Summary of the principal findings
As noted earlier, the original research call was for ‘ambitious research studies assessing the cost-effectiveness of new and innovative models of care or clinical pathways for people with long term conditions. The aim is to generate high-impact research which will provide commissioners and providers with useful evidence when re-designing services’.39
The broad aims of the CLASSIC study were to meet this brief, assessing, in detail, the process of implementation of the new SICP and the degree to which it was influenced by the local and national context, and to complement this with a detailed analysis of the impact of the SICP on patients and its clinical effectiveness and cost-effectiveness. The CLASSIC study had the following research questions:
- How do key stakeholders (commissioners, strategic partners) view the SICP, what do they expect from it and how is it aligned with their objectives and incentives?
- What is the process of implementation of two key aspects of the SICP: the MDGs and ICC?
- What is the impact of the MDGs on the outcomes and costs of people with long-term conditions?
- What is the impact of health coaching from the ICC on the outcomes and costs of people with long-term conditions?
As an overview, the results presented in this report could characterise the SICP as showing rapid progress in terms of organisational integration, with slower implementation of the planned mechanisms of integration. At this point in time, there is limited evidence of patient benefit, in terms of either reach (the numbers of patients receiving exposure to mechanisms of integration) or impact (the size and scope of the benefits reported).
Our interviews with stakeholders made it clear that the development of the SICP (and the ICO) was facilitated by strong partnerships between organisations, local geography and a history of local joint working. The initial governance model (an Alliance Board and Alliance Agreement) ensured that the initial impetus was sustained despite the complexities of the integration process. The Alliance Agreement did not represent a legally enforceable contract and was not ‘tested’ during the development of the SICP, nor have applications of this model been formally evaluated.151 Nevertheless, the process was important in cementing partnerships. Managerial work associated with implementing the ICO may have distracted attention from operational detail, but the structures in place to manage the SICP (operational managers and management groups) meant that the programme continued to be implemented even as the ICO drew in attention and resources. The failure to fully engage primary care providers (in particular GPs) is perhaps the most obvious limitation of the early implementation. The creation of the Salford GP provider organisation in mid-2016 (towards the end of the research) provided new opportunities for the development of effective ways of working with the ICO, but has occurred fairly late in the delivery of the CLASSIC research programme.
As befits a ‘large-scale service transformation’, the SICP delivered integration of various types and levels.6,9 System-level integration was well developed, with functional and structural integration in pooling health and social care budgets, the Alliance Agreement and development of the ICO. ‘Service-level’ integration was observed in the ICC and the MDGs, although the speed of development trailed somewhat behind the system level. This may reflect the changes in the programme theory outlined in Chapter 10, that is, a move towards a logic that closer structural integration would lead to functional integration, in which working together across organisational and professional boundaries would become the norm, leading to better outcomes and patient experience, rather than the mechanisms of integration being the primary driver of change. Whether or not structural integration will deliver those benefits152 and whether the additional focus on structure facilitates or delays patient benefit remains to be seen.
Implementation of the mechanisms of integration in the SICP
As noted earlier, the progress on structural integration through the SICP to the ICO was not closely connected to the delivery of integrated care services, and the various management processes put in place by the SICP ensured that progress continued on delivery. The next section will consider how much progress was achieved in delivering the planned mechanisms of integration.
The MDGs were the largest mechanism in terms of scope and resource, and the most rapidly implemented (with some delays around planned pilots and ‘tests of change’). There were some significant challenges in implementation (owing to issues with engaging with GPs), dealt with in time through relevant contractual arrangements. SICP staff involved in the MDG process reported that consistent input from all professional groups was achieved around August 2016, when it might be said that the complete model was in place, placing it towards the end of the CLASSIC study timeline and thus limiting our ability to assess impact of the complete model given the data that were available.
