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Multimorbidity and integrated care

Stokes, Jonathan

[Thesis]. Manchester, UK: The University of Manchester; 2016.

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Abstract

BackgroundHealth systems internationally face a common set of challenges: ageing populations,increasing numbers of patients suffering from multiple long-term conditions(multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ ispitched as the solution to current health system challenges. But, in the literature, whatintegrated care actually involves is complex and contested.Aims1. What does ‘integrated care’ currently look like in practice in the NHS?2. What is the effectiveness of current models of ‘integrated care’?3. To what extent are there differential effects of ‘integrated care’ for different typesof multimorbidity?MethodsThe thesis utilises routinely collected data, systematic review and meta-analysis,combined with quasi-experimental methods (difference-in-differences, and subgroupanalysis, difference-in-difference-in-differences).ResultsThe current implementation of the concept of integrated care is predominantly carriedout through multidisciplinary team (MDT) case management of ‘at risk’ (usually ofsecondary-care admissions) patients in primary care. This approach, however, has notproven capable of meeting health outcome and utilisation/cost aims. Patientsatisfaction, though, is consistently improved by the approach. There might also bepositive spill-over effects of increased team-working through MDTs for the wider practicepopulation. There does not appear to be a multimorbidity subgroup which benefitssignificantly more than others in terms of secondary-care utilisation or cost. However,patients at the end of life and/or those with only primary-care sensitive conditions mightbenefit slightly more than others.ConclusionsIntegrated care, in its current manifestation, is not a silver bullet that will enable healthsystems to simultaneously accomplish better health outcomes for those with long-termconditions and multimorbidity while increasing their satisfaction with services andreducing costs. The current financial climate might mean that other means of achievingprioritised aims are required in the short-term, with comprehensive primary care andpopulation health strategies employed to better prevent/compress the negative effectsof lifestyle-associated conditions in the longer-term.