Integrated care: what about the users?

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Integrating health and social care is universally seen as a good thing. But results from a report this week, though generally positive, show that patients don’t always agree

Better integration between NHS providers and between health and social care
was a key recommendation of the Future Forum.  But this notion is not new -
Lord Darzi’s NHS Next Stage Review of 2008 also highlighted the problem of
poor integration and set in train 16 pilots to test how integrated working
could be achieved. These were subject to an independent evaluation which
was published this week.

The pilots were very different but they broadly shared a number of similar
aims: bringing care closer to the service user, creating teams that crossed
organisational boundaries, providing greater continuity of care, and
avoiding unnecessary hospital care. In particular, six pilots focused on
intensive case management of elderly people at risk of emergency hospital
admission. They did this by identifying older people at risk of admission
followed by the use of a case manager, most often a nurse, to coordinate
the care of individual patients.

The evaluation showed that integration was warmly welcomed by staff. For
example, 60% thought that they worked more closely with other team members,
51% that communication had improved within their organisation and 72% that
communication had improved with other organisations. They also reported
changes to the nature of their own work as a result of the pilot. For
example, 84% of those directly working with the pilots felt their job had
expanded and 63% thought that it had become more interesting.

It had been expected that the pilots would reduce emergency admissions. In
fact, the evaluation showed that this reduction did not happen – indeed it
appeared that emergency admissions may actually have gone up. However,
other types of hospital care did reduce significantly. For the pilots that
implemented case management, statistically significant falls of 22% and 21%
occurred for outpatients and elective admissions respectively.

Applying cost estimates to these utilisation changes suggests that for all pilot
sites there was a non-significant reduction in overall secondary care costs
and for the case management sites a significant reduction in overall
secondary care costs of 9%. Although in neither case has any increased
costs in primary or community care been taken into account.

Perhaps the most surprising results concerned patient views of integrated
care. While staff felt confident that their care had improved, patients
reported a more mixed picture. More technical aspects of care were
perceived to have improved, with increases in patients receiving a care
plan and in those knowing who to contact with questions after hospital
discharge.

However, these positive results were balanced by a number of negative
findings. For example, there were significant reductions in patients being
involved by their doctors in decisions about their care and of seeing the
nurse of their choice of 5% and 9% respectively. Moreover, there was a
significant drop of 15% in those patients feeling that their opinions and
preferences were taken into account by their care workers.

These negative findings were generally more evident in the case management sites.
Overall, there are grounds for cautious optimism. Professional staff
believed that integration allowed them to offer better care and, in the
round, use of hospitals reduced with some likely cost savings. The reaction
of patients is surprising with some aspects of patient experience
diminishing. One hypothesis is that integrated care within the pilots
became ‘professionalised’ and, in the process, lost focus on the individual
patients at the centre of that care.

There is a further concern for policy makers if integrated care is to
become widespread – the 16 pilots were enthusiastic volunteers. Moreover,
they were volunteers who were supported by a national programme, project
management support and funding. Even these enthusiasts struggled at times
to cope with the demands of leading change in a difficult and shifting
environment. Translating the efforts of a few into the actions of many will
be the challenge if integrated care is to shift from pilot to mainstream.

This blog is based on research carried out by Ernst & Young, RAND Europe and the University of Cambridge. Richard Lewis is a partner at Ernst & Young, and Martin Roland is professor of health services research at the University of Cambridge

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