Are integrated care systems improving population health outcomes?
A four-part series exploring how integrated care systems are faring against their core purposes. In this edition, we delve into how systems are improving population health outcomes.
When integrated care systems (ICSs) were established in 2022, they were under no illusions about the scale of the task ahead of them – or the reasons for their existence. Still recovering from the COVID-19 pandemic, the NHS and social care system faced the most challenging time since their creation, and a deterioration in the nation’s health.
ICSs’ North Star, often known as their four core purposes, focused early efforts, and in the summer of 2022 a renewed energy and sense of optimism was palpable. Yet more than two challenging years on, how are systems faring against their strategic missions?
"We have brilliant examples of where we have transformed the process of discharge from hospitals, and where community interventions have helped people to be treated closer to home,” remarks Dr Kathy McLean, who chairs two integrated care boards (ICBs) in the East Midlands and the NHS Confederation’s ICS Network. “ICBs, working collaboratively, are transforming services and improving prevention. But we can’t create these innovations in isolation,” she says.
“It is only by working together – differently – that we will be able to ensure residents get the best from their health and care service.”
Working together differently has been the ‘secret cause’ behind notable improvements in health in Bedford, Birmingham and Solihull, and Surrey, and will be vital in contending with projected patterns of illness in England over the next two decades.
Keeping residents warm in Bedford
In Bedford, analysis of population health data by a joint council/NHS data unit identified almost 2,000 patients with pre-existing health conditions who were especially vulnerable to rising energy costs.
“Every time the temperature drops by 1 degree below five degrees centigrade, we see an increase of about 20 per cent in GP consultations for respiratory diseases,” says Ian Brown, chief public health officer at Bedfordshire, Luton and Milton Keynes (BLMK) ICB.
“It was really clear when we saw that data, when we saw the impact price hikes were having on our population that we needed to do something about it.”
The result was the Warm Homes Bedford Borough project. Funded by Bedfordshire, Luton and Milton Keynes (BLMK) ICB, commissioned by Bedford Borough Council and run by the National Energy Foundation’s warmth and wellbeing service, Better Housing Better Health, it was designed to help support these households.
Over 1,600 patients whose GP records showed they were at risk of fuel poverty and had a chronic health condition which could worsen by living in a cold or damp home, were invited to take part.
Three-quarters of the residents, who went on to receive support from the scheme, said they felt that their property had a negative effect on the health of someone in their home.
Fifty-three households benefited from direct installations in their homes of equipment such as replacement gas boilers, heating controls and loft insulation.
It is anticipated the NHS will make savings against the total project cost of £358,000, through reduced attendances at general practice and A&E.
“I’d like to see how we can bring all of our data together, not just health and social care, but police and fire services, so that we can really look at populations in the whole,” says Felicity Cox, chief executive of BMLK ICB.
“If we can get the data together and use single, shared workers across lots of the statutory sector and the voluntary sector, we can make a real difference to both helping [people] and making it simpler for them to support and help themselves.”
Improving health outcomes in Birmingham and Solihull
Integrated neighbourhood teams, known as INTs, across Birmingham and Solihull (BSOL) are aiming to improve the health outcomes of circa 20,000 local people over the next two years.
These teams will provide “better joined-up care for people who already have long-term chronic conditions, who are often getting care from lots of different parts of health and social care at the moment in a way that isn’t working as well for them as it could,” explains Richard Kirby, chief executive of Birmingham Community Healthcare NHS Foundation Trust.
Cross-system BSOL data, connected up for the first time, has enabled the ICS to identify a cohort of patients to target with this new approach.
“We’re bringing lots of different people with different expertise in the same place to share experiences and what works and what doesn’t work to solve a patient’s problem,” says GP Dr Nahmana Khan. INT BSOL partners include primary care services, Birmingham City Council, Solihull Metropolitan Borough Council, NHS providers and community, voluntary and faith organisations.
Aligning an integrated neighbourhood team to all 35 primary care networks within the next two years could generate a potential £20 million-plus financial benefit to the system, initial data evaluation modelling suggests.
The programme “gives us a chance to make a fundamental difference to people for the long term,” says Richard Kirby.
