Implications and priorities for future work

Our analysis indicates that the ICTs did not reduce emergency admissions and A&E attendances in their first 23 months of operation and might have even led to increases. It may be that the increased rates of emergency care reflect a positive effect on the health and wellbeing of patients by identifying unmet need. However, further analysis is needed regarding the impact of the ICTs on the coordination of care and patient experience, or indeed on health, health confidence or quality of life, since we could not examine these aspects within the constraints of NHS data sets.

Below, we set out our reflections on the results of the evaluation. Some of these points might be useful for NHS teams to consider when exploring the introduction of integrated care teams or improvements to their ways of working.

Which patient groups should the ICTs target?

During our study period, GPs and health care workers in North East Hampshire and Farnham were asked to identify patients whom they felt were most vulnerable and would most benefit from additional support from the ICTs. Patients referred to ICTs were aged 81 years on average and 19% of patients died during the study. Although such high-risk patients may benefit from the additional support from the ICTs, there may be limited scope to reduce their hospital use, given their clinical history. There’s therefore a question about whether reduction in emergency hospital use is an appropriate objective for ICTs or whether ICTs should be targeting a different patient group.

Interestingly, the vanguard is working on developing criteria for selecting patients for ICT referral, including the use of a risk stratification tool. These algorithms are often better at identifying high-risk patients than clinicians, but may not identify those likely to benefit from additional care or do so before they deteriorate. Practitioners may be more able than algorithms to identify patients who are willing and able to interact with ICTs. Since March 2017, Farnham has been combining risk stratification and clinical judgement to proactively identify patients for referral. This may be the best way forward, as it combines the objectivity and reliability of the models with the insights of practitioners.,,

The question remains whether changes to the way patients are selected alone will achieve the desired effect of reducing emergency hospital use. To achieve this aim, not only must people at risk be accurately identified before they go into crisis, they also must have genuinely preventable admissions and then be offered an intervention that is effective at reducing their risk. For the impact to be felt at population level, the percentage of the population covered would need to be of sufficient scale to deliver this impact.

The value of ICTs

This and other research shows that it may be difficult for ICTs to reduce emergency hospital use. Instead, their value may lie elsewhere, for example in improving the coordination of care, reducing fragmentation, and improving patients’ health and experience when using the NHS. In this case, it will be important to establish data collections that can monitor these aspects of care to help teams show impact, as well as to be realistic about what can be achieved in relation to reducing emergency admissions.

There are also some suggestions from our analyses that different groups of patients referred to ICTs may use hospital care in different ways, which could be explored further. For example:

• those with unmet health care needs may have these swiftly identified and acted on by ICTs

• those nearing end of life may benefit from ICT care that supports them in dying at home.

However, a qualitative study would be needed to explore this further. Such information could help inform the CCG when considering changes to the service.

Ongoing assessment of impact

In this report, we have evaluated the impact of ICTs in their early phases of implementation in North East Hampshire and Farnham, and proposed possible mechanisms which could explain the results, for example that ICTs are identifying unmet need. However, there is still a need to monitor the ongoing impacts of the ICTs, especially since the ICTs have continued to evolve, and have already been adapted in response to learning. This is why it is so positive that the CCG has shown commitment to producing evidence to better understand the Happy, Healthy, at Home vanguard interventions and the ICTs, both in its own regular monitoring and through its collaborations with the Improvement Analytics Unit and the local evaluator.

In its continued work, it might be helpful to expand monitoring of the ICTs to examine the characteristics of ICT patients. This could assess whether a change in selection methods affects which patients are selected, as well as monitoring outcomes. Further in-depth analyses using a matched control group could be conducted to evaluate whether ICTs reduce hospital use in the longer term and assess the effect new selection criteria might have on hospital use.

Also, to fully understand what contributions the ICTs are making, robust quantitative analyses are needed on metrics other than hospital use, for example health confidence, patient experience and quality of life. Unfortunately, this information is not collected routinely at patient level in the NHS. However, the value of integrated care might relate to improving these other metrics rather than emergency hospital admissions. Qualitative evaluation would be helpful to explore potential mechanisms and provide more definitive answers.

A recurrent message from the Health Foundation’s improvement work is that, to improve the quality of care, repeated measurement is necessary to allow timely modification of initiatives, and inform their more effective evolution. Over the coming years, the Improvement Analytics Unit will analyse more local initiatives, feeding back analysis quickly to inform ongoing decision making and practice. To find out more, visit www.health.org.uk/IAU

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