1. Integrated Care: What can the
evidence tell us?
Naomi Fulop
King’s College London
November 2008
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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
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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
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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)
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5. Need for integrated health care
“The current care systems cannot do the job.
Trying harder will not work, changing systems of
care will.”
Need systems of care in which “clinician and
institutions… collaborate and communicate to
ensure appropriate exchange of information and
co-ordination of care”
(Institute of Medicine, Crossing the Quality Chasm, 2001)
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6. Continuum of configurations of health care
--------------------------------------------------------->
autonomy co-ordination integration
(Source: Grone and Garcia-Barber, 2002)
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7. Types of organisational integration
Vertical
- 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 provide
Horizontal
- combination of two or more firms producing similar
goods or services.
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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
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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
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10. Typologies of integration (1)
Functional + Physician = Clinical
Integration of support, Clinician alignment Extent to which patient
functions 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)
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11. Typologies of integration (2)
Denis et al add:
 Normative integration – role of values
 Systemic integration – coherence of rules and
priorities
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12. How integration can occur
Three 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)
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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)
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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.
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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
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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.
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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)
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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.
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19. Lessons
 Lesson 3. Ensure local contexts are supportive of
integration
Key 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.
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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
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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)
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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
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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. 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.
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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
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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
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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’?
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