Integrated Care: What can theevidence tell us?Naomi FulopKing’s College LondonNovember 2008                                1
Acknowledgements NHS Confed publication: Building integrated care  (with Nigel Edwards and Alice Mowlam, 2005) Backgroun...
Defining integration (again) Economic approaches  - markets vs. hierarchies vs. networks  - 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...
Continuum of configurations of health care--------------------------------------------------------->autonomy             c...
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...
Types of vertical integration where agencies involved at different stages of the  care pathway are part of a single organ...
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...
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 ...
Summary of evidence (1) Summary of the impact of integration of payment and provision Most evidence from US (e.g. Burns ...
Summary of evidence (2)   Summary of the impact of integration of provision   Evidence from US, UK, Sweden and the Nethe...
Summary of evidence (3) Summary of the impact of networks e.g. managed clinical networks in Scotland, Chains of  Care in...
Lessons Lesson 1. Integrate for the right reasons Objectives of integration need to be made explicit Is it to improve q...
Lessons Lesson 2. Don’t necessarily start by integrating  organisations Integration that focuses mainly on bringing orga...
Lessons Lesson 3. Ensure local contexts are supportive of  integrationKey contextual elements: a culture of quality impr...
Lessons Lesson 4. Be aware of local cultural  differences significant challenge of bringing together  organisational cul...
Lessons Lesson 5. Ensure that community services  don’t miss out Integration of acute and primary/community  services ma...
Lessons Lesson 6. Give the right incentives If trying to reduce use of hospital beds, need to  address PbR (e.g. through...
Lessons Lesson 7. Don’t assume economies of scope and  scale Potential economies of scope and scale are likely to take  ...
Lessons Lesson 8. Be patient Time required to implement effective integration  is a recurrent theme and is unsurprising ...
Key broader policy issues Integration of payer and provider: problematic in  NHS context – creates monopoly Integration ...
What we still need to know [1] Impact on patient experience   Development of ‘markers’ for improved processes of    care...
What we still need to know [2] Need to be clear about different components of  integration and what is having an impact i...
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Naomi Fulop: What can the evidence tell us

  1. 1. Integrated Care: What can theevidence tell us?Naomi FulopKing’s College LondonNovember 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 vs. networks - 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. Continuum of configurations of health care--------------------------------------------------------->autonomy co-ordination integration(Source: Grone and Garcia-Barber, 2002) 6
  7. 7. 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. 7
  8. 8. 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 8
  9. 9. 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 9
  10. 10. Typologies of integration (1)Functional + Physician = ClinicalIntegration of support, Clinician alignment Extent to which patientfunctions eg. Finance, with aims of delivery care services are co-HR, IT etc system ordinated across people, functions, activities and sites over time(Shortell, 1996, 2000) 10
  11. 11. Typologies of integration (2)Denis et al add: Normative integration – role of values Systemic integration – coherence of rules and priorities 11
  12. 12. 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) 12
  13. 13. 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 Little large scale evaluation Evaluation of ‘boutique’ pilots (Ouwens et al, 2005) 13
  14. 14. 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. 14
  15. 15. 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 15
  16. 16. 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. 16
  17. 17. 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 (Burns and Pauly, 2002) 17
  18. 18. 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. 18
  19. 19. 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. 19
  20. 20. 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 20
  21. 21. 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) 21
  22. 22. 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 22
  23. 23. 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) ‘integration costs before it pays’ (Leutz, 1999) e.g. due to significantly different practices in organisations to be integrated ‘make or buy’ decision bigger problem for primary care taking over hospital services than hospitals undertaking ‘outreach’ – changes in technology 23
  24. 24. 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. 24
  25. 25. Key broader policy issues Integration of payer and provider: problematic in NHS context – creates monopoly Integration and system reform – how to deal with PbR? Nature of GP contract and incentives/opening up of primary care market Governance and regulation issues 25
  26. 26. What we still need to know [1] Impact on patient experience  Development of ‘markers’ for improved processes of care required e.g. no. interactions between patients and professionals (i.e. is fragmentation reduced?) Impact on use of services Impact on costs Impact on outcomes – needs careful thought 26
  27. 27. What we still need to know [2] Need to be clear about different components of integration and what is having an impact i.e. interventions needs to be well-described Some of the evidence comes from ‘boutique’ experiments or pilots – how far can these be ‘mainstreamed’? What needs to happen to ‘mainstream’? 27

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