Integrated Care

Following the listening exercise carried out by the NHS Future Forum, the government has pledged that the economic regulator, Monitor, will additionally now be required to support the delivery of integrated patient services, rather than solely promoting competition between providers.1

During the listening exercise, a large number of organisations reportedly stressed the importance of integrated care packages for patients with complex long‐term conditions.2 This group absorbs a large share of health care budgets,3 but co-ordination of their care is currently poor.4 Integrated care may focus on bringing together aspects of primary and secondary care, or it may involve health and social care. A key aim is patient-centred care, with greater co-ordination across care settings.3 In ‘real’ integration, organisations merge their services; in ‘virtual’ integration, providers work together in networks.5

Evidence of the possible benefits

There are several examples of integrated care pilots in the NHS, including care for older people in Torbay, leading to a reduction in emergency bed use.6 Several other benefits may arise from service integration, including improvements in quality of life and patient experience.3

Other pilots have not, however, led to a reduction in acute hospital usage.7 Robust evidence on health outcomes is limited, and much of the evidence focuses on the American experience.8 One of the best known examples of integrated care is Kaiser Permanente – a virtually integrated system in the United States involving hospitals, primary care and commissioning. A key focus is on pro-active care co-ordination, and its members require fewer hospital admissions than average.6 However, there may be questions about the relevance of these findings to the NHS, given the fundamental differences between the two health care systems.

Another premise of integrated care is that it will result in greater value for money,9 although there is only limited cost-effectiveness information available.8 Others argue, however, that health systems employing integrated care models tend to be associated with lower costs, as well as better outcomes and higher patient satisfaction.10

Evidence of the possible risks

For some there is no contradiction between the drive to increase patient choice and provider competition, and the argument for greater integration.5 However, reconciling integration with greater patient choice will be a key challenge,11 as integration necessarily implies some restriction on patient choice of provider.12

Other potential barriers to greater integration of care include the requirement for NHS foundation trusts to maximise their income and thus patient throughput; potential public and political concerns about service reorganisations; and professional resistance to integrating services.5,13

Implications for health and well-being

This policy summary has focused on the integration of care for patients with complex conditions, but provider collaboration is also important in areas such as urgent care and cancer services, where better outcomes depend on services being provided in networks.14

While the formal evidence underpinning greater integration of care is as yet underdeveloped, many commentators believe it offers scope for large gains in both efficiency and health outcomes.9 Integration has been promoted as a means by which health systems in Europe and America could address the challenges of ageing populations and increased prevalence of chronic diseases.15 The financial pressures facing the NHS have added additional urgency.13

Author: Dr Helen Barratt, Wellcome Trust Research Training Fellow, Department of Epidemiology & Public Health, University College London

UK area affected: England only

Further reading

Ham C, Dixon J, Chantler C. Clinically integrated systems: the future of NHS reform in England? BMJ 2011;342:d905

Ham C, Imison C, Goodwin N, Dixon A, South P. Where next for the NHS reforms? The case for integrated care. London: The Kings Fund, 2011.

References

1. Department of Health. Government changes in response to the NHS Future Forum. London: Department of Health, 14 June 2011.

2. NHS Future Forum. Summary report on proposed changes to the NHS. 13 June 2011

3. Imison C, Naylor C, Goodwin N, Buck D, Curry N, Addicott R, Zollinger-Read P. Transforming our health care system: Ten priorities for commissioners. London: The Kings Fund, 2011.

4. The King’s Fund. Improving the quality of care in general practice. Report of an independent inquiry commissioned by The King’s Fund. London: The King’s Fund, 2011.

5. Ham C, Dixon J, Chantler C. Clinically integrated systems: the future of NHS reform in England? BMJ 2011;342:d905

6. Ham C, Imison C, Goodwin N, Dixon A, South P. Where next for the NHS reforms? The case for integrated care. London: The Kings Fund, 2011.

7. Steventon A, Bardsley M, Billings J, Georghiou T, Lewis G. An evaluation of the impact of community-based interventions on hospital use. London: The Nuffield Trust, 2010.

8. Ramsay A, Fulop N. The Evidence Base for Integrated Care. Summary of research evidence prepared for the Department of Health, 2008.

9. Lewis R, Rosen R, Goodwin N, Dixon J. Where next for integrated care organisations in the English NHS? London: The Nuffield Trust, 2010.

10. Singh D, Ham C. Transforming Chronic Care: Evidence about improving care for people with long-term conditions. Birmingham: University of Birmingham, Health Services Management Centre, 2005

11. Ham C. Integrating NHS Care: Lessons from the Front Line. London: The Nuffield Trust, 2008

12. Walshe K, Ham C. Can the government’s proposals for NHS reform be made to work? BMJ 2011;342:d2038

13. Ham C, Smith J. Removing the policy barriers to integrated care in England. London: The Nuffield Trust, 2010.

14. Ham C. The coalition government’s plans for the NHS in England. BMJ 2010;341:c3790

15. Rosen R, Ham C. Integrated Care: Lessons from Evidence and Experience. London: The Nuffield Trust, 2008.