• Better integration between health and social care services is a longstanding policy objective in England and other countries. Recent reforms to the NHS in England established 42 area-based integrated care systems (ICSs) to lead local efforts to develop more integrated models of care.
• A common approach is the development of community-based multidisciplinary teams (MDTs), in which a mix of health and care professionals come together to plan and coordinate people’s care. Many MDTs are based around general practices and typically focus on care for adults with complex health and care needs. This briefing brings together evidence from Improvement Analytics Unit (IAU) evaluations of three MDTs and wider evidence to inform current efforts to develop integrated care in England.
• Despite widespread policy support, evidence on the impact of community-based MDTs is mixed. Our three IAU evaluations found that MDTs did not reduce emergency hospital use – and may even have led to increases – at least in the short term. Our longer term evaluations of the broader programmes in which these teams were implemented found some evidence of reductions in emergency hospital use, but this took between 3 and 6 years. Wider evidence on the impact of community-based MDTs was limited and mixed – though some studies suggest broader integrated care interventions can improve patient satisfaction, perceived quality of care and access.
• MDTs are not new and are widely thought to be needed to deliver high-quality care for people with chronic conditions. There could be several explanations for lack of clear evidence on impact – including unrealistic assumptions about MDTs and challenges in evaluating impact. The effect of MDTs also depends on many factors, including team resources and skills, staff engagement, IT resources, access to data, population characteristics and the broader context, such as local community services and overall levels of investment.
• To realise the potential of MDTs, local implementation needs to be carefully planned and supported by ongoing monitoring and evaluation. We make four recommendations:

1. Develop a clear, evidence-informed ‘logic model’ (or ‘theory of change’) for how service changes are expected to lead to improvements in care. This will help identify the support needed to make MDTs work and set meaningful goals.
2. Collect data on key aspects of the logic model as part of the implementation of MDTs. This should include resource inputs, activities and outcomes that can be accessed in a timely way.
3. Monitor inputs, activities and short- and medium-term outputs. This can provide early indications of whether the MDT is working as intended and identify opportunities to learn and course-correct.
4. Undertake robust evaluation to understand what works, for whom and in which contexts. This should include measures beyond emergency hospital use and reflect outcomes that matter to patients. Robust evaluation requires careful design, reliable data and resources – and input and support from both local and national decision makers.

The Improvement Analytics Unit (IAU) is a unique partnership between NHS England and the Health Foundation. We evaluate complex initiatives in health care in order to support learning and improvement.

Better integration between health and social care is a longstanding policy objective in England. Recent NHS reforms divided the country into 42 area-based integrated care systems (ICSs), covering populations of around 500,000 to 3 million. ICSs are based on the idea that collaboration between the NHS, social care and others is needed to improve health and reduce health inequalities.

ICSs follow a long line of policy initiatives to encourage more integrated care in England – including integration ‘pilots’, ‘pioneers’, ‘vanguards’, and more. Similar reforms are being developed elsewhere in the UK, and other countries. And new policy initiatives continue to appear. Government published a further white paper on health and social care integration in England in 2021. A new programme of ‘integration frontrunners’ was also announced to help improve discharge for patients leaving hospital.

The rationale for developing more integrated care is clear. More people are living with multiple long-term conditions that require ongoing management and support, such as diabetes or depression. The prevalence of multimorbidity increases with age, but people in more deprived areas are at greater risk of having multiple health conditions and develop them earlier in their lives., Improving health and care for people with complex needs depends on a mix of services and professionals. Yet care is often fragmented and imbalanced towards treating illness in hospitals rather than preventing it further upstream. Over the past 20 years, there has been a major shift in the composition of NHS spend towards hospital care and away from other areas, despite policy goals to strengthen prevention and primary care.

What are multidisciplinary teams?

Integrated care is a broad concept and efforts to achieve it differ depending on the aims and context. A common approach is to develop multidisciplinary teams (MDTs), in which a mix of health and care professionals come together to plan and coordinate services for patients (Box 1). The intended rationale is that professionals care for patients in a more holistic way – they exchange information, make shared decisions and plan interventions to meet patients’ needs, contributing to better quality care.

