At first sight, integrated care appears very much in the ascendency in the United Kingdom and it is hard to find a document issued from the Department of Health or a ministerial press release that doesn’t argue that better integration of care must be at the heart of a health and social system that is “fit for purpose.”
In June 2013, Health Secretary Jeremy Hunt announced £3.8 billion (about 3% of the NHS annual budget) was going to be earmarked for health and social care. That’s about $6 billion. Enthusiasts hope this will lead to the first accountable care organizations (ACOs) in the National Health Service (NHS).
Readers may be forgiven for being confused by the notion of the U.K.’s health system needing to be integrated — isn’t this precisely one of the supposed advantages of a cradle-to-grave National Health Service? However the U.K. does not have an integrated health and social care system.
Social care is provided by local government, significant parts of it are means tested, and in any case the NHS has its own budget silos, hand-offs, and inter-organizational rivalries.
These are probably as endemic in the U.K. as anywhere else. Primary care physicians, known as general practitioners, in the U.K. are largely self-employed and entirely separate from hospitals, although many do work in hospitals. Community care straddles numerous organizations. To this can be added very different contract arrangements.
In England, hospitals are largely funded on a case-by-case basis using a methodology known as Healthcare Resource Groups, similar to DRGs in the United States. In contrast, many community services are funded by block grants.
Local government has to fund social care from a pot of money for which other services — schools and libraries, for instance — also compete for resources.
When care isn’t integrated, patients can fall into gaps between agencies. Such care needs to be coordinated but some care — maybe a lot — currently is not.
In a fully integrated system, patients’ needs, not organizational boundaries, determine how care is provided. The requirement to deliver effective, seamless care to patients should be the organizing principle of service delivery.
Many people find this proposal intellectually and emotionally attractive and are naturally in favor of integrated care.
Unfortunately, the natural attractiveness of integrated care is also one of its weaknesses. People tend to say they are in favor of integrated care because it can be described in many ways.
Discussion of the need to coordinate care has a tendency to be subsumed into a discussion of organizational models. This is particularly the case in the U.K. where the NHS has endured a protracted and prolonged period of organizational restructuring.
Therefore it is unsurprising that much of the debate about promoting integrated care in the U.K. has taken place in the context of the proposal that it will require further organizational change — in particular the idea that for integrated care to work, health and social care needs to come under one body. This has set the stage for NHS and local government to stake out their respective claims. What both parties have in common is a nearly uniform poor opinion of the others’ capabilities and suspicion of the others’ motives.
Where’s the patient?
In such an environment, the patient’s perspective, far from being the organizing principle, is in significant danger of being forgotten.
The typical case study for integrated care is someone with a complex mix of health and social care needs.
It is sometimes forgotten that most patients do not fall into this category, although that is not to deny that the growing prevalence of chronic disease combined with an aging population makes this a significant and enlarging category.
Most patients have conditions that do not require much, if any, coordination of care between agencies — or even between specialties in the same agency. A lot of illness is of limited duration.
Despite this there is a tendency for integrated care to be regarded as a nearly universal good. Pointing out that a particular health care service/intervention doesn’t necessarily need an integrated approach carries with it a danger that you will be labeled a health care Philistine.
In the U.K., Kaiser Permanente is often cited as an example of a well-run integrated health care organization (with California a popular destination for study tours by NHS staff). In the U.K., the evidence to date of integrated care delivering measurable benefits is unfortunately somewhat mixed, perhaps mirroring the U.S. experience with ACOs.
To what degree this relates to the limitations of integrated care as an idea that will actually deliver on its promise, versus inadequate or incomplete implementation, is open to debate. Integrated care has been the subject of a number of research studies in the U.K.
To summarize two of the best known in a sentence, there were some encouraging results in Torbay, a rural area in South West England, and generally disappointing results in North West London in terms of the impact on hospital admission and costs.
The latter pretty much mirrors a study of 16 pilot programs, which reported a frankly underwhelming reduction of secondary care costs of about $50 per patient.
The studies focused on organizational issues and how participants felt about the initiatives, with relatively little attention given to contracting mechanisms and how available resources would be redistributed.
What incentives do contracted community providers have to increase their workload? If social care funding is under pressure and there is a need to increase it to allow patients to get out of the hospital earlier (or avoid admission), then what funding is going to be released from other areas to enable this to happen? Integrated care is not a free lunch.
As if to emphasize that point, discussion about the U.K. government’s creation of a $6 billion fund for promoting integrated care has been dominated by concerns over the NHS budget cuts required to fund it, and whether this is a back door way of funding local government expenditure at the expense of the NHS. Tellingly, discussion of the potential benefits to patients has yet to figure much.
Integrating health and Social care in Torbay: Improving care for Mrs Smith Kings Fund: London 31 March 2011.
Evaluation of the First Year of the Inner North West London Integrated Care Pilot Nuffield Trust: London 17 March 2103
National Evaluation of the Department of Health’s Integrated Care Pilots Final report: Full version: Full version RAND Europe, Ernst & Young LLP. Prepared for the Department of Health March 2012.