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Engagement and evidence gathering
In March 2023, BSOL launched a period of intensive analysis, engagement, and design into INTs (figure 1). To provide the necessary senior and corporate cross-sector dialogue, appropriate forums were put in place with senior representatives from all partners, operational and financial sponsors at director level, finance managers, informatics, digital and data teams, estate and services and primary care. Figure 2 shows the finding of the analysis.
Figure 1: The INT engagement and design journey
Figure 2: Data analysis pulled from key BSOL health and care providers
Design ways of working
In addition to frontline engagement, a series of citizen engagement sessions were held. These focussed on people who are using two or more health and/or social care services, the aim being to find out their ideas about how these services could work better together.
Investment into digital systems was made to support secure and fluid data sharing between organisations. This resulted in the development of a Single Patient Care Plan across BSOL which provided analytics and insight into the frequent service users (FSUs).
Evaluation and testing
Phase 1: East and West INTs results (August 2023 – May 2024)
BSOL launched two pilot INTs in the East and West of Birmingham in August 2023. These areas were chosen as accelerator sites as they have multiple deprivation and notable health inequalities. They also had existing multi-agency partnerships up and running that could quickly become part of the new INT approach.
The pilot teams were provided with details of 100 FSU complex patient cases from two PCNs in the East and West of Birmingham. The findings showed:
- 71 per cent (142) of the 200 FSUs were driving service demand.
- 45 per cent (90) of the 200 FSUs could benefit from INT support.
- BSOL-wide this represents c.20,000 people who could benefit from INT support.
Phase 2: North, South and Central INTs (January – May 2024)
Three further teams went live in January 2024. Testing of these teams is still underway but to date (January – May 2024) 270-plus holistic conversations have been held with FSUs.
Challenges
- Traditional organisational barriers still exist.
- Availability of key groups of staff slows recruitment and delivery.
- Lack of joined-up thinking regarding estates and the need to co-locate teams.
- Lack of awareness of voluntary and community services that exist.
- Difficult to effectively engage with some FSUs, often with complex needs.
Lessons learned
- Need to access INTs in a more proactive way.
- Establish information governance to enable digital systems to share data.
- Services need to be tailored to meet the needs of different neighbourhoods.
- Full-time neighbourhood experts are intrinsic to the success of INTs.
Adopt ways of working - next steps
- Launch of Solihull INT in summer 2024.
- Evaluation of North, South and Central INTs.
- Continued investment into technology to support and drive integrated working.
- Work with estates to centre teams in neighbourhoods they serve.
- Strengthened INT interface with care coordination centres in the East and West locality hubs as part of winter planning.
Figures 1 and 2 in plain text
Figure 1: The INT engagement and design journey
- Identify cohort: Data analytics - Bringing data together from primary, secondary and social care to identify trends, patterns, and variations, creating a view of which residents could benefit from preventative support.
- Build understanding: Case reviews - Practitioners from across the system actively participating in collaborative review of relevant cases, to form a view of the potential for prevention and available interventions.
- Ensure effectiveness: Deep dive studies - Further investigation into prioritised interventions, to understand effectiveness, best practice, and any blockers.
- Enable action: Design ways of working - Cross-system leadership to define the longer-term vision and implementation options. Pilot teams to design future ways of working. Digital leaders across the system to identify the technology infrastructure that enables INTS.
- Evaluation: Evaluate - Use new ways of working in a live environment to measure and demonstrate the effectiveness of INTs and iterate new ways of working based on experience.
- Roll out: Adopt ways of working - Build rollout strategy, identify and train workforce, develop data and technology infrastructure, and roll out to other neighbourhoods.
Figure 2: Data analysis pulled from key BSOL health and care providers
- Fifty-seven per cent of service use, across system partners, is driven by the top 5 per cent of service users. By securely bringing together system data, we learned that 5 per cent of the population make up 57 per cent of service demand across key services. Focussing on this Frequent Service User (FSU) cohort initially will enable INTs to achieve maximum impact quickly.
