Background Health and care services are becoming increasingly strained and healthcare authorities worldwide are investing in integrated care in the hope of delivering higher-quality services while containing costs. The cost-effectiveness of integrated care, however, remains unclear. This systematic review and meta-analysis aims to appraise current economic evaluations of integrated care and assesses the impact on outcomes and costs. Methods CINAHL, DARE, EMBASE, Medline/PubMed, NHS EED, OECD Library, Scopus, Web of Science, and WHOLIS databases from inception to 31 December 2019 were searched to identify studies assessing the cost-effectiveness of integrated care. Study quality was assessed using an adapted CHEERS checklist and used as weight in a random-effects meta-analysis to estimate mean cost and mean outcomes of integrated care. Results Selected studies achieved a relatively low average quality score of 65.0% (± 18.7%). Overall meta-analyses from 34 studies showed a significant decrease in costs (0.94; CI 0.90–0.99) and a statistically significant improvement in outcomes (1.06; CI 1.05–1.08) associated with integrated care compared to the control. There is substantial heterogeneity in both costs and outcomes across subgroups. Results were significant in studies lasting over 12 months (12 studies), with both a decrease in cost (0.87; CI 0.80–0.94) and improvement in outcomes (1.15; 95% CI 1.11–1.18) for integrated care interventions; whereas, these associations were not significant in studies with follow-up less than a year. Conclusion Our findings suggest that integrated care is likely to reduce cost and improve outcome. However, existing evidence varies largely and is of moderate quality. Future economic evaluation should target methodological issues to aid policy decisions with more robust evidence on the cost-effectiveness of integrated care.

ObjectiveTo evaluate the impact of child and adolescent mental health services (CAMHS) transformation in South East England on patient access, resource utilisation and health outcomes.DesignIn an observational study, we use difference-in-differences analysis with propensity score matching to analyse routinely collected patient level data.SettingThree CAMHS services in South East England.ParticipantsAll patients attending CAMHS between April 2012 and December 2018, with more than 57 000 spells of care included.Main outcome measuresThe rate and volume of people accessing CAMHS; waiting times to the first contact and waiting times between the first and second contact; and health outcomes, including the Strengths and Difficulties Questionnaire (SDQ) and the Revised Child Anxiety and Depression Scale (RCADS).ResultsThe intervention led to 20% (incidence rate ratio: 1.20; 95% CI: 1.15 to 1.24) more new patients starting per month. There was mixed evidence on waiting times for the first contact. The intervention led to 10% (incidence rate ratio: 1.10; 95% CI: 1.02 to 1.18) higher waiting time for the second contact. The number of contacts per spell (OR: 1.08; 95% CI: 0.94 to 1.25) and the rereferral rate (OR: 1.06; 95% CI: 0.96 to 1.17) were not significantly different. During the post intervention period, patients in the intervention group scored on average 3.3 (95% CI: −5.0 to −1.6) points lower on the RCADS and 1.0 (95% CI: −1.8 to -0.3) points lower on the SDQ compared with the control group after adjusting for the baseline score.ConclusionsOverall, there are signs that transformation can help CAMHS achieve the objectives of greater access and improved health outcomes, but trade-offs exist among different performance metrics, particularly between access and waiting times. Commissioners and providers should be conscious of any trade-offs when undertaking service redesign and transformation.

