Can integrated care deliver?

The ageing population and accompanying increasing multi-morbidity underpins the NHS Long Term Plan's (NHS England (NHSE), 2019) commitment to roll out integrated care systems as part of redesigning patient care delivery within the context of the future population needs. Importantly, the NHS Long Term Plan (2019) acknowledged that the majority of medical consultations occurred in GP practices and in hospital outpatient clinics, although it suggested that roughly a third of outpatient appointments could be unnecessary. Integrated care, with collaborative working between and across health and social care services, was seen as the panacea to achieve improved outcomes and care quality, avoid unnecessary admissions and reduce costs. However, the evidence is less than compelling.

Baxter et al's (2018) systematic review of 167 studies reported perceived improved quality of care, increased patient satisfaction and improved access to care related to integrated care pathways, but inconsistent or limited evidence regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and healthcare costs. Rocks et al's (2020) systematic review and meta-analysis of 34 studies showed a significant decrease in costs and improvement in outcomes associated with integrated care, but there was substantial heterogeneity in both costs and outcomes across sub-groups (for example, studies in Australia/Asia reported the largest cost savings and health benefit, followed by Europe; integrated care pathways showed no significant changes in costs or effect). These findings were echoed in Vestjen et al's (2019) cost-effectiveness study of integrated care supporting community-dwelling frail older people (intervention n=182; control n=176) in the Netherlands, which found a small but significant difference in wellbeing in favour of the control group, no difference in quality-adjusted life years (QALYs) but significantly higher costs in the intervention group. Deschodt et al's (2020) systematic review and meta-analysis of 19 studies, involving 22 168 home-dwelling older people, revealed large variability in nurse-led integrated care and was not able to demonstrate benefit against predefined outcomes.