Integrated care programmes: We need to think long term when implementing and evaluating complex change

Setting out his vision for The Future of Health Care on 30 July, Matt Hancock outlined the need to ‘drive forward’ the integration of all health and social care services. This is not a new concept – over the years the NHS has launched various initiatives that seek to integrate care, at different levels of the system. Recent examples set out in the 2019 NHS Long Term Plan include multi-disciplinary teams aligned with new primary care networks (PCN) to the regional system-wide Integrated Care Systems (ICS), both of which are currently being rolled out nationally.

However, existing evidence surrounding integrated care initiatives is mixed. Although they may improve patient satisfaction and increase perceived quality of care, there is little or inconsistent evidence that they improve other outcomes relating to the effectiveness, efficiency and quality of care. Some evaluations have found evidence of increased hospital use in the short term, foe example emergency hospital admissions, but these have not looked at the longer-term impacts, making it unclear whether benefits might eventually be realised. 

A whole programme evaluation

Our analysis set out to evaluate the overall impact of the ICTP and not to discern the individual effects of each intervention. To dig a little deeper, we did try to align the pattern of impacts with the timings of the different interventions. However, because so many were introduced, and because they interacted and matured over time, it was not possible to accurately disentangle individual effects. Qualitative analyses could therefore complement our analysis by exploring the effect of the individual components. 

It takes time to realise the full effect of complex change

Our evaluation is unique because it spans 6 years of the programme, allowing us to track impacts as different interventions were introduced, embedded and matured over a long period. It provides promising evidence that integrated care programmes have the potential to reduce hospital use over the longer term, even if there are increases in the short term.

The study suggests that policymakers and local teams need to have realistic expectations of what complex initiatives can achieve in the short term and allow interventions enough time to evolve and mature before changing policy direction. 

Of course, it’s not possible to generalise based on one study and so we are planning to carry out further analyses on two other integrated care programmes to see if the long-term benefits we saw in Mid-Nottinghamshire exist in other settings. These will be available in the new year.

It’s important to allow enough time to capture the effect of complex change

Our evaluation shows that it is important to allow sufficient time before judging the ‘success’ of a complex initiative. This doesn’t mean that evaluations conducted within the first years of a programme aren’t useful – on the contrary, they can provide valuable insight into how changes are affecting people’s health and health needs in the short term. This information can then be used to fine tune the design and delivery of an initiative. However, policymakers need to allow initiatives to run their course – otherwise, they run the risk of drawing conclusions too early that could lead to abandoning potentially effective changes.

Geraldine Clarke is a Senior Data Analyst and Therese Lloyd is a Senior Statistician within the Health Foundation's Data analytics team and the Improvement Analytics Unit (IAU).

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