Integrated health and social care in the community has been high on the UK Government agenda for a number of years; the aim is to reduce inappropriate admissions and hospital stays while increasing the quality of care by providing coordinated care for patients in their homes. An increase in the ageing population, rise in morbidity within the population, and the current period of austerity demand fundamental changes to the way in which health care in the country is organised and delivered. However, the evidence in relation to the benefits of integrated care is limited and mixed. Some researchers claim that providing integrated care in the community reduces hospital admissions (Ham and Curry, 2011); others claim that this is not the case and that the benefits are related to the increased coordination of care and quality (Coupe, 2013). This may reflect why, despite the existing literature on the subject area, numerous government recommendations, and drivers to support integrated care, progress has been slow. Nonetheless, integrated health and social care in the community remains a priority within the NHS.
Background
The NHS in England is facing some of its greatest challenges since its inception more than 65 years ago. Advancements in medical treatments have resulted in people living longer, with many living with one or more chronic long-term condition. As a result, long-term conditions are now the most common cause of morbidity and mortality in England (Coulter et al, 2013). The cost of hospital care is more expensive than the provision of care in the community (Coast et al, 1998; Health Foundation, 2011), and as such a common theme in NHS reform is to transfer care into the community setting. Steventon et al (2011) suggest that the aim of community care is twofold: to reduce unplanned admissions and to promote the quality of care being delivered. Thus, to address this challenge, integrated health and social care is now a core policy aim of the Government in England (Thistlethwaite, 2011) and the need to improve the treatment and management of long-term conditions is the most significant challenge to the NHS (Coulter et al, 2013).
Long-term conditions
‘A long term condition (LTC) is a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies.’
[Department of Health (DH) and Long Term Conditions Team, 2012: 3]Long-term conditions can have a significant effect on a person's quality of life and are very costly to manage, significantly greater than treating patients without a long-term condition (DH and Long Term Conditions Team, 2012); this is often because of the associated hospital admissions, hospital attendances, and social care packages (Purdy, 2010). As such, people with long-term conditions are often described as high intensity users of both health and social care services, with an estimated 70% of the health and social care budget being spent on people with long-term conditions (DH and Long Term Conditions Team, 2012). Moreover, estimates suggest that the number of patients with a long-term condition is expected to rise from 1.9 million in 2008 to 2.9 million by 2018 (DH and Long Term Conditions Team, 2012). Owing to the adverse effect on a patient's quality of life and the costs associated with caring for the increasing number of patients with long-term conditions, this study focuses on this particular group.
Integrated care
Shaw et al (2011: 4) describe integrated care as:
‘An organising principle for care delivery to improve patient care and experience through improved coordination’.
To be more specific, and for the purpose of this review, the focus of integrated care will be on a specific patient group, that is, adults living with long-term conditions and being cared for in the community by community-based services. This approach is referred to as integrated health and social care in the community.
Despite the extensive literature and political directives promoting integrated care, there remains limited progress on the implementation of integrated health and social care teams across the country. To gain a deeper understanding, an appropriate investigation into the subject area will be conducted by adopting the principles of a systematic review.
Literature review
Aim
The aim of this review was to critically examine existing evidence to identify factors that will enable the successful implementation of integrated health and social care for people with long-term conditions in the community. The objectives are to:
- Conduct a comprehensive search of the literature to identify relevant evidence
- Critically appraise the quality of evidence and analyse the findings to identify if there are any factors essential to the successful implementation of integrated health and social care teams
- Explore the implications of the body of research evidence for professional practice in health and social care.
The SPICE model (Booth, 2004) (i.e. Setting, Perspective, Intervention, Comparison, Evaluation) enables the search question to be broken down into key aspects. Although the SPICE model identifies five aspects, all are not necessarily required for every search (Beecroft et al, 2010). For the purpose of this review, the comparison and evaluation aspects of the model were not used as no comparison or evaluation would be taking place. The other aspects are summarised below:
- Setting: for the purpose of this review, the setting would relate specifically to the community environment—either the patient's own home or within residential homes
- Perspective: as the area of focus is in relation to integrated health and social care, children under 18 years, are excluded from the search. Long-term conditions are another perspective considered
- Intervention: this is essentially integrated health and social care, defined as a co-ordinated and collaborative approach to the provision of both health and social care.
