Integrated primary care and social services for older adults with multimorbidity in England: a scoping review

Background As the prevalence of older adults with multimorbidity increases, greater integration of services is necessary to manage the physical and psycho-social needs of this cohort. This study describes and summarises current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England. Methods A scoping review was conducted involving systematic searches of a range of electronic academic and policy databases. Articles were screened and extracted in duplicate by two independent reviewers. Data were extracted onto a charting sheet and thematic synthesis was used to summarise findings. Articles were included if published in English and related to primary care, social care and multimorbidity in older adults in England. Conceptually, the review was framed using the Rainbow Model of Integrated Care. Results The search yielded 7656 articles of which 84 were included. Three themes were identified: (1) a focus on individual level services rather than multi-level or multi-sector integration, with an increasing emphasis on the need to consider broader determinants of population health as critical to integrated care for older adults with multimorbidity; (2) the need for policymakers to allow time for integration to embed, to enable new structures and relationships to develop and mature; and (3) the inherent tension between top-down and bottom-up driven approaches to integrated care requires a whole-systems structure, while allowing for local flexibilities. Conclusions There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in England. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organisation or design across services as one single system of provision. This may take time to establish and will require local input. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02618-8.


Introduction
Closer health and social care integration has been a key policy goal of successive UK governments for 40 years but the advancement of this agenda has not been achieved at the pace required to meet the demands of an increasingly ageing population with higher levels of multimorbidity [1,2]. Recent prediction forecasting of care dependency profiles suggests that 80% of the ageing population, that is people aged 65 years or older according to the UK National Health Service, will require medium or high dependency care due to multimorbidity [3]. In this context, it is essential that primary care is capable of working closely with social services and wider community care providers to harness collective capacity, which can address the range of behavioural, social, and physical health care needs of the population. This requires more careful consideration of the organisation, structures, systems and funding across providers to identify specific opportunities for successful integration. The scoping review adopted Leutz's definition of integration 'as the search to connect the healthcare system (acute, primary medical and skilled) with other human service systems (e.g. long-term care, education and vocational and housing services) to improve outcomes (clinical, satisfaction and efficiency)' . [4].
Given the substantial funding provided for integration pilots including a variety of testbeds, and the extensive research and evaluation in practice that has already been conducted [5], it is valuable to learn from these to understand current progress and anticipate future challenges to successful implementation. Whilst previous reviews have been conducted, these have mainly been limited to searches of the published literature, which may not adequately capture efforts in private or voluntary sector care organisations, where most social care is provided [6][7][8][9]. Moreover, few earlier studies have specifically examined the literature related to England in order to consider the contextual factors of this setting. There is also a relative paucity of evidence that considers integration in relation to primary care, where most care of older adults with multimorbidity occurs [7,10]. To address these gaps in the evidence base, a scoping review was conducted to describe and summarise current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England.

Review approach and conceptual framework
The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews [11]. The scoping review allowed rapid mapping out of key existing work and current progress in this field. Conceptually, the review was framed using the Rainbow Model of Integrated Care, a framework that permits better definition and understanding of integrated care from a primary care perspective [12]. This multi-level conceptual framework describes dimensions that play inter-connected roles on the macro-(system integration), meso-(organisational and professional integration) and micro-level (clinical, service and personal integration), alongside dimensions (functional and normative integration) that enable the integration between different levels within a health system [13]. The model promotes the provision of continuous, comprehensive and coordinated care to the individual and population [12].

Search strategy
A systematic electronic search was conducted in Medline, EMBASE, The Cochrane Library, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, and Science and Social Science Citation Indices from database inception until the 16th June 2020. For searches of electronic databases, text and MeSH terms were limited to primary care, social services and older adults. Detailed search terms are available in supplementary file. Unpublished literature was searched for in Opengrey and through the websites of Clinical Commissioning Groups, GP federations, the Department of Health and Social Care, third sector bodies and private organisations who deliver social care. Hand searching of the bibliographies of included works and relevant systematic reviews for any additional relevant data was conducted. The views of topic experts and service users were sought to source further data. All articles identified were imported into Rayyan software for screening, which was conducted in blinding mode.

Inclusion/exclusion criteria
Articles were eligible for inclusion if published in the English language and their content was primarily related to the key inclusion/exclusion criteria of primary care, social care and multimorbidity in older adults, specifically in England. Due to the broad aim of this scoping review, researchers adopted flexibility in study designs including newsletters, discussion papers, government reports, company reports, blogs, working papers, policy recommendations, webinars and dissertations. Quality assessment is not a priority for scoping reviews, therefore articles were not excluded on this basis.

