Coinciding nicely with the NHS 70th Birthday celebrations and the parallel discussions of ‘where next and how to do it better’ for the NHS, last week saw the publication of our evidence review on models of integrating care. We also presented a poster, sharing our evidence-informed principles of integrated care at the Health Services Research UK conference.
Our review explores the evidence in relation to the Multispecialty Community Provider (MCP) model, which is focused on primary care and community-based services. We worked with the School of Health and Related Research [link], University of Sheffield, recognised internationally for their expertise in evidence review.
What we did
Our goal was to provide actionable insights for people involved in integrating services. For this reason, we used a method called realist synthesis. This approach extends the usual question of “what works” to “what works, for whom, in what respects, to what extent, in what contexts, and how?”
The MCP model was piloted in 14 ‘vanguard’ areas – these models shared some common features but also developed local innovations. We worked with our Project Advisory Group to decide what aspects to focus on and agreed to explore three key features in depth:
- Access to integrated services closer to home, through the shift of services from hospital to community settings and the redesign of primary care
- Closer working between professionals and services with the public and local communities
- New forms of contracting and paying for services to enable population healthcare
In our report, we also signpost evidence for other aspects of integrated working, including: integrated pathways; multidisciplinary teams; staff engagement and development; learning for improvement; and data sharing.
What we found
It will come across as no surprise to those working within integrated care systems that they are complex! We were influenced by current thinking on “complex adaptive systems”, a concept often applied to healthcare systems. This concept is useful as it recognises how the various people, organisations and services are inter-connected and how these links can influence behaviours in ways which makes it impossible to completely predict the impact of new services, roles and ways of working.
Using this complexity lens, we found relationships to be a common theme. This highlights the role of interpersonal dynamics between professionals, services, organisations and sectors - whilst this may seem obvious in relation to people-focused activities (like workforce planning or community engagement) we found good relationships are also important for structural change (such as contracting). For example, new contracts can be more effective if based on meaningful outcomes for all those involved, through engagement with clinicians and patients and alignment with personal, professional and organisational values.
Underpinning integrated working, a critical factor seems to be the time and space for shared engagement, reflection, discussion and deliberation – during the design of the model, throughout implementation and to inform continuous improvement. This can encourage cultural change, creating an environment where people feel empowered to improve and innovate. However, this takes time - the evidence we found suggests a timescale of at least five years.
We’re using the review findings to inform our ongoing work and have found the findings to be transferable to population health-based models of care in general. We’ve consolidated findings into eight principles which can be used to guide design and delivery of any integrated system.
We’re currently developing a short briefing to summarise these principles and key messages from our review, to provide a guide for anyone involved in integrated working across services and sectors. If you’re interested in finding out more, please get in touch
We’re also working with colleagues from the other four studies on new care models funded by the NIHR, to share our collective findings. We’ve already co-presented two workshops, one aimed at researchers and one aimed at patient and public representatives. Over the summer, we’ll be developing an information pack.
We’d like to take this opportunity to thank the following people for their help and support during our work:
- attendees of the focus group held in May 2017 for their valuable contributions
- members of our Project Advisory Group for their engagement
- colleagues from the New Care Models and Operational Research teams, NHS England for sharing opportunities to align our work
- Sharon Townsend, Deborah Mabbley and Lorna Crofts for providing administrative support
- Louise Rowan and Katrina Wilcox for their work on communications and engagement
- Peter Spilsbury and Fraser Battye for their helpful steer
- All our colleagues at The Strategy Unit for their practical support and advice.