A ship without a compass? The case for a more intimate relationship between research, policy and practice to enable the more successful adoption of integrated care
In his seminal article on the Five Laws of Integrated Care published in 1999, Walter Leutz included two key statements that continue to be true yet are largely overlooked. The two laws in question are: ⁃ “All integrated care is local” and ⁃ “You cannot fit a square peg into a round hole”
The first law speaks to a truth that the real impact of integrated care happens at the interface between care professionals, patients and carers, and the communities in which they belong. The ability to provide relational continuity to individuals; to coordinate care and services flexibly around people’s needs; and the insight to bring together all the assets across a community that help to improve health and wellbeing – this is where the transformational effect of integrated care happens. Yet, in our design of integrated care programmes – and in the subsequent evaluations we put in place – we focus on the efficacy of programme interventions or structural reforms and so usually fail to dig deep enough to understand ‘how’ integrated care happens and why.
For example, there is growing evidence that – after 3 years of innovation – multi-specialty community providers in England (where specialists work in and alongside primary and community care teams) are collectively having a positive impact on reducing unnecessary hospitalisations. The problem is that the results are highly variable, depending on design and context, and evaluations don’t have the granularity of information to understand the mechanisms that have made the difference. In other words, something positive is happening but nobody knows what it is – a real problem if you want to replicate or scale up a programme that is positive overall but with a significant variation that means success is not guaranteed.
The second of Leutz’s laws is closely related – the we design our integrated care programmes and systems without enough consideration to the actual contexts in which they will be deployed. Too often we end up with schemes that may be evidence-informed but can never become adequately deployed. This leads to a lot of frustration as you attempt to either fettle the square peg or (usually in vain) look at the round hole and expect it to transform – usually through a local change management process to effect ‘cultural change’. It’s largely ineffective – better to get everyone together and co-design a round peg instead.
The core message to my presentation to the conference, therefore, was that research needs to get under the skin of the problem – to examine the ‘black box’ of complexities that happen when integrated care innovations are put in play – and therefore get a deeper and richer understanding of what that round peg should look like.
The practical utility of this might result, for example, in understanding better the roles and functions of multi-professional teams; the workforce and managerial skills and competencies required; the way in which people and communities are engaged and empowered to participate; the dynamics of successful partnerships and networks; and so on.
Without such knowledge we plunge into integrated care without the guidance and tools to navigate through the process. Like a ship without a compass.
Therefore – and assuming we want our research to be priority-led and translate to societal benefits (which is often not the case) – the evaluations in this area needs to be more grounded in implementation and forge a more intimate relationship between research, policy and practice. There are plenty of international examples where success can be demonstrated.
In my new role as Director of the Central Coast Research Institute (CCRI) – a joint venture of the University of Newcastle and the Central Coast Local Health District – it is my ambition to actively demonstrate that transformational change that brings direct health and wellbeing benefits to all people in the local community can be achieved quicker and more effectively through such a partnership. This reflects a personal ambition to put 25 years of knowledge sharing and advocacy into action – a demonstration project of what may or may not be possible.
For those who know me, the challenge is irresistible.
Professor Nick Goodwin
Director, Central Coast Research Institute Chair,
IFIC Australiaco-Editor In Chief,
International Journal of Integrated Care