Integrated Care Fund evaluation (summary)

The Integrated Care Fund (ICF) is a Welsh Government funded preventative programme which aims to integrate and encourage collaborative working between social services, health, housing, and the third and independent sector to improve the lives of the most vulnerable people in Wales. It has been delivered since 2014 and has funding in place until the end of March 2022. Originally known as the Intermediate Care Fund, the ICF has made available annual funding to the seven Regional Partnership Boards (RPBs) across Wales to better meet people’s care and support needs through more joined up and seamless services.

ICF includes both capital and revenue allocations, although the focus of this evaluation has been on ICF revenue allocations. The annual value of the revenue fund has increased over time, from its initial £30 million allocation in 2014/15 to £89 million in 2021/22.

Annual changes have been made to the ICF over time and significant changes were made to the fund during 2017/18 to ensure that ICF aligned with the objectives and priority groups set out within the Social Services and Wellbeing Act. Each RPB submits annual Revenue Investment Plans to the Welsh Government for review to ensure that they adhere with funding guidance.

ICF is currently designed to focus on five key priority groups:

• older people with complex needs and long-term conditions, including dementia
• people with learning disabilities
• children with complex needs
• carers, including young carers
• children on the edge of care

The aim of the evaluation was to assess the perceived and/or potential impact of the ICF in creating system and behaviour change to improve capacity to meet people’s health and social care needs.

The evaluation was expected to assess:

• the impact of the programme between 2016 and 2021 on individuals and the communities involved
• the effect of the programme upon service delivery across the health and social care sector
• the impact of preventative projects in reducing pressures upon the health and care system
• the critical success factors and barriers which can inform future programmes and interventions
• the extent to which models of delivery can be upscaled and spread for wider adoption across Wales

The evaluation was undertaken between January and October 2021 and involved:    

• an inception stage, which included an inception meeting with Welsh Government officials and preparing a project plan   
• a desk-based review of relevant policy and legislation, relevant evaluations, and programme level documentation
• drafting discussion guides for interviewing contributors and developing a web-based survey for ICF project leads
• a meta-analysis of documentation for a sample of 77 ICF projects
• hosting an on-line survey which was completed by 68 ICF project leads
• fieldwork with 15 ICF projects which involved gaining the views of 48 project staff and 26 project recipients
• interviewing 74 stakeholders from across all seven RPBs as well as three Welsh Government officials and two representatives from stakeholder organisations
• synthesising the findings of the fieldwork and desk-review and preparing an evaluation report

The findings of the evaluation need to be considered in light of some key methodological considerations:  

• whilst a cross-section of projects was selected for the macro analysis and case study work, the sample was designed to focus on projects which had at least some evaluation evidence in place. As a result there may be a possible bias towards the inclusion of more successful and better managed projects within the study
• it was not possible for the evaluation to report upon programme level outcomes achieved due to the lack of consistent national, programme level outcome measures. Outcomes were set and defined by individual projects making it impossible to compare and aggregate achievements
• much of the evidence gathered via this evaluation about the impact of the programme was anecdotal in nature and based upon contributor’s perception of the difference made by project services

The evaluation found that:

• ICF has supported Welsh Government’s ambitions to transform the health and social care sector in Wales. It has positively contributed towards the objectives set out in Programmes for Government, the Social Services and Wellbeing (Wales) Act and A Healthier Wales
• ICF has funded appropriate preventative interventions which have helped to sustain core services at a time of significant pressure and has been instrumental in stimulating integrated working across health, social care, housing and the third sector
• ICF is a highly valued funding stream and without continued funding, the sustainability of current services is precarious, and their withdrawal would be detrimental
• funded projects have made good progress, although those established more recently have not had the same opportunity to pilot delivery models compared to longer-established projects
• the COVID-19 pandemic has had a profound and contrasting impact on funded provisions. ICF projects have played a critical role in supporting front-line efforts during the pandemic.

The evaluation found that in terms of impact on individuals and communities:

• ICF projects are making a positive, often transformational, difference to people in terms of health and wellbeing benefits including improved mental health and quality of life. Projects are also making a difference to how people are accessing services
• a wide range of outcomes are being achieved, not least because ICF interventions vary in scope and priority target groups, and as such it is impossible to aggregate service user outcomes at a programme level
• projects have tended to concentrate on project output reporting, despite these not necessarily reflecting the difference that interventions are making, because evidencing longer-term, intensive interventions is challenging and better illustrated through individual case studies and distance travelled journeys

In terms of impact upon health and social care service delivery and reducing pressures on the system, ICF has:

• helped improve partnership work between organisations and across regions; encouraged and facilitated a more regional way of working; and supported a move towards integrating services
• enhanced the role of the third sector, who are well positioned to deliver preventative services in an adaptable and flexible manner. Third sector projects tend to be less integrated than those led by statutory services and face unique challenges as a result
• contributed to a reduction in institutionalised care and use of hospital beds; as well as shifted the balance towards preventative, closer to home services through the development of intermediate care pathways
• funded various projects which are considered effective in preventing hospital admissions and facilitating early discharge, allowing more people to remain safe and well at home; and helped to change attitudes towards the value of early intervention and prevention approaches
• contributed to many positive changes across health and social care service delivery although it is impossible to disentangle the impact of ICF from other sources of funding when assessing the degree of attributability

In terms of key enablers and barriers for funded projects:

