The ageing population and accompanying increasing multi-morbidity underpins the NHS Long Term Plan's (NHS England (NHSE), 2019) commitment to roll out integrated care systems as part of redesigning patient care delivery within the context of the future population needs. Importantly, the NHS Long Term Plan (2019) acknowledged that the majority of medical consultations occurred in GP practices and in hospital outpatient clinics, although it suggested that roughly a third of outpatient appointments could be unnecessary. Integrated care, with collaborative working between and across health and social care services, was seen as the panacea to achieve improved outcomes and care quality, avoid unnecessary admissions and reduce costs. However, the evidence is less than compelling.
Baxter et al's (2018) systematic review of 167 studies reported perceived improved quality of care, increased patient satisfaction and improved access to care related to integrated care pathways, but inconsistent or limited evidence regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and healthcare costs. Rocks et al's (2020) systematic review and meta-analysis of 34 studies showed a significant decrease in costs and improvement in outcomes associated with integrated care, but there was substantial heterogeneity in both costs and outcomes across sub-groups (for example, studies in Australia/Asia reported the largest cost savings and health benefit, followed by Europe; integrated care pathways showed no significant changes in costs or effect). These findings were echoed in Vestjen et al's (2019) cost-effectiveness study of integrated care supporting community-dwelling frail older people (intervention n=182; control n=176) in the Netherlands, which found a small but significant difference in wellbeing in favour of the control group, no difference in quality-adjusted life years (QALYs) but significantly higher costs in the intervention group. Deschodt et al's (2020) systematic review and meta-analysis of 19 studies, involving 22 168 home-dwelling older people, revealed large variability in nurse-led integrated care and was not able to demonstrate benefit against predefined outcomes.
‘Integrated care, with collaborative working between and across health and social care services, was seen as the panacea to achieve improved outcomes and care quality, avoid unnecessary admissions and reduce costs. However, the evidence is less than compelling.’
Data from different models of multi-morbidity integrated care practices from 24 European countries were analysed by Rijken et al (2018). This revealed a range of type, breadth and degree of integration, reflecting varied foci on specific and combined diseases, with greater discipline involvement enabling higher levels of integrated care. Non-disease-specific practices demonstrated more patient involvement and more comprehensive care. Looman et al (2021) studied 17 integrated care programmes for multi-morbidity from eight European countries to understand key characteristics of successful implementation. These were: incremental growth, as opposed to disruptive innovation, with a balance between flexibility and formal structures in service delivery; collaborative governance and distributed leadership; multidisciplinary team culture with mutual recognition of roles, which stimulated the development of new roles and competencies for integrated care; secure long-term funding; information and communication technology to support collaboration and communication, with feedback loops and a continuous monitoring system (Looman et al, 2021). Indeed, successful implementation of integrated care is crucial to achieving desired benefits; however, as Holterman et al (2020) noted in a Dutch mixed-method case study, while perceived quality of care improved and most health outcomes were positive, there were no clear cost savings across integrated care. Costs were also not balanced across stakeholders, creating financial disincentives, rather than incentives, for integrated care (Holterman et al, 2020).
It is to be hoped that lessons can be learnt not only from our past, but also from other countries, so that integrated care in the UK benefits our clients, enriches the professional lives of all practitioners involved in its delivery, and yields value for money as the country recovers from the pandemic.