Multidisciplinary group meetings were generally well attended, and staff were broadly positive about the model. They reported some issues with what was perceived to be slow progress, as well as a focus on patients at certain levels of need who may have fewer opportunities to experience proactive care. These concerns echoed the general debate about risk stratification of patients and about where resources are best placed to generate real gains in health and reductions in utilisation.78
Early implementation in MDGs focused on process measures (such as creation of records). Actions arising from the MDGs were often relatively limited, echoing similar interventions elsewhere in the UK.153 Although ‘care co-ordinators’ were allocated to patients being discussed by MDGs, interviews with patients and carers showed that MDG discussions were taking place without their involvement. As MDGs were quickly implemented across the locality, we could not conduct a formal experiment. We compared admissions in Salford with those in other areas, which showed little difference from the national trend, with the strongest evidence suggesting an increase in emergency admissions. The SICP is not the only integrated care initiative to report such outcomes.33 There is a legitimate question as to when the MDGs could reasonably expect to see effects on utilisation, and the timing of the full implementation may have reduced the ability to show benefits of MDGs in the CLASSIC timeline. Further analysis can continue to explore utilisation to see if the initial effects change over time.
The ICC faced some significant challenges in implementation and clarity of vision. Patients’ experiences of the ICC were mixed, which in part reflected the need to adapt to new ways of engaging with services. It was not clear that the centre was functioning to enhance patient experience of an integrated service, although colocation was noted by staff to be a potentially important mechanism of integration in terms of understanding roles and identifying new possibilities for support, which suggests that initial benefits may be focused on staff rather than patients.153 Such benefits in the process of care are likely to show benefits in patient outcomes over the longer term, if at all.
We conducted a formal trial of a health coaching intervention within the ICC. Patients using the service reported that it was acceptable and useful. Impacts on self-management and self-reported health were small, but the economic analysis suggested a reasonable probability that the intervention was cost-effective at conventional levels of willingness to pay. However, the intervention delivered improved health-related quality of life at an additional cost, and did not reduce utilisation overall (although the pattern of use suggested less use of emergency care and more use of planned appointments).
The SICP sought to increase access to community assets, and we saw a small increase in reported use of assets plausibly attributable to the SICP. Asset use was associated with better quality of life, when accounting for other factors, but impacts on utilisation were not significant. As with coaching, and in line with other quality improvement projects in integrated care, improving outcomes seems easier to deliver than reductions in utilisation.154,155
Overall, the SICP made some modest improvements in outcomes to some patients, including patient experience and quality of life, although the numbers impacted were relatively small and the magnitude of the benefits was limited. There was much less evidence that the programme was leading to reductions in health-care utilisation.
Interpretation of the findings: overall
As noted in Chapter 1, there is a fairly large body of international literature on integrated care, and this has demonstrated some benefits of this model, although effects are somewhat inconsistent and impacts on economic outcomes are difficult to demonstrate consistently. However, there are issues concerning the interpretation of that very broad set of studies and applying the results to the particular context of the NHS. Empirical studies of integrated care in the NHS have demonstrated more modest impacts. A key motivation for the present study was to explore whether or not a particular model of integration (the SICP) delivered in a receptive context49 could demonstrate improved outcomes. Overall, the results suggested that the receptive local context facilitated moves to structural integration, but it is not clear if benefits translated to the delivery of the specific mechanisms of integration, which faced the challenges and delays that have been reported in other evaluations.36,37 There were initial indicators of benefits among a modest proportion of patients (increases in reports of community assets and care plans, themselves associated with improved outcomes).
Interpretation of the findings in the context of the wider literature: multidisciplinary groups
Multidisciplinary groups (and linked case management interventions) have a peculiar place as mechanisms of integration in the NHS. They are very common, with a survey of CCG plans finding that around 80% included some form of MDG.79 Nevertheless, since Evercare,29,30 evidence that this model can reliably reduce hospital admissions is weak.18,19,33,77,78,156 The recent National Audit Office report stated that:
While popular approaches, such as multi-disciplinary teams focusing on patients with multiple and complex needs, may improve the care experience for a minority of patients, the evidence to date does not suggest that they will achieve the widespread efficiencies and outcomes needed in the current financially constrained times.
A realist model would hypothesise that the mechanism of MDGs might activate only in certain contexts. We identified a number of contextual factors that might be present in the SICP, including the partnership underlying the SICP, high-quality IT, the potential for self-management support via the interface between MDGs and other mechanisms of integration in the SICP, support for MDG development through quality improvement and ‘tests of change’, and the use of a ‘neighbourhood’ model for MDGs. Although many of these contextual facilitators are plausible effect modifiers, there is no strong evidence either way as to their actual impact.
