Integrated Care : A Pill for All Ills?

There is an increasing policy emphasis on the integration of care, both within the healthcare sector and also between the health and social care sectors, with the simple aim of ensuring that individuals get the right care, in the right place, at the right time. However, implementing this simple aim is rather more complex. In this editorial, we seek to make sense of this complexity and ask: what does integrated care mean in practice? What are the mechanisms by which it is expected to achieve its aim? And what is the nature of the evidence base around the outcomes delivered

Integrated care systems and equity:prospects and plans

Abstract Purpose – Policies on integrated care have waxed and waned over time in the English health and care sectors, culminating in the creation of 42 integrated care systems (ICSs) which were confirmed in law in July 2022. One of the four fundamental purposes of ICSs is to tackle health inequalities. This paper reports on the content of the overarching ICS plans in order to explore how they focus on health inequalities and the strategies they intend to employ to make progress. It explores how the integrated approach of ICSs may help to facilitate progress on equity. Design/methodology/approach – The analysis is based on a sample of 23 ICS strategic plans using a framework to extract relevant information on health inequalities. Findings – The place-based nature of ICSs and the focus on working across traditional health and care boundaries with non-health partners gives the potential for them to tackle not only the inequalities in access to healthcare services, but also to address health behaviours and the wider social determinants of health inequalities. The plans reveal a commitment to addressing all three of these issues, although there is variation in their approach to tackling the wider social determinants of health and inequalities. Originality/value – This study adds to our knowledge of the strategic importance assigned by the new ICSs to tackling health inequalities and illustrates the ways in which features of integrated care can facilitate progress in an area of prime importance to societ

Public spending must improve health, not just healthcare : A narrow focus on the NHS neglects the much wider determinants of health

Last week’s budget held few surprises for the NHS because the “star bunnies”1 had already been released from the chancellor’s hat by the prime minister, whose summer announcement included a £20.5bn (€23bn; $27bn) “70th birthday present” for the NHS.2 But, as many have noted, the extra funding committed by 2023 (3.4% a year) is relatively low compared with historical trends—average annual increases since 1948 have been around 3.7%3— and it follows a long period of very modest growth. When adjusted for need, NHS spending has risen by only 0.1% a year since 2009-10 in real terms,4 and the spending pledge is widely viewed to be only enough to get the basics back on track.5 Top line figures also ignore what is happening to different funding streams. Increases are directed at only one part of the healthcare system—NHS England—ignoring NHS infrastructure such as training, IT, and buildings, all of which are under increasing pressure, as well as spending in Wales, Scotland, and Northern Ireland. Despite the efforts of local authorities to protect social care spending, it has fallen by 1.5% a year between 2009-10 and 2016-17,4 and as the deputy chief executive of NHS Providers put it, “When social care is cut, the NHS bleeds."

The relationship between social care resources and healthcare utilisation by older people in England : an exploratory investigation

