Abstract
‘Integrated care’ is pitched as the solution to current health system challenges. In the literature, what integrated care actually involves is complex and contested. Multi-disciplinary team case management is frequently the primary focus of integrated care when implemented internationally. We examine the practical application of integrated care in the NHS in England to exemplify the prevalence of the case management focus. We look at the evidence for effectiveness of multi-disciplinary team case management, for the focus on high-risk groups and for integrated care more generally. We suggest realistic expectations of what integration of care alone can achieve and additional research questions.
Keywords
Introduction
Health systems internationally face a common set of challenges: ageing populations, increasing numbers of patients suffering from multiple long-term conditions (multi-morbidity) and severe pressure on health and care budgets. This has led to calls for the development of new models of care which ‘integrate’ services across different sectors. 1 It is suggested that these models should be centred in primary care. Health systems with a stronger primary care base generally deliver better outcomes in terms of health gain, patient satisfaction and cost-effectiveness. 2
Integrated care in theory
The precise definition of ‘integrated care’ is complex and contested. One hundred and seventy five definitions of the concept were identified in one recent literature review. 3 Shared by all definitions, ‘integration’ involves processes that overcome fragmentation of care through better linkage and co-ordination of services and seeks to improve outcomes for those with complex needs. 4
It is widely claimed that integrated care is capable of achieving significant health gains alongside improvements in patient satisfaction and cost-effectiveness.5,6
Integrated care in practice
England
‘Promoting integration’ is a mandated objective for each of the 200+ Clinical Commissioning Groups (CCGs) in the NHS in England. We used documents produced by a random sample of 10% of these CCGs to identify the primary approach taken to implementing ‘integrated care’. Multi-disciplinary team (MDT) case management was the main method of integrating care in the vast majority (estimated, over 80%) of CCGs. 7
Case management involves:
Case finding (identifying ‘at risk’ individuals to case manage) Assessment of individual needs Individualized care planning Care co-ordination with regular review, monitoring and adaptation of the care plan.
MDT case management thus combines ‘professional integration’ with co-ordination activity. 8
Beyond integration at the level of CCGs, a number of government initiatives have attempted to encourage innovative integration strategies. These schemes include the ‘Integrated Care Pilots’ (ICPs, 2009–2012), the ‘Integrated Care and Support Pioneers’ (wave 1 began in 2013, and wave 2 in 2015, both ongoing), the ‘Vanguards’ (2015 and ongoing), and most recently announced, ‘Devolution’ of health and social care (first to Greater Manchester, starting in April 2016).
The ICPs again predominantly focused on MDT case management in practice, 9 and this central position of the MDT case management intervention has persisted through all of the subsequent schemes. However, more recent schemes also incorporate plans for wider ‘population-level’ integration strategies. The Pioneers plan ‘whole system integration’ and tackling the ‘barriers and enablers’ of integration, for example, ‘information and technology [IT], workforce, organizational forms, communications and engagement and contractual mechanisms’. 10 Many Vanguard sites also have plans to change payment mechanisms to incentivize better integration, to implement shared IT records, to pool budgets, etc. 11 The Devolution agenda is focused primarily on implementing a large shared health and social care budget (estimated at around £6 billion in Greater Manchester). However, ‘integrating care’ will once again involve the ‘key feature … targeted case management of the population most in need delivered by upskilled multi-disciplinary teams’. 12 Again, the extent of change that will be implemented beyond this model is unclear.
Even these specially supported and funded sites have found it difficult to implement wider reaching organizational and structural change. Organizational change was ‘found to be difficult within the bounds of NHS competition regulations … which prohibited purchasing and provision functions within a single organization’ for the ICPs, with many finding ‘that NHS regulations prevented them from implementing their plans’. 9 Progress to date has been slow for the Pioneers implementing more meso- and macro-level changes too, as reported in their second annual report, and independently identified by researchers at the Policy Innovation Research Unit (PIRU).10,13 Vanguards and Devolution are still in their infancy, so it is too soon to say what additional progress will be made. Theoretically, devolved responsibility should enable national barriers to change to be overcome more easily. However, it remains to be seen the extent of central control that is actually handed to local government.
International
Although there is less detailed evidence from the international literature, this focus on MDT case management when integrated care models are implemented in practice appears to hold. A recently updated Cochrane review examined interventions for improving outcomes in patients with multi-morbidity, and similarly identified MDT case management as the predominant approach. 14 Likewise, a large literature review in the recently drafted National Institute for Health and Care Excellence (NICE) guidelines on management of multi-morbidity identified the MDT case management approach as key to integrated care. 15 Therefore, the evidence for the MDT and wider case management approach has international relevance.