The quantitative analysis was unambiguous in showing that the introduction of the MDGs failed to reduce admissions, with the strongest evidence showing an increase. This core result was robust to a variety of analytical models, comparators and the staging of the MDGs, and reflects similar outcomes found in previous work.33
There are a number of possibilities that account for this lack of effect:
- MDGs are not effective. As noted, the lack of effect demonstrated here is not unusual.19 There are potential competing interventions to reduce admissions, such as enhanced continuity of care,157 although they are more difficult to test in a controlled fashion.
- MDGs are effective, but are so widespread that showing differences for an intervention in any one area compared with comparators is difficult (as noted, most CCGs include the intervention in some form). The SICP MDGs may be unable to outperform similar interventions elsewhere, rather than being ineffective per se.
- The contextual facilitators we describe are incorrect or ineffective. We did not find strong evidence that IT was a strong facilitator of the MDGs, linkage to other parts of the SICP (such as community assets) to support self-management was limited, GP engagement was variable and the advantages of the neighbourhood model not fully articulated or observed.
- MDGs are effective if targeted. Critics suggest that excessive focus on ‘high utilisers’ means that interventions are provided to a patient group that is both too small to show meaningful change in admissions and impervious to change because of the severity of their conditions.78 A variety of risk algorithms have been used worldwide, but these were not adopted here, which may have attenuated effects, although there is little strong evidence that particular algorithms are effective. Targeting of specific groups and specific contexts, such as hospital-led case management for heart failure, may increase impact but clearly restricts the scope of benefits.20 It is interesting to note that the health coaching intervention (which is based on an assessment of patient activation, not future risk of admission) actually led to reductions in emergency care use, providing some support to the idea that a focus on prevention among larger groups of lower-risk patients may be an alternative strategy (although the evidence here is also weak).
- The evaluation of MDGs was too early to show benefits. A significant focus of the early work on MDGs was on forming the groups, identifying patients, developing ways of working and organising required systems. The numbers of patients managed by MDGs and the various performance indicators in place may have led to a focus on certain aspects (such as the creation of records), to the detriment of others (such as referral to other parts of the SICP to support self-management). Analysis of the work of similar teams in north-west London also found improved collaboration, but a lack of actions to take forward,158 as well as suggestions that the benefits might be more apparent for professionals (via shared learning) than patients.153 There was some evidence that MDG function improved over time. Improved patient outcomes may become apparent only later.
- Patient involvement in MDGs was insufficient. There were aspirations for patients to be involved (such as being informed that they were subject to a discussions and involvement in care planning). However, the numbers of patients to be managed and pressure of performance targets may have limited scope for patient involvement. There may be aspects of integrated care that can be achieved without significant patient involvement (such as better co-ordination between agencies) and through which patient benefits may accrue, even if integration is ‘behind the scenes’. The empirical evidence that the effects of MDGs are multiplied by effective patient involvement is not strong. However, there is an argument that some of the potential benefits of MDGs are lost without that involvement. Recent research has outlined some of the ways in which they could contribute and the barriers to them doing so.159
Interpretation of the findings in the context of the wider literature: health coaching
Compared with MDGs, health coaching is focused on patients lower down the ‘risk pyramid’, with a simpler intervention focused on improving self-management. The benefits of such an intervention on high-cost health-care utilisation (such as admissions) is likely to be deferred in time, as patients are not at high risk. However, such prevention models may be more effective in the longer term, as the numbers of patients in this group are so much higher and their potential to benefit from intervention may be greater.160,161
Of course, realising those benefits requires two features: (1) a significant level of uptake of the intervention among patients with needs who are not necessarily seeking help and (2) enduring impact on health attitudes and behaviour which will translate to longer-term benefits, especially in relation to care utilisation.
We did not demonstrate significant impacts on patient-reported outcomes, despite largely positive assessments from patients in the qualitative research. An important limit on effectiveness was the low uptake among patients. In terms of uptake, the levels found (40%) are reasonable, given that this was not a help-seeking group and the invitation came from outside usual services routes (such as GPs). This suggests a willingness to take part in such ‘preventative’ interventions among an older population with long-term conditions. It is, of course, important to remember that the CLASSIC cohort was itself selected, in that patients had to agree to be part of it.
The cmRCT estimates the effect of being selected for treatment, regardless of whether or not that offer is taken up. This is different from a conventional trial, in which patients who do not give consent are excluded from the trial and the effect being estimated is that of randomisation to treatment. Therefore, demonstrating effectiveness in a cmRCT is even more challenging than in a conventional pragmatic trial, as the cmRCT faces loss of potency through variability in quality of delivery and adherence as well as overall uptake, as opposed to the former alone in a pragmatic trial.
We argue that the treatment effect estimated is an appropriate one for health coaching, as it is a model of integrated care designed to be proactive, using identification of patients in the community according to external criteria rather than their own help-seeking, and designed to achieve population benefit. However, it cannot be assumed that the rates of consent in PROTECTS would generalise to delivery in routine practice.162
The economic analysis suggested that the intervention was likely to be cost-effective, delivering modest improvements in quality of life at some increased overall cost. The methods of the cost-effectiveness analysis are not based on notions of clinical or statistical significance. Decisions to adopt one intervention over another are based on the expected cost-effectiveness of the interventions and the probability of making the correct decision.163
Interpretation of the findings in the context of the wider literature: community assets
Although there is a consensus that community assets improve health, the experimental literature around assets and related interventions, such as social prescribing, is limited.164 We found a small increase in use of assets among cohort participants and found that increases in asset use were related to improvements in quality of life, but not care utilisation. It is possible that benefits in quality of life have a longer-term impact on utilisation, in line with the prevention model underlying some discussions of integrated care.160
Strengths and weaknesses of the CLASSIC study
There is an increasing recognition that the scale and pace of reform and reorganisation in the NHS calls for new methods of evaluation that balance rigour with speed and responsiveness.41
Our broad methods were conventional, using routine data and non-randomised comparisons to assess causal relationships, allied to detailed descriptive and qualitative research to provide depth, explore context and assess mechanisms.29,30,33,51
The use of the cmRCT represented a methodological innovation. The cohort provided an ongoing assessment of patient experience (absent from assessments based on routine data only), eased recruitment of the trial sample and allowed modelling of the impact of mechanisms of integration, such as community assets, by providing a measurement framework into which interventions were introduced, rather than measurement following the intervention. The cohort also provided the opportunity to produce a variety of papers related to the general management of patients with multiple long-term conditions.114,115 Attempts were made to run additional trials, but funding bids were not successful.
It had been hoped that mechanisms of integration in the SICP could have been allocated in ways that allowed more scope for causal inference (such as ‘stepped’ allocation). In reality, the practical demands of the programme were such that the only ‘staging’ of change involved the early introduction of the MDGs in two neighbourhoods, driven by a desire to pilot the service.
The challenges faced in the delivery of the SICP are not dissimilar to many of these reported in the wider literature, with slower than anticipated implementation a common feature of integrated care evaluations that causes difficulties for the timing of any evaluation.165 As noted previously, the impact of investment in community assets, delivery of care plans and significant engagement by MDGs with large numbers of patients had yet to materialise, and thus clear evidence of benefit may be deferred. As noted in Chapter 2, the formal ‘end date’ for evaluation of the SICP is 2019–20. The original CLASSIC bid was for 5 years, and extending the evaluation could assess longer-term effects.
We took a population perspective, exploring the effects of the mechanisms of integration on a large cohort (for self-reported outcomes) and the population of Salford (for hospital utilisation), rather than a more restrictive view exploring effects on those patients who were specifically targeted by particular SICP mechanisms. The latter approach may be more likely to show impacts, as there is a direct link between the mechanisms and the outcome. However, the restricted view would ignore wider effects; for example, MDGs might generate benefits by focusing on a sample of patients, with worse outcomes among those who are not targeted and thus receive less attention.
Although some outcomes may take time to become apparent, some previous evaluations of integrated care have reported impacts on issues such as patient experience at an earlier stage.33 We found only limited evidence of such impacts here, with the most notable change being in reports of written care plans and access to community assets. Although there were initial concerns among the research team that the SICP may have been implemented before the necessary ethical and governance arrangements were in place for CLASSIC, in reality, the introduction of CLASSIC proceeded at a pace that may have been too rapid for the benefits of the SICP to be evident.
