International study shows that governance, leadership and IT are required for greater integration in health care

Published on Thursday, 07 July 2011 10:40
Posted by Scott Buckler

Recent changes to the Health and Social Care Bill have put the integration of health services centre stage. However, research published today by the Nuffield Trust suggests that many practical issues will need to be addressed if health and care organisations are to improve integration and deliver better care for patients (July 7th)

The new report: Integration in action: four international case studies is based on a detailed study of four separate organisations in Europe and the United States that have made good progress integrating health (and in one case) social care services, despite a sometimes challenging policy climate.

Across all four sites, several external factors were found by researchers to have driven integration – for example the prospect of reduced payments to doctors by funders was a key catalyst for integration on both sides of the Atlantic. External forces could also act as a constraint however – payment systems might inadvertently discourage integration between providers, and data protection regulations sometimes limited the degree to which personal information could be shared between health professionals.

The organisations covered by the study were notable for having found routes around such hurdles by focusing on operational processes that helped to align incentives and practices across teams and organisations. Six ‘integrative processes’ were identified by the researchers: clinical, organisational, informational, financial, administrative and normative.  

Of these, leadership and effective governance arrangements were particularly critical to developing shared objectives and embedding a virtuous interaction between clinical tools, and the intelligent use of data and IT systems. In some cases targeted payments linked to the performance of specific tasks were also used to encourage the greater coordination of care.

The findings have a number of important implications for current debates about how best to organise and deliver more integrated and seamless patient care:


  • Specific issues to be addressed include: the tension between choice and integration; the financial incentives associated with Payment by Results that reward hospital activity in preference to integrated, community based services; regulatory and assurance frameworks that divert managerial and clinician attention away from integration; and public resistance to service reconfiguration that may be needed to support integrated care.


  • Structural merger was not necessary to achieve integrated care, although the contribution of integrative processes to align incentives and coordinate care is likely to be just as relevant where organisations have merged.


  • National policy is important in providing an encouraging context for integrated care to develop. As the systems for regulation, accountability and measuring outcomes are redeveloped in the NHS there is a window of opportunity to promote a supportive context for integration. In particular the NHS Commissioning Board and Monitor may wish to consider developing more radical models for bundling payments across pathways, as well as devising regulations that more actively support further integration where it can be shown that this will deliver measurable benefits to service users.

The case studies analysed were: Community Care North Carolina (CCNC): a government funded network that aims to improve access and quality levels for Medicaid beneficiaries;  Greater Rochester Independent Practice Association (GRIPA): an independent practice association in upstate New York;  Regionale HuisartsenZorg Huevelland (RHZ): a Dutch organisation providing support to GPs to deliver integrated diabetes care in the Maastricht region; and North Lanarkshire Health and Social Care Partnership: an NHS and social care partnership in Scotland.

Dr Rebecca Rosen, Senior Fellow at the Nuffield Trust and one of the report’s authors said:

There is now a window of opportunity to promote moves to deliver more integrated and seamless care for patients following the Government’s commitment to amending the Health and Social Care Bill. Our international study underlines the fundamental importance of building a shared vision and goals across different providers and teams, developing robust operational processes and drives home the crucial role that that trusted and respected clinical leaders play in this respect.’

Source: Nuffield Trust

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