Study selection and data extraction
Titles and abstracts were screened with each article assessed for relevance according to the inclusion criteria. Full-text articles were retrieved. Both screening and data extraction were carried out independently by two reviewers. A data charting form was used, which was specifically designed according to the study conceptual framework described above. The level of integration within each included article was examined in line with the Rainbow Model of Integrated Care conceptual framework (i.e. macro, meso or micro-level and vertical/ horizontal integration), article characteristics and key findings.
A list of data extracted on the charting form is summarised in Table 1 below. Any disagreement between reviewers about data was resolved through discussion until a consensus was reached.

Summarising and analysis
Researchers used counts to summarise article characteristics, and the charting technique to iteratively synthesise and interpret findings by sifting and sorting material [14,15]. Repeated reference to the study conceptual framework was made during this process. Using thematic synthesis, key excerpts of extracted text were first coded by three members of the team (HDM, GS and SH). Deductive analysis was used in deriving a conceptual framework from the research aims and theory, while also seeking to inductively identify codes and themes from the synthesis of included articles. Initial codes were refined into themes. Members of the team experienced in systematic reviewing who had not previously been engaged in the coding process, were involved in the final stages of the analysis. This provided an additional perspective on the analytical process to strengthen both the quality and validity of the findings.

Results
In total 7656 articles were identified including 6426 from electronic databases, 1118 via Opengrey and 112 from websites and experts. Following title and abstract screening, 809 articles underwent full-text screening, which resulted in a final 84 articles being included in the review. A flowchart of the screening process, including the reasons for exclusion, is shown in Supplementary material [16].

Characteristics of included studies
The 84 included articles represented multiple locations across England, including regions in the south-west, north-east, north-west and Greater London. These were from a range of sectors; primary care, secondary care, social care, voluntary sectors, local government, local authority and public health. The most frequent study designs or types were qualitative (n = 18), followed by mixed-methods (n = 12), analysis/commentaries (n = 12), systematic/scoping/evidence reviews (n = 10), randomised controlled trials (n = 9), policy documents (n = 8), quantitative studies (n = 7), thesis (n = 4), editorials (n = 2) and books/book reviews (n = 2). Included articles were published between 1996 and 2020. The characteristics of included articles have been summarised in Table 2.

Level of integration
The number of studies that considered integration were counted at each level as set out in the conceptual framework (i.e. macro, meso or micro-level). There were 7% of studies that considered integration at the macro-level, 5% at meso-level and 30% at micro-level. Thirty-five per cent of the articles considered integration at all three levels. However, the combined number of studies focused on either one or both of micro and meso levels was 52%.

Summary of themes amongst included studies
Three themes were identified from the analysis, which summarised current research and progress on integrated primary care and social services for older adults with multimorbidity in England: (1) a diverse focus on multi-level vs. multi-sector integration; (2) time needed for integration to embed; and (3) seeking structural integration while applying local flexibility. Each of these is described in turn below.  Taking 'a long view' of initiatives promoting integration between local government and the NHS, with the objective of seeking to understand why they have achieved consistently disappointing results.
Barriers lie in the foundational principles of basing: (a) responsibilities on the skills of providers rather than service user need (b) organisational forms are based on separation rather than interdependence with national uniformity driving the NHS and local diversity driving local authorities.   Overview of current integrated health and social care, the rationale behind care integration, facilitators and barriers to integrated working, and related workforce and funding issues.
Integrated care might be seen politically as a quick fix for the problems facing a health and social care system. Achieving real long-lasting change will take time, as well as prolonged effort to establish and maintain successful integrated working practices. No specific context.
Examine the fragmentation in patient services observed in many health care systems. This article discusses how integration may be achieved.
Implementing integrated care holds the potential for improving health care outcomes, access and significant financial savings.  Multiple contexts.
Empirically identify the complex elderly patient based on degree of multimorbidity.
Identification of multi-morbidity patterns can help to predict the needs of the older patient and improve resource provision. None.
Multimorbidity -older adults need health care that can count past one. Banerjee S. 2015.
Study the healthcare needs of older people with multimorbidity, and the extent to which these needs are met.
Develop a system that works for multimorbidity, and create policy, commissioning, services, research, and education to deliver good quality care to patients with more than one condition.   Exploring the effectiveness of current models of integrated care. The extent to which there are differential effects of integrated care for different types of multimorbidity. Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with LTC and multimorbidity, while increasing their satisfaction with services and reducing costs. Develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions to improve long-term care for stroke survivors with multimorbidity.
Stakeholder engagement to identify data-driven solutions is feasible but requires resources. None.
Better value primary care is needed now more than ever. Watson  The programme provides a whole system approach to the delivery of proactive and responsive care for nursing home residents. The service model enables information exchange across organisational and professional boundaries. To change practice in order to deliver a Hospital at Home programme (admission avoidance and early supported discharge) for frail older people across a regional commissioning area.
Against a backdrop of intense financial pressures, significant community bed closures, and difficult relations between hospital and community services, outcomes remained stable.    Assess effective and practical paths to accelerate the adoption of better integrated, higher-value care.
Barriers to integrated care included: tight budgets, pressure to meet performance targets in the short term, conflicting requirements among regulatory entities with overlapping oversight, and the perception of frequently shifting policy objectives. So long as separate performance requirements and perverse funding incentives remain in place, systemcentred reform will always trump a person-centred approach. Universities.
Understand and respond to one of the largest and most complex challenges facing modern health and care systems.
A better understanding of the experiences, wishes and goals of people with multiple conditions will help inform the design and delivery of health and social care services.