• key delivery enablers include effective arrangements for collaborating with others; having a strong delivery team; adopting a flexible and adaptable delivery model and provision which enhances the knowledge of other practitioners through training or collaborative working
• key barriers include the COVID-19 pandemic, the impact of annual funding arrangements and the implications this has had upon staff recruitment and retention

Recommendations

The report presents recommendations which are aligned with five key themes identified during the research. The five sets of recommendations are offered as ideas rather than a prescriptive list for change. They are accompanied by ‘test’ questions which would be useful to consider for the future. The five key themes are:

• Theme 1: The need to maintain some form of ring-fenced funding in the future to support innovation and integration
• Theme 2: The need for the fund to support sustainable improvement and change
• Theme 3: Achieving the right balance between prescription and discretion
• Theme 4: Using data to drive service and quality improvements
• Theme 5: The need to ensure that outcomes from the fund lead to learning and the spread of good practice

A summary of suggestions and recommendations are set out below:

1. Continue to make available ring-fenced funding to support innovation and integrated and collaborative provisions across health and social care in Wales.
2. Consider streamlining existing funding available via ICF and the TF into a single fund from April 2022 onwards which supports the objectives set out in A Healthier Wales and the Social Services and Well-being (Wales) Act.
3. Provide greater clarity on what true innovation means in practice to avoid any ‘synthetic’ innovation that purports to be new but actually isn’t.
4. Ensure regions are not inadvertently encouraged to interpret the pursuit of innovation as increasing the number of projects.
5. Clarify the potential impact of projects before they are agreed.
6. Broaden the requirement for other stakeholders to be involved in the development of initiatives arising from the fund, in particular service users and carers, the independent sector, and the Welsh Ambulance Trust.
7. Clarify that it is acceptable for benefits from the fund to be accrued disproportionately by different partner agencies provided this has been collectively agreed.
8. Make future funding available for a longer-time period, of at least three years but ideally five years, to allow for transformative change and address delivery challenges.
9. Build contingency arrangements into the fund to ensure exit strategies can be properly managed.
10. Enable shared ownership of the sustainability of projects, programmes and initiatives that are generated by funds such as ICF.
11. Engage with stakeholders to establish the most appropriate arrangements for ensuring that projects can begin and end without fear of having to face, whether in reality or not, temporal cliff edges.
12. Seek a clearer understanding with stakeholders of the difficulties associated with mainstreaming and upscaling and make provision within the new fund to overcome them.
13. Support the flexible use of the fund and continuation of pooling different funding streams to achieve objectives in guidance for the new fund and clarify how this impacts on local and regional accountabilities in the light of any changes arising from the recent White Paper. Clarify the extent to which using the new fund flexibly is acceptable.
14. Ensure understanding and, ideally, agree with stakeholders, the objectives of the new fund. Ensure wherever possible the objectives meet the principles of being ‘SMART’.
15. Consider establishing separate components of the new fund for innovation, consolidation and transformation, and termination.
16. Favour the maximisation of regional discretion when considering the balance between prescription and discretion in the new fund. Establish this balance through a process of effective engagement between Welsh Government and stakeholders and undertake this at the earliest opportunity.
17. Ensure that engagement mechanisms go beyond direct liaison with nominated regional representatives and include representatives of all key stakeholders, e.g., ADSS Cymru, the Welsh NHS Confederation, WCVA, WLGA, Care Forum Wales.
18. Reconsider how data and information are collected, monitored, and used. Provide greater clarity about how data are used by different stakeholders with a view to ensuring that the methodology of data collection and monitoring of projects is mutually beneficial to them and Welsh Government.
19. Encourage the adoption of standardised methods of measuring the distance travelled by service users, with similar models of care, ideally exploring the option of adopting common tools.
20. Shift the emphasis from compliance focused data collection and monitoring to driving local, regional, and inter-regional quality improvement.
21. Retain the use of results-based accountability methodology but clarify expectations of how it is applied.
22. Ensure the new fund is informed by a well-defined set of national outcomes, which are grouped to reflect the expected outcomes for specific models of care or priority groups.
23. Ensure the future focus is on the most important data and metrics, engaging key partners like the Bevan Commission, Social Care Wales, and Improvement Cymru in that process.
24. Shift the emphasis from a project approach to a programme approach to which projects could be aligned. Supports this through improving alignment across multiple data systems, including consideration of making use of the Welsh Community Care Information system mandatory.
25. Increase the pace of successful projects being applied across Wales by the creation of peer led communities of practice for project leads involved with similar models of care to share good practice and experiences, and to refine delivery models.
26. Reconsider how projects are piloted with a view to smaller multiples of regions piloting initiatives for subsequent learning and roll out rather than all seven regions initiating the same projects.
27. Encourage collective ownership of the new fund by stressing it is an all-Wales fund aimed at demonstrating benefits beyond local and regional boundaries.
28. Consider the use of levers and incentives, such as access to further finance, to encourage the cascading of learning.

Report Authors: Nia Bryer and Heledd Bebb, OB3 Research, Professor Mark Llewellyn and Professor Tony Garthwaite, Welsh Institute for Health and Social Care, University of South Wales

Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.

For further information please contact:
Victoria Seddon
Email: research.healthandsocialservices@gov.wales

Media: 0300 025 8099

Social research number: 26/2022
Digital ISBN: 978-1-80391-831-0

Image