Integrated Care: Lessons from theresearchNaomi FulopKing’s College LondonSeptember 2008                                    1
Acknowledgements NHS Confed publication: Building integrated care (with Nigel Edwards and Alice Mowlam, 2005) Background l...
Defining integration (again) Economic approaches - markets vs. hierarchies - transaction cost economics                   ...
Integrated health care  ‘Integrated care is a concept bringing together  inputs, delivery, management and organisation of ...
Need for integrated health care“The current care systems cannot do the job.Trying harder will not work, changing systems o...
Types of organisational integrationVertical- combination of firms at different stages of the  production process, with a s...
Drivers of vertical integration Improve quality of care, esp for long term conditions Savings in transaction costs (esp wh...
Types of vertical integration where agencies involved at different stages of the care pathway are part of a single organis...
Typologies of integration (1)Functional         +      Physician         =     ClinicalIntegration of support,   Clinician...
Typologies of integration (2)Denis et al add: Normative integration – role of values Systemic integration – coherence of r...
How integration can occurThree possible directions:  Hospital trusts expand outwards and downwards  Primary care trusts ex...
Nature of the evidence Limited – a lot on processes, less on outcomes Quite a lot from US More recently, evidence from oth...
Summary of evidence (1) Summary of the impact of integration of payment and provision Most evidence from US (e.g. Burns an...
Summary of evidence (2) Summary of the impact of integration of provision Evidence from US, UK, Sweden and the Netherlands...
Summary of evidence (3) Summary of the impact of networks e.g. managed clinical networks in Scotland, Chains of Care in Sw...
Lessons Lesson 1. Integrate for the right reasons Objectives of integration need to be made explicit Is it to improve qual...
Lessons Lesson 2. Don’t necessarily start by integrating organisations Integration that focuses mainly on bringing organis...
Lessons  Lesson 3. Ensure local contexts are supportive of  integrationKey contextual elements:   a culture of quality imp...
Lessons Lesson 4. Be aware of local cultural differences significant challenge of bringing together organisational culture...
Lessons Lesson 5. Ensure that community services don’t miss out Integration of acute and primary/community services may pr...
Lessons Lesson 6. Give the right incentives If trying to reduce use of hospital beds, need to address PbR (e.g. through po...
Lessons Lesson 7. Don’t assume economies of scope and scale Potential economies of scope and scale are likely to take time...
Lessons Lesson 8. Be patient Time required to implement effective integration is a recurrent theme and is unsurprising giv...
Key broader policy issues Integration of payer and provider: problematic in NHS context – creates monopoly Integration and...
What we still need to know Impact on patient experience   Development of ‘markers’ for improved processes of   care requir...
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Naomi Fulop: Integrated care lessons from the research

  1. 1. Integrated Care: Lessons from theresearchNaomi FulopKing’s College LondonSeptember 2008 1
  2. 2. 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 2
  3. 3. Defining integration (again) Economic approaches - markets vs. hierarchies - transaction cost economics (Williamson, 1975) Organisational theory - integration/differentiation in organisational design - degree of co-ordination among units within organisations 3
  4. 4. 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) 4
  5. 5. Need for integrated health care“The current care systems cannot do the job.Trying harder will not work, changing systems ofcare 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) 5
  6. 6. Types of organisational integrationVertical- 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 provideHorizontal- combination of two or more firms producing similar goods or services. 6
  7. 7. Drivers of vertical integration Improve quality of care, esp for long term conditions Savings in transaction costs (esp where integration of payer and provider) Economies of scale and scope Managerial control 7
  8. 8. Types of vertical integration where agencies involved at different stages of the care pathway are part of a single organisation where payer and provider agencies are part of a single organisation networks/virtual integration 8
  9. 9. Typologies of integration (1)Functional + Physician = ClinicalIntegration of support, Clinician alignment Extent to which patientfunctions eg. HR, IT with aims of delivery care services are co-etc system ordinated across people, functions, activities and sites over time(Shortell, 1996, 2000) 9
  10. 10. Typologies of integration (2)Denis et al add: Normative integration – role of values Systemic integration – coherence of rules and priorities 10
  11. 11. How integration can occurThree possible directions: Hospital trusts expand outwards and downwards Primary care trusts expanding outwards and upwards Formation of new organisations of delivery(Feachem and Sekhri, 2005) 11
  12. 12. Nature of the evidence Limited – a lot on processes, less on outcomes Quite a lot from US More recently, evidence from other more comparable health care systems 12
  13. 13. 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 partnerships increased focus on case management and use of IT systems important some increases in capacity are reported, but not quantified mixed 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. 13
  14. 14. Summary of evidence (2) Summary of the impact of integration of provision Evidence from US, UK, Sweden and the Netherlands (eg. Ouwens et al, 2005) Models from England – Care Trusts, Unique Care Some evidence of strengthened partnerships organisational integration being hampered by lack of coordination at national policy level some reports of improved capacity, e.g. personnel improved focus on governance and adherence to guidelines little evidence of impact on health outcomes limited evidence of impact on cost 14
  15. 15. Summary of evidence (3) Summary of the impact of networks e.g. managed clinical networks in Scotland, Chains of Care in Sweden mixed 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; and little evidence of improvements in costs or health outcomes. 15
  16. 16. Lessons Lesson 1. Integrate for the right reasons Objectives of integration need to be made explicit Is 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 16
  17. 17. Lessons Lesson 2. Don’t necessarily start by integrating organisations Integration 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. 17
  18. 18. Lessons Lesson 3. Ensure local contexts are supportive of integrationKey contextual elements: a culture of quality improvement a history of trust between partner organisations existent multidisciplinary teams local leaders who are supportive of integration personnel who are open to collaboration and innovation effective and complementary communications and IT systems. 18
  19. 19. Lessons Lesson 4. Be aware of local cultural differences significant 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 19
  20. 20. Lessons Lesson 5. Ensure that community services don’t miss out Integration 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) 20
  21. 21. Lessons Lesson 6. Give the right incentives If 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 21
  22. 22. Lessons Lesson 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 22
  23. 23. Lessons Lesson 8. Be patient Time 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. 23
  24. 24. Key broader policy issues Integration of payer and provider: problematic in NHS context – creates monopoly Integration and system reform – how to deal with PbR? 24
  25. 25. What we still need to know Impact on patient experience Development of ‘markers’ for improved processes of care required (e.g. no. interactions between patients and professionals) Impact on use of services Impact on costs Impact on outcomes – needs careful thought 25

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