A rationing framework for Integrated Care Systems.
Authors: Tsiachristas Apostolos , Perera Rafael , Fitzpatrick Ray 
Published: January 2024

Background: Over the last 20 years, the NHS has introduced multiple changes in the commissioning structures, aiming at promoting integrated care in England. The Health and Care Bill 2021 is the latest and farthest-reaching reform, under which local commissioners from the emerging Integrated Care System (ICSs) are expected to accelerate the implementation of ‘integrated care programmes’. This overhaul demands local commissioners to develop approaches to robustly monitor and assess ‘integrated care programmes’ when making investment decisions. This research project aims to develop a framework to support the local commissioning of integrated care in England.

Methods: To understand the decision-context and identify the most relevant monitoring and assessment criteria, we conducted 26 semi-structured interviews with local stakeholders. To supplement the criteria and inform the development of the evaluation component, we conducted a systematic literature review on the use of multi-criteria decision analysis (MCDA) in healthcare. The monitoring component of the framework is based on key performance indicators. A system-adjusted time-trend is used to identify ‘integrated care programmes’ that underperform and consequently should be re-assessed. For the evaluation component, we develop a value-measurement MCDA. To define the relative importance of the assessment criteria on the basis of public values, we conducted a discrete choice experiment (DCE) with members from the public in England. In the DCE, participants are presented with two hypothetical care programmes, described by six attributes (assessment criteria), and are asked to state their choice. The design of this experiment was informed by the literature, local stakeholders, and representatives from the Oxford & Thames Valley Patient and Public Involvement group. Standardised performance scores will be estimated using routinely collected data and quasi-experimental methods.

Preliminary results: The emerging ICSs open an opportunity for local decision-makers to strengthen the commissioning process, and the proposed framework can potentially contribute to this end. In the interviews, stakeholders indicated that health outcomes, quality of care, cost and equity should be the main drivers of investment decisions. Similar criteria were used in 55 MCDA studies developed to guide priority-setting decisions in high-income countries, with most of these studies using the value-measurement approach. Intermediate health outcomes, compliance with national guidelines, quality of care and equity in access are defined as the monitoring criteria. The assessment criteria are six: final health outcomes, health-related quality of life, patient experience, size of the target population, equity and cost.  According to the DCE conducted with 440 members from the public, the six attributes are statistically significant.

Next steps: The structure of the framework has been presented to local stakeholders. Based on the data available and how ICSs are starting to operate, it seems that the framework could be applied to support the local commissioning of integrated care. We will demonstrate the framework’s applicability with an evaluation of integrated mental health services in Oxfordshire. We also aim to incorporate social care into the framework and, with this, identify potential data gaps. Afterwards, we will develop a user-friendly software to facilitate the use of the framework by other ICSs across England.