The introduction to this resource book explains how integrated care can be analysed on three levels: the client level, the organisation and network level, and the care system level. In this chapter, we discuss arrangements in integrated care that are located on the second of these levels.
The term ‘integrated organisational structures’ refers to organisations, relations between organisations, and networks. This chapter relates especially closely to issues of quality management, information management, leadership, cultural change, and strategic planning, dealt with in other chapters of the resource book.
Integrated care particularly focuses on relations between organisations, since problems with integration typically arise in fragmented care systems with insufficient co-ordination between care providers (as stated in the introduction). But integrated care can also be provided within integrated organisations – in other words, solutions ‘under one roof’ of a larger organisation – so the chapter also examines this option.
There are no simple solutions for integrated care on this level. So the reader is invited to consider some basic concepts, models and strategies that should provide guidance in the search for practical arrangements.
The term ‘integrated structures’ combines two concepts: structures and integration.
The word ‘structures’ refers to the more or less stable arrangements of co-ordination and co-operation within, or between, organisations or agencies. These might include hierarchies, contracts, regulations, agreements, pooled budgets, and technological infrastructures.
Depending on the intensity and quality of the integrating relations, it is possible to distinguish between:
The term ‘integrated structures’ refers to both types of integration. There are also ‘mixed cases’, which combine integrated organisations and integrated networks, since arrangements in social and health care systems are relatively complex.
The word ‘integrated’ describes a characteristic of these structures or processes. It implies that actors (members) and activities (functions) are relatively:
‘Integration’ always implies the inclusion of certain actors and activities and the exclusion of others – in other words, it makes a distinction between the system and the environment.
Integrated structures of care are well-balanced or fair, and well-organised or ‘optimised’ arrangements, that will promote and support seamless care or integrated care.
The distinction between these types of relations is fundamental, but they should not be confronted as representing different, incompatible, ‘cultures’ (for example, the social model as opposed to the medical model, or discursive co-ordination versus systemic rationality – see Dahme and Wohlfahrt 2000), but should be reconciled in practical solutions.
It is important to note that the ‘optimal’ solution in the eyes of one partner may well not seem fair, or even optimal, in the eyes of another.
Integrated structures are a means to an end. They are designed as a result of an integration strategy being put in place. It should be evident from the principles of fairness and optimising (see ‘Integrated structures’, above) that strategies of integration can be dominated by certain interests:
Such interests are not inherently bad, and may in fact result in some improvements to the way that care is integrated. However, they may be unbalanced. They may also provoke resistance, which can arise when the state or an organisation attempts to reorganise existing care systems to function more optimally for their own benefit. Politicians and administrations will claim to integrate for the common good, but in practice the goals tend to be more partial following, for instance, an overriding goal of cost containment. In another common situation, they might impose supposedly successful models of integration from other fields on to social and health care – where they may or may not be helpful (see Goodwin et al 2003).
So the basic goals and strategies have always to be negotiated with, and within, the care system to be