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Integrated Care: Lessons from the researchNaomi FulopKing’s College LondonSeptember 2008

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Acknowledgements

NHS Confed publication: Building integrated care(with Nigel Edwards and Alice Mowlam, 2005)Background literature review (with Alice Mowlam, 2005)Review of relevant evidence for Integrated Care Pilots prospectus (with Angus Ramsay, 2008)Health warning

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Defining integration (again)

Economic approaches- markets vs. hierarchies- transaction cost economics

(Williamson, 1975)

Organisational theory - integration/differentiation in organisationaldesign

- degree of co-ordination among unitswithin organisations

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Integrated health care

‘Integrated care is a concept bringing together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency’

(WHO, 2002)

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Need for integrated health care“The current care systems cannot do the job.Trying harder will not work, changing systems of care will.”

Need systems of care in which “clinician andinstitutions… collaborate and communicate toensure appropriate exchange of information andco-ordination of care”

(Institute of Medicine, Crossing the Quality Chasm, 2001)

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Types of organisational integration

Vertical- combination of firms at different stages of the

production process, with a single firm producing the goods or services that either suppliers or customers could provide

Horizontal- combination of two or more firms producing similar

goods or services.

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Drivers of vertical integration

Improve quality of care, esp for long term conditionsSavings in transaction costs (esp where integration of payer and provider)Economies of scale and scopeManagerial control

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Types of vertical integration

where agencies involved at different stages of the care pathway are part of a single organisationwhere payer and provider agencies are part of a single organisation networks/virtual integration

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Typologies of integration (1)

(Shortell, 1996, 2000)

Functional + Physician = Clinical

Integration of support, functions eg. HR, IT etc

Clinician alignment with aims of delivery system

Extent to which patient care services are co-ordinated across people, functions, activities and sites over time

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Typologies of integration (2)

Denis et al add:Normative integration – role of valuesSystemic integration – coherence of rules and priorities

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How integration can occur

Three possible directions:Hospital trusts expand outwards and downwardsPrimary care trusts expanding outwards and upwardsFormation of new organisations of delivery

(Feachem and Sekhri, 2005)

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Nature of the evidence

Limited – a lot on processes, less on outcomesQuite a lot from USMore recently, evidence from other more comparable health care systems

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Summary of evidence (1)Summary of the impact of integration of payment and provision Most evidence from US (e.g. Burns and Pauly, 2002; Enthoven and Tollen, 2004) , but also Italy, Canada and UK (Johri et al, 2003)

Perceived improved partnershipsincreased focus on case management and use of IT systems importantsome increases in capacity are reported, but not quantifiedmixed evidence on admissions and lengths of stay (e.g. Evercare in England)mixed evidence on costs, with little information available from the NHS domain; and inconsistent information internationally.

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Summary of evidence (2)Summary of the impact of integration of provisionEvidence from US, UK, Sweden and the Netherlands (eg. Ouwens et al, 2005)

Models from England – Care Trusts, Unique CareSome evidence of strengthened partnerships organisational integration being hampered by lack of coordination at national policy levelsome reports of improved capacity, e.g. personnelimproved focus on governance and adherence to guidelineslittle evidence of impact on health outcomeslimited evidence of impact on cost

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Summary of evidence (3)Summary of the impact of networkse.g. managed clinical networks in Scotland, Chains of Care in Swedenmixed evidence: while some cases show improved communication across organisations and with patients, others show key personnel resistant to role changes;some evidence of improvements in care provision, but few statistically significant; andlittle evidence of improvements in costs or health outcomes.

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Lessons

Lesson 1. Integrate for the right reasonsObjectives of integration need to be made explicitIs it to improve quality of care, reduce costs, both?Can objectives be achieved in other ways?Are new services related to core business? –unrelated diversification may not create real value

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LessonsLesson 2. Don’t necessarily start by integrating organisationsIntegration that focuses mainly on bringing organisations together is unlikely to create improvements in care for patients. Some evidence that more successful integration can be achieved through formal and informal clinical integration (King et al, 2001)

Excessive focus on patient pathways might lead to a loss of the benefits of overall service coordination, e.g. in managing co-morbidities.

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LessonsLesson 3. Ensure local contexts are supportive of integration

Key contextual elements:a culture of quality improvementa history of trust between partner organisationsexistent multidisciplinary teams local leaders who are supportive of integrationpersonnel who are open to collaboration and innovationeffective and complementary communications and IT systems.

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Lessons

Lesson 4. Be aware of local cultural differencessignificant challenge of bringing together organisational cultures that have, in many cases, evolved separately over decades. e.g. seems to be particularly challenging when attempting to integrate health and social care

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Lessons

Lesson 5. Ensure that community services don’t miss outIntegration of acute and primary/community services may prove detrimental to primary/community services due to longstanding power imbalances esp with regard to distribution of resources (King et al, 2001)

Evidence that integration led from primary sector more successful than integration led from acute sector (Enthoven and Tollen, 2004; Burns and Pauly, 2002)

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Lessons

Lesson 6. Give the right incentivesIf trying to reduce use of hospital beds, need to address PbR (e.g. through pooled budgets, sharing risks between primary care and hospitals)Incentives for frontline staff required – raises issues e.g. for GP contract

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LessonsLesson 7. Don’t assume economies of scope and scale Potential economies of scope and scale are likely to take time to achieve integration has seldom increased efficiency - evidence from the US (e.g. Burns and Pauly, 2002; Robinson, 2004)

costs of integration – e.g. due to significantly different practices in organisations to be integrated‘make or buy’ decision more of problem for primary care taking over hospital services

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Lessons

Lesson 8. Be patientTime required to implement effective integration is a recurrent theme and is unsurprising given the changes required to address all six elements of integration. Takes time to effect demonstrable changes in organisational structures, and to processes; and to have these filter down to outcomes.

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Key broader policy issues

Integration of payer and provider: problematic in NHS context – creates monopoly

Integration and system reform – how to deal with PbR?

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What we still need to know

Impact on patient experienceDevelopment of ‘markers’ for improved processes of care required (e.g. no. interactions between patients and professionals)

Impact on use of servicesImpact on costsImpact on outcomes – needs careful thought