Common Pitfalls and Essential Strategies for Successful Integrated Care Systems

Health and care systems are fragmented and fail to address comprehensive community needs, which is especially problematic as populations age and complex health needs grow. Despite efforts to implement people-centred integrated care, these programmes frequently fail due to poor design, lack of sustained engagement, and inadequate long-term funding.

Key Points

• Fragmentation: Health and care systems are fragmented and disease-centred, leading to poor quality care as populations age and health needs grow.
• Integrated Care Vulnerabilities: Integrated care programs often fail due to political changes, non-recurrent funding, rigid governance, and lack of evidence or belief.
• Common Implementation Mistakes: Mistakes include using integrated care for cost containment, focusing on structural changes, neglecting people and communities, and treating programs as temporary projects.
• People-Centred Approaches: Engaging people as partners in their care is crucial, with evidence showing better outcomes from people-driven methods.
• Need for Sustainable Change: Integrated care needs long-term commitment, learning from past mistakes, and integration into core services, not just pilot projects.

Today, health and care systems internationally are fragmented, disease-centred, challenging to navigate and do not consider the needs of the whole person or community. As populations age and the number of people living with complex physical and mental health needs grows, too many people are experiencing poor quality care, often in the wrong settings with undesirable outcomes. Though health and social care systems have been slow to change, the need for a more sustainable business model that promotes better value in care has resulted in a sustained global effort to promote people-centred integrated care.

Yet, within this movement for change, integrated care programmes have proven to be highly vulnerable to failure. However, it's important to remember that these programmes, like many small businesses, have the potential to succeed with the right support, funding, leadership, and management. Since most integrated care programmes operate in the public sector, their potential for success can be hindered by factors such as political change, non-recurrent financial investments, inflexible governance and accountability arrangements, professional tribalism, embedded norms and values, and the lack of evidence or belief.

However, the steady growth of supra-national, national, and regional policies and programmes prioritising integrated care over the past two decades has brought a much greater understanding of the building blocks for success. It is in the light of such knowledge that we highlight here four of the most'regrettable’ yet common business decisions that continue to be made when implementing integrated care programmes:

1. Integrated care designed and driven as a cost containment measure.
2. Integrated care focusing on structural solutions as the endpoint.
3. Integrated care that fails to place people and communities at the centre.
4. Integrated care that remains treated as a special project rather than as a core business.

Mistake 1: Integrated Care Designed as a Cost Containment Measure.

Given the accelerating cost of health and care services worldwide, the inevitable strain on budgets and the ongoing need to contain costs pose a problem for health system decision-makers to find new ‘business models’ in which to promote financial sustainability whilst trying not to compromise on access to and quality of care. The belief that integrated care can achieve this is supported by a substantial body of evidence (Rocks et al., 2020; Stadhousers et al., 2019), yet, at its heart, integrated care is a path for improving the quality of care and not a means to reduce costs (Goodwin, 2016).

A good example of failed business logic here is case management, a well-established tool for integrating services around the needs of individuals with long-term conditions. As a targeted, community-based approach to co-ordinate care to people living with complex needs, an expectation is raised that costs should be reduced as fewer people require hospitalisation. Whilst the evidence does point to improved care experiences and outcomes for people, it is often poor for cost containment, especially in the short term (Stokes et al., 2015; Klaehn et al., 2022). Multiple but predictable reasons for this include the unlocking of unmet needs in the community that increases demand for care, the inability to prevent hospitalisations due to the lack of primary and community care capacity to respond, a lack of focus on supporting people to self-care, poor patient targeting and inappropriate design and delivery in the context of where case management is deployed. The blind assumption that case management can, on its own, contain costs is always likely to lead to failure since it only works best as part of a broader programme of care in which multiple strategies are employed (Ross et al., 2011).

Mistake 2: Integrated Care Focusing on Organisational Solutions as the Endpoint.

