A number of evaluations of different models of integrated care have not produced the expected results of reduced hospital admissions, and in some cases even found people receiving integrated care services using hospitals more than matched controls. Drawing on a wide range of expert opinion, we identify a number of reasons why this may be happening.
- Problems with the design of the model: these may be poorly designed or lacking logic, targeting the wrong population, or not listening to patient preferences. Models with a large number of complex work streams are a particular hazard.
- The model may be well designed, but fails at the implementation phase when the plan meets the real world. Getting multidisciplinary teams to work well, effectively involving primary care, and the likelihood of uncovering undiagnosed pathology are all issues that have caused problems.
- The expectations of those designing the models about the outcomes that are likely, and the speed that they can be achieved, are sometimes higher than can be achieved in the often short periods allowed for evaluation – not least because of the frequency of delays in implementation. The rather narrow outcomes used, and in particular the focus on hospital utilisation, are also a problem.
- The underuse of process evaluation also means that the active ingredient of models can be missed – this is an important issue where it is hoped to replicate the model.
There are a number of steps that can be taken to address these and other issues we identified:
- For model design and implementation: more focus on the problem that is being addressed and the evidence base about what tends to work. Rigorously testing the underlying logic is also important.
- For commissioners of evaluation: there is a need for more realistic timescales and openness to different methods and approaches, including more formative evaluation. Seek out help from experts and patients/professionals in the commissioning of evaluation.
- For evaluators: Choose outcomes and study designs wisely – consider mixed methods; describe interventions fully; collaborate with others to produce novel work; and use regular feedback loops with all stakeholders.
The hypotheses and recommendations are the culmination of ideas gathered from the integrated care literature base and discussions with 50 integrated care experts who attended a seminar organised by the Nuffield Trust and The Health Foundation on 1 May 2019. Attendees represented providers, researchers and commissioners of evaluations.