Seamless care for the patient: A goal further off now than 10 years ago

“Integrated care” has been one of the big ideas getting plenty of traction in 21st century health policy.

There is no such thing as integrated care that is sitting on the shelf ready to be implemented

The concept has its own international foundations and conferences, and has occupied a significant amount of air time in the broader pursuit of health system improvement.

There’s plenty to like about the big idea of integrated care.

After all, why shouldn’t we expect healthcare services to provide patients with a seamless experience, in which the advice and treatment of one practitioner does not cut across another’s? Why shouldn’t we aim to overcome funding and organisation silos that pervade all health systems?

The integrated care movement has provided a great deal of food for thought about how the design and funding of health systems can support integration. Indeed, integrated care was a key plank of the then National Government’s Better, Sooner, More Convenient policy programme of the early 2010s. This was part of a much wider international trend at the time.

New Zealand has often been portrayed to international audiences as a poster child of integrated care. This was largely on the back of sustained evangelism from key figures in the Canterbury Clinical Network. The Canter­bury example certainly showed our policy settings and funding systems are not necessarily the significant barriers to healthcare integration we often make them out to be.

However, we are further from this goal than we were 10 years ago, it seems, from the conversations I have had over the past two years about integrated care with key leaders in community-based health services. They say that, for every step forward, such as the handful of integrated family health centres, there have been equivalent, or larger steps back.

DHBs became less interested in integration once they became convinced they didn’t have any flexible resources to sponsor it. Third-sector, not-for-profit primary care organisations have traditionally taken a far more integrated approach to service design. But, apart from Māori and Pacific providers, all have disappeared as a result of the PHO mergers of 2010/11.

If we look internationally, integrated care evangelists have searched high and low for good examples to scale and spread. Tellingly, all examples given are local (such as Canterbury, or the Nuka model in Alaska), or in the case of the US, limited to specific organisations such as Kaiser Permanente and Intermountain Healthcare, which serve as both “payers” and “providers”. There is a dearth of examples of integrated care at the national or even state or provincial scale.

It is noteworthy that we don’t see integrated care in the Health and Disability System Review Panel’s final report, although there is plenty of reference to “a cohesive system” and “connected and whānau-centred services”.

The word “integrated” appeared twice in health minister Andrew Little’s 24 March speech about health reform, but was sheared from its partner, “care”. Is this a sign that integrated care is yesterday’s idea, that the idea no longer generates the excitement it did in 2010? Or is it just the name that has worn out, and the core ideas are being given new labels?

I think there are some fundamental reasons why integrat­ed care has become something of a policy chimera. The first reason is that it is not really one thing at all. At least, there is no such thing as integrated care that is sitting on the shelf ready to be implemented.

This point is made persuasively by Gemma Hughes, Sara Shaw and Trisha Greenhalgh in their exhaustive review in Milbank Quarterly (online 20 May 2020). It is possible, they argue, to point to real integrated care initiatives and systems that have emerged in specific places, but each of these has emerged in response to quite diverse conditions.

This suggests that we can get much better traction in understanding an idea, by understanding what it is not. So, what is the antonym of integration? Fragmentation. Okay; what, exactly, is fragmented? Quite a bit wherever you look, but the specific details of fragmentation also vary considerably from place to place.

Anyone working in community-based healthcare understands that funding systems are fragmented, and that organisational responsibilities are fragmented, and that services are fragmented geographically. However, integrating services geographical­ly might cut across attempts to integrate funding, especially when funding is allocated nationally.

And then there is the biggest driver of fragmentation, the engine of professionalisation and specialisation. Specialisation is one of the greatest sociological inventions of the late 19th and 20th centuries that has reaped enormous benefits.

Specialisation is also a prodigious engine that drives pro­fessional status, income and (sometimes) work satisfac­tion. It has its ultimate expression in health services. But fragmentation is a fundamental, hard-wired consquence of a health system based on professional territories and scopes of practice.

The very things that are the source of professional pride – sticking to one’s competencies, having a clear domain of expertise, and associated autonomy in decision-making are the foundation of health-service fragmentation.

This is just as true in community-based settings as in hospitals. Practitioners in primary healthcare settings may well identify as generalists, in contrast to medical specialists. But the logic of specialisation also dominates the landscape of inter-professional relationships between doctors, nurses, pharmacists, social workers and other occupations.

A very astute Canadian health policy commentator, Steven Lewis, observed recently that the tolerance of interdepend­ence required for integrated care is often highly challenging, because it takes practitioners out of their comfort zone and into zones of potential professional risk.

At any one time, a great many health practitioners are still prepared to put themselves on the line and enter this zone.

Nevertheless, the reason why all “live” examples of integrated care are limited in scale is that you have to know and trust your collaborators, and that is very difficult, if not impossible, to sustain over larger scales.

All of this has huge implications for the viability of integrated care as a policy objective.

Governments have very little, if any, control over the forces of professional specialisation. It’s an international engine, and therefore any attempt to control it runs the gamut of unintended consequences in the international labour market. Governments simply don’t bother. They can, of course, attempt to address organisational, funding and geographic fragmentation. But here, Walter Leutz’s aphorism “your integration is my fragmentation” clearly applies.

Is this overly pessimistic? Not necessarily. Integrated care may still make sense as an aspiration in local contexts in limited and specific ways, and governments can clear some of the obstacles out of the way. But it is never going to work as a driving logic of health system and policy reform.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland