Over the past 20 years there have been numerous initiatives to encourage more joined-up care between services, focusing on meeting individuals’ needs. The Five Year Forward View set out a vision for transforming the NHS and social care in England to become more integrated. Not quite five years on, we now have a new Long-Term Plan, which once again has closer integration of services at its core. So how much progress has been made?
Improving how health services work together, and with social care and the independent and voluntary sectors, is seen as a mechanism to improve the quality of care for patients and manage the costs of health and social care. Alongside this drive for better integration of services, there is also a willingness to enable patients to manage their own care better at home and in the community, reducing the need for unnecessary hospitalisations.
Although there is a compelling story for why integrated care should be better for patients and enable the health service to be sustainable financially, evidence for many of the initiatives is lacking. The NHS has also struggled to put resources into transforming services, alongside managing increasing demand for care.
Each year QualityWatch makes an assessment of the current state of care in the NHS in England, drawing on information from our extensive range of care quality indicators. As efforts to better integrate services are renewed yet another time, we consider what impact the drive for integration has had on quality of care, and whether patients and the public are likely to notice any difference in how joined-up their care is.
What do we mean by integrated care, and how can we measure it?
The term integrated care has been used in different contexts, and means different things to different people. For the purposes of our analysis, and drawing on the NHS England definition, integrated care means that:
- patients are actively involved in decisions about their care and are supported to manage and improve their own health;
- services are patient-centred and tailored to meet the needs of the individual: care is designed so that patients can access the right service at the right time – usually as close to home as possible;
- health and social care services work well together, and are focused on delivering the best care for their populations.
In the absence of a nationally agreed set of measures for integrated care, we reviewed a number of potential indicators, drawing on QualityWatch, our evaluations of new service models, and other sources. We selected indicators which address each of these aspects of integrated care, and used them to follow a patient’s journey from home, into hospital, and back. The indicators use data from a variety of sources, including surveys of patients and carers, Hospital Episode Statistics and NHS Digital data. We looked at the trend in each indicator since 2011 or 2012, depending on data availability, to observe trends before and after the Five Year Forward View was implemented. We also unpicked the trend – for example, how much variation exists across England or between different groups of patients - and we cross-referenced with the further analysis we have undertaken on the chosen indicators.
What do our indicators tell us about the state of integrated care?
Since 2012, patients report feeling less supported to manage their own care, find it more difficult to see their preferred GP when they want to, and there has been no improvement in how involved people feel in their GP care. Patients with developmental disabilities, learning disabilities or a mental health condition feel the least supported to manage their condition. The proportion of people who are able to see or speak to their preferred GP varies between patient groups, and involvement in decisions about care is lower for community mental health service users and adult inpatients than for maternity and children and young people’s service users. There has also been a marked decline in carer quality of life, and in how well supported informal carers feel.
We also looked at how well the NHS is preventing people from being admitted to hospital unnecessarily. Rates of admissions in ambulatory care sensitive conditions (where effective care from GPs, community services and outpatient clinics can prevent the need for hospital admission) and urgent care sensitive conditions (where a care system should aim to treat and manage acute exacerbations of ongoing conditions as close to home as possible) have remained stable over time. This is arguably a good result, given that the total number of emergency admissions has risen dramatically.
Furthermore, we looked at what happens when people leave hospital. Between 2014 and 2016, the number of people who were still in hospital even though they were ready for discharge increased substantially. Better discharge planning for patients has now reversed that trend, although the number of people delayed is still higher than in 2014. Many of these delays are due to people waiting for home care packages as well as further non-acute NHS care, indicating that NHS services need to be joined-up better, just as effectively as health and social care.
Finally, the proportion of people who are able to die at home has increased over time, reflecting a long-standing policy to provide better support for people outside of hospital at the end of life.
Alongside the indicators we have selected, additional measures in QualityWatch are also relevant, such as patient experience of out of hours GP services, the quality of care for community mental health service users, and rehabilitation services for older people. These measures all show stable or fluctuating trends over the time period.
And what don’t we know?
Although we have drawn on the best information available, there are some caveats to bear in mind. Some of the measures are proxy measures – for example, we have not been able to find a direct measure for how well health social care teams are working together over time, and none of the patient surveys ask about coordination of care between different services. There are also gaps in our understanding of the quality of community services. Further to this, our indicators will reflect underlying health and care trends, and funding and workforce factors, not just progress with developing integrated care. However, they still offer a valid picture of how well the health and care system is working from a patient’s perspective.
Our verdict on the progress of integrated care
Overall, there is limited evidence that patients are benefiting from better integrated care: only one of the seven indicators has improved, three have deteriorated, and three show either no change or an inconsistent pattern. In particular, patients and carers are feeling less supported, and there are also important variations between different groups of patients. However, measures of how well services are keeping patients out of hospital have remained stable, despite a large growth in the number of admissions, and an increase in the proportion of people able to die at home.
There are significant gaps in our ability to track the progress of integrated care, for example, how well health and social care teams are working together locally. The success of the latest Long-Term Plan will depend on whether Integrated Care Systems are successful in strengthening out-of-hospital services, so it is essential to develop new ways of monitoring progress on joining up care.
Scobie S (2019) 'Are patients benefitting from better integrated care?', QualityWatch blog. Nuffield Trust and Health Foundation. www.nuffieldtrust.org.uk/news-item/are-patients-benefiting-from-better-integrated-care