Background Since 2010, adult social care spending has fallen significantly in real terms whilst demand has risen. Reductions in local authority (LA) budgets are expected to have had spill over effects on the demand for healthcare in the English NHS. Motivation If older people, including those with dementia, have unmet needs for social care, their use of healthcare may increase. Methods We assembled a panel dataset of 150 LAs, aggregating individual-level data where appropriate. We tested the impact of changes in LA social care resources, which was measured in two ways: expenditure and workforce. The effects on people aged 65+ were assessed on five outcomes. 1. Rates of emergency hospital admissions for falls in people with dementia aged 65 and over. 2. Rates of emergency hospital admissions for fractured neck of femur in people 65 and over. 3. Extended length of stay in people with dementia, 7 days and over 4. Extended length of stay in people with dementia, 21 days and over 5. Rates of NHS Continuing Healthcare (NHS CHC) Outcomes (utilisation) data were derived from the Hospital Episode Statistics (1, 2, 3 and 4), the Public Health Outcomes Framework (2), and publicly available datasets from NHS Digital (5). Datasets varied in the timeframes available for analysis. Planned analysis of the effects of social care cuts on delayed transfers of care in mental health trusts, and on deprivation of liberty safeguards were not undertaken because of data quality concerns. We tested the effect of two separate explanatory variables: adult social care gross current expenditure (per capita 65 and over) adjusted by area cost; and adult social care workforce staff (per capita 18 and over). Workforce measures distinguished LA and independent sector employees and included professional and non-professional staff providing direct social care. We ran negative binomial models and linear models, and controlled for a range of confounding factors, including deprivation, ethnicity, age, unpaid care, LA class and year effects. To account for potential endogeneity (‘reverse causality’), we also tested the Area Cost Adjustment (ACA) as an instrumental variable and ran dynamic panel models. Sensitivity analysis explored the effects of the additional effects of the Better Care Fund. Results The level of social care expenditure on older people was not significantly related to emergency admission rates for falls in people with dementia or for fractured neck of femur. Extended stays of 7 days or longer were significantly and positively related to the level of social care spend, but this association was no longer significant when additional spend from the Better Care Fund was taken into account. There was no significant relationship between the level of social care spend and hospital stays of 21 days or longer or between spend and uptake of NHS CHC. We also tested the effect of four social care workforce measures. LAs employing higher rates of social care staff (especially professional staff) had significantly higher levels of NHS CHC, but there was no significant relationship between LA staffing levels and the remaining four outcomes. LAs with higher levels of independent social care staffing had significantly lower rates of extended stays, but there was no association with either emergency admissions or on NHS CHC. The effect of ‘full time’ ii CHE Research Paper 174 unpaid care on outcomes was mixed, with tentative evidence of a protective effect on admissions for falls, and on extended stays of 21 days or longer. When the Area Cost Adjustment was used as an instrument in place of expenditure, results were largely consistent with the main analysis: there were negative effects on NHS CHC but no effect on any other outcome. The dynamic panel models found a positive relationship between spend and emergency admissions for falls, but the effect on other outcomes was statistically insignificant. Conclusions The study found no consistent evidence that reductions in social care budgets led to the expected rises in hospital admissions, hospital stays or uptake of NHS CHC. However, findings suggest that public sector staff providing direct social care, particularly professional staff, may be instrumental in facilitating access to NHS CHC. In addition, the study found tentative evidence that extended hospital stays are partially offset by social care provision by the independent sector and by unpaid carers providing intensive care. To test the validity and robustness of these findings, future research using linked individual-level health and social care data is needed

Defining and measuring unmet need to guide healthcare funding: : identifying and filling the gaps.

Budget allocations to Clinical Commissioning Groups include adjustments for unmet need for healthcare, but there is a lack of robust evidence to support this. This article describes a literature review with an objective to understand the available evidence regarding unmet need. We developed a conceptual framework for what constitutes ideal evidence that; defines unmet need for a given population, indicates how that need can be met by health care, establishes the barriers to meeting need and provides relevant proxies based on observable measures. Our search focused on recent and empirical UK data and conceptual papers. We found no one article which satisfied all requirements of ideal evidence; the literature was strongest in defining need but weakest in regard to establishing observable proxies of need capable of being used in budget allocations. Our review was limited by its timescale and a vast body of literature, which translated into a limited number of key words for the search. We conclude that further research to inform budget allocation is required and should focus on conditions or services where adverse health outcomes from unmet need are amenable to healthcare interventions and which affect a sizeable proportion of the population

The impact of primary care quality on inpatient length of stay for people with dementia : An analysis by discharge destination

Dementia is a chronic and progressive condition involving memory loss, mood swings, and difficulties in communication, mobility, reasoning and self-care. Older people with dementia occupy up a quarter of NHS hospital beds and tend to have prolonged hospital stays. Being admitted to hospital can have a significant negative impact on the person’s physical and mental health, and have an emotional impact on carers. As part of a national scheme known as the Quality and Outcomes Framework (QOF), GPs are rewarded for providing an annual review for patients with dementia. In the review, the GP checks the patient’s physical and mental health, and the support needs of the patient and carer. The GP also ensures services are coordinated across different parts of the system, e.g. that the patient is linked to community mental health services who can support them at home after a hospital stay. So does the QOF dementia review help achieve timely discharge from hospital? We used several large linked datasets to answer this question, analysing data on around 36,700 people from 2006 to 2010. The analyses took account of the influence of the GP practice with which people were registered and adjusted for other factors that might shorten or lengthen hospital stay. On average, hospital stay for people with dementia was around 18 days but was longer for those who were subsequently discharged to a care home (33 days). The QOF review had little effect on length of stay, with slightly shorter stays achieved only for individuals discharged back into the community and slightly longer stays for those who were discharged to a care home. Older people tended to be discharged from hospital more quickly than younger people, and Sunday admissions were shorter than admissions initiated on other days of the week. Unsurprisingly, people with multiple conditions had longer stays. Better availability of social care options – care home beds, or local authority intermediate care facilities – was linked to shorter hospital stays, which suggests that these sorts of services can be used instead of hospital care if they can be accessed. Another finding was that intense levels of unpaid care are associated with longer hospital stays – so it’s particularly important that GPs make sure these types of carer are well supported