The combination of the population perspective and the timing of the SICP and CLASSIC mean that the limited impacts shown at this point are provisional; the SICP has not demonstrated significant population-level impacts at this point in its development. It remains to be seen if those effects will become apparent in time.
The CLASSIC study does represent a single-site evaluation, with consequent limits on external validity. We have provided as detailed a description as possible of the local context (within the limits of the report format) to enhance interpretation. Of course, there is no consensus on the numbers of sites and amount of variation between sites that would allow stronger statements about generalisability in the context of ‘large-scale transformation’.
The study was premised to a degree on the idea that the local context provided a particularly fruitful one for integration. The health and social care system was largely coterminous (with one council, one commissioner, one mental health provider and one principal provider of acute and community health), and included a long history of partnership working and an integrated care record. If the overall outcomes had been more positive, then a debate would have ensued about the ability to replicate it in other settings. Given the more modest impacts, despite the context, the interpretative task is different. In the realist model, mechanisms of integration will show more or less potency in certain contexts. We have outlined the ways in which the chosen site was one in which integration was enabled by history and geography. The fact that there was only limited evidence of improved patient outcomes could be seen as a challenge for the realist model, as mechanisms of integration should arguably be more potent – more modest effects might be expected in areas with a less amenable context, such as multiple providers and more complex interorganisational relationships. This will be most evident in comparative data that uses external locations, as external sites may potentially lack both the ‘mechanism of integration’ and the contextual enabler. Of course, an alternative interpretation is that the effective mechanisms of integration are yet to be identified.
Meaning of the study: possible explanations and implications for clinicians and policy-makers
The SICP has been implemented consistent with the original vision. However, there has been more rapid success in establishing new integrated structures, rather than delivering mechanisms of integration at the level of services which impact on patients.
As with many integrated care transformations, it has proved challenging to deliver transformation in care, which means that the evaluation data reported here may be premature. It is still not clear if greater improvements in outcome will flow from integrated structures.
The failure to evidence improvements in patient outcomes may reflect a number of issues. Although the chosen mechanisms of integration were broadly supported by existing reviews (in the case of health coaching), or consistent with wider service activity (in the case of MDGs), there is still limited evidence about each. The ‘decoupling’ of the system and service-level integration means that the SICP is not wedded to these particular mechanisms. The potential for improved integration in the ICO (such as staff working in a common organisation) could support other mechanisms of integration.
The data would suggest that there is an urgent need to develop and evaluate new mechanisms that could be deployed from integrated organisations. It is also possible that more modest ambitions than the ‘triple aim’ (better outcomes, enhanced experience, lower costs) need to be set for those interventions, given the difficulties in achieving health gain without increasing cost.24 Other writers have emphasised more radical changes to the approach, such as an additional focus on prevention,79 and the recent plan for health and social care under the devolved arrangements in Greater Manchester suggests a preventative focus, allied to a drive to ‘enhance our primary care services, with local GPs driving new models of care and local care organisations forming to include community, social care, acute, mental health services, the full range of third-sector providers and other local providers such as schools’.161 The Salford vanguard (see Chapter 10) is one of the new organisations mooted in the plan.
The SICP has introduced new services, but it is not clear that the scale or ‘dose’ of the programme is sufficient to have an impact on wider population health. To talk of a ‘dose’ of integrated care may seem inappropriate, as it suggests that the complexity of the SICP can be reduced to a simple measure. Nevertheless, considerations of ‘dose’ may have some utility. Box 3 outlines some relevant data. These are crude indicators of ‘dose’, and ignore wider changes in the structure and organisation of care that may not be immediately apparent or easily measured. Examples would include MDGs that impact on general ways of working, with the potential to impact on all patients. However, some issues are worth noting. The programme that involved the largest numbers of patients (community assets, of relevance to all patients and most relevant to the larger numbers of patients at lower levels) showed only limited evidence of direct engagement with patients in the study period. This is supported by analyses in Chapter 9, which showed that large numbers of older people reported engagement with assets at baseline (unlikely to have been affected by the SICP), with only small changes over the timeline of the programme. The numbers directly affected by the ICC were more significant, and the impacts were more likely to translate to immediate benefit. Nevertheless, the proportion of patients was still relatively small. Finally, the MDGs delivered a ‘mechanism of integration’ to a relatively large number of patients, especially in proportion to those at levels 2 and 3 who were eligible. Nevertheless, as detailed earlier, actual MDG activity with respect to many patients was limited, with minimal patient involvement and small changes in care delivery.