Using the SPICE model, the review question was formulated: ‘Are there any factors that enable implementation of integrated health and social care for adults with long-term conditions in the community setting?’
Method
A review was conducted following the principles of a systematic review. This involved a comprehensive and iterative search to identify published and unpublished literature from 2006 onward from Medline, Cumulative Index to Nursing and Allied Health Literature (Cinahl), Social Policy and Practice, and Proquest using the keywords identified with the SPICE model. Additional approaches were also employed such as the use of MeSH terms, wild cards, and smart text searching to expand the search field to try and capture all relevant information. Boolean operators were used to link the individual search areas and identify papers relating specifically to the subject area. Hand searches were also conducted on various websites such as The King's Fund and The Health Foundation. The Centre for Reviews and Dissemination (CRD), Cochrane Library, Evidence for Policy and Practice Centre (EPPI), and NHS Evidence were also searched to try and identify any additional studies.
A total of 776 papers were retrieved. To ensure the retrieved papers were specific to the research question, all papers were reviewed against the inclusion and exclusion criteria (Table 1), resulting in a total of seven studies being selected for inclusion in the review.
Data extraction
Relevant data were extracted from the identified papers using the UK CRD approach to systematic reviews (CRD, 2009). On the basis of this approach, headings such author, year, title, type of publication, etc., were included in the data extraction. For detailed information see the complete study (Mackie, 2014).
Quality appraisal
Research quality can vary considerably and no research is without flaws; therefore, an essential aspect of a systematic review involves appraising the quality of the research selected for inclusion within the study (CRD, 2009). All studies were subjected to a quality review, based on the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies, and taking into account factors such as study design, research methods, data collection, and analysis.
In all studies, the aims were clearly defined and the design and methods used were appropriate to enable the research questions to be answered. However, with regard to bias, in three of the seven studies (i.e. Syson and Bond, 2010; Thistlethwaite, 2011; and Coupe, 2013), the authors were employed within or associated with the organisations where the studies were conducted. Regarding sample selection, although two studies (Challis et al, 2006; Thiel et al, 2013) used purposive sampling to select the cohort to be involved with the study, the remainder of the studies did not discuss how the sample was chosen. In relation to data collection and data analysis, only two studies (Challis et al, 2006 and Ling et al, 2012) discussed the process in any detail. In the remaining five studies, information regarding the data collection and analysis is limited, which makes it difficult to determine the level of rigour and rule out any bias.
Apart from the aims and objectives, there is key information missing in all the studies, which makes it difficult to be able to report any confidence in the findings; however, the fact that studies reported similar outcomes, suggesting a degree of data saturation, may provide some assurance. Data saturation refers to when the researcher continually encounters the same responses (Roberts and Priest, 2010), suggesting that all the evidence has been identified. In summary, the quality of the included studies was variable, but overall, the quality was low because of key information missing.
Data synthesis and findings
Data synthesis is the process of analysing and synthesising data. Daly et al (2006) describe the synthesis of qualitative data as the process of sorting the data into different conceptual categories. Following review of the papers, information was extracted that linked to the research question specifically: are there any factors that enable implementation?’ The findings were then themed into the following categories.
Co-location of staff and teamwork
Co-location of staff was one of the most common themes to emerge from the data, identified in five out of the seven studies. Both Coupe (2013) and Ling et al (2012) stated that co-location was an important factor in enabling integration and was also necessary for developing relationships that would be required for the formation of new teams. Ling et al (2012) suggested that members working in the same environment facilitated face-to-face working, which in turn resulted in an enhanced quality and frequency of communication. This view is also supported by Sheaff et al (2009), who suggest that being organisationally separate will pose a barrier to effective communication.
