Financial Integration across Health and Social Care: Evidence Review

The issue

The effective, affordable and sustainable provision of social care is a challenge in many high income countries due to increasing demand and pressure on limited resources. As it is increasingly unsustainable for health care systems to focus on treatment and secondary care, preventive measures and ways to integrate health and social services are being examined.

This report includes a rapid review of the international literature on integrated resource mechanisms used within health care and across health and social care. The review identifies various techniques that have been used to enable financial integration, the context in which they were used, their overall effectiveness, barriers to implementation and critical success factors. Funding models were identified and critically appraised from an economic perspective.

Findings

Three reasons for adopting integrated funding approaches were identified. Individuals with complex needs often have difficulty receiving quality care in existing separated structures. Increasing demand for medical care, along with scarce resources and financial pressures, are showing current healthcare systems to be economically unsustainable. Current financial structures may include incentives that encourage over-supply and discourage disease prevention measures.

While there was no evidence of joint financing leading to an improvement in health outcomes, this may be because the analytic approach used was not appropriate and few studies analysed health outcomes. There is limited evidence on the effectiveness and cost-effectiveness of integrated resource mechanisms. However this may be due to study design rather than absence of effect.

It is difficult to determine which integrative approaches are the most effective due to the degree of heterogeneity between them. But there is little evidence that structural integration, which involves combining health and health-related social care units into a single health body, is necessary for achieving integration of care.

Policy Considerations

Although the review did not find robust evidence of integrative approaches generating cost-savings and/or improvements in health outcomes, it did identify several lessons and barriers to change.

Lessons in implementing financial integration mechanisms:

1. Clear, joined up vision: The goals and benefits behind integration must be made clear to all parties involved. Signed agreements can be used to ensure that mutual understanding, clear accountability and governance have been obtained. The use of a central coordinator, as well as financial and non-financial incentives, may be useful to support staff and encourage change.
2. Flexibility: The type and degree of integration should reflect local needs and goals. Integrative approaches should also fit within distinct administrative, regulatory and governance structures.
3. Assessment of schemes: Obtaining unbiased estimates of the effectiveness and cost-effectiveness of financial integration systems across health and social care is required. Randomized controlled trials and experimental studies should be encouraged to gain a better understanding of overall effectiveness.
4. The need for data collection: A common dataset, with key resource use, activity, process and outcomes data, to which all health and social care bodies contribute, will enable analyses to adjust for confounding factors.
5. Integration costs: The costs of integration can be substantial with high costs in the short term. Services need to be sustainable and mechanisms need to be in place to link upstream substitution of programmes to cost savings.
6. Time-frame for evaluation: While there is no certainty, it may be important to extrapolate outcomes over longer periods since outcomes may not be evident in the short term.

Main barriers to implementation:

1. Financial: Although the nature of financial barriers encountered is dependent on the type of financing mechanism, implementing integrative approaches involves high up-front investment with possible outcomes and cost-savings only in the long term.
2. Organizational: These include the time and resources involved in systems restructuring, lack of patient retention, geographical boundaries and difficulties linking services along the continuum of care. Practical challenges involving the transition to multi-disciplinary care teams may also be encountered.
3. Cultural: Difficulties and power imbalances involved with bringing together organizational cultures such as hospital and community based care can cause fragmentation in integrative approaches.

The evidence suggests that central government can support integration through practical support, legal and regulatory guidance, guidance on data collections and setting national outcome targets.

Type of Evidence

As a rapid review of 119 studies focused on financial integrative approaches in high income countries, not only may this study not be comprehensive, but the results may not be transferrable to developing countries.

Further, three gaps were identified in the evidence base: quality of studies, the outcomes assessed and reporting of the model for financial integration. Many studies did not evaluate long term effects and the majority of studies focused on improving the process of integration rather than on health outcomes. As some studies lacked detail on the approaches for financial integration, it was not possible to properly classify or make conclusions about these models.

The views expressed in this summary are based on a publication of a HEN Network member agency and do not necessarily represent the decisions or stated policy of WHO/Europe.