In 2019, the NHS published plans (‘The NHS Long Term Plan’) promising to introduce inventive, ambitious ways to bring NHS and social care together across England, working with the private and voluntary sector, and users and carers. Needless to say, things have changed since 2019.
Nevertheless, the recent COVID-19 pandemic is showing us just how important it is to have joined-up health and care services, especially for caring for vulnerable people like the elderly in care homes. If anything, there has been a renewed urgency to roll out ‘integrated care’ initiatives.
However, there is also the risk of acting too rapidly without a clear direction. In fact, we do not know yet the best way of integrating services or what factors lead to successful integration. There is no detailed review of locally implemented integration policies to enable stakeholders to compare them and share learning on best practices. We need this to understand what works best and why, to identify areas for improvement and encourage good and sustainable practice nationally.
In a paper, published (Open Access) in the journal Health Policy, we have conducted the first independent national evaluation of the main ‘Vanguard’ integrated care prototypes trialled by NHS England from 2015-2018. This was a massive programme, costing about £389 million and covering a population of around 5 million people (around 9% of the population of England).
The declared aspiration of the Vanguard programme was the development of `locally driven’ prototypes, which, if successful, could be rapidly spread across England. We summarise our analysis and findings below, which provides some preliminary evidence that can help policymakers choose their integrated care direction in this turbulent time.
The NHS Vanguard integrated care models
Fifty local areas were selected across England to act as Vanguards. Some Vanguards focused upon improving the integration between primary, secondary, community and social care, with the aspiration to provide more integrated care in the community. These included 23 sites who developed “population-based” flexible models to be adapted to the needs of their whole local population (known to policymakers as either ‘MCPs’ or ‘PACS’) and others focused specifically on care home residents, mainly older people (6 sites, referred to as ECHs).
There was little instruction or advice as to what should be trialled within each model, beyond the populations outlined above. They generally aimed to improve care, but the official main aspiration was to reduce hospital admissions.
What we found
The easiest way is to visualise this. The figure below shows that there are parallel trends on the outcomes prior to the intervention being introduced (before the vertical grey line). In fact, non-Vanguard sites were doing consistently better on each measure (fewer emergency admissions and bed days), and there was an increasing trend of emergency admissions across the board.
What is also clear from below is that, in the post-intervention period, especially in the final year of the Vanguard programme, the Vanguard sites were resistant to a national trend of increasing emergency admissions. The sites that implemented integrated care aimed specifically at care homes did the best in this respect, starting with a worse rate of emergency admissions prior to the intervention and finishing better than the population-based Vanguards.
On the other hand, there was very little change in the bed days outcome, trends remain parallel throughout the post-intervention period.
Using a robust difference-in-difference statistical approach, we estimated that over the three-year period of the Vanguard programme, care home sites experienced an overall significant net reduction in emergency admissions of about 4.2% relative to the non-Vanguards. The net reduction in emergency admissions occurred mainly in the third year following implementation (-6.5%).
There was a reduction in emergency admission in sites involved in “population-based” models (MCP/PACS) too, but the effect was found to be statistically significant only in the third and final year of the programme (-3.1%).
We did not find any significant effect on total bed-days.
The take-away message
National and international experiences have shown that arranging an efficient integrated health and care system is not straightforward. The positive finding we have shown, is that integrated care has some potential to change desired outcomes, especially by targeting vulnerable groups in care homes that are a priority.
But, it is important to consider these were modest relative reductions in emergency admissions. Moreover, our results clearly show no net changes in the first year and relative reductions in emergency admissions only became significant after three years. This suggests that, even in a relatively straightforward organisational context such as care homes, where initiatives can be applied to whole resident population, achieving desired results takes time.
Finally, the modest net reduction in emergency admissions we have documented was achieved with the help of considerable additional funding and a dedicated support programme for Vanguard sites. It remains to be seen what can be achieved in a different environment. Three important lessons to be taken into account when re-shaping the system for the post-COVID-19 era.
Project Research Team:
We are researchers from the Health Organisation, Policy and Economics (HOPE) research group at the Universities of Manchester, and from Kent that have worked with Charles Tallack, now at the Health Foundation. We have undertaken joint research commissioned and funded by the NIHR Policy Research Programme (PR-R16-0516-22001) in evaluating the Vanguard “New Care Models Programme”.
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