Analyses conducted by Haelo as part of a mid-term assessment of the SICP, and of data collected by the CLASSIC team, provide the following indicators of ‘dose’.
In terms of community assets, £100,000 funding was provided for 19 groups, and 53 ‘well-being champions’ were enlisted. Well-being plans were created for 435 Salford residents, and 24 ‘tech and tea’ events to improve older people’s access to technology were run and included 76 older people.
In terms of interventions within the ICC, 236 were on simple telehealth (‘Flo’), before that service was suspended, and 733 were on care call, including 197 on PROTECTS.
MDGs discussed 1651 patients, out of a population of 36,074, 4.5% of the total number of > 65-year-olds and 63% of patients at levels 2 and 3.
Although the data related to dose are only indicative and do not cover all the changes made as part of the SICP, they suggest that, although many older people may have received some form of integration, the dose at the level of the population may have been limited.
Unanswered questions and future research
Demonstrating significant health benefits from integrated care interventions remains a significant challenge. In part this represents difficulties in defining integration of care in a way that makes it amenable to evaluation. When integrated care programmes are part of a larger-scale transformation of services, there are additional complexities around the timing of evaluation. The enormous challenges associated with integration at scale do suggest that benefits may be deferred. However, if evaluation is delayed, then services may already be so committed to a model that responding to the results of the evaluation may be difficult. Identification of comparators (and keeping them from adopting new services rapidly) is also made more problematic.
Some of the results reported here are in line with other evaluations of integrated care: slower than anticipated progress on aspects of the programme36,37 and limited impacts of interventions on patient experience and admissions (including increases in some outcomes).33 In Chapter 2, we hypothesised that context would be a significant enabler in the SICP, given the long history of joint working, but the context seems to have facilitated the speed of higher-level organisational change, rather than enhancing the delivery of mechanisms of integration and consequent impact on patient outcomes. Although there is consensus in the health services research literature as to the importance of context,166,167 the ways in which it interacts with discrete interventions and impacts on patient outcomes are less well understood. A recent exploration of the context–mechanism–outcome relationships in integrated care for diabetes mellitus reported many barriers involving organisational issues (such as deficits in IT and provider self-management support skills), whereas facilitators more often involved social issues (such as involvement in staff in decision-making, leadership and culture).168
The future research questions around MDGs are complex, as there is now a weight of evidence suggesting limited benefits, despite the popularity of the model.79 Within the SICP, and integration initiatives more generally,36,37 the usual patient under consideration is an older patient with multimorbidity. One of the barriers faced by integration initiatives is that, despite large amounts of evidence about the challenges faced by these patients,169 the evidence base concerning interventions that demonstrably improve the care of multimorbidity is very poor,98 as highlighted by the recent NICE guidelines,170 with consequent funding calls from NIHR. Indeed, there is a debate about whether the concept of multimorbidity is optimal, or whether a focus on frailty would be better, as the populations captured under these terms are related but not identical.171 The success or otherwise of integrated care may be dependent on the development of that evidence base.
It is possible that the model needs improved targeting of patients or disease subgroups to demonstrate effectiveness, although there is the challenge of identifying suitable subgroups. Although the targeting of patients at high risk has face validity, effectiveness will be dependent on the ability of services to make significant improvements to their care without increasing the risk of other patients who are not targeted. The best way to undertake risk stratification and the types of patients who should be targeted remains controversial,78 and the field awaits the results of trials of different methods.172
One of the limitations of risk stratification models is that they only identify risk and do not necessarily drive intervention (which has been called the ‘impact’ of such prognostic tools).173 There is clearly a role for further detailed qualitative examination of the actions generated by such multidisciplinary working, given the findings of this study and those of others that suggested limited impacts on patient care.132,153 It is important to explore if these limited impacts reflect the nature of work in these groups, the amount of support that these patients are already receiving and the limitations in available resources to manage problems that have been identified through multidisciplinary meetings. Nevertheless, the weight of evidence would suggest a more limited role for the model in integrated care and the consequent need to identify alternative mechanisms.
