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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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...

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.