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"Integrated Care"

Stewert Player is the co-author with Colin Leys "The plot against the NHS"

New study concludes:

1 No shared understanding of what integration means
2 Pilots achieved “only mixed results” and made little progress on unplanned hospital admissions, although staff reported improved communication.
3 Little engagement with GPs, and the impact on patient experience was “mixed”, they reported improved organisation but being less likely to see a doctor or nurse and less involvement in decisions.
While we challenge the flawed provisions of the Health and Care Bill, it’s also important to recognise that NHS England’s claim the Bill is all about creating “integrated care” is founded on bogus assumptions.
Not only will the new system NOT be integrated (all the existing divisions – between commissioners and providers, primary care and secondary care, acute care and mental health, health and social care, NHS quangos and elected local government – remain intact, with outsourced contracts and private providers still in place with no end in sight) but the model of ‘integrated care’ itself has been shown again and again to be flawed.
The relentless drive towards a fresh top-down reorganisation of the NHS in England, to leave decision-making in the hands of just 42 so-called ‘Integrated Care Boards’ (ICBs), with little if any accountability to the local communities they cover, began without evidence – and has continued despite the evidence.
Too many senior managers, policy experts and academics have nailed their colours firmly to the mast of ‘integrated care’ as a supposed magical key to more effective and efficient health services – despite the lack of NHS staff and resources, the necessary bold reform to replace the current largely privatised and dysfunctional social care system with a national care and support service, and the wider policies needed to address widening health inequalities.
None of them now really dares to point to the uncomfortable truth.
This the real takeaway message from a new study (‘Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?’) published in the International Journal of Integrated Care.
The authors are five British academics, a management consultant, and the head of evaluation of RAND Europe. All of them have been involved in funded projects over the past 10 years to establish or investigate and evaluate the three national pilot programmes on integrated care in England, the earliest going back to 2008.
Their combined report seeks to bring together and evaluate the outcomes of these projects: and it’s clear from the summary that there is precious little good news to celebrate:
“There was little stable or shared understanding of what ‘integrated care’ meant, resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. … Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.”
The authors, apparently aware that many similar findings can be found in the growing array of studies and reports on “integrated care” opted nonetheless to focus narrowly on the experience of the three national schemes – and ignore the warning signs on all sides that most of the techniques being adopted are failing to deliver much, if any benefit.
Their report makes it obvious that the schemes being evaluated varied hugely “in terms of their scale of operation, the priorities emphasised, patient groups targeted, interventions implemented and types of organisations involved.”
It appears they shared only two things: all of the schemes were lumped into the general bag of “integrated care” – and they shared the “general expectation among programme sponsors, usually shared by pilots themselves, that integrated care would result in a reduction in the level of unplanned hospital admissions.” However this has not been achieved.
Integrated Care Pilots, the first of the national schemes, launched in 2008 with “some funding” and support from management consultants, actually led to a significant increase in unplanned hospital admissions, along with “reductions in elective inpatient and outpatient care.” And a reduction of 9% in overall costs of hospital care for patients who were individually case managed ran alongside an increase in numbers of them requiring unplanned admission.
Obviously transforming patients from electives into emergencies was not one of the objectives of the pilots.
The impact on the patient experience is politely summed up as “mixed:” in fact patients were less likely to be able to see the clinician of their choice and less likely to have their opinions and preferences taken into account.
Integrated Care and Support Pioneers, beginning from 2013, with “relatively modest financial support” and closer scrutiny by NHS England, apparently delivered “a modest impact on unplanned admissions,” aka limiting the increase in demand to below the average – but only for one year, and not in all pilots. Data are only now, years later, being collected on the patients’ experiences.
New Care Model Vanguards were launched in 2015 with “comparatively lavish amounts of additional funding.” They “slowed the rise in unplanned admissions,” but achieved “no overall reduction in bed-days,” and some of the sites had higher than average unplanned admissions beforehand. No systematic study had been made of patient experience, and evaluations by individual Vanguards schemes were of “mixed” quality.
On other levels, too, the pilot projects have failed to deliver, and highlighted the lack of any real drive to integrate services. Despite reports from all of the schemes of problems sharing data between organisations, for example, “there is little compelling evidence that national NHS organisations did much to address such barriers.”
And despite the obvious importance of linking with GPs to ensure services out of hospital can integrate with hospital care, some so-called ‘Primary and Acute Care Systems’ had “little engagement with local primary care.”
