The Effectiveness and Cost Benefit of Integrated Health and Social Care: A Rapid Review of The Evidence

Introduction

Integrated care is an approach to overcome fragmentation in health and social care and may be best suited to people with complex medical needs, but the term extends to the wider definition of promoting health and wellbeing [1]. It involves a structured approach to delivering coordinated, proactive, and person-centred care, and should be understood as a complex adaptive system in which outcomes emerge from interactions between patients, professionals, organisations and communities. Consequently, effectiveness is shaped by context, relationships, collaboration and the capacity of the system to adapt over time [2].

Integrated care is provided by two or more care providers who communicate and collaborate, whether they work within the same organisation or across different organisations. These organisations can be within the healthcare sector or span across health, social, or community care sectors, including informal care providers [3]. Integrated care is illustrated in Figure 1, which was originally presented in a report to support the final report of the evaluation of the social services and well-being (Wales) Act, 2014 [4].

Figure 1: Types of working together and their relationship with one another [4].

Integrated care is a complex intervention, making economic evaluation challenging [5]. Integrated care interventions typically involve multiple organisations, cross-sector collaboration, service redesign, workforce changes, new governance arrangements and digital and information-sharing systems. This complexity means traditional economic evaluation methods often struggle to capture the full costs and benefits as benefits may occur across different sectors (health, social care, community services) and over long time horizons [6].

This review will focus on the United Kingdom (UK). However, healthcare systems and social care systems worldwide are increasingly adopting integrated care models to improve patient/ client outcomes and enhance the efficiency of service delivery. Health and care 6 providers are changing how they work with people as partners in care. Countries around the world, including Australia, Canada, New Zealand, and various European nations (e.g., Sweden, The Netherlands, and the UK) have implemented integrated care initiatives to better manage chronic conditions, improve access to services, and enhance the quality of care [7].

The International Foundation for Integrated Care (IFIC) has an annual survey to reflect on the progress of integrated care delivery worldwide. Their annual survey in 2024 showed that health and care providers were more positive about person centred care than the person at the centre of care [8]. In the UK integrated health and social care systems are organised and not all funded in the same way. Different regions of the UK may have specific approaches to integrating health and social care. For example, England, Scotland, Wales, and Northern Ireland have their own health services and policies, which can lead to variations in how integrated care is implemented and funded. In England, Integrated Care Systems (ICSs) are partnerships that bring together National Health Service (NHS) organisations, local authorities, and other stakeholders to plan and deliver services collectively. ICSs aim to improve health outcomes, reduce inequalities, and enhance the efficiency of services. For residents of the UK these services are funded through general taxation. However, members of the public can opt for private health insurance to access private healthcare services, which can offer shorter waiting times and additional services, which are not available on the NHS. The UK Government strives to build strong ICS everywhere.

England is divided into 42 ICSs and these systems bring local health and social care organisations together to improve outcomes for their populations by creating better services [9]. In Wales, the Welsh Government have provided a fund for Health and Social Care integration on a regional basis within Communities of Practice (CoP) to provide integrated care to members of the community [10]. The Health and Social Care RIF in Wales focuses on establishing and mainstreaming six new national models of care (MoC). These models aim to provide seamless and effective services across the country.

The six models of care in Wales are:

• Community-based care - prevention and community coordination.
• Community-based care - complex care closer to home.
• Promoting good emotional health and well-being
• Supporting families to stay together safely, and therapeutic support for care-experienced children.
• Home from hospital services.
• Accommodation based solutions.

These six models of care are part of a broader effort to integrate health and social care services in Wales, ensuring that care is person-centred and delivered as close to home as possible.

To date, models of care have mainly been used for administration and reporting purposes rather than shaping and informing delivery [11]. See overleaf for detailed descriptions of the models of care. In Scotland ‘The Integrated Health and Social Care plan for Scotland’ (2019) addresses several key issues to ensure that Scotland can provide high-quality, integrated health and social care services [12]. The key issues are workforce integration, mental health services, workforce supply and demand, graining and recruitment, retention and development, and data and intelligence.

In Northern Ireland, the Integrated Care System for Northern Ireland (ICSNI) Framework was established in 2024. ICSNI are working with the Irish Department of Health and Health and Social Care Ireland towards creating a healthier population. The key objectives are population health, community‑centred care, integration of services, workforce development, digital transformation and learning from past initiatives [13]. Although the concept and implementation of integrated care is relatively new in terms of policy direction, there are examples of successful implementation. For example, evidence examining the drivers of successful implementation of integrated care for multi-morbidity identified 17 case studies from 8 European countries including Scotland in the UK [14]. The 17 programmes were analysed using implementation theory.

Detailed Descriptions of the Six MoC in Wales:

1. Community-based care - prevention and community coordination MoC is an integrated approach that emphasises prevention and early intervention to improve health and well-being. This model aims to deliver seamless health and social care services within communities, ensuring support is provided as close to home as possible.
2. Community-based care - complex care closer to home MoC is an approach that aims to deliver specialised health and social care services within the community, ensuring that individuals with complex needs receive support as close to home as possible.
3. Promoting good emotional health and well-being MoC - Promoting good emotional health and well-being is part of the broader Welsh Government objectives under the Well-being of Future Generations (Wales) Act 2015 [15]. This involves creating environments and conditions that support individuals

to be happy, healthy, and comfortable with their lives. The focus is on improving social, economic, environmental, and cultural well-being through sustainable development principles.

1. Supporting families to stay together safely and therapeutic support for care experienced children MoC Supporting families to stay together safely is providing early intervention and support to families to prevent the need for children to enter care. This involves identifying and addressing issues early, using family strengths and community resources, and ensuring that interventions prevent needs from becoming critical.
2. Home from hospital services MoC - Home from Hospital services is part of the “Home First” approach. This approach emphasises that the best place for recovery after a hospital stay is at home, whether that be a personal residence, a care home, or the home of a friend or family member. The goal is to maintain independence and reduce the risks associated with prolonged hospital stays, such as deconditioning and infections.
3. Accommodation based solutions MoC Accommodationbased solutions is part of the Welsh Government strategy to integrate health and social care services within the community. This approach involves creating and supporting housing options that provide a stable and supportive environment for individuals, particularly those with complex needs. The goal is to ensure that people can live independently with access to the necessary health and social care services.

Ten mechanisms for successful implementation of integrated care were identified including;

• Commonly adopted an incremental growth model rather than a disruptive innovation approach;
• A balance between flexibility and formal structures of integration;
• Collaborative governance;
• Distributed leadership throughout all levels of the system;
• Multi-disciplinary team culture with mutual recognition of each other’s roles;
• The development of new roles and competencies for integrated care;
• Secured long-term funding;
• The implementation of Information and Communications Technology (ICT) that was specifically developed to support collaboration;
• Continuous monitoring system; and
• An overarching mechanism for alignment of work across the different components and levels of the health and social care system.

According to the Welsh Government documentation regarding the RIF, regions are encouraged to use outcome measures such as the Warwick Edinburgh Mental Well‑being Scale (WEMWBS) and the EQ-5D, for example. However, they also stated that regions may also continue use tools already being used successfully [10] There is no evidence to date to indicate which tools the regions in Wales are using to collect measurement data on the effectiveness of the RIF funding stream.

The Welsh Government has commissioned a research team led from the University of South Wales to provide ongoing review and phased evaluation of the impacts of the RIF [10] Collaborators on the RIF evaluation include partners outside of the University of South Wales, including Brunel University of London and OB3, a research and consultancy firm based in Wales. The evaluation will help to identify the key success factors in developing and embedding the national models of integrated care [11]. This rapid review is aligned to that Welsh national evaluation [11]. The six models of care in Wales are presented in Table 1.

The aim of this rapid review is to determine the evidence regarding the effectiveness and cost benefit of integrated health and care programmes in the UK. The rapid review protocol is published on Prospero [16].

Method

A rapid review methodology was utilised for this review. A rapid review is a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining methods to produce evidence for stakeholders in a resource‑efficient manner [17‑19].