3
Beyond barriers. How older people move between health and social care in England. Care Quality Commission. 2018.
Primary care. Community health services. Social care. Third sector.
Review local health and social care systems in 20 local authority areas.
People experience the best care when they and organisations work together to overcome the fragmentation of the health and social care system and coordinate personalised care around individuals. Review available evidence about the effects of interventions intended to involve older people with more than one long-term health problem in decision-making about their health care during primary care consultations.
No consistent evidence that interventions for involving older people with more than one long-term health problem in decision-making about their health care can improve their self-rated health or healthcare engagement. The interventions make little or no difference in patients' quality of life.

Multi-level and multi-sector integration
Several articles described previous research and clinical provision in primary care or social services for older adults with multimorbidity in England [17][18][19][20]. These were often concerned with particular sectors (e.g. primary care) or scales of integration (e.g. clinical level), rather than whole-systems reform [21][22][23][24][25][26][27]. Studies focused on improving specific dimensions of integration such as leadership [17,28], care models [22,[29][30][31][32] or considered integrated working from the perspective of one or two levels of integration [33][34][35][36], most frequently the micro-scale or the micro/meso-scales together. Little evidence was found of functional or normative forms of, or approaches to, integration as described in the Rainbow Model of Integrated Care conceptual framework [12]. Studies from 1996 onwards repeatedly stressed the need for more multi-level, systemic and comprehensive integration [37,38], although limited evidence was found of significant progress in achieving this ambition over the last two decades. A prevalent theme was the urgent requirement to mitigate or remove long-standing barriers to integration, such as incompatible record sharing systems and inadequate information sharing processes between sectors [39][40][41][42][43]; 'siloed' thinking in service provider organisations [44][45][46]; poor communication among health and social care professionals, both internally within their organisations and across sectoral boundaries [47][48][49]. There was an increasing emphasis on the need to tackle wider determinants of population health with suggestions that to achieve this, it is necessary to go beyond primary care and social services to include hospitals, GP community services, voluntary sectors and local government partners [10,32,48,50,51]. There was a growing recognition in more recent literature that improving clinical care in one or two sectors may not be as effective as simultaneously improving organisation or design across services, as one system of provision [43]. Solutions that were proposed emphasised the need for system-wide leadership across all scales, alongside a shared vision of integrated working across sectors [52][53][54][55]. There was evidence highlighting the importance of the quality and style of organisational leadership, both in terms of delivering change and maintaining an integrated approach to service delivery [9,28,56]. Few examples were found of where this approach had led to individual and local successes, and widespread evaluation and evidence of application was very limited [31,34,47,57].

Time for integration to embed
A number of studies highlighted that integration requires time to allow new structures and relationships to develop and bed-in. Integrated care programmes take years to establish and need sufficient time to allow new care models to fully mature [19,[58][59][60]. Effective and enduring integration is 'the result of a long-term process, facilitated by key local leaders, during which the capability and legitimacy of new ways of working is built up over time' [50]. The King's Fund report of the Vanguards concluded that the most successful models of integrated care are built on 'trusting relationships and collaborative organisational cultures' , which 'often developed over time, ' enabling 'clinical teams as well as key organisational leaders to work together effectively' [29]. This highlights the importance of time in supporting and sustaining long term individual, inter-professional and co-operative organisational relationships and cultures, which are a key component of normative integration [12], understood as "the development and maintenance of a common frame of reference (i.e., shared mission, vision, values and culture) between organizations, professional groups and individuals" [61]. Some studies suggest that the answer to the challenges of integration may lie in persistence and perseverance over several years to enable integrated care programmes to achieve their 'objectives and become self-sustaining' [53,62,63]. This appeared to be influenced by the sustained commitment of key partners and the 'longevity of the senior leadership' [57]. The challenge in the next phase of integrated care reform is 'building clinical collaboration and system leadership in a statutory context' that is 'not designed for this purpose' , [29] alongside policymakers providing the necessary time for integrated care programmes to 'evolve and mature' , [64] rather than moving onto the next new policy initiative.

