The case for integrated care is unassailable with an ageing population living with long-term conditions (multimorbidities), needing continuous care and treatment delivered across settings and providers. Integrated care systems have the potential to improve care access, the quality of care as well as continuity of care, with users at the centre of the care system, thereby overcoming the shortcomings of the traditional model of single medical speciality treatment and care focused on single organ disease (Barraclough et al, 2021; World Health Organization, 2018).
The UK is not alone in recognising the benefits of integrated care (Carrigan et al, 2023), but its implementation has not been without challenges, as many readers probably know. A qualitative interview study of 28 managers, commissioners and clinicians across various settings in the West Midlands and the South East revealed the challenges which needed to be managed to deliver integrated care within the anachronistic NHS structures, and established fragmentation between services (Litchfield et al, 2022). An in-depth study of the implementation of integrated care in Switzerland identified payment mechanisms, as well as the territorial behaviours of some healthcare professionals in the face of newly emerging roles, as impediments to good integrated care (Carron et al, 2023). Similarly, a Dutch-controlled cohort study revealed the real life challenges of implementing an integrated care pathway for COPD and asthma in the face of logistical complexity, which highlighted the need for the streamlining of the existing provisions, as well as the need to enable those of low socioeconomic status and limited literacy (Witte et al, 2023).
The Fuller stocktake report (NHS England and NHS Improvement, 2022), which was endorsed by the 42 integrated care board leaders in England, acknowledged that there are no quick fixes to transforming NHS services into integral components of integrated care systems delivering within neighbourhood teams. The report used illustrative case studies as examples of successful innovations to understand daily demand and capacity across primary care. These included the Healthy Hyde Primary Care Network to address health inequalities, a shared clinical pharmacy service in the Wirral, Growing Health Together in east Surrey, changes to patient management at the Foundry Health Centre in Sussex, and the Humber Coast and Vale system. The report rightly touched on the challenge of continuity of care in its various forms, including informational, relational, and care management within and across services, and echoed Fraser and Clarke (2023) regarding the importance of understanding the patient's/user's perspective of what they need in terms of personalised care (NHS England and NHS Improvement, 2022).
Both the International Foundation for Integrated Care (IFIC, 2022) annual survey and Carrigan et al (2023) have illustrated that what is important for integrated care may differ depending on perspective, including being a user, healthcare professional, manager or policy maker. In the global IFIC (2022) sample, which included respondents from the UK and Ireland, users reported wanting integrated care, which included informal care, to be coordinated, holistic/comprehensive, and person-centred with the user fully involved; in other words, ‘right care, in the right place at the right time’. They ranked population health management as least important. Practitioners ranked person-centred care as the most important, followed by comprehensive, equitable and coordinated care, and gave the lowest rankings to population health management and community-centred care. In Carrigan et al's (2023) Australian qualitative focus group study, the users and providers discussed similar topics but their foci differed. While users highlighted aspects related to the individual experience such as case coordination, clear communication and help to navigate the system, providers were concerned that a large team with multiple practitioners may make communication and individual accountability challenging. Carrigan et al (2023) noted that integrated care offers the opportunity to reduce in-patient stays, it enables early and frequent team input and may increase the job satisfaction of practitioners. It is likely that there are similar differing views of integrated care within the UK (Fraser and Clarke, 2023).
Additionally, the success of integrated care will depend on workforce development so that practitioners, many of whom have worked and trained in silos, are able to contribute effectively to complex patient care. The scoping review by Barraclough et al (2021) included 62 studies of workforce development in integrated care. They mapped the essential skills and competencies as being: understanding across the health and social care systems; ability to develop deep relationships with patients and their families; patient-centeredness; health promotion and disease prevention; interprofessional education and effective teamwork. However, the review highlighted that, while workforce development is an imperative, research into effective models to develop the workforce is very limited. Further, Castelli et al (2023) have pointed out that the English NHS care pathways are designed to assess, diagnose and treat single medical conditions which mitigate against holistic and person-centred care for multimordid patients – a shortcoming, which the Chief Medical Officer's report raised in terms of trends in medical specialisation (Department of Health and Social Care, 2023). An evaluation of organisational learning to help develop effective, integrated care in three boroughs in East London revealed that much of the learning in the teams was single loop in reaction to issues as they arose, with the cultural differences of the professionals and organisations across health and social care impeding the potential for organisational learning (Lalani et al, 2020). This suggests that the UK is on a journey to achieve effective integrated care, especially as learning is not yet inherent within all organisations.
‘…the success of integrated care will depend on workforce development so that practitioners, many of whom have worked and trained in silos, are able to contribute effectively to complex patient care.’
Another aspect of the journey towards effective integrated care is the variation by location, which not only includes local healthcare provision but also local authority (Naylor and Tiratelli, 2023) and user involvement (The Medical Technology Group, 2023). Local authorities have the statutory powers relating to planning, housing, benefits, social care and leisure facilities, including green spaces, and can influence the wider determinants of health. More importantly, they have the links with local communities (Naylor and Tiratelli, 2023). Thus, local authorities are key to integrated care delivering on its ambitions. However, their budgets are increasingly stretched, with public health budgets particularly hit, especially in deprived areas. Furthermore, reduced local authority resources increases the pressure upon unpaid carers who need to be supported if they are to fill the gaps in care (Knight et al, 2023). The Medical Technology Group (2023) found that 40% of the 42 English integrated care systems had no formal user involvement in their board or subcommittees, despite evidence that user involvement improves the planning/design and delivery of services. They recommended various approaches, including using citizen panels, voluntary, community and social enterprises, and community groups, alongside individual lay representatives.
It may not be realistic to expect the implementation of integrated care as a guiding principle to change the culture and behaviours of practitioners. But it is this which actually determines how different services work together. At the same time, integrated care is expected to address the pinch points of urgent care demand and enable timely hospital discharges. A scoping review of 30 papers derived from 22 studies evaluating interventions to improve collaboration in healthcare through combinations of process and system changes to address communication and coordination issues (Tomaschek et al, 2022) reported potential benefits in terms of practitioner and patient satisfaction, health outcomes and reduced care fragmentation. The extent to which these interventions have been rolled out in the UK is unclear.
The integrated care systems in England are on a journey towards becoming a perfect jigsaw. That journey could be swifter if learning was a key feature of all integrated care systems, alongside meaningful user engagement and attentive listening to the user voice. In the meantime, it may be more accurate to accept that current provision is more like spinning plates.