Syson and Bond (2010) strongly advocated co-location of staff, believing that this was central to the development of learning and networking across professions, which resulted in an increase in knowledge and understanding of the different roles. In addition to this, they also reported that co-location enabled timely communication regarding patients, meaning that care could be discussed and agreed much quicker. When considering organisational structure, team members interviewed by Thiel et al (2013) felt that where teams were co-located, more progress had been made in relation to team development and work processes, although they made it clear that they had found no evidence of enhanced care outcomes in teams that were co-located.
Communication
Ling et al (2012) partially attributed the success of integrated teams to strong relationships within the team, which was facilitated by good communication between individuals. In order to establish good working relationships, Ling et al (2012) suggest that clear communication is required to ensure that all team members understand their role within the team. Moreover, to maintain the functioning of the teams, wider communication is required at a senior level and between partner organisations.
Sheaff et al (2009) claimed that for the integrated care teams to achieve their purpose—that is, reduction in hospital admissions—effective communication extended wider than the immediate team, for example, to other primary and secondary care staff. In order to prevent hospital admission or facilitate a speedier discharge, staff would be required to effectively communicate and negotiate with their colleagues in secondary care.
Co-location of staff, teamwork, and communication are inextricably linked and have been identified as enablers to integrated health and social care teams. Data saturation in these areas may provide some assurance in relation to the validity of the findings.
Integrated organisations
In a review by Challis et al (2006), a comparison of integrated care for older people in the community was undertaken between England and Northern Ireland. Within Northern Ireland, social and health care services have been jointly administered since 1972, quite the opposite to England where services are separately administered. The results of Challis et al's review (2006: 344) suggest that ‘the delivery of integrated health and social care by a single organisation enables a more integrated approach.’ However, it needs to be acknowledged that the integrated organisations in Northern Ireland had been established for over 30 years at the time of the case study, compared with integrated health and social care teams in England, which was a relatively new concept.
The opinion that integrated teams take a number of years to become established and start realising the benefits of an integrated care approach is widely acknowledged (Ham and Curry, 2011; Steventon, 2011; Hayes et al, 2012); therefore, it is possible that the success in Northern Ireland is partially attributable to a well-established service that was implemented into a culture of integration. However, this does not imply that an integrated team approach (as opposed to an integrated organisation) will not facilitate integrated care; it may just take time to embed the changes into practice. Sheaff et al (2009) also support integrated organisations and propose that being organisationally separate can pose barriers to communication—another key enabler, already discussed.
However, in 2001, the Health and Social Care Act introduced the concept of an integrated organisational approach to the delivery of health and social care, an approach similar to the integrated organisations in Northern Ireland discussed by Challis et al (2006). A UK example of the integrated organisational approach is described by Thistlethwaite (2011), where in Torbay, Devon, an integrated trust was established, bringing together both health and social care providers as one organisation to deliver what is considered to be one of England's most successful examples of integrated health and social care (Ham et al, 2012). Within the UK, the majority of health and social care is provided by completely separate organisations: the NHS and local authority, respectively. As a result, there are a number of operational systems and processes that may pose a barrier to integrated working across the two organisations.
Management support and leadership
Management and leadership support was identified as an enabler in four of the seven studies, with Coupe (2013) suggesting that leadership support was essential for the successful implementation of integrated health and social care teams. Managers have a key role to play with regard to implementing changes within a service, and the first stage of the process involves familiarising and engaging staff with the change (Sullivan and Decker, 2005). Change management can be complex, and Thomas et al (2006) suggest that changes are more likely to be adopted when the change meets an identified need. Ling et al (2012: 4) support this belief, as they reported that ‘where staff felt that change was being forced upon them then they were less likely to support the new activity.’ However, in Coupe's study (2013), although the changes were organisationally driven, it was acknowledged that for the teams to be successful, they needed to share a common understanding, beliefs, and expectations toward integration.
