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.
Promising findings from our long-term evaluation of an integrated care programme
Our latest briefing from the Improvement Analytics Unit (IAU) looks at the impact of the Mid-Nottinghamshire Better Together Integrated Care Transformation programme (ICTP) on adult hospital use between 2013 and 2019.
The ICTP was established in 2013. It brought together the NHS in Newark and Sherwood, Mansfield and Ashfield, and other local partners to look at how they could join up health and social care services in order to improve the quality of care for patients and reduce costs. In 2015, the ICTP secured funding as an NHS new care model vanguard. In 2016, the partners formed an alliance and now operate as part of the Nottingham and Nottinghamshire ICS.
The ICTP included a range of complex interconnected interventions: some targeted at specific patient groups, for example implementing integrated multi-disciplinary teams to support people with complex needs in the community; and others at the overall population, for example standardising how elective referrals were managed. Successful elements of the ICTP are now being spread more widely by the ICS.
Like other studies, we found some early increases in rates of hospital use in Mid-Nottinghamshire compared to our carefully selected comparison area: for example, in the first 2 years, A&E visits were approximately 4–5% higher in Mid-Nottinghamshire. After that, trends started reversing and by year 6 adults in Mid-Nottinghamshire had 4% fewer A&E visits than the comparison area. In general, we found that it took between 2 and 6 years to see positive effects on various hospital metrics in Mid-Nottinghamshire.
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.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.