Evidence
Alert

The Vanguard programme to integrate health and social care achieved some of its aims but took time to show an effect

An NHS England programme to integrate health and social care services slowed the rise in emergency admissions to hospital among care home residents but did not achieve its other aims.

It was hoped that integrating health and social care would ease the growing pressure upon services and reduce the time people spend in hospital. For example, older people who suffer falls could recover at home rather than in hospital, supported by telephone advice, rapid response home visits from health professionals, and other services.

This research is the first evaluation of integrated care models that were piloted across England between 2015 and 2018. Two models focused on the general population; another on care homes.

This evaluation supports the NHS plan to expand integrated care for care home residents. It also cautions that positive outcomes may be slow to appear. There are outstanding questions over the cost-effectiveness of integrated care schemes and how best to structure them.

What’s the issue?

The increasing number of older people with multiple chronic health conditions is placing growing pressure on health and social care. There is widespread consensus that integrating these services will help them deliver the best outcomes for patients. But there is an ongoing debate over which populations and services to target.

This research is the first independent national evaluation of the Vanguard `New Care Models’ programme. This flagship NHS England programme cost about £389 million and covered around 5 million people (around 9% of the population). Fifty local areas across England were selected to be ‘vanguards’ and lead the way in putting five new models of integrated care into practice.

The intention was to reduce hospital use by moving specialist care out of hospitals and into the community or into care homes. The aim was to improve coordination between service providers to make care flexible and responsive to the needs of local populations and care home residents.

Three of the five Vanguard prototypes were evaluated in this research:

  • Two schemes moved specialist care for the general population out of hospitals and into the community. They aimed to foster closer collaboration between GPs, hospitals, communities and social care services. These approaches were called Multi-speciality Community Providers (MCPs) and Primary and Acute Care Systems (PACS).
  • The other focused on care home residents and aimed to improve the quality and coordination of health, care and rehabilitation services. The Enhanced Care in Care Homes (ECH) model increased the medical support available in care homes and promoted collaboration between the NHS, local authorities, the voluntary sector, carers and relatives.

What’s new?

Researchers obtained monthly counts of emergency admissions and hospital bed-days before and after the Vanguard pilots. They compared outcomes in Vanguard sites with those observed elsewhere.

They found that, with the Vanguard programme:

  • over the three-year period, there was a small reduction (of 4.2%) in emergency admissions among care home residents; most of this reduction happened in the third and final year.
  • for the population-based sites, a reduction (of 3.1%) in emergency admissions was found only in the third and final year.
  • the biggest reductions occurred in adults and older age groups
  • there was no significant reduction in bed-days.

Why is this important?

Vanguard’s original aim of immediate improvement may have been unrealistic. Producing marked effects from major reconfigurations of health and social services takes time. Integrated care may not result in large reductions in hospital activity in the short-term.

This evaluation shows that the Vanguard programme did not achieve all its aims. There may be wider, unseen benefits, such as improved patient experience and local relationships . But these outcomes are difficult to quantify and measure over a wide population.

The authors state that the small reduction in emergency admissions was only achieved following extra funding and a dedicated support programme. The evaluation has not assessed the cost-effectiveness of this approach to integrating care.

What’s next?

The 2019 NHS Long Term Plan committed to expanding integrated care models across England. Its initial focus is on policies aimed at care home residents. It will use elements of the Vanguard programme, such as personalised care plans and regular pharmacy input for managing medicines. The current evaluation supports that policy.

Some Vanguard sites reduced the rate of increase in emergency admissions. Others did not. The reasons for that remain unclear and it is not known which integrated care models work best, why they work, and under what circumstances they work. A better understanding of how to integrate health and social care from the perspective of patients and service providers is needed.

This research also highlights that outcomes for integrated care and other initiatives should be assessed over the long-term.

You may be interested to read

The full paper: Morciano M, and others. New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis. Health Policy. 2020;124:826-833

The NHS Long Term Plan (2019), which committed to expanding integrated care models across England

The University of Manchester interim report: National evaluation of the Vanguard new care models programme, 2019

The Health Foundation report: The long-term impacts of new care models on hospital use: An evaluation of the Integrated Care Transformation Programme in Mid-Nottinghamshire, 2020

A related paper showing the need for longer-term analysis: McCarthy A, and others. Rapid evaluation for health and social care innovations: challenges for “quick wins” using interrupted time series. BMC Health Services Research. 2019;964

 

Funding: This research was funded by the NIHR Policy Research Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

The COVID-19 pandemic is showing us how important it is to have joined-up health and care services. This is especially true when caring for vulnerable people like the elderly. But providing more integrated care for patients is not straightforward and it takes time to produce discernible effects.

Our study suggests that the approach taken by the Vanguard programme – of making funding contingent upon achieving measurable impact against a narrow set of metrics within two years – was unhelpful.

We don’t know whether the small impact seen in the Vanguard programme can be reproduced without the same funding and support. We also don’t yet know the best way of integrating services or what factors lead to successful integration. We need this to understand what works best and why, to identify areas for improvement and encourage good and sustainable practice.

Marcello Morciano, Senior Lecturer and Associate Professor in Health Policy and Economics, University of Manchester

Member of the public

The paper makes the useful point that providing more integrated care needs to be measured in the long term. It could be expected to reduce hospital activities, but this paper shows that may not be the case in practice. This paper may support local teams to be more considered and cautious in their assumptions, as well as, perhaps, being more adventurous and curious about alternatives.

This paper considers a narrow range of impacts. There may be additional evidence which conflicts or highlights other priorities. For example, it would be interesting to hear the views and experiences of people using the service and their carers, as well as staff, to understand the wider implications.

Karen Machin, St Helens, Merseyside

Researcher

The Vanguard programme cost £389 million – not counting local add-ons – and achieved very little. We need more analysis of why it did not work.

Coverage of 9% of the population meant the outcome indicators were very ambiguous with broad statistics. This kind of scheme needs to work on a more personal, patient level.

Initiatives to develop better programmes – with quality measures – should be encouraged at a local level. Funding should be used, not just for implementation, but to reward results.

Nick Bosanquet, Professor of Health Policy, Imperial College London