In April 2026, members of the International Foundation for Integrated Care (IFIC) team sat down with Professor Sara Singer of Stanford for an exploratory conversation about the Comprehensive Theory of Integration and IFIC’s recently relaunched Nine Pillars of Integrated Care. What began as a comparison of two ways of conceptualising integrated care became something more useful: a conversation about who each is for, what they share, and where they might be developed together.
Both the Comprehensive Theory and the Nine Pillars are the product of years of collaborative work by teams of researchers working with policymakers and providers to turn theory into actionable practice.
Different audiences, different altitudes
One of the most interesting and eye-opening moments in our conversation came when we were talking about the application of each in the real world.
The Comprehensive Theory has been used almost exclusively with providers, that is, clinicians and operational leaders who need to understand why structural mergers, signed contracts and shared protocols so often fail to produce integrated care. The Nine Pillars, by contrast, have travelled best with policymakers and system leaders. They give those working at system level a clear sightline to the levers they can actually pull: payment, governance, legislation, information systems, workforce planning, and engagement with people and communities.
The two frameworks, in other words, are not competing models. They operate at different altitudes. The Comprehensive Theory offers a process-oriented account of how integration is achieved inside organisations. The Nine Pillars offer a system-level taxonomy of what needs to be in place around them.
A shared underlying insight
What unites them is a shared underlying claim: integration is multi-dimensional. Sara traced the origins of the Comprehensive Theory to a series of failed and partial mergers between major US academic medical centres, and to a multi-site study where high and low performers could not be told apart by any single dimension. Not structure, not function, not culture. What distinguished them was how these elements combined to create an effect, and in particular the ability of leaders to focus collective attention on the person at the centre of care.
The Nine Pillars take a parallel position. Developed deliberately as a meta-framework following a review of the existing literature, they rest on the observation that many frameworks aimed at supporting the implementation of integrated care in different contexts "are all in their own way saying these nine things". The Pillars’ central visual of overlapping circles echoes the messiness of integration.
The person at the centre
Both frameworks place the person receiving care at the centre. In the Comprehensive Theory formulation, the patient or person is the arbiter of integrated care — only they can judge whether the care they receive is genuinely holistic, and her early psychometric work consistently pulled toward patient-oriented dimensions, particularly the experience of "being heard".
A reminder during the conversation captured why this matters in practice: a former board member of our organisation with lived experience once said, "integration is your language. I don't care about integration… I need to feel that I lead my own care." Sara's pragmatic reflection on this was that we should adopt whatever language an organisation uses, but push them toward the underlying dimensions of continuity, shared responsibility, person-centredness, and reliable processes. These are core to the Nine Pillars and the Comprehensive Theory.
A productive tension around culture
Sara asked why culture was not called out as a separate pillar. The answer that came from our discussion is that culture is deliberately distributed throughout the framework. It is present in shared purpose, in people as partners, in teamwork, in coordination. We found common ground in the principle that "you can't work on culture. What you have to do is work on the work, and that's what changes the culture."
Sara highlighted an interesting lesson from her current research: in cancer centres, culture appears to drive the form integration takes. Patient-oriented cultures produce patient-oriented integration; technology-oriented cultures (and we mean technology as the application of knowledge to solve problems) produce trial-oriented integration. Culture, on this account, may not be one pillar among nine, but the orientating layer that determines how the others are configured. A productive question for both frameworks to keep working on.
Three modes of use
The conversation surfaced three complementary modes of use. Sara described her own application of the Comprehensive Theory as primarily diagnostic — walking organisations through their current condition across structures, functions, norms, relationships and processes, identifying gaps, and prioritising interventions. Niamh highlighted that the way in which the revised Nine Pillars has been presented has been deliberately designed to simplify, so that the framework can function as a trigger and a knowledge spine for country-level adoption. And the Nine Pillars also serve as a meta-framework, helping practitioners orient themselves among the many existing models in the field.
Sara endorsed the simplicity as a virtue provided that vignettes, case studies and country examples build out the operational depth behind it. That is very much the direction IFIC is taking the work next.
Where this leads
We closed by sketching directions for collaboration.
The Nine Pillars and the Comprehensive Theory will not collapse into a single model, and they should not. But put alongside one another, they tell a more complete story than either does alone and they suggest that the next phase of integrated care research will benefit from drawing on both.
Dr Niamh Lennox-Chhugani
International Foundation for Integrated Care (IFIC)