Ling et al (2012) further reported that pilot sites were more successful when there was evidence of a shared vision, along with a commitment from management in relation to longevity of the change. This could be viewed as a key enabler, as previous reviews into integrated care (Steventon et al, 2011; Hayes et al, 2012) also identified that pilot studies were often concluded before the teams have been fully embedded, preventing teams from reaching their full potential. Coupe (2013) suggested that it would take between 3–5 years for the benefits of integrated health and social care teams to be realised, again implying that long-term support will be required. Thistlethwaite (2011) partially attributed the success in Torbay to the stable leadership within Torbay and the ongoing managerial support to deliver on the integration project. Therefore, a shared vision, that is, a long-term commitment from management to enable an integrated health and social care team to become fully embedded and operational, may be an enabler.
Resources and capacity
The implementation of integrated health and social care teams was often implemented without any or insufficient additional funding. Sheaff et al (2009), Thistlethwaite (2011), Ling et al (2012), Coupe (2013), and Thiel et al (2013) made reference to resource implications and the effect on the success of integrated health and social care teams. These teams are tasked with reducing hospital admissions (Sheaff et al, 2009; Ham and Curry, 2011) by enabling patients who may have previously been admitted into secondary care for treatment, to be cared for at home; this will undoubtedly have resource implications for the teams. Coupe (2013) attributed the main cause of under-performance of the integrated health and social care teams to a lack of investment in the teams, which is required to embed the change into practice; so investment could be considered a key enabler to integrated health and social care teams. Ling et al (2012) also reported that the lack of resources in the integrated health and social care teams resulted in an increased workload, which had an adverse effect on staff motivation. Furthermore, financial pressures that developed during the pilot resulted in some of the teams losing staff, which further affected capacity and the ability to deliver the objectives (Ling et al, 2012).
Sheaff at el (2009) also considered resources, but from a slightly different perspective. They suggested that for integrated health and social care teams to be effective, there would need to be evening and weekend cover to try and prevent hospital admissions. Thiel et al (2013) further concluded that specialist staff would need to be employed to care for patients with chronic conditions, while Thistlethwaite (2011) suggested that the appointment of health and social care coordinators would have a considerable effect on the project's success.
Resources and capacity have been identified as a key enabler in five out of the seven studies. In 2013, NHS England announced the £3.8 billion Better Care Fund, which was implemented to enable the transformation of local services to facilitate a more integrated approach to care (NHS England, 2014). This could be interpreted as the Government prioritising integration by investing in integration and disinvesting in other areas.
National policy
National policy was considered an enabler in four of the studies. Coupe (2013) identified that the NHS payment systems, such as payment by results and block contracts, do not incentivise the delivery of care in the community, and thus pose a barrier to integrated health and social care teams. Sheaff et al (2009) also referred to the NHS financial system, suggesting that paying hospitals for each case treated was an actual incentive to increase admissions, which completely conflicts with the aims of integrated health and social care teams. A review of the NHS payment systems could be necessary to ensure that organisations are incentivised to reduce hospital admissions and facilitate a speedier discharge where appropriate.
Ling et al (2012) also described how national policy can facilitate integration, for example, the introduction of Transforming Community Services (Transforming Community Services team and DH, 2009) was perceived as supporting an integrated approach to health and social care. Thistlethwaite (2011) further suggests that prioritising continuity of care at home in government policies may help to facilitate integrated health and social care; yet, despite numerous policies, there is little evidence of integration happening at scale. Coupe (2013) suggests that integration requires a degree of cooperation as opposed to competition and that the effectiveness and efficiency of integrated teams will be compromised if care is provided by the delivery of separately commissioned services (e.g. any qualified provider (AQP)). So, although the NHS has started investing in integrated care, by way of the Better Care Fund (NHS England, 2014), initiatives such as AQP could potentially undermine the progress of integration.
