This review from the University of York’s Centre for Health Economics is certainly timely for commissioners in England, with plans for the Better Care Fund well underway and Simon Stevens, the new Chief Executive for NHS England, recently quoted as saying “no-one should pretend just combining two financially leaky buckets will magically create a watertight funding solution” (HSJ, 3 April 2014).
Integration is high on commissioning agendas, and not a week seems to go by without another report or review on integrated care. Integration, particularly across health and social care, is seen as a solution to deliver coordinated and comprehensive care to people with complex needs and to manage increasing admissions and financial pressures. The thinking is that by managing the whole of a pathway of care, it should be easier to anticipate or avoid problems (e.g. falls prevention), provide care closer to home, and to reduce avoidable admissions whilst improving patient experience/outcomes and reducing duplication/fragmentation. One of the barriers to integration often cited is the issue of separate funding for health and social care. This review looks specifically at the following mechanisms available to integrate funding, their costs and effects and the barriers and enablers to successful implementation:
- Transfer payments (grant transfer)
- Cross charging
- Aligned budgets
- Lead commissioning
- Pooled funds
- Integrated management without pooled funds
- Integrated management with pooled funds
- Structural integration
The review notes that uptake of these mechanisms has been low to date but the reasons for this are not explored in detail.
The review evaluates 38 different integration schemes (across 8 countries), reported in 122 articles; these schemes were selected as they involved integration across health and social care; papers relating to only health or only social care were excluded. The only randomized evidence was Australian in origin; most of the evidence is from qualitative studies.
23 of the 38 schemes measured health outcomes and findings are mixed: in 13 of the schemes, there was no evidence of improved outcomes in integrated care; 5 schemes showed mixed findings; 1 showed worse outcomes; and 4 showed better outcomes. Of the 13 English schemes, 3 of the schemes reported improvements in health outcomes. 34 of the 38 schemes analysed impact on costs and utilization. The evidence here was also mixed, with some evidence to suggest reductions in unplanned admissions for individuals at high risk of admission. None of the schemes were able to demonstrate a sustained impact on hospital utilization; the duration and follow up periods varied. Where reduced admissions were demonstrated, e.g. Torbay, there are some question marks over the methodological rigour of the evaluations (e.g. not all confounding factors were accounted for). The findings were also equivocal in relation to the impact on residential care.
Not all of the schemes considered unintended consequences; the authors note some examples which were given, including the risk of cherry picking less complex patients (such as excluding those with mental health or substance abuse problems) and increased risk of readmission due to early discharge.
The limited evidence highlights the difficulty of integrating budgets, despite statutory and regulatory measures; the ability to translate cost reductions into savings was only achieved in a minority of cases and then only due to prior agreements at senior level. The report notes that if budgets are constrained and focused on crisis management, there will be little room for prevention therefore those with less severe needs are at greater risk of deterioration, thus perpetuating the cycle of crisis management. Eligibility criteria for specific services need to be clear to ensure patients don’t fall through the gaps; to avoid the loss of purchasing power, this cannot be led solely by providers. Other problems highlighted included potentially conflicting governance and performance systems; lack of engagement of clinicians; lack of service user engagement particularly in relation to self management; and difficulties in linking different IT systems. The authors conclude there is currently a lack of strong evidence to suggest that integrated funding will lead to improved outcomes or reduced unplanned care but acknowledge this may be due to difficulties in operationalising the mechanisms rather than a problem with the concept of integrated funding itself.
Implications for commissioners
Commissioners may be disappointed by the findings given the investment of time and effort into integration efforts. However, the authors acknowledge that improved coordination may “reveal rather than resolve” unmet needs, therefore, increasing rather than decreasing costs initially. It would be interesting to evaluate outcomes and utilization over a longer timeframe to understand if this effect changes over time. The absence of strong evidence suggests that commissioners have a responsibility to establish rigorous evaluation and measurement, thus creating a more robust evidence base. Evaluations will need to consider costs and effects of integrated funding within a context where there are likely to be a number of policy initiatives and change programmes underway at any one time. Outcome measures should include patient experience and health outcomes in addition to system measures such as admissions, length of stay and readmissions. A key message from the authors of the review is to start integration efforts with realistic expectations, with a clear understanding of the time and effort involved in implementing and operationalizing integrated mechanisms:
Integrating funds across health and social care services is not a panacea that will reliably resolve the practical and policy challenges of providing integrated care, as success is contingent upon many factors – but this does not mean that success is an unattainable ‘Holy Grail’, but only that expectations should be realistic.
Mason A, Goddard M and Weatherly H (2014) Financial mechanisms for integrating funds for health and social care: an evidence review, University of York: Centre for Health Economics.