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IntroductionIncreased demand for Child and Adolescent Mental Health Services (CAMHS), alongside concerns that services should be better commissioned to meet the needs of the most vulnerable, has contributed to a requirement to transform services to improve accessibility, quality of care and health outcomes. Following the submission of government-mandated transformation plans for CAMHS, services in England are changing in how, where and by whom they are delivered. This protocol describes the research methods to be applied to understand CAMHS transformations and evaluate the impact on the use of mental health services, patient care, satisfaction, health outcomes and health resource utilisation costs.Methods and analysisA mixed-methods approach will be taken in an observational retrospective study of CAMHS provided by a large National Health Service (NHS) mental health trust in South-East England (Oxford Health NHS Foundation Trust). Quantitative research will include descriptive analysis of routinely collected data, with difference-in-differences analysis supplemented with propensity score matching performed to assess the impact of CAMHS transformations from 2015 onwards. An economic evaluation will be conducted from a healthcare perspective to provide commissioners with indications of value for money. Qualitative research will include observations of services and interviews with key stakeholders including CAMHS staff, service users and guardians, to help identify mechanisms leading to changes in service delivery, as well as barriers and enabling factors in this phase of transformation.Ethics and disseminationThis project has been registered with NHS Oxford Health Foundation Trust as a service evaluation. Informed consent will be sought from all stakeholders partaking in interviews according to good clinical practice. A local data sharing protocol will govern the transfer of quantitative data. Study findings will be published in professional journals for NHS managers and peer-reviewed scientific journals. They will be discussed in seminars targeting CAMHS providers, managers and commissioners and presented at scientific conferences.

An understanding of the past helps us to prepare for the future. In this, the REAL Centre's first report, we look back at the care and treatment provided by the NHS in England over the past two decades-as measured by health care activity. Measures of activity-what the NHS does-form the basis of much NHS planning. Together with measures of quality, these are used as proxies for understanding the contribution the NHS makes to population health. Understanding the drivers of this activity is therefore crucial to service and resource planning. In this report, we provide a framework for understanding the drivers of health care activity. We describe how supply and demand side factors interact, and how policy can influence the care the NHS provides. We look at the overall trends in activity and how specific services have changed. Where possible, we estimate the proportion of any change that can be explained by four demographic factors: population size, age, gender, and proximity to death. We then explore what drives the remaining change, unexplained by demography. Although we focus on England, many of the lessons may be relevant to the other countries of the UK. We take an in-depth look at emergency and planned hospital care, mental health, community and primary care, but do not look in detail at areas such as high cost drugs or highly specialised services. Social care, too, is beyond the scope of this initial report but will be the focus of subsequent analysis by the REAL Centre. * This is cost-weighted. See section 3 for further detail. The bigger picture: learning from two decades of changing NHS care in England seen between services, combined with changes to the cost of different activities, have produced a major shift in the composition of spend towards hospital-based care and away from other areas. The expansion in activity means the population receives significantly more health care today, which has contributed to lower mortality rates for a range of conditions and, up until 2010, increasing life expectancy. However, improvements and increases in care have not been uniform over the past two decades. Between 2000/01 and 2010/11 activity rose by 5.3% a year, quality of care improved, and life expectancy grew by nearly 3 months a year for women and almost 4 months a year for men. As funding slowed after 2010 so too did activity. Between 2010/11 and 2017/18 activity grew by 3.6% a year, quality gains slowed and life expectancy has stalled overall and for some groups declined (notably for women younger than 50 in deprived areas). But it is not just life expectancy that has changed. Over the past two decades the amount of life spent living with long-term health conditions has increased and more people are living for prolonged periods with multiple long-term health problems. New technologies, changes in prices, and the increasing availability of information about treatments have increased clinician and public expectations about what the NHS can and should provide. Medical advances have meant more treatments can be provid...

Background: In many high-income countries, primary care practitioners are the main point of referral for specialist mental health services. In England, Child and Adolescent Mental Health Services (CAMHS) are increasingly adopting a Single Point of Access (SPA) to streamline referrals and introduce self and parent/carer-referrals. This involves a significant shift of responsibility from primary care towards CAMHS who adopt a more active role as gatekeeper for their service. This study evaluates the adoption of a SPA in CAMHS across a large region in England. Methods: We conducted an observational mixed methods study in two CAMHS from January 2018 to March 2019 to evaluate the adoption of a SPA. We collected quantitative data from electronic patient records and qualitative data through ethnographic observation and in-depth interviews of staff and stakeholders with experience of using CAMHS. Additional data on volumes was shared directly from the SPAs and a further snapshot of 1 week's users was collected. Results: A similar SPA model emerged across the two services. Staff were positive about what the model could achieve and access rates grew quickly following awareness-raising activities. Despite the initial focus being on a telephone line, online referrals became the more regularly used referral method. Increased access brought challenges in terms of resourcing, including identifying the right staff for the role of call handlers. A further challenge was to impose consistency on triage decisions, which required structured information collection during the assessment process. Similar to GP referrals, those self-referring via the SPA were mainly from the least deprived areas.