Structure with flexibility
The scoping review identified inherent tensions between top-down and bottom-up driven approaches to integrated care, in particular, having in place a single comprehensive 'whole-systems' structure combined with local flexibilities. Studies suggested that integration should be implemented within a clear framework and a set of higher-level principles that allows for both macrolevel systems-wide strategic management and oversight, combined with local autonomy and flexibility, described as 'structured flexibility' [19,[65][66][67][68]. The benefit of holistic systems-wide approaches is that they 'tend to be more strategic with clearer paths for scaling up, compared to 'bottom-up' approaches driven by highly motivated individuals at the micro-level' [56]. Nevertheless, a whole-systems strategy requires a twin-track approach [55], with 'leadership from the bottom up' driven by staff who are 'empowered to integrate services where they see the need' [53]. Mechanisms for horizontal integration (structures, strategies and practices that connect care across the same level in the system) [12], were also seen as essential 'at each organisational level (for example whole systems, community and individual levels). Vertical mechanisms (structures, strategies and practices which link together services up and down the different scales of the system) are also necessary 'to integrate the various levels' [37,42]. Successful examples of integrated care in the NHS indicate that when this is 'pursued at all levels' , it could 'overcome the risks of fragmentation, and of 'service users falling between the cracks' of care [69]. Critically however, the studies included in the review suggested that any programme of integrated care must be based on an understanding that 'as barriers to integration are systemic in organisations designed for separation rather than integration and the historic paradigms of building bridges and tearing down walls is inherently flawed, and of limited effectiveness: a better metaphor is one of weaving integration into the fabric of organisational life' [37].

Discussion
This scoping review aimed to summarise current evidence, clinical provision and progress on integrated primary care and social services for older adults experiencing multimorbidity in England. The findings highlight a paucity of research evidence and clinical practice pursuing multi-level or multi-sector integration across services. Furthermore, existing literature in this field are often limited to individual sectors [21][22][23][24][25][26][27]. The value of considering primary care and social services alongside local government, third sector and secondary care organisations in tackling the broader determinants of population health was frequently emphasised [10,32,48,50,51]. In addition, several studies highlighted that integration requires time [19,[58][59][60] to allow new structures and relationships to evolve and mature. The recent development of the Primary Care Network (PCN) Maturity Matrix, as a methodology and systems development approach, has potential to address this issue. PCN sets out a developmental pathway or framework to guide systems leaders, which focuses attention on the importance of allowing integrated care programmes sufficient time to bed-in and reach a state of maturity [70,71]. The scoping review identified inherent tensions between top-down and bottom-up driven dimensions of integrated care reform. The evidence gathered by this scoping review suggests that addressing this dichotomy requires both whole system structures, which allow for local flexibilities [19,[65][66][67][68].
This study was scoping in nature, thus allowing a rapid capture of a broad range of information on integration between primary care and social services in older adults with multimorbidity. It did not aim to answer a strictly defined research question and as a result, broad inclusion criteria were adopted, which allowed for the inclusion of a wide-range of study designs and grey literature to permit a higher-level overview of this research area and the related clinical provision. As much of social care delivery takes place outside of the NHS, and as a consequence of the relative paucity of research in this field, this approach was necessary to capture the diverse range of existing work in the field. There were high levels of heterogeneity amongst the study designs and settings which is a strength of this work but also challenging to collate and summarise comprehensively. The quality of the evidence presented was not assessed and those articles not written in English were excluded. As the study was focused on England, it is unlikely that non-English language articles would have substantially altered the results.
This scoping review is one of the first to examine the literature on integration between primary care and social services, with a particular focus on England. The findings are consistent with previous evidence outside of a primary care context, which highlights the need for greater consideration of wider health determinants in managing the increasingly diverse needs of older adults with multimorbidity [72,73]. Earlier reviews on integrated care have also emphasised the need for more multidisciplinary and multi-sector co-operation within a single over-arching system [74]. The study highlighted that this system must incorporate traditional health and social care services, alongside voluntary, private and government organisations. Furthermore, the scoping review emphasised the value of time in allowing integrated care to embed. Although some previous reviews and policy calls argue that a more rapid and urgent pace is needed for integration due to rising demand, this scoping review suggests that a slower process of change is perhaps necessary to permit successful and long-lasting implementation at the local level [7]. This has been highlighted by a previous scoping review although it was not specific to primary care or social services [50,59,63,74].
Finally, the tensions identified between top-down and bottom-up integrated care reform [56,65] and related calls for whole system structures of integration allowing for local flexibilities, has been articulated in government policy but not yet operationalised [55]. To support this, the next steps will need to go beyond a scoping review towards more robust service evaluation and trials of whole-system multi-sector and multi-level integration interventions that address both clinical and social need.

Conclusions
This scoping review aimed to summarise current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England. It found studies describing