The evidence
The evidence suggests that the case management approach is a poor choice for achieving significant cost reduction or health benefits. We previously carried out a meta-analysis to establish the effectiveness of case management for ‘at risk’ patients in primary care. We identified few cost or health effects on those patients directly managed, with only a small increase in patient satisfaction. 16 This evidence aligns with the previous ICP evaluation 9 and other rigorous review evidence. 17
Targeting the highest risk patients only and expecting significant system-level changes may be fundamentally flawed.18,19 The numbers available to treat are not large enough to allow significant reductions in health care use and cost savings to be achieved. 20 ‘High-risk patients’ need not be a stable group over time at the individual-level. Patients identified in this group may regress to the mean of health care use or be intense care users at the end of their life. 21 The MDT case management of patients at the highest risk appears to yield the least benefits, perhaps because these patients are already past the point at which intervention might affect their illness course. 22
The wider evidence for effectiveness of integrated care suggests similar limitations. There is ‘no conclusive evidence that joint working or integrated services either improves clinical or organizational outcomes or that it can “unlock efficiencies”’. 23 A review measuring the economic impacts of integrated care suggests that we should change our expectation of integrated care being ‘inherently cost-effective and supportive of financial sustainability’ in light of the evidence. 4 Integrated services, however, can lead to improvements in the experiences of patients and their carers. 23
Where we are now
There are a number of reasons why MDT case management may be so widely adopted as the default form of integrated care. For example, in the English NHS, the concept of case management has been prevalent for many years in some form. 24 This is true in a number of other health systems too, particularly a long history in the US where it originates. 25 Additionally, it conforms with the Chronic Care Model, a widely adopted conceptual framework for treating chronic disease. 26 Moreover, defining integrated care in terms of patient experience outcomes (as exemplified in the official English NHS definition), 5 naturally draws the focus of relevant interventions directly to the service delivery level. The intervention targets those at ‘high-risk’, which is synonymous with high-cost. 27 Therefore, targeting these high-cost, high-need individuals appears at face value sensible if the goal is to reduce costs.
More recent integrated care schemes in the English NHS suggest that there may be a move towards a broader population focus, at least in planning. There is some evidence that lower risk patients may benefit slightly more from these wider integration strategies. For example, we found indications of small beneficial spill-over effects at the wider practice level (fewer emergency admissions) for MDT working, despite the lack of direct effects at the individual level for high-risk patients. 22 Progress towards broader population-level integration strategies remains slow, however, and the understanding of how payment schemes and cross-sectoral incentives contribute to better integrated services is sparse.
What we still need to know
The definition of integrated care used will partially determine our goals and outcomes achieved. The English NHS uses a definition focused on patient experience. Potentially, there is some opportunity for conflict between patient experience and the other aims of integrating care (e.g. reducing emergency admissions/costs). 28 Do we need to better prioritize these goals?
The likely effectiveness of integrated care to date, particularly if aimed at high-risk groups, is limited. However, implementing more system level integrated care (by definition, with the opportunity to affect a larger proportion of the population) has faced legal and organizational difficulties to date.9,10,13 Will more localized control over health systems (e.g. through Devolution) 12 overcome these barriers, or will national level targets and policies remain obstructive? Will more population-based integrated care models be any more effective?
Thinking at the system level, is there more we can be doing beyond the traditional boundaries of health system delivery models to address system challenges? Can demand be better contained before it reaches health systems? For example, could better co-ordinated prevention influence chronic disease risk factors (which the WHO estimate contribute to ‘80% of all heart disease, stroke and type 2 diabetes … [and] … over 40% of cancer’ that may be preventable), 29 and compress the negative effects of multi-morbidity to a smaller period at the end of life? 30 Is there more we can do to address overtreatment and burden of care for these complex patients, 15 addressing potential oversupply of resources? Answers to all these questions are now needed.
Conclusions
All of the evidence to date suggests that integrated care in its current form will not be the ‘silver bullet’ it is hoped to be. The focus of integration on high-risk groups is particularly misplaced. There remain a number of important questions for research relating to how to best define, enable and enact integrated care, and whether it can ever contribute significantly to tackling global health system challenges.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the National Institute for Health Research Greater Manchester Primary Care Patient Safety Translational Research Centre (NIHR GM PSTRC). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.