Sites in all three programmes “complained that insufficient resources were hampering their activities – whether a lack of funding or available workforce.” If the pilots are having these problems with extra funding, it bodes poorly for the national roll-out of “integrated care”.
The upshot is that the failed pilots have also yielded few, if any, wider lessons on how integrated care might be made to work:
“No single programme has been able to distil key, generalisable ‘lessons’ that have then been applied subsequently. Indeed, successive programmes did little to build on one another in their conception nor to synthesise learning as they progressed.”
Part of the reason at least must be the failure to deliver what has become the key objective of reducing the need for hospital beds:
“The evaluations have shown that even a modest curbing in the upward trend of unplanned admissions is not guaranteed, takes a long time, may not always be sustained, and may arguably not prove to be value for money.”
So why are these lessons not being learned? Partly there is the reluctance of large numbers of NHS managers to admit that they cannot make the new models deliver: instead their reports roll out reams of bluster and evasion.
One expert at such bluster is Boris Johnson’s advisor on new models of careSamantha Jones, who annoyed local MPs by “walking away” from her post as CEO of West Hertfordshire Hospitals trust after just two years in 2015, to lead Simon Stevens’ “New Care Models Programme” for NHS England. After less than two years presiding over this shambles she again stepped down, to become an ‘independent’ consultant, and six months later signed up as UK chief executive of American health corporation Centene from January 2019.
Ms Jones is one of many who will not be keen to draw attention to the failures of the new systems for fear it might undermine their own credibility. But there is evidence a-plenty that “integrated care” as implemented in England and elsewhere falls well short delivering the expected results.
But it should come as no surprise. Back in 2012 an analytical paper in the BMJ co-authored by one of the new report authors, Professor Martin Roland, questioned one of the central tenets of ‘integrated care’: that hospital admissions could be reduced (and costs cut) by improving primary care interventions, especially aimed at those of high risk (whose chronic health problems often lead to them being perjoratively dismissed by NHS bureaucrats as “frequent flyers”).
Among the bevy of myths dispelled by this study was the illusion that high risk patients account for most admissions, or that case management of such patients could save money:
“most admissions come from low risk patients, and the greatest effect on admissions will be made by reducing risk factors in the whole population. […]
“[…] even with the high risk group, the numbers start to cause a problem for any form of case management intervention – 5% of an average general practitioner’s list is 85 patients. To manage this caseload would require 1 to 1.5 case managers per GP. This would require a huge investment of NHS resources in an intervention for which there is no strong evidence that it reduces emergency admissions.”
Four years ago the National Audit Office also warned of the lack of evidence to show integrated care could deliver the promised improvements in patient care.
In early 2019, the Public Accounts Committee (PAC), commenting on the move to commissioning of services by Integrated Care Systems across much larger areas, noted the dangers of reducing the number of bodies commissioning services:
“… as CCGs become responsible for commissioning services across larger populations there will be a tension between commissioning at a larger scale while maintaining an understanding of the health needs of local populations.”
Last year The Lowdown reviewed an article from the US journal Milbank Quarterly that also exposed the weakness of targeting the small number of patients with complex medical and social needs who “account for a large proportion of health care costs.” The article went on to debunk claims that such action to tackling individual cases could impact on social determinants of health:
“Red flags also have been waving for many years regarding the limits of trying to address the upstream, social drivers of health through individual-level interventions aimed at complex patients.”
The author, Paula Lantz, drew the wider conclusion – also relevant in England – that addressing wider ‘social determinants of health’ and health inequalities can not be successfully done by targeting individual cases:
“Reduced health inequities are not going to result from better care transitions from hospital to home or from tertiary care that attempts to connect patients to beleaguered social safety nets. Achieving health equity requires that we strengthen public policy and community investments to ensure education, economic, social and political resources, opportunities, and well-being over the life course, and that we prioritize evidence-based primary and secondary prevention interventions aimed at populations and communities.”
As discussed in The Lowdown last month, the once left of centre IPPR (“The Progressive Policy Think Tank”) also published a new critical report Solving the Puzzle – Delivering on the promise of Integration in Health and Care, and from the right wing the Thatcherite Centre for Policy Studies has also published a report questioning the evidence that “integrated care” can deliver any improvement in outcomes for patients.

It seems the only people not getting the message are the NHS bosses with fingers in their ears, eyes shut and singing la la la to avoid the warnings that they are riding a dead horse.