The main review question was: What is the effectiveness and cost benefit of integrated health and social care programmes in the United Kingdom and Ireland? The eligibility criteria for inclusion of papers in this rapid review is described below and existing systematic reviews were included in the rapid review. See table 2.

Table 1: Detailed descriptions of the six models of care in Wales.

Table 2: Eligibility criteria (PICO: Population, Intervention, Comparison and Outcomes).

The following databases were searched for papers of interest:

• EMBASE
• OVID Medline
• EBSCO CINAHL
• EBSCO APA PsycINFO
• SCOPUS

The search strategy was reviewed by an Information Scientist, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences. A table of abbreviations can be found in Supplementary file 1 and the full search strategy for the databases can be found in Supplementary file 2. Common keywords used in all database searches are shown in Table 3.

Table 3: Common keywords used in all database searches.

The database searches are outlined in the PRISMA diagram in Figure 2 (Page et al., 2021).

Grey literature was also searched and a description of the sources used is contained in Supplementary file 3.

Figure 2: PRISMA diagram of included studies.

Covidence reference management software was used as the main systematic review management tool and to delete duplicates [20]. Mendeley reference manager was used for intext citations [21].

Study selection process, data extraction and assessment of quality

Two reviewers screened 100% of titles and abstracts independently. Following this, the level of agreement was assessed with disagreements settled by discussion and consensus. During independent screening, the lead researchers (LHS & ML) consulted with a third reviewer (DF) to come to an agreement on the final inclusions if there was disagreement. Data extraction was based on the outlined eligibility criteria. The extracted data captured details/characteristics on study region/country, study design, type of intervention, type of economic evaluation, number of participants, relevant costs and outcomes (see eligibility criteria) and study settings. Critical appraisal assessments were conducted on all selected peer reviewed studies using the Joanna Briggs Institute Critical Appraisal Tools [22].

Results

Overview of the evidence base

An evidence map of the literature is presented in Table 4 and guidance documents from the developed nations are presented in Table 5. The database searches are outlined in the PRISMA diagram in Figure 2 [24]. The data extraction table is in Supplementary file 4, and the critical appraisal tables are in Supplementary file 5.

Table 4: Evidence map of the included studies according to study design.

Table 5: Guidance documents for the integration of health and social care in the UK.

The included papers from the database searches (n=15) were mapped on to four of the models of care in Wales (Table 6): Complex care closer to home; Home from hospital services; Promoting emotional health and well-being; and Accommodation based solutions. None of the included papers provided economic evidence for the ‘Supporting families’ model of care.

Table 6: Included paper according to model of care.

See supplementary file 5 for the critical appraisal tables. Please note that there are a different number of critical appraisal questions for each type of study, therefore the maximum score ranges from 11 to 13. The studies ranged in quality from low quality to high quality (n = 8 high quality studies; n = 5 moderate quality studies and n = 2 low quality studies).

Community Based Care: Complex Care Closer to Home

Nine of the included studies focused on complex care closer to home [24‑32] See Table 7 for the main cost findings from the complex care closer to home included studies.

The economic evidence from the identified studies focusing on care closer to home were mixed. Whilst, Evans et al [24] Garner et al [25] and Visram et al [31] provided positive evidence for beneficial integrated health and social care, Jones et al [27] and Thomson and Chatterjee [30] provided mixed evidence, and Heslin et al [26], Yu et al [32], and Stokes [28,29] found no economic evidence in favour of integrated health and social care.

Evidence from an observational study aimed to examine data from the Acute Chronic Obstructive Pulmonary Disease (COPD), Early Response Service (ACERS) intervention [25]. Pre-ACERS and post-ACERS datasets were analysed. The intervention sample size was 69 COPD patients. A multi-disciplinary team made up of COPD Specialist Nurses, Respiratory Physiotherapists, Nurse Consultant (team leader), Respiratory Consultant (who provided medical advice and leadership) delivered the intervention.

The types of costs measured were cost of ACERS team, length of stay, bed days saved, and cost of death outside of hospital. There was evidence that the integrated COPD team improved the qualityof-care provision, reduced the number of bed days and length of stay in hospital. The bed days saving was £400,000 per year. The model also calculated the rise in patients dying outside of hospital, leading to a £252,000 saving per year. The overall finding was that the implementation of the ACERS integrated care service was cost neutral, whilst improving the quality of care [25]. This study was rated as high quality (10/13).

