organisational cultures that have, in many cases, evolved separately over decades.

e.g. seems to be particularly challenging when attempting to integrate health and social care

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Lessons

Lesson 5. Ensure that community services don’t miss out

Integration of acute and primary/community services may prove detrimental to primary/community services due to longstanding power imbalances esp with regard to distribution of resources (King et al, 2001)

Evidence that integration led from primary sector more successful than integration led from acute sector (Enthoven and Tollen, 2004; Burns and Pauly, 2002)

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Lessons

Lesson 6. Give the right incentives If trying to reduce use of hospital beds, need to

address PbR (e.g. through pooled budgets, sharing risks between primary care and hospitals)

Incentives for frontline staff required – raises issues e.g. for GP contract

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Lessons Lesson 7. Don’t assume economies of scope and

scale Potential economies of scope and scale are likely to take

time to achieve integration has seldom increased efficiency - evidence

from the US (e.g. Burns and Pauly, 2002; Robinson, 2004)

‘integration costs before it pays’ (Leutz, 1999) e.g. due to significantly different practices in organisations to be integrated

‘make or buy’ decision bigger problem for primary care taking over hospital services than hospitals undertaking ‘outreach’ – changes in technology

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Lessons

Lesson 8. Be patient Time required to implement effective integration

is a recurrent theme and is unsurprising given the changes required to address all six elements of integration.

Takes time to effect demonstrable changes in organisational structures, and to processes; and to have these filter down to outcomes.

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Key broader policy issues

Integration of payer and provider: problematic in NHS context – creates monopoly

Integration and system reform – how to deal with PbR?

Nature of GP contract and incentives/opening up of primary care market

Governance and regulation issues

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What we still need to know [1]

Impact on patient experience Development of ‘markers’ for improved processes of

care required e.g. no. interactions between patients and professionals (i.e. is fragmentation reduced?)

Impact on use of services Impact on costs Impact on outcomes – needs careful thought

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What we still need to know [2]

Need to be clear about different components of integration and what is having an impact i.e. interventions needs to be well-described

Some of the evidence comes from ‘boutique’ experiments or pilots – how far can these be ‘mainstreamed’?

What needs to happen to ‘mainstream’?