Community-based MDTs have been a core component of recent efforts to integrate health and social care services in England, often introduced as part of broader programmes to improve the quality and efficiency of local services.,,,,, Greater MDT working is also a central part of the ambition for primary care networks (PCNs) in England, where GPs are expected to work alongside an expanded primary care team., ICSs are likely to pursue similar approaches – and national guidance for the new systems includes developing community-based MDTs., But introducing new models of care is challenging and may not deliver the benefits policymakers expect. If MDTs are to realise their potential, they need to be carefully designed and implemented, drawing on existing evidence and insights.,,

The IAU has undertaken quantitative evaluations of three local MDT programmes implemented as part of NHS England’s New Care Models programme, as well as of the longer term impacts of the broader vanguard programmes of which these MDTs formed part.

In this briefing, we bring together findings from these evaluations to inform current efforts to develop more integrated care in England. We put these findings in the context of broader evidence on the effect of community-based MDTs in the UK and other countries. In the final section, we reflect on what this means for local leaders looking to implement MDTs, as well as for national leaders seeking to support these models of integrated care.

IAU evaluations of three MDT initiatives

The IAU evaluated the effect of three MDT initiatives in England (Box 2) by comparing the outcomes of patients receiving care or support from MDTs to a comparison group. This group consisted of patients with similar characteristics to those enrolled in the MDT (eg age, gender, ethnicity, level of deprivation, long-term conditions, frailty and historic hospital use).

Characteristics were identified from pseudonymised patient-level hospital records. As one of the aims of the new care model vanguard programmes was to reduce unnecessary emergency hospital use, we predominately investigated the effect of MDTs on A&E attendances and emergency hospital admissions. As we used routine health data for our analyses, we were not able to analyse the effect on other outcomes, such as patient satisfaction or quality of life. Further details on the methods can be found in the original reports and in the Appendix.,

IAU evaluations on the longer term impact of integrated care programmes with MDTs

Implementing and embedding new models of integrated care is complex and it can take time to deliver improvements. The IAU also evaluated the broader integrated care programmes that implemented the three MDTs over a longer time period. The evaluations covered the areas of Fylde and Wyre, Blackpool (both of which implemented EPC and ECS under the overarching Fylde Coast vanguard but were analysed separately as they differed in demographics, rurality and deprivation) and NEHF. We also evaluated the Integrated Care Transformation programme in Mid-Nottinghamshire, which included MDTs as one of its main initiatives (Box 2).

For each of the analyses, we evaluated the effect of the integrated care programme by comparing emergency hospital use against a comparison area for a period ranging from 4.5 to 6 years. These comparison areas were constructed from other comparable areas in England (in terms of factors such as population size, age distribution and deprivation levels) in such a way as to have similar outcomes to the evaluated areas in the 2 years prior to the start of the programme. We looked at the effect on the whole populations aged 18 years and older and 65 years and older, respectively. Further details on the methods can be found in the original reports.,,

Wider evidence of MDT impacts

To put the findings from our IAU studies in the context of the broader evidence, we conducted a rapid review of relevant systematic reviews of quantitative evidence on the impacts of community-based MDTs for adults with complex health and care needs – for example, with multiple long-term health conditions – or people living with frailty or at high risk of hospitalisation. We focused on reviews that included at least one study of MDTs from the UK alongside evidence from other high-income countries, and where the MDTs included at least one health care professional, such as a GP. More detail about the studies is included in Box 3. See the Appendix for further detail on the methods.

MDTs are a core part of efforts to provide more integrated care for people in the UK and other countries., MDTs are not new and are widely thought to be needed to deliver high-quality care for people with chronic conditions.,, They also appear to be here to stay: the ambition for ICSs and PCNs in England involves developing MDTs to join up health and care services in the community. Expanded team-based working in primary care – with GPs working alongside physiotherapists, pharmacists, social workers and others – is also seen as one way to help mitigate growing shortages of GPs in England.,

What we found

Despite widespread policy support, evidence on the impact of community-based MDTs is mixed. Our evaluations of three MDTs involved in new care model vanguard programmes found that MDTs did not reduce emergency hospital use – and may even have led to increases – at least in the short term. Our longer term evaluations of the broader programmes in which these MDTs were implemented found some evidence of reductions in emergency hospital use. However, this took between 3 and 6 years – and we could not assess the contribution of MDTs to these reductions. The broader evidence was often of poor quality and paints a mixed picture – though some studies suggest that broader integrated care interventions involving MDTs can improve patient satisfaction, perceived quality of care and access. Other more recent studies of MDTs in England also show mixed effects on health care usage.,

The evidence summarised in this briefing pre-dates the pandemic. The IAU evaluations of MDTs covered periods up to 2018, while the wider evidence refers to studies predominately pre-dating 2018 and the IAU evaluations of the wider integrated care programmes covered periods to March 2019 or February 2020. Since then, pressures on services have grown and staff shortages have widened. Nonetheless, the MDTs we evaluated are likely to share similarities with community-based MDTs currently being implemented in England.