Health coaching is in a somewhat similar position as an evidence-based intervention, as early reviews of small studies in particular groups showed promise,85,87 whereas larger, more pragmatic evaluations suggested more modest gains.90 Overall, the evidence seems stronger than that for MDGs, although the search for a reliable model of coaching that can be implemented at scale remains. The benefits reported here, although cost-effective at conventional levels of willingness to pay, would not translate to savings for commissioners or providers. This means that the model may have a limited role in achieving the sorts of reductions in health-care utilisation that are critical to many integrated care initiatives. Nevertheless, the positive patient experience (as reported in Appendix 2) and the changes in patterns of resource utilisation (see Chapter 13) should not be discounted.
The data suggest a role for community assets in generation of gains in quality of life. Further quantitative exploration is required to assess longer-term benefits, especially longer-term impacts on utilisation, which may be generated by short-term improvements in quality of life. It would also be useful to explore the patient and contextual factors that drive asset use and that influence the level of benefit derived by older patients. For example, many social prescribing schemes have a focus on mental health, in terms of both inclusion criteria and measurement of outcomes. Appropriate qualitative methods might be employed to explore the factors underlying access to assets (beyond the effects of proximity explored in Chapter 9), and the psychological and social mechanisms by which they achieve their effects (such as improvements in self-efficacy or activation, reductions in loneliness or improved social support).
Community asset interventions as described here are linked to social prescribing interventions, which have received recent interest from policy-makers,174 although the evidence base remains weak.164 Social prescribing schemes are generally based on a GP referral mechanism, which differs from the broader community assets intervention employed in the SICP. The relative impact of the different schemes could be usefully explored. Referral through a GP may well increase access to assets in principle, and provide greater linkage to other aspects of management of long-term conditions through an effective primary care-based care planning process. However, enthusiasm for such schemes may be highly variable among GPs. There is a useful debate to be had about the amenability of such schemes to formal test, compared with the quasi-experimental models employed here, but examples of randomised evaluation do exist.175
As noted previously, it remains an open question whether or not health impacts from community assets convert to genuine savings in care utilisation. Although the ‘triple aim’ remains part of the vision of integrated care, the pattern of results reported here (achieving improved outcomes at increased cost) is less likely to be sustainable.
The use of the cmRCT design in the CLASSIC programme has identified a number of issues with the design, including the management of low levels of uptake among patients and the logistics of follow-up. As more trials utilise the design, synthesis of the findings will be required to better understand the advantages and disadvantages of the model and how it can best be used to meet the challenges of evaluation in the NHS in years to come.41
Although many integrated care initiatives share common mechanisms (especially variants of the MDG), there is no reason why a wider variety of interventions might be employed and tested within the context of integrated services. For example, many integration initiatives have an initial focus on prevention36,37 and future work could explore preventative interventions that could be facilitated through integrated services to improve the outcomes of older people.
Summary
The SICP has been implemented in a way that is consistent with the original vision for services, built around three main mechanisms of integration. Although the SICP has been successful in establishing new integrated structures, the progress at a system level has not been matched by such rapid progress in terms of delivery of integrated services. The SICP has introduced new services, but it is not clear if the scale of the programme is sufficient at this point in time to make an impact on population health.
The greatest resource and fastest progress has involved MDGs, with the ICC facing the greatest challenges to implementation.
In terms of the outcomes reported in the CLASSIC timeline, patient experience is only one of the core outcomes of the SICP, and there was little evidence that a sample of older patients in Salford were experiencing care as feeling more ‘joined up’ at this point of the evaluation of the SICP.
The evaluation of individual components of the SICP (MDGs, health coaching, community assets) suggests only limited evidence of benefits, focused around quality of life, even in the facilitative context of a system with a significant history of joint working and supportive structures for organisational integration.
As with many integrated care transformations, the evaluation data reported here may be ‘early’ in terms of the evolution of new services for which benefits may be delayed. Whether or not better outcomes will flow from these new integrated structures remains to be seen.