World Health Day: Integrated Care – an unfinished project

World Health Day

Integrated Care – an unfinished project

7 April 2024

Dr. Niamh Lennox-Chhugani & Prof. Áine Carroll

As we approach WHO World Health Day 2024 with its theme of My health – My right, the emphasis across the world, is on securing access to quality healthcare for all against a backdrop of inequality exacerbated by climate change, natural disasters and conflict. Although many countries have recognised health as a human right in their constitutions, that right is not being translated into laws. Put simply, countries are not walking the talk.

Similarly in the field of integrated care, although we have seen much development over the last 10 years (and a sense, from policy-makers particularly, that that box has been ticked and integrated care is being delivered) responses to our 2022 and 2023 Annual Surveys show that this is far from being the case, particularly for people and communities that want and need care. It may be mentioned in strategies and plans from ministry level down, but few people would describe the care they or their loved ones experience as integrated.

At is core, integrated care is only really integrated if that is the experience of the person who needs care. Person-centredness matters. You know it when you see it and more importantly, feel it.  Our Annual Survey this year is looking into this in more detail.

Coordination and continuity are the main mechanisms for addressing poor integration and as Hughes and colleagues have stated in their review, interdisciplinary team (IDT) working is the single most important mechanism for effecting this[1]. Workforce challenges in health and care make relational and interpersonal continuity a rarity in most systems. This really matters both from an experience of care point of view but also as a way of reducing waste, inefficiency and clinical risk. If we look at the recommendations of the WHO practice brief[2]  from 2018, we can clearly see how limited our progress has been since then. That brief identified 8 priority practices and table 1 below summarises the findings of a recent review IFIC conducted of integrated care models in 10 settings across 4 continents.

 

Priority practice Progress
Continuity with a primary care professional This remains very challenging in many systems where the primary care medical staff especially (GPs) are in short supply and practice nurse models are still immature.
Collaborative planning of care and shared decision making Shared goal-oriented care with health coaching is presented as an innovation, often digital first in emphasis, and at a relatively small scale.
Case management for people with complex needs Requires quality data collection, analysis and use that is still under-resourced in many health systems and in those that are resourced, still at the early stages of development.
Collocated services or single point of access The site of collocation is important. Collocation within the community that is served is so important and too often collocation happens where there is existing health provider space rather than where is easily accessed by the community.
Transitional or intermediate care This is an area in which many systems have invested to shift care out of hospitals. Such care does not automatically improve continuity and coordination without investment in the other priority practices.
Comprehensive care along the entire pathway Coordination of care across a whole pathway that includes home, community services, primary care, secondary care, social care and other services is limited. Many projects across the world have been working on this for over a decade and sustainability over the long term remains a challenge with one of the biggest constraints being fragmented payment models.
Technology to support continuity and coordination Technology is often held up as the potential solution to end all the fragmentation problems faced. Increasingly though, it is recognised as a hygiene factor. It is essential to enable informational continuity, but practice transformation informs technology transformation.
Building workforce capability A hugely under-invested priority in almost all health and care systems as an upcoming report by the Integrated Care Academy will show and a critical implementation gap.

 

Mathews (1998, 155-6)[3]  has argued that ‘an injustice is done when healthcare resources are allocated unequally’ and that ‘a health care system available to all free at the point of delivery is morally justified, indeed required’. Therefore it could be argued that failing to implement integrated care is morally unjust.

The pandemic can no longer be an excuse for failure to accelerate progress. Some actions that need to be taken now:

  1. Recognise that a label is not a reality; just because it says integrated care over a door or on someone’s name tag, integrated care is still not being delivered in the eyes of the person at the centre of care;
  2. Integrated care is measured by the people and communities at that centre of care. If you don’t know what they think, you don’t know if you are delivering care that is integrated;
  3. Health and care professionals need the skills and tools to work as IDTs and to put people and their families at the centre of their own care so it is essential to prioritise training and continuous development in integrated care;
  4. Every individual with complex needs should have a comprehensive needs assessment by an IDT, identification of a care co-ordinator/manager and an iterative responsive care plan
  5. Start with quick wins to deliver continuity and coordination through health navigation, primary and secondary care collaboration around chronic disease and frailty, and carer support networks; and then
  6. Think about adopting whole systems methods like The Liberated Method[4] used in the North East of England to innovate with communities and mobilise for real change.

Our International Conference on Integrated Care 2024, ICIC24, in Belfast later this month, will be an opportunity to reflect not just on the progress being made in integrated care, but also a call to action. We want to see an acceleration of integrated care progress at scale. Talk is not enough.

References

[1] Hughes, G., Shaw, S.E. and Greenhalgh, T., 2020. Rethinking integrated care: a systematic hermeneutic review of the literature on integrated care strategies and concepts. The Milbank Quarterly, 98(2), pp.446-492.

[2] World Health Organization, 2018. Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services.

[3] Matthews, E., 1998. Is health care a need?. Medicine, Health Care and Philosophy, 1, pp.155-161.

[4] https://www.changingfuturesnorthumbria.co.uk/rethinking-public-service

Dr. Niamh Lennox-Chhugani
Chief Executive

IFIC

Prof. Áine Carroll
Chair

IFIC