An Academic Perspective on the Development of Integrated Care

• Introduction
• Primary Aims of Integrated Care
• Advantages and Disadvantages of Integrated Care
  • Maori Health and Integrated Care
• Key Issues Facing Providers
• Lessons Relating to Delivery Systems in Integrated Care
• What is the Appropriate Approach to delivering Integrated Care in New Zealand?
• The Contribution of Academia to Integrated Care
• References

Introduction

The New Zealand health reforms are at an interesting stage. Crown Health Enterprises, now called Hospitals and Health Services (HHS), are under pressure to perform according to budgets and to become commercially viable operations. Demand for services by the general public continues, despite more services than ever being provided.

Expectations remain high for publicly funded surgical services. Access to surgical services is still used as a barometer of the health system and the ability of government to meet the public demands. General practice has responded to the desire of the Health Funding Authority (HFA), formerly the Regional Health Authority to contract with groups of doctors by forming Independent Practitioner Associations (IPAs). Certain of these groups have taken on budget-holding for pharmaceuticals and laboratory services, without significant risk.

Approximately 15% of practices are capitated and the HFA has declared in “The Next Five Years in General Practice”  ¹   that it plans to capitate nationally, wherever possible, based on a system of patient enrolment with practices.

Within the existing framework there are proposals to progress towards integrated care, and New Zealanders are promised that policy in relation to integrated care is presently being developed and the proposed strategy will be published. In the meantime, the HFA has published a paper entitled “Service Integration”   ²   which sets out the guidelines for the development of Integration Demonstration Pilots. 10 of the projects submitted by various provider groups and organisations were recently selected to begin in the near future. This paper discusses the theoretical basis for integrated care, considers some of the key issues, addresses an approach to delivering integrated care in New Zealand, and offers some suggestions as to the contribution that academia can make to integrated care.

Primary Aims of Integrated Care

In many managed care models, particularly those used in the UK where primary care commissioning has held sway, a primary care led approach has resulted in a shift of power, and purchasing, to primary care providers.

Historically in New Zealand, power has been predominantly held by specialists and hospitals, based on an outmoded model that the specialist knows best. With the increasing complexity of health care, driven by new technology, the role of the clinical generalist is increasingly important. Fiscal imperatives are leading to shortened hospital stays, and there is a resultant strong drive to see how primary and secondary care can work together to provide better co-ordinated and “integrated” care to improve cost-effectiveness and health outcomes.

An early definition of integrated care produced in a draft document written by the Southern RHA in September 1997 was: “Integrated care is the coordination of community and hospital based health and disability support services, and is aimed at providing quality, access and health outcomes.” This definition provided some key direction about the components of integrated care.

Subsequently, the HFA has steered away from a definition of integrated care, but instead has approached the subject from the point of view that there is fragmentation of service provision, that policy and structural barriers exist, that the absence of integrated information systems spans various types of services, and that fragmentation causes waste of valuable resources and creates variability around quality and access to services.

In addition, the HFA  ¹   considers that a solution must be found to ensure that citizens, government and service providers find ways to balance demand for access to high quality, effective services within sustainable and acceptable budgetary limits.

The HFA  ²   states that an integrated system relies on:

• Collaboration across services
• Emphasis on health promotion, and prevention of disease, avoidable complications and disability
• Accessible and effective consumer support services for people managing their own health, especially those with chronic disease
• Effective information and management systems
• Practice based on evidence of effectiveness
• Partnerships between service users and professionals
• Achieving targeted health and independence improvement goals (ie outcomes).

The clear focus of this set of objectives is that care should be co-ordinated across the boundaries of various health systems, services and professionals, in a way that leads to better quality of care, better health outcomes (than those previously achieved) and cost-effectiveness. The public’s almost insatiable demand for access to high quality health services would be tempered by economic imperatives which demand cost-effectiveness. This is one driver towards clinical and economic imperatives and the international trend to the use of best practice guidelines which are “mindful of resources”, using an evidence-based approach to medicine.

Ovretveit defines integrated care as referring to “the methods and type of organisation which will provide the most cost-effective preventative and caring services to those with the greatest health needs and which will ensure continuity of care and co-ordination between different services.”  ³   This definition again focusses on the concept of health outcomes for a population in need having cost-effectiveness as a central requirement.