- Twenty thousand people across Birmingham could be supported by INTs to reduce their service usage. By convening multi-disciplinary professionals to discuss 100 cases, we learned that 45 per cent of frequent service users could benefit from INT support. This represents circa 20,000 people across Birmingham and Solihull.
- Four key preventative interventions, relevant in over 75 per cent of preventable cases. Speaking to those already providing four key preventative interventions, that were relevant in 75 per cent of cases, we believe INTs could reduce service usage for these individuals by 30 per cent. These are social prescribing; community mental health; social care assessment; and structured medication reviews.
Creating the conditions for health in Surrey
Surrey Heartlands ICB has been supporting Growing Health Together as a place-based approach to population health, given the pressing need to tackle inequalities in health status, access to care and wider determinants of health. The NHS Core20PLUS51 strategy recommends integrated care systems focus resources on the most deprived 20 per cent of the population and those groups who experience poorer-than-average health outcomes. Place-based approaches offer a way to address the underlying causes of these inequalities.
Growing Health Together is a place-based approach which is supported by the East Surrey Leadership team and focuses on prevention and health creation underway in neighbourhoods. It mobilises and connects the assets of individuals, communities, organisations and the built and natural environment, to co-create improved health and wellbeing outcomes from the ground up.
Dr Gillian Orrow is a GP and co-founder of Growing Health Together, which helps primary care networks collaborate with community members and local organisations to improve health and prevent disease.
Born of an idea in the surgery coffee room, Growing Health Together has grown into a model which is embedded across the local health system.
“As a GP, patients used to come to me every day with different stories but the same message, recounts Dr Orrow, “the healthcare solutions on offer weren’t getting to the root of their problems.”
“I wouldn’t be depressed if I had more friends,” they would say. “My children wouldn’t be obese if I knew how to cook.” “My diabetes would be manageable if the pavements were less cracked and I could cycle to work.” “My daughter wouldn’t have asthma if there was less air pollution.”
In response, she set up conversations to find out what others in her community thought. “We met incredibly passionate people who could see massive potential to improve things in our area but who had no means to access resources to put their ideas into practice.
“The idea behind Growing Health Together was to help bridge this gap, providing resources for community members to co-create improved conditions for community health. Help could be in the form of funding, mentoring, connecting people, or finding physical space,” she says.
Over the past three years diverse initiatives have begun to flourish in the neighbourhoods of East Surrey, including:
- peer support groups for carers
- perinatal support for South Asian women
- creative arts sessions for refugees
- citizen science water quality monitoring
- community food-growing for families
- African cultural events offering food, belonging and health checks
- inclusive golf for autistic people
- gardening and food-growing initiatives
Health and wellbeing networks are now being established across East Surrey to act on the issues and opportunities identified by local people.” These networks are tackling issues that simply wouldn’t have been possible without those of us living and working in an area coming together.”
Dr Orrow reflects that the role of Growing Health Together has been to make it easy for health to be created locally. “We have welcomed a mosaic of diverse contributions, connecting people, places, organisations and resources so that great ideas have come to life."
"Taking small steps to connect with, listen and respond to community members, particularly those who have been underserved by health services in the past, can unleash huge energy and potential for positive change."
For those looking to adopt a similar approach, Dr Orrow’s advice it to “invert the foundational assumptions of healthcare.” “Rather than start with diseases and how to fix them, start with the evidence base on health and the conditions in which it is created.
This shifts health “from a concept of scarcity, to one of abundance. And with it, shifting long entrenched patterns and perceptions around power and agency when it comes to our health."
Localised and connected
Are integrated care systems helping to improve population health outcomes? As these examples show, they are, but there is still a long way to go. Improving health is not just about treating conditions, it is much more complex than that.
“Whole-system responsibility is vital to combat health inequalities and to help improve population health, says Dr Kathy McLean. "It’s only by having a holistic approach across the whole of the health and care, voluntary and wider public sector that this will work."
She adds that the system needs to be targeting those with the poorest health, in their own homes, and moving away from a focus on hospitals as the first port of call. "For this, services need to be more localised, created by, and connected with communities – we need a continuum of services from public health to hospitals, from social care to GPs, from community care to the ambulance service."
Further information
Find out more about improving outcomes in population health and healthcare.