The evidence for effective integrated care requires optimising care at the service and clinical level – for example, by professional care teams that pro-actively coordinate care in partnership with patients and carers (Gonzalez-Ortiz et al., 2018). In contrast, the same evidence demonstrates that structural reforms are often inversely related to the ability to deliver better value in care. In other words, most well-functioning integrated care programs happen despite the organisational and systemic solutions designed to support them. For example, a study of structural reforms in Scotland and Norway demonstrated how focusing on organisational solutions meant the system lost sight of user outcomes as they became compromised by other agendas (Huby et al., 2018). In both countries, complex regulatory environments stultified the ability to deliver partnerships working at a local level, leading to little tangible impact.

This does not mean, of course, that structural reform will always be futile. In the Basque Country, Spain, their Strategy to Tackle the Challenge of Chronicity understood that transformation initiatives led ‘top-down’ were doomed to fail. Instead, their focus was placed on bottom-up initiatives with consensual, collaborative, and ‘messier’ decision-making processes leading to tangible and beneficial results (Alvarez and Nuño-Solinís, 2016; Bengoa, 2013; Nuño-Solinís et al., 2012). As Glasby (2016) argued in the UK context, evidence from policy reforms demonstrated how structural change needs to encourage local partnerships to be creative and provide the scaffolding to support them to be impactful. This lesson, however, is seemingly unlearned consistently. A recent Independent Review of Integrated Care Systems in the UK, for example, found that they have yet to ‘deliver on their promise’ due to complex regulatory, accountability and systemic requirements that have disabled the pace at which integrated care solutions have been able to emerge (Hewitt, 2023).

Mistake 3: Integrated Care that Fails to Put People and Communities at the Centre.

One of the results of these first two failures is their complicity in crowding out the voices and needs of the people and communities they are intended to serve. For example, a retrospective review from the National Integrated Care Pilots in the UK showed that while a user focus was central to their purpose, the sustained engagement of citizens and patients was absent (Lewis et al., 2021). The limited evidence for any positive impact from consumer involvement in integrated care programmes is essentially an artefact of the general lack of engagement at any or all stages in the design and implementation process (Nilsen et al., 2006; Wiles et al., 2022).

Engaging people as partners in care is essential to integrated care’s core business model. Many available tools and methods enable people to take control of their care and bring services together to achieve outcomes important to them. These are proven to improve the quality of care and outcomes (Ferrer, 2015). Yet, evidence demonstrates that integrated care programmes remain too passive, condemn patients and carers to subservient roles, and preserve a power imbalance favouring systems and professionals over people and communities. Though more research is needed, evidence shows that people-driven approaches to system change that respond directly to community needs and goals - like the NUKA health system in Alaska and the Eksote model in Finland – do better than traditional ‘top-down’ methods (Goodwin et al., 2022).

Mistake 4: Integrated Care That Remains Treated as a Special Project Rather than as Core Business.

Perhaps the most enduring of all failures is that integrated care programmes themselves are too often established as time-limited pilot projects with ‘special’ but non-recurrent funding. As a result, they sit ‘outside’ of established core service delivery models rather than being integrated within them. The general idea is that pilots may act as vehicles to provide a ‘proof of concept’ for further growth, but the majority are neither given the time nor the attention needed to do so. Hence, the mortality rate of integrated care programmes is high, even when they prove successful, as a lack of core funds and support results in their discontinuation. A recent editorial by Stein et al. (2021) examining the lessons learned from 20 years of integrated care as a public policy concluded that the prevailing ‘top-down’ approach to implementation lies at the heart of many business failures.

Conclusion

As authors, we have all been involved in designing, implementing, and evaluating integrated care at different levels in health and care systems for many years. While we have seen how integrated care can succeed in improving care and outcomes for people, its implementation necessitates thinking and acting in different ways from the traditional. Perhaps the most regrettable business decision is seemingly the failure to learn from past mistakes, an inability to acknowledge and be open about when things do not work, and the lack of commitment to long-term sustainable change.

Conflict of Interest

None