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Integrated care is an old concept revisited in today’s health reform environment. In simple terms integration simply implies better collaboration and co-operation between providers.
Government and its health care purchasing organisations want integrated care because they see that integrated health services may be more efficient. At best integrated care might free up resources to buy additional health services; at worst it may enable Government to better live within its health budget or at least slow that budget’s yearly blow-out.
Providers want integrated care if it will improve patient care. An individual provider organisation will be especially keen if it sees itself holding the resources for an integrated care project. Providers become alarmed about integrated care if they see themselves being disadvantaged.
The public is ambivalent about integrated care. The common sense of the ’man in the street’ wonders if integrated care might pick up diseases earlier when they are more easily treated. However the public quite rightly queries why providers are not co-ordinated now, and they become alarmed at stories about the supposed excesses of managed care in the United States. When public commentators talk about integrated care they usually compare it to managed care.
The papers in this edition of Healthcare Review – OnlineTM suggest a considerable focus on structural and financial drivers to implement integrated care. An appropriate emphasis is placed on project evaluation.
Examples of financial drivers are some of the general practitioner budget-holding initiatives. In theory these should produce effective means for co-operation between providers and a drive for the most efficient and effective service provision. The aim is to maximise health gain and minimise wastage.
Examples of structural drivers are some of the Maori initiatives where Iwi and pan-tribal organisations provide a range of health services under one management structure and within a capped budget. The aim is to devolve health purchasing and provision to a level where there is significantly improved community control over services so as to improve health status.
Structurally and financially driven integrated care initiatives tend to be driven from the top down. Somebody in management decides a proposed project is a good idea, a contract is struck, and the frontline health care employees, doctors and nurses, are then expected to follow the new direction.
This, of course, is the flaw. Integration is about people co-operating with each other and co-ordinating their services. If these people don’t agree with a management direction, they will either leave, comply reluctantly and possibly poorly, or even actively sabotage the process.
The recent debate over the points system for waiting lists is a case in point. The reason for the debate is that doctors and nurses have a different philosophy from managers. The health professional’s primary focus is on the individual patient in front of them, and in doing their best to meet that patient’s needs.
This puts doctors and nurses in a position of considerable power compared to, for example, a retail salesman. The manager of a retail store may know as much about a product as does the salesman. There may be considerable information asymmetry between a doctor and his or her manager.
This means that integration will be best driven by not only appropriate structural and financial drivers, but by ensuring that projects are planned, developed, owned and operated with significant public input and clinical input from all clinicians likely to be affected. Clinical and public drivers are perhaps the most important of all. Clinicians need a clear personal and collective stake in each integrated care project to ensure a positive outcome. Public and community representatives need to be involved at an early stage to ensure their expressed needs are heard. If projects are designed and built at this level then appropriate financial and structural drivers may well become obvious and can be built into the project. At least the integrated care project then has an enhanced chance of both producing health gain and being efficient. All stakeholders are winners.