What the findings mean

A lack of clear evidence on impact does not necessarily mean that community-based MDTs ‘don’t work’. There may be several explanations for limited or mixed evidence – from the assumptions about how MDTs function to the way MDTs are set up, their wider context and how they are evaluated. These explanations have implications for policymakers and local leaders seeking to support new care models.

Unrealistic assumptions about MDTs

One explanation may be that the rationale for some MDTs is underdeveloped or flawed, contributing to unrealistic assumptions about what MDTs can deliver., For example, there is often an assumption that by providing more coordinated care in the community, MDTs will lead to patients needing less emergency hospital care. But MDTs often target patients at highest risk of hospital admission and with the greatest health and care needs. Although these patients will likely benefit from additional support, it may not be possible to prevent a hospital admission.,,, MDTs may also affect the behaviour of patients or staff in unanticipated ways – for example, if MDT staff are more risk averse because they do not know the patient’s medical history.

There may also be unrealistic assumptions about how quickly MDTs can achieve their aims. New models of integrated care are complex to develop and take time to implement – often over several years. Even then, it can take time for a patient’s health to improve as a result of an intervention. And although MDTs could lead to better health in the long run, they may identify unmet need that could increase the need for emergency care at least in the short term.,

MDTs might not be implemented as intended

Another potential explanation is that MDTs are not implemented as intended, or in line with the underlying theory of change. For example, MDTs may receive fewer referrals than expected, or referred patients may be more severely ill than planned, eg due to a shift in referral pathways, limiting the MDT’s ability to proactively address care needs as intended.

Implementation of MDTs could also fall short. A combination of factors shapes how well MDTs work – from how teams are organised and managed, to the wider policy context in which they are developed. At a team level, a mix of studies identifies factors that can support effective MDT working, such as strong relationships, staff resources, clarity on staff roles and responsibilities and lines of accountability, strength of management, and access to shared data.,,, Broader evaluations of integrated care initiatives in England also point to wider factors shaping the success of local integration efforts, such as the history of joint working between organisations, relationships between local leaders, staff engagement in the changes (especially of GPs) and conflicting changes in national policy. Patient voice in MDTs and broader initiatives is also often lacking, yet can provide meaningful input into their development and improvement. Table 1 in the Annex lists some of the factors that shape team working.

Wider contextual factors shape the impact of MDTs

MDTs are just one component in a complex system of interventions that interact to shape how care is delivered. In the new care models vanguard programmes, community-based MDTs were implemented alongside a mix of other interventions to coordinate services for high-risk patients, as well as changes in health and care governance and decision making and additional funding.

The broader context can shape the impact of MDTs in both directions. For example, a recent review of evidence on the impact of integrated care models found that while evidence on the impact of MDTs was mixed, UK studies of MDTs implemented alongside other interventions generally reported more positive results. This included perceived improvements in quality and access and some reductions in hospital use.,

On the flip side, analysis of MDTs introduced in the integrated care pioneer programme identified lack of services in the community as a common barrier to success. Local authority budgets have been cut substantially over recent years – public health budgets, for instance, fell by a quarter per person between 2015 and 2020 – with funding falling furthest in more deprived areas.,, Diminishing community resources are likely to affect the potential impact of MDTs, as well as adding to the pressure on unpaid carers, who play a crucial role in bridging gaps in community support.,

Evaluations may not be able to detect an effect

A final explanation is that evaluations of MDTs may be of insufficient quality to reliably assess their impact. MDTs are complex interventions – and evaluations need to be carefully designed to understand whether the intervention is having an effect and for whom. Yet evaluations of new models of care are often short term, small scale and lack robust methods – frequently due to lack of easily available data. Evaluations may also fail to capture important activities or outcomes, such as those that matter to patients, carers or staff. This could be due to an underdeveloped theory of change or lack of data.