A randomised control trial (RCT) study was conducted to investigate the cost‑effectiveness of a health promotion intervention used to improve physical health while decreasing substance use among people living with a psychotic disorder [26]. The RCT examined the ‘Improve health and reduce substance use in established psychosis’ - IMPaCT intervention, which was an integrated health promotion intervention designed to improve physical health and reduce substance use in individuals with established psychosis.

The IMPaCT intervention included health promotion sessions, individual support, training and supervision. Data and analysis included 104 care coordinators along with 446 patients. Research findings indicated that there is no difference in health and social care or societal costs between those individuals with a diagnosis of psychosis receiving the integrated health promotion intervention or not receiving the intervention. In addition, there was no improvements in quality‑of‑life outcomes or cost‑effectiveness [26]. This study was rated as high quality (10/13).

An economic evaluation of The Wellbeing for Life (WFL) intervention [33]. Included 3179 clients who received services from Health trainers (lay individuals who had been trained up). The interventions varied, with one-to-one behaviour change clients receiving up to eight sessions with a health trainer, or twelve sessions for those in the ‘high need’ intervention. Groupbased activities typically lasted for at least four sessions. The WFL service had a total delivery cost of £3,528,894.25. The main findings were that the total health gain from the WFL service (287.7 QALYs) implies an estimated cost saving to the NHS of £1,477,911, not including £300,000 for costs offset from asset mapping and £498,800 from signposting and events.

The results indicate an additional cost saving to social care of £126,326 (linked to the reduction in adverse health outcomes) and to criminal justice of £3883 (from reduced alcohol and substance abuse by clients). Therefore, the total public sector cost saving attributed to the WFL service was £2,406,920. Being able to demonstrate value for money like this is crucial for the sustainability of interventions such as WFL, especially given the broader context of austerity and reductions in public health funding [31]. This study was rated as moderate quality (7/11).

A RCT investigating the impact of the short-term integrated palliative and supportive care intervention for older people living with chronic noncancer conditions was conducted in four NHS general practices in England between January 2019 and December 2020. Multidisciplinary teams including community nurses and GPs provided in‑person palliative care [24]. The cost‑effectiveness analysis showed that the ICER was: £12,000 per QALY gained, which would be considered cost effective according to guidelines in the UK context [34]. The findings remained robust after sensitivity analysis was conducted. It showed that the cost‑effectiveness of the community-based short-term integrated palliative and supportive care intervention remained consistent even when key assumptions and parameters, such as costs and discount rates, were varied [34]. This study was rated as high quality (10/13).

Mixed evidence for the benefit of integrated health and social care was found in a feasibility study to investigate the effectiveness of a self‑management programme integrated into stroke rehabilitation service in England [27]. The study included 78 patients with a diagnosis of stroke over a 14‑month period during 2014‑2015. Rehabilitation clinicians were trained to integrate defined selfmanagement principles into scheduled rehabilitation sessions, supported by a patient‑held workbook. Cost utilisation data was collected at baseline, 6 weeks, and 12 weeks from 2014‑2015. Healthcare costs included staff costs, training costs and healthcare utilisation costs. Costs collected were those associated with the use of healthcare services, such as hospital readmissions and outpatient visits. The main cost finding from the feasibility study was that costs varied by site. This variation was likely due to differences in how the self-management programme was integrated into existing community rehabilitation services.

Total rehabilitation inputs were similar in the two control sites (24 therapy hours per patient). However, a difference was found between the two intervention sites (20.1 vs 50.7 therapy hours). Intervention sites reported a proportionately higher use of therapy assistants than control site. Costs of patient-facing time ranged from £600 in the low resource use intervention site to £1667 in the high resource use intervention site. The costs of the two control sites were similar (£754 and £763). Total costs for control sites (mean of two sites) ranged from £930 to £1459, depending on the assumptions made about the ratios of patient-facing to patientrelated non-face-to-face costs. The equivalent range for the low resource use intervention site was £721–£1103, and for the high resource use intervention site it was £1987–£3012 [27]. This study was rated as high quality (10/13).

