Integrated Care ‘Pilots’ and their Evaluation
This Care Initiative event was held at Green Templeton College on 23 November 2017. This report was written by Suchita Shah.
It is a refrain that echoes from the World Health Organisation to Westminster: people work in silos. The antidote to this, it is claimed, must be integration. This was the focus of the latest authoritative lecture at Green Templeton College, given by Professor Nicholas Mays from the London School of Hygiene and Tropical Medicine.
Introducing Professor Mays—who, as well as being Professor of Health Policy, also has extensive experience working across the NHS, academia, independent sector and the public service in New Zealand—Professor Mary Daly referred to integrated care as one of the ‘great hopes for the future,’ and a key to health system sustainability.
Integration is a significant task that promises to bring together two systems, health and social care, which have been separate since the beginning of the NHS in 1948, and which differ enormously with regard to historical development, ideological underpinning, organisational culture, and operations. Nonetheless, as Professor Daly told us, the government in England remains committed to it.
The Integrated Care Pioneer programme
Professor Mays set the scene by pointing to repeated efforts since 1973 to integrate health and social care, from shared administration, to multidisciplinary team working—reminding us just how hard it has been. He then focused on one of the government’s most recent initiatives: England’s Integrated Care & Support Pioneer programme. Two waves of volunteer Integrated Care Pioneers were announced in 2013 and 2015, with 25 localities now aiming to develop and test different ways of joining up health and social care services, with support from national agencies (e.g. NHS Improvement and the Local Government Association). Guided by national priorities and an overall aim to improve care, quality and effectiveness, the 25 Pioneers have each identified their own areas of work.
Main findings from the programme evaluation
Professor Mays and his team conducted an early (2014-15) evaluation based on longitudinal, self-reported data, and have published interim (2016-17) findings on the Integrated Care Pioneers programme. So far, the evaluation has found little hard evidence of major service change. This did not come as much of a surprise, since there has been no extra financial support for the Pioneers to deliver their goals and, during the early stages of the programme, the national focus turned again to reducing hospital admissions, rather than improving user experience which is the main goal of the Programme.
The headline findings, to date, also revealed that Pioneers’ plans tended to be led by Clinical Commissioning Groups (CCGs) and local authorities, with providers being less involved; that progress to date has been more related to planning and building inter-organisational links than service change visible to users; and that barriers such as lack of money, incompatible information technology (IT) systems, and conflicting central government/national policies and priorities all make integration an uphill struggle.
Barriers to successful integrated care
The discussant for the evening, Mr David Smith, Chief Executive of Oxford Clinical Commissioning Group, reinforced these headline messages. Drawing on his experiences, including holding executive positions across both health and social care in London, he pointed to the difficulties others in his position faced when attempting to unite health and social care. These included different financial structures between health and social care (and also within the NHS), clashes of regulatory regimes, a lack of strong top-level leadership, incompatible IT systems, and the tendency for short term political agendas to impede longer term change.
Mr Smith also pointed to the workforce crisis that is paralysing both systems. Not only is the workforce insufficiently trained to meet population needs, but there is also a growing shortage of people to realise the aspiration of integrated care. Murmurs from the floor signalled agreement, and workforce was an issue that people repeatedly returned to over dinner at Green Templeton College; as a jobbing GP, it also resonated hugely with me. The reality is that people on the front line are struggling to do their own jobs: increasing demand, combined with decreasing time and resources, means that there is little extra capacity or headspace for integration.
These barriers were also acknowledged by the audience, which included academics, clinicians, managers, and representatives from the voluntary sector. So, why is overcoming them so hard to achieve?
The dream versus the reality of integrated care
Firstly, there is a gap between the dream of integrated care and its reality. At the heart of the Integrated Care Pioneers programme lies personalised care, brought to life in a centrally-defined, high-level aspirational statement supported by a series of ‘I’ statements (e.g. ‘I tell my story only once’).
Nods from the audience affirmed the importance of person-centredness. However, Professor Mays’ team found that, whilst the aspiration was useful in generating consensus, there was no central guidance on how it should be implemented or link with wider issues such as the cost-effectiveness of services. For Pioneers, this translated into limited support to put the dream of integration into practice, and a tendency to converge on more medically-oriented initiatives involving case management through multi-disciplinary teams (MDTs) in primary care, which often focused on reducing unnecessary hospital admissions. As Professor Mays observed, this is ‘not so different from twenty years ago’.
The system versus its parts
Secondly, there are questions over the extent to which the reported slow progress within the Pioneer programme is due to systemic issues, as opposed to local weaknesses in implementation. One very memorable slide of Professor Mays’ highlighted the increasing number of central initiatives on care integration that organisations are meant to respond to—suggesting an anxiousness by higher powers to ‘do something.’
The hand of politics has been firmly felt on the ground: the spectre of austerity has caused Pioneers to constrict and become insular, rather than collaborate. Additionally, top-down requirements to save money (e.g. through reducing unplanned hospital admissions) appear to have stifled the innovative practices that were supposed to be at the heart of the mandate. Recognising the influence of systems on the effective implementation of integrated care was something that this evening’s audience clearly felt was needed.
Doing the wrong thing?
Lastly, Professor Mays asked, are we doing the right thing in the wrong way, or are we “repeatedly trying to do the wrong thing right”? Somewhat surprisingly, according to Mays’ interim findings from summer 2016, over 60% of Pioneers were confident they would achieve their goals for integrated care. Yet, the evidence presented suggested that the Pioneer programme is not really delivering—a view that is mirrored by a comparable gloom in the wider research literature. So, who is right?
The government seems to think that more of the same is needed. However, as Professor Mays stated early in his talk, the enduring policy paradigm for collaboration between health and social care has been, thus far, to build bridges between ‘parallel’ organisations and overcome barriers, rather than to integrate mainstream processes. This has not worked.
Could we learn more lessons from history? Is it exhortations and initiatives from policymakers, or is it scientific and technological advances and exogenous events, such as periods of turbulence, that facilitate change? Or perhaps, as one audience member put it, the ‘great hope’ of integration should be de-emphasised in favour of small-scale, bottom-up operational changes that improve patient and user experiences.
If our collective aspiration for what to do with health and social care might be wrong, then is the way we are evaluating it also wrong? The discussion returned, full circle, from real life to policy to evidence. If, as Professor Mays described, respondents from the Pioneer evaluation were more likely to report progress subjectively (e.g. in terms of planning and early intervention) than against routinely measurable indicators (e.g. unplanned admissions, savings) and if, as the subsequent discussion alluded to, cost-effectiveness and financial sustainability might be at odds with improving service user experience, then maybe researchers should be actively looking for lived experiences and systemic factors that enable positive change, as well as ‘hard’ outcomes.
As the evening drew to a close, one astute member of the audience asked, given the vast differences between health and care, should the NHS become part of social care, or vice versa? Politically, responded Professor Mays, they are regarded as two separate entities and nowhere is this reflected better than in the allocation of budgets. As he put it, ‘the left hand is funded while the right hand is eviscerated’. ‘If you want money for care’ he continued, ‘call it health’. This nicely encapsulated the undercurrent of the evening: that politics matters. Mr Smith agreed, emphasising that, however we go about it, ‘integration is really hard to do and is never going to be quick’.
Professor Daly concluded on a note of optimism, echoing views from the floor that we need to have an inclusive, sustained national conversation about the future of health and social care in England.