Broad evaluations of MDTs providing care to patients with a range of conditions and needs may mask differing effects within subgroups of patients. For example, studies by the IAU on enhanced support in care homes found that while the overall effect of the programme was broadly positive, an analysis of the effect separately in nursing and residential care homes revealed large reductions in emergency hospital admissions in residential care homes but none in nursing homes.,

The role of monitoring and evaluation

While there is guidance on MDTs and evidence on enablers and barriers to effective team working,,,,,, there is no single blueprint for MDTs that would guarantee better health outcomes, reduced emergency hospital use or improved patient experience. In some contexts, MDTs and integrated care initiatives have been shown to have a positive impact on patients and the wider system, but this is not always the case. Given the diversity of MDTs and the contexts in which they operate, this is perhaps not surprising. The effect of MDTs depends on many factors, including team resources and skills, staff engagement, IT resources, access to data, population characteristics, and broader context such as local community services and overall levels of investment.

Therefore, to realise the benefit these initiatives can have, implementation needs to be carefully planned and supported by ongoing monitoring and evaluation. Applying learning health system approaches and providing rapid feedback on whether MDTs are being implemented as planned and achieving the results expected will allow for ongoing learning and improvement.

Recommendations

In designing an approach to monitoring and evaluation we make four recommendations:

1. Develop a clear, evidence-based ‘logic model’

A clear, evidence-informed logic model (or theory of change) for how service changes are expected to lead to improvements in care – along with the resources needed and factors that will shape progress – can help identify the support needed to make MDTs work and set meaningful goals.

This requires thinking through the planned service changes in detail and identifying underlying assumptions, such as referral routes, target population and access to services in the community. While existing evidence should be used to develop the logic model, the model should also be rooted in the local context and used as an opportunity to challenge thinking on how the model is expected to work. It is useful to put expected or target numbers against aspects of the logic model, (eg the required number of staff hours, the number of patients enrolled each month and the period of time for support), as well as the timeframe and magnitude of change expected in outcomes. These can form a basis for planning as well as assessing actual implementation.

A useful step-by-step guide to developing a logic model is available from the Strategy Unit. A logic model should be designed with input from staff and patients, and the public.

2. Ensure data collection is part of implementation

Collecting data on key aspects of the logic model, including resource inputs, activities and outcomes should be part of the implementation of MDTs. Access to timely data is crucial to allow local teams to monitor the implementation and impact of interventions, test assumptions and identify opportunities for improvement.

Where possible, data should be recorded routinely in a way that facilitates easy extraction and analysis for monitoring and evaluation purposes. Some data will be available from existing systems such as patient records. Where relevant information is collected in several datasets, data may need to be linked. Or new data collections may be needed, for example to capture data on broader outcomes beyond hospital use to provide a fuller picture of the outcomes that matter to patients and their families, such as experience of services or quality of life. However, manual data collections can be resource intensive.

Local linkages of data sources (eg hospital, primary care and social care or ambulance data) have provided new insights and there are instances where new data collections are being developed.,,,,,, To be most effective, there needs to be a systematic, national approach to collect a wide range of outputs and outcome metrics for all patients, not just those receiving a new service. Good-quality data on both patients receiving an intervention and those who are not will allow for more robust evaluation.

Collecting data on costs associated with setting up and running MDTs will allow for assessments of value for money. These should ideally include not only staff and infrastructure costs but also data on opportunity costs, such as diverting staff from other services.

3. Monitor inputs, activities and short- and medium-term outputs

Regularly monitoring activities, for example the number of referrals, referral routes and characteristics of patients referred, can provide early indications of whether the MDT is working as intended and opportunities to learn and course-correct. As such, done well, monitoring is a vital part of evaluation, providing rapid, actionable insights. Combining monitoring with qualitative insights can help understand patient and staff perspectives on the service changes being introduced and the underlying mechanisms. For example, if lower than expected numbers of referrals are due to a lack of clarity on referral criteria, communication to potential referrers on referral criteria can be adapted.

