What is integrated care?
In broad terms, the aim of integrated care is to join up the health and care services required by individuals, to deliver care that meets their personal needs in an efficient way.
This is easier said than done, because health and care services are made up of many constituent parts, and arrangements for delivering and funding them are complicated. Treatment and care for a single problem can require care from GPs, ambulance and hospital services, and a range of professionals working in the community including nurses, therapists and home carers. Funding arrangements vary between health services – which are generally funded from taxes, with few charges to individuals – and social care, which is paid for by individuals, or at the very least is means tested.
Policies for integrated care have addressed integration within the health service (for example between GPs and hospitals, or between physical and mental health services) and integration between health and social care. The levels at which integration could work are summarised below.
Box 1: What are the different types and levels of integration?
Organisational integration focuses on coordinating structures and governance systems across organisations, such as organisational mergers, or developing contractual or cooperative arrangements.
Administrative or functional integration involves joining up non-clinical support and back-office functions, for example, accounting mechanisms or sharing data and information systems across organisations.
Service integration involves the coordination of different services, such as through multidisciplinary teams, single referral structures, or single clinical assessment processes.
Clinical integration involves the coordination of care into a single or coherent process, either within or across professions. This could involve developing shared guidelines or protocols across boundaries of care.
How has integrated care changed?
Plans to join up services up go back decades. However, the number and frequency of new policies on integration make it clear this challenge still remains. In 2014, the Five Year Forward View set out a vision for transforming the NHS and social care in England to become more integrated. This was followed in 2018 by the NHS Long Term Plan that set out further steps towards in integration, and in 2021 by a white paper setting out legislative change to enable better integration in England. At the time of writing, the related Health and Care Bill is going through parliament.
Despite these polices, poor integration remains a significant problem for people using the health service, and in some ways is becoming harder to achieve. Medical advances mean the possibilities for treating health problems have increased, but this often requires more specialised services. And at the same time more people are living with several health issues. For individuals, this can mean appointments with multiple hospitals or other providers, which are time consuming to keep up with, particularly if the different specialists are not coordinated.
While policies to address integration continue to be developed, a lack of resources in social care and general practice, for example, threaten progress to deliver better joined-up care. Real-terms spending on social care by local authorities fell sharply from 2010/11, and levels of spending have only just recovered. This has stretched services further, making it harder for people to access social care advice or support. And increased demand for GP appointments means that patients with multiple health conditions are not getting the support they need to meet their needs.
What is happening with integrated care in England and in other countries?
England is currently enacting legislation aimed at improving integration between different health care providers and between health and social care services. The Health Bill will establish new Integrated Care Boards, with representation from NHS providers and commissioners, and the local authorities. They will be responsible for promoting better integration between services, using levers that might include pooled health and social care budgets and shared outcome frameworks across the two sectors. This represents a shift away from the division between purchasers and providers that has existed in health care since the 1990s.
Meanwhile, in Scotland plans are underway to establish a National Care Service that would see organisational reforms to transfer existing Integration Authorities into new Community Health and Social Care Boards. These could be directly funded and accountable to Scottish ministers in hopes of rebalancing budgets between acute, community and social care services. Northern Ireland and Wales are also planning changes to deepen health and social care integration.
The United Kingdom is not the only country to face the challenge of integrating health and care services. Countries worldwide have developed policies to integrate health and care services, and approached the challenge in a range of ways. In the case of New Zealand, this was supported by collaborative working, while in the United States integration has been led by health care providers. In Japan, integration efforts have focused on addressing the funding and sustainability of long-term care and developing strong community-based networks to underpin integration across all local services.
Can we measure integrated care?
The aims of integrated care policy reform in the UK have largely been consistent – to improve patient experience, quality and efficiency, and reduce health inequalities, by reducing fragmentation within and across services and supporting more care out of hospital.
However, despite consistent aims, measures of integration are not well developed. Much more data is collected about hospital services than social or community services, so integration is often measured by its absence – for example, unplanned emergency admissions, or delays in patients being discharged from hospital, which might indicate poor coordination of services or an absence of support closer to home. Other challenges include different boundaries for health and social care organisations, making it difficult to analyse data at a local level, particularly if boundaries change over time with each NHS reorganisation. Further tracking changes over time are beset by changes in data quality and definitions.
In England, guidance to support systems in evaluating integrated care from the user perspective locally has been developed. Work is also in progress to collect data from patients and service users of their experience of integrated care. This data, currently referred to as the integration index, is being piloted with people who have a range of long-term health and care needs.
Does integrated care work?
The story of integrated care has been one of many overlapping health policies and initiatives. This is amply demonstrated by the long history of integrated care policies in the UK.
Although new initiatives have built on previous policies, there has been a conspicuous lack of learning from previous policies, or those from overseas. While the policies are individually well intentioned, and might make intuitive sense – after all, no one wants an un-integrated service – attention to fully implementing policies and addressing long-standing barriers has been lacking. Successful integration often comes down to good relationships at a local level, leadership and an amenable culture. These things take time to develop and frequent new policy initiatives rarely give previous changes long enough to bed in.
Evaluations of integration initiatives have more often than not found limited success in meeting stated goals although, as noted above, measurement is challenging. Schemes targeted at particular populations, such as end-of-life care, have had most success.
While improved patient experience and quality of care are key aims of integration policies, achieving these within constrained funding is challenging, particularly if investment is needed to set up new services or change existing ways of working. Short-term financial pressures can lead to investment in integration being diverted. At a national level, priorities for integration programmes have focused on reducing unplanned admissions as a core goal, at the expense of wider benefits.
So while integration remains firmly on the policy agenda in England and elsewhere, realistic expectations about what the policy can achieve are needed, particularly in the face of pressure on public finances and the disruption caused by the Covid-19 pandemic.
Scobie S (2021) “Integrated care explained”, Nuffield Trust explainer.