This report presents the REAL Centre's projections of future health and social care funding requirements, both for the next 3 years and longer term funding to 2030/31. The projections are based on underlying funding pressures -such as population size and age structure -and additional funding pressures, such as potential policy choices. The report seeks to answer the question of how much funding the health and social care system may need over the next decade. This includes overall Department of Health and Social Care (DHSC) budgets, day-to-day NHS funding and the funding made available to local authorities for adult social care.Although the report does not seek to recommend a course of action, it does set out the funding implications of choices about the speed of service recovery and staff pay. As such, scenarios and sensitivity analysis are presented to reflect considerable uncertainty, including in the external environment, particularly regarding COVID-19, and in the trade-offs and decisions government will need to make about its level of ambition for the pandemic recovery.The report presents two scenarios that reflect varying levels of ambition for the post-pandemic world -stabilisation and recovery. In the longer term to 2030/31, the scenarios require real-terms average annual increases in NHS funding of 3.1% and 3.5% respectively. In the short term, the stabilisation scenario would require additional NHS funding over and above that set out in the NHS Long Term Plan. This equates to an additional £4.7bn in 2021/22, £4.0bn in 2022/23 and £2.9bn in 2023/24. The scenarios include funding to enable a modest expansion in the availability of adult social care services, support provider sustainability and pay social care workers more. To achieve these aims funding for adult social care would need to rise more quickly than for the NHS. * See chapter 5 for a full breakdown of scenario assumptions. * Absolute values after 2018/19 include NHS pensions adjustment of £2.85bn in nominal terms; growth rates exclude this pension adjustment. Note, our DHSC RDEL estimate excludes the costs of running an ongoing test and trace system. Health and social care funding projections 2021 8 Table 3: Average annual increase in funding for social care, projected and historical Government Years Average annual increase for social care Coalition government 2009/10-2014/15 -2.0% Cameron and May governments 2014/15-2018/19 1.8% Johnson Conservative government 2018/19-2020/21 1.7% Scenarios 2019/20-2030/31* Projected growth rates Stabilisation Recovery 4.3% 5.8% Source: REAL Centre calculations. *For social care modelling, the baseline year is 2019/20.COVID-19's economic legacy has an impact on the share of national wealth that would be spent on health and social care in response to rising funding pressures. Under both scenarios, the share of national income required to meet the funding needs for the UK would be in the range of 10% by 2030/31. This is an increase of more than 2 percentage points against the 2018/19 baseline. This is similar to...

ObjectivesTo investigate whether the rate of spend on child and adolescent mental health is influenced by demand for other competing services in local commissioning decisions.DesignAnalysis of spend data by Clinical Commissioning Groups (CCG), including other publicly available data to control for variation in need.SettingLocal commissioning decisions in the National Health Service.ParticipantsCommissioning of health services across 209 CCGs.Main outcome measuresAssociation between the rate of child and adolescent mental health spend and demand for child and adolescent mental health services (CAMHS), adult mental health services and physical health services after adjusting for confounding factors.ResultsAn additional percentage point in the proportion of children in care is associated with 4% higher child and young person mental health (CYP MH) spend per person aged 0–18 (ratio of means: 1.04; 95% CI 1.00 to 1.07). Spending £100 more on physical health services was associated with 9% lower spend in CYP MH per person aged 0–18 (ratio of means: 0.91; 95% CI 0.84 to 0.99).ConclusionsHealthcare commissioners in England face a challenge in balancing competing needs. This paper contributes to our understanding of this by quantifying the possible extent of the trade-off between physical health and CYP MH when allocating budgets. Any attempt to explain the variation in CAMHS spend must also take account of demand for other services.