4. Undertake robust evaluation of outcomes

As MDTs ultimately aim to improve outcomes – whether these are patient outcomes or health service efficiencies – it is important to assess if this has been achieved, though it can be difficult to do this well. Outcomes can be slow to emerge – requiring longer term studies – or are not always well defined or routinely recorded (particularly for those patients who might form a comparison group). It is also not always straightforward to establish whether an observed change in outcomes is due to a particular intervention.

Robust evaluation requires careful design and reliable data on all patients in the analysis (including the comparison group) and their interactions with services. A good logic model will help inform a robust evaluation, for example on data collection, study population and potential subgroups, outcomes and, length of patient follow-up, and help identify potential biases.

Evaluations often compare patient outcomes before and after the intervention has been introduced (‘pre-post’ studies). But this approach risks identifying changes that would have happened anyway without the intervention – a phenomenon known as regression to the mean., A more robust method than pre-post studies, used by the IAU in its studies of MDTs, is to compare outcomes of MDT patients with the outcomes of a similar group of patients who were not cared for by an MDT. Hospital and primary care data, if available, can be used to identify a group with similar characteristics, such as age and long-term conditions. But this method can also have limitations: routinely collected data may not adequately record severity of disease or social isolation or other social factors that affect emergency hospital use,, and details on comorbidities are often incomplete in hospital data.

Robust evaluation requires resources and skills. There are a growing number of evaluation teams that specialise in service evaluation.,,,, However, for a true learning health system, these skills and methods need also be embedded within local teams. There are established local collaborations, including universities and health or social care organisations, such as Applied Research Collaborations and numerous local teams doing insightful analyses – as well as a growing acknowledgement in the NHS of the importance of data and analysis to inform decision making.,,,,, There are also opportunities for better networking and peer support,,, knowledge sharing, available written resources and open access code,,, as well as training.,, But more needs to be done. As well as having the resources to develop analytical roles and embed monitoring and evaluation, local and national decision makers throughout the system need to understand and recognise the value of analysis to derive insights, if analysis is to inform decision making.

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We would like to thank Phoebe Dunn, Adam Briggs and Cordis Bright for their involvement in the review of reviews and Hugh Alderwick for providing advice, input and review of the briefing. We would like to thank PPIE representatives Margaret Ogden, Dianna Moylan, Anna Ferguson Montague, Jan Davies, Jeremy Dearling, Lynne Wright and Rashmi Kumar for their insights and comments on an earlier draft. We would also like to thank Robin Miller, Mike Lawrie, colleagues within NHS England and the NHSE Proactive Care team and staff in North East Hampshire and Farnham who reviewed and provided comments on an earlier draft.

When referencing this publication please use the following URL:https://doi.org/10.37829/HF-2023-IAU01

Table 1: Examples of team-based factors that can support MDT working,,,,

Domain	Example enablers
Planning and design	Emphasis on workforce and workflow planning Carefully designed skill mix mapped to patient needs Engagement and inclusion of patients and the public in design and implementation of teams. Ongoing co-production Clear governance arrangements Treating MDTs as core, rather than just a ‘bolt-on’ to existing services Track implementation progress and iterate as needed
Learning and development	Access to good clinical supervision Appraisals incorporating team goals and involving feedback from MDT members Emphasis on cross-professional and cross-organisational training Willingness to learn from and with each other Training for skills to both support the staff member’s role in the MDT and for making the most of MDT working itself Gaining buy-in from team members for changes in ways of working
Culture and leadership	Shared commitment to the delivery of high-quality, coordinated care High levels of respect and trust Appreciation of the importance of relationships and creating time and willingness to build them Commitment to creating a shared system of beliefs, values and common philosophy within the team Embracing collective leadership
Working across boundaries	Clarity on roles, responsibilities and lines of accountability (especially for roles shared or spread across different organisations) Willingness to identify, name and work through cultural differences between staff from different organisations and professions Inclusion of bridging roles such as care coordinators within teams
Communication	Prioritising, valuing and constantly improving communication within the team Promotion of psychological safety (staff feeling able to speak up or make mistakes without retribution) Use of huddles and other forms of short, frequent check-ins between team members Access to digital communication tools and agreement on preferences and expectations for their use Adoption of MDT regular meetings that follow best practice Communication with patients about what the MDT is and does, what it can mean for their care and what patients want it to mean for them
Technology and estates	Shared IT systems and access to patient records Redesign of physical spaces to promote collaboration Co-location of team members (where appropriate)

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