There was also mixed evidence of the benefit of integrated health and social care in a rapid review [30]. The aim of the rapid review was to determine the barriers and enablers of integrating health and social care and community resources in the UK, and to ascertain the extent of this evidence. A variety of interventions were included in the review. All were aimed at improving the coordination and delivery of health and social care services. These interventions encompassed both medical (clinical and diagnostic) and non-medical (public health services and community-based or person-centred care) strategies. The rapid evidence included 34 review articles, and 21 grey literature reports published between 2018 and 2022. The review highlighted the paucity of robust research to evaluate integrated health and social care interventions and lack of standardised methodology to assess cost effectiveness. This study was rated as moderate quality (5/11).

A further three of the included papers found no evidence for the benefit of integrated health and social care [28,29,32]. The Diabetes Integrated Care Initiative was evaluated in England [32]. The study included a sample size of 2,700 patients with Type 2 diabetes in the Cambridgeshire intervention area. The intervention was delivered by specialist nurses, dietitians, podiatrists and medical professionals. The length of follow-up was 3 years, and the types of costs measured were inpatient care costs, community service costs, and expenses related to the enhanced community diabetes services, including specialist nursing, dietetic, podiatry, and medical support. The approach involved comparing the area under the curve (AUC) of inpatient payments at baseline and follow-up periods.

This method allowed the researchers to estimate the effect of the integrated care intervention on commissioner payments by analysing the distribution of inpatient payments over time. The Diabetes Integrated Care intervention did not lead to cost savings for the healthcare commissioners. However, there were reductions in inpatient payments for certain age groups. Specifically, the study observed a reduction in inpatient payments for 3.2% of patients aged under 70 years and 4.1% of patients aged 70 years and older in one of the two adjacent areas. This suggests that the impact of the Diabetes Integrated Care Initiative varied across different age groups [32]. This study was rated as high quality (9/11).

An economic evaluation of The Better Care Fund (BCF) assessed the effects of BCF on secondary care utilisation and costs using a dataset recording all secondary care use in England [28]. The study analysed data from a cohort of 14.4 million patients, focusing on the short (1 year) and intermediate‑term (up to 2 years) effects. There were various health and social care interventions funded by the BCF and the types of costs which were measured were, hospital inpatient admissions, emergency department visit costs, outpatient appointment costs and cost of bed days. The evaluation found no significant reduction in hospital use or costs in the short to intermediate term. For patients with multimorbidity, the use of bed days increased by 0.164 bed days per patient per year, which is approximately a 4.9% increase in the short term. Stokes et al [28] acknowledge that while pooling budgets has potential benefits, it is not a guaranteed solution for reducing hospital use and costs. Successful integrated care requires careful implementation and realistic expectations [28]. This study was rated as moderate quality (5/11).

Another large evaluation study aimed to examine the effectiveness of two integrated care models in Salford and South Somerset in England in relation to patient experience, health outcomes and costs of care [29]. Data was collected three years following the introduction of the new integrated care models which aimed to enhance inter-organisational support for chronic condition management, improve coordination between primary and secondary care services, and proactively manage patients with complex needs to prevent hospital admissions. The sample included 1.2 million patients, and the intervention deliverers were healthcare professionals including General Practitioners (GPs), nurses, specialists, community health workers, and social care providers. Costs of secondary care were measured, including all hospitalrelated expenses along with cost per user of secondary care, and avoidable emergency admissions. Both intervention sites showed an increase in total costs of secondary care (approximately £74 per registered patient per year in Salford, £45 in South Somerset) and cost per user of secondary care (£130–138 per person per year). Additionally, there were no statistically significant effects on health status or patient experience of care [29]. This study was rated as high quality (10/11).

Table 7: Economic evidence from the complex care closer to home services studies.

Promoting Emotional Health and Wellbeing

Of the included papers, (n=2) were focused on promoting emotional health and wellbeing [35,36] See Table 8 for the main economic evidence relating to promoting emotional health and well-being.

Table 8: Economic evidence from the promoting emotional health and wellbeing service.