Bridging the gap : the impact of quality of primary care on duration of hospital stay for people with dementia

Abstract Purpose – The purpose of this paper is to explore the link between one aspect of primary care in England – the annual review by general practitioners for dementia patients – and length of hospital stay (LoS). The annual review should identify the needs of both patients and carers and co-ordinate services across health and social care to address those needs. If this is done well, timely discharge from hospital may be facilitated. Design/methodology/approach – The study uses linked national data from 2006/2007 to 2010/2011 on over 36,000 patients, employing sophisticated statistical techniques to isolate the effect of the annual dementia review on LoS. Findings – Hospital patients discharged to the community have significantly shorter stays if they are cared for by practices that reviewed a higher percentage of their patients with dementia. However, this effect is small and is not evident for patients discharged to care homes or who died in hospital. Longer LoS is associated with a range of co-morbidities, markers of low availability of social care and with intensive provision of informal care. Practical implications – Although the dementia review has only a modest effect on LoS, the components of the review could improve the health and well-being of those with dementia and their carers. Originality/value – The study is the first to employ a robust methodology to investigate the impact of the annual dementia review on hospital LoS, an important aspect of the interface between primary and secondary care. There are implications for clinical and financial aspects of health and social care policy. Keywords England, Care and support, Dementia, Primary care, Integrated care, LoS, Length of stay, Hospital stay Paper type Research pape

Modeling the Economic Impact of Interventions for Older Populations with Multimorbidity: A Method of Linking Multiple Single-Disease Models

Introduction. Individuals from older populations tend to have more than 1 health condition (multimorbidity). Current approaches to produce economic evidence for clinical guidelines using decision-analytic models typically use a single-disease approach, which may not appropriately reflect the competing risks within a population with multimorbidity. This study aims to demonstrate a proof-of-concept method of modeling multiple conditions in a single decision-analytic model to estimate the impact of multimorbidity on the cost-effectiveness of interventions. Methods. Multiple conditions were modeled within a single decision-analytic model by linking multiple single-disease models. Individual discrete event simulation models were developed to evaluate the cost-effectiveness of preventative interventions for a case study assuming a UK National Health Service perspective. The case study used 3 diseases (heart disease, Alzheimer’s disease, and osteoporosis) that were combined within a single linked model. The linked model, with and without correlations between diseases incorporated, simulated the general population aged 45 years and older to compare results in terms of lifetime costs and quality-adjusted life-years (QALYs). Results. The estimated incremental costs and QALYs for health care interventions differed when 3 diseases were modeled simultaneously (£840; 0.234 QALYs) compared with aggregated results from 3 single-disease models (£408; 0.280QALYs). With correlations between diseases additionally incorporated, both absolute and incremental costs and QALY estimates changed in different directions, suggesting that the inclusion of correlations can alter model results. Discussion. Linking multiple single-disease models provides a methodological option for decision analysts who undertake research on populations with multimorbidity. It also has potential for wider applications in informing decisions on commissioning of health care services and long-term priority setting across diseases and health care programs through providing potentially more accurate estimations of the relative cost-effectiveness of interventions

Investigating the relationship between social care supply and healthcare utilisation by older people in England

Since 2010, adult social care spending in England has fallen significantly in real terms whilst demand has risen. Reductions in social care supply may also have impacted demand for NHS services, particularly for those whose care is provided at the interface of the health and care systems. We analysed a panel dataset of 150 local authorities (councils) to test potential impacts on hospital utilisation by people aged 65 and over: emergency admission rates for falls and hip fractures (‘front-door’ measures); and extended stays of 7 days or longer; and 21 days or longer (‘back-door’ measures). Changes in social care supply were assessed in two ways: gross current expenditure (per capita 65 and over) adjusted by local labour costs; and social care workforce (per capita 18 and over). We ran negative binomial models, controlling for deprivation, ethnicity, age, unpaid care, council class and year effects. To account for potential endogeneity, we ran instrumental variable regressions and dynamic panel models. Sensitivity analysis explored potential effects of funding for integrated care (the Better Care Fund). There was no consistent evidence that councils with higher per capita spend or higher social care staffing rates had lower hospital admission rates or shorter hospital stays