Table 1
Description of the three integration pilot programmes.
| INTEGRATED CARE PILOTS (ICPS) | INTEGRATED CARE AND SUPPORT PIONEERS (PIONEERS) | NEW CARE MODEL VANGUARDS (VANGUARDS) |
|---|---|---|
| Programme launched in 2008 following the NHS Next Stage Review. Sixteen pilots appointed in 2009 designed to support care integration. Loose collection of aims including care closer to the user, greater continuity of care and a reduced use of hospital care. As NHS finances became constrained nationally, the focus shifted to aim of reduced cost Deliberately heterogenous mix of pilots in terms of:
National programme support including project management resources and modest central funding for pilots. | Two waves of pilots launched since 2013 (14 pilots and 11 pilots respectively) Relatively homogenous goals including the ‘triple aim’ and person-centred care. Focus on three overlapping cohorts: older people with multiple long-term conditions; high service users, those at risk of hospital admission Pilots pursued a broadly similar range of interventions. Over time these narrowed to focus on: care navigators, multi-disciplinary teams, care planning and a single point of access for service users Pilots designed around horizontal and vertical integration of NHS and social care providers with a small number of pilots explicitly led by Local Authorities. Limited national programme support with modest central funding for pilots | Launched in 2015 with the aim of using pilots to define new ‘models’ of care which could subsequently be spread more widely. Focus on horizontal and vertical integration between sectors. Nationally prescribed range of three different integration ‘types’:
Local discretion over how these models were to be designed and implemented with expectation that new models to be scaled across the NHS. Multiple new services implemented with no clear differentiation between the three ‘types’ Over time, increased national focus on reducing use of hospital services Extensive national support programme and significant additional funding |
Table 2
Comparison of significant pilot experiences and outcomes (extracted from publications of the national evaluation teams and selected studies) [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12].
| THEME | ICPS | PIONEERS | VANGUARDS |
|---|---|---|---|
| Facilitators | Effective senior leadership Shared values and vision Strong, pre-existing relationships locally Staff engagement Low complexity interventions (compared to high complexity) Specific education/training interventions Co-location of staff Availability of funding and other resources | Effective cross organisation and professional relationships Effective leadership Kudos as part of a pilot programme Shared vision and values Lack of organisational complexity (especially if shared boundaries) History of successful integrated care Availability of resources Staff engagement and ‘ownership’ | Development of relationships with national programme team Multi-modal communications Strong local and national leadership Access to expert knowledge and skills Good level of funding Perception of a licence and platform to do things differently as a result of being part of a high-profile national programme |
| Barriers | Complexity of organisations and interventions IM&T issues and information governance concerns Poor communication Poor professional engagement (especially GPs) Erosion of professional identity ‘Red tape’ Wider NHS financial pressures Lack of resources and high existing workforce pressure Conflicts with new national policy context | Financial constraints and high existing workforce pressure IM&T issues and information governance concerns Limits to local freedom to innovate Limited national support to tackle systemic barriers Difficulty breaking down professional and organisational roles and culture Leadership tensions between organisations Engagement and commitment of GPs Conflicts with new national policy context | Continuation of standard national regulation and oversight Lack of high quality data and issues with information governance, inter-operability of systems and data sharing Short timescales and expectations of rapid progress (especially against government targets) |
| Impact on hospital activity | Significant increase in unplanned admissions and reductions in elective elective inpatient and outpatient care. More marked increase in unplanned admissions for case management sites. Overall costs of hospital care reduced by 9% (statistically significant) for case management patients. | A modest impact on unplanned admissions to hospital, with Wave 1 pilots experiencing a lower increase than non-Pioneers. However this was only statistically significant in Year 1 and not in Year 2. Significant variation found between pilots and within pilots. | Vanguards slowed the rise in unplanned admissions compared to controls. Over three years a significant 4.2% reduction in those admissions found for Enhanced Care Home pilots (increased over time and became statistically significant in third year and overall). MCP/PACS significant 3.1% reduction in Year 3 but not significant over whole period. No overall reduction in bed-days Sites had higher unplanned admissions and bed days than controls in two years prior to start of pilot. Impacts most visible in sites which had previously been Pioneers |
| Impact on patient experience | Mixed response. No more likely to have discussions about how to deal with health problems, more likely to have care plans In case management sites: more clarity regarding discharge; less likely to have been given wrong medicine. But also less likely to be able to see clinician of choice and fewer felt opinions and preferences taken into account. | Data are being collected on MDT caseload patients’ experiences of care received, and on the impact of being on an MDT caseload on health and quality of life. | No systematic study of patient experience across the programme. Individual Vanguards procured individual evaluations, but quality mixed. |
| Impact on staff experience | Staff reported improved team working and communication; increase of breadth and depth of their job; more responsibility; more interesting jobs; improvements to patient care. | Currently completing data collection on strategic level managers’ and operational as well as front line staff perceptions of health and social care integrated, community-based MDT working. | Staff reported increased job satisfaction associated with the feeling that they had licence to innovate and were part of a high-profile national programme. |