With pressure to contain health spending being a world wide phenomenon, the theoretical concept of integrated care offers hope for “greater value for the health dollar”. It is widely recognised that there is no one model for integrated care, but instead a multiplicity of models exist, adding confusion on the one hand, but diversity capable of meeting local need on the other. The fact that there is no single model, or one that has proven advantages, is a reflection both of local variation and of the absence of rigorous research to provide evidence that one model leads to better health outcomes and cost-effectiveness. The results of comparative studies of health systems and services are awaited with interest. The evaluation of the demonstration integration pilots in New Zealand will provide local evidence on health outcomes and cost-effectiveness as a function of various systems of integrated care.

Advantages and Disadvantages of Integrated Care

The advantages that are presumed to follow from integrated care are set out in “Service Integration – Guidelines for the Development of Integration Demonstration Projects”.  ⁴   In addition, this document states eight hypotheses being tested.  ⁵   They include the concepts that integrated care would: improve health outcomes and be cost-effective; support greater use of guidelines in service provision; allow contracting strategies that align incentives and promote collaboration across traditional service boundaries; integrate service delivery; allow budget responsibility for a wide range of primary care services or specific bundle of services or for a full range of services; allow integrated service networks run by Maori for Maori; and improve consumers’ choices of health service options.

Further advantages of integrated care perceived by Health Funding Authority personnel (informal discussions) include: firstly, the opportunity to address the issues of seamless and co-ordinated care; secondly, transfer of political and fiscal risk to provider organisations and providers themselves; thirdly, reduction in duplication of services; fourthly, prioritisation of services supplied within an integrated care organisation, and reduction in purchasing inappropriate or unnecessary services; and lastly, possibly a greater ability to adhere to the principles of the Treaty of Waitangi by providing Maori greater access to health care in a culturally acceptable manner.

There are also some perceived disadvantages of integrated care. These include the potential loss of control of health services provision to providers and the political and fiscal risk which might flow from this loss of control. “Cream skimming” might occur where integrated care organisations fail to provide care for at risk populations. There is a risk of “cost-shifting” where, in the absence of integrated funding streams, costs are shifted from one provider in the health sector to another. The “privatisation” of the market might allow non-governmental organisations to gain control. There may be reduced local variation (although this could also be an advantage) and provider dissatisfaction may develop due to change, more administration and less freedom.

Maori Health and Integrated Care
One particular advantage of integrated care provided by Maori, for Maori, is that Maori models of health could be instituted. There are several models which describe Maori perspectives of health and well-being. The most frequently cited is Te Whare Tapa Wha,  ⁶   (the four-sided house) incorporating four health components: taha hinengaro (emotions and mind), taha wairua (spirituality), taha tinana (body) and taha whanau (extended family). Disruption in any one component can interfere with the well being of other components. A holistic approach to health delivery is essential.

In addition, a number of principles relating to health service delivery have been described.  ⁷   These are as follows:

• Whaka piki – Enablement of client decision-making on service options
• Whai wahi – Participation of clients, whanau and Maori institutions
• Whakaruruhau – Safety including both physical and non-physical safety
• Totika – Effectiveness with a focus on health status issues and health gains
• Putanga – Accessibility which requires good service information, service availability
• Whakawhanaungatanga – Integration by making links with other appropriate services.

Services which attempt to incorporate both Maori models of well-being and the principles given above, are more likely to be appropriate for and acceptable to Maori, and have greater opportunity to impact positively on Maori health. It would appear that integrated care in some form could be considered by Maori as an option for health services.

However, one potential disadvantage for Maori is the possibility that the unique care of a “by Maori for Maori” organisation will be lost in an integrated care organisation if it were of mixed ethnicity. There is also a risk of underfunding if, in a predominantly Maori population-based integrated care organisation, a capitation formula is used which does not take sufficient account of ethnicity and socio-economic status.

Analysis of these advantages and disadvantages of integrated care supports a hypothesis that the advantages will outweigh the disadvantages, providing caution is exercised over structural issues and fiscal risk. The diathesis between primary and secondary providers in New Zealand is such that integrated care offers an opportunity to purchase health services for better health outcomes and cost-effectiveness.

Key Issues Facing Providers

Integrated care is presently uncharted territory for most providers in New Zealand. Thus, there is both lack of experience and associated potential risks. The key issues can be divided into the following groups.