Information technology systems
Shared information technology (IT) systems were identified as an enabler in two studies. Ling et al (2012) identified that separate IT systems caused issues in relation to accessing and sharing data and could therefore cause issues with relation to team performance and efficacy of the teams. Following the evaluation of an integrated health and social care team pilot, where staff had access to both health and social care IT systems, Syson and Bond (2010) proposed a model for the roll out of integrated teams across the city, where one of the key requirements was a shared IT system. However, Syson and Bond (2010) did not discuss how this was managed internally with regard to information governance. This may pose a concern for a number of organisations considering data sharing owing to issues with information governance and maintaining patient confidentiality. Thus, this is an area that requires further exploration to identify the feasibility of data sharing.
Conclusion
In reviewing the literature related to integrated care, there is an abundance that claims integrated care is more cost-effective and reduces hospital admissions (Sheaff et al, 2009; Ham and Curry, 2011); however, the evidence from the included studies does not always appear to support this. A systematic review conducted by Hayes et al (2012) concluded that while integrated care has the potential to reduce costs and hospital admissions, studies are often concluded too soon for these benefits to be realised. This may be partially responsible for the lack of wide-scale spread and adoption of integrated care. The lack of attention on how to effectively implement integrated care may also be partially responsible for the limited number of successful integrated care teams across the UK, despite this being high priority on the political agenda for many years. Out of the seven studies identified and included within this review, only one looked specifically at barriers and facilitators to integrated care. Although all studies made reference to barriers or facilitators, often this was quite subtle and not the main focus of the study.
Thematic analysis identified a number of factors that may be considered as enablers to the implementation of integrated health and social care teams. Although the quality of the included studies is considered to be low, data saturation may offer a degree of assurance in relation to the themes identified.
Recommendations
Following the review, there are a few key recommendations, in relation to the actual benefits of integrated care, organisational support, and research. Literature on health and social care teams often claims that integrated health and social care teams will reduce hospital admissions and be more cost-effective; however, the evidence does not always support this (Steventon et al, 2011). Nonetheless, the evidence does support greater patient experience and care coordination (Coupe, 2013). A recommendation following this review would be to shift the focus away from the unproven financial gains, to the actual benefits of integrated care, which may then facilitate greater engagement and adoption of integrated care. This in turn may act as an enabler for integrated health and social care.
Although a number of studies have been conducted into integrated health and social care teams, Hayes et al (2012) and Steventon et al (2011) claim that often they have been concluded too soon to allow changes to become embedded in practice and to allow for some of the benefits to be realised. Coupe (2013) further suggests that it takes between 3–5 years for integrated health and social care teams to become fully established and embedded. If an organisation intends to implement integrated health and social care teams, there needs to be due consideration for the length of time it takes for these teams to become fully operational, and teams need to be assured of a long-term commitment from the organisation. It is acknowledged that this may be difficult owing to the ever-changing landscape of the NHS, but strategic planning may be needed to help to facilitate this.
Finally, with regard to research, this literature review did not identify any longitudinal studies on integrated health and social care that had been completed and evaluated. Thus, it is recommended to carry out longitudinal studies into integrated health and social care that look at enablers to implementation as well as determine the benefits of an integrated approach for both patients and organisations.
This article was originally published in the British Journal of Community Nursing
Key points
- Integrated health and social care can improve patient experience
- Current evidence does not appear to support the belief that integrated health and social care reduces hospital admissions
- Organisational support and long-term commitment is key to the successful implementation of integrated health and social care teams
- Longitudinal research studies are needed to fully understand the benefits of integrated health and social care
- To implement integrated teams, there needs to be due consideration for the length of time it takes for these teams to become fully operational, and the teams need to be assured of a long-term commitment from the organisation
Declaration of interest: The authors have no conflicts of interest to declare.
Sue Mackie, Lead Nurse, Quality and Safety, Bolton Clinical Commissioning Group, England
Angela Darvill, Senior Lecturer, Human and Health Sciences, Huddersfield University, West Yorkshire, England
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