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ObjectivesIntegrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.MethodsWe propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.ResultsThe review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of ‘integrated financing plus integrated care’ (i.e. ‘integration’) relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders’ control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes – including those that failed to improve health or reduce costs – reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.ConclusionsIt is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is like...

Summary Background There is clinical uncertainty about the appropriate use of first‐line topical treatments for psoriasis. Objectives To assess the relative effectiveness and tolerability of topical treatments for psoriasis suitable for use both in primary and secondary care. Methods All major medical databases of published literature were searched electronically; references of trial reports and recent reviews were searched; authors and companies were contacted for missing data from published reports. The study selection comprised: (1) randomized placebo‐controlled trials of topical treatments for psoriasis; and (2) randomized head‐to‐head studies of the new vitamin D3 derivative treatments for psoriasis that reported clinical outcome using a Total Severity Score (TSS), Psoriasis Area Severity Index or Investigator Assessment of Global Improvement. Eligibility and validity were assessed and data extracted independently by two authors. Clinical outcomes were pooled using a random effect standardized weighted mean difference (SWMD) metric, including 3380 patients randomized in 41 placebo (vehicle)‐controlled trials and 4898 patients randomized in 28 head‐to‐head studies. Results There was a significant benefit in favour of active treatments against vehicle, SWMD: −1·06 (95% confidence interval [CI]: −1·26 to −0·86), approximately a 2‐point improvement on a 12‐point TSS after 6–8 weeks of treatment. The only significantly different benefit was for very potent corticosteroids: SWMD: −1·51 (95% CI: −1·76 to −1·25), approximately a 3‐point improvement on a 12‐point TSS. Head‐to‐head studies support these findings, except that calcipotriol was estimated to be more effective than dithranol, coal tar and other vitamin D3 derivatives. Polytherapy, using a potent steroid and calcipotriol, was more effective than calcipotriol alone: SWMD 0·42 (95% CI: 0·12–0·72) approximately a 0·8‐point improvement on a 12‐point TSS. No important differences in withdrawal or reporting of adverse events were identified. Conclusions Trials of short duration neither adequately inform the management of chronic disease nor describe the sequelae of treatment. The evidence base for long‐term care, reflecting the disease pathway, should be improved. Combination therapy with topical vitamin D analogues and steroids, and maintenance therapy following treatment response merit further investigation.

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Trials of short duration neither adequately inform the management of chronic disease nor describe the sequelae of treatment. The evidence base for long-term care, reflecting the disease pathway, should be improved. Combination therapy with topical vitamin D analogues and steroids, and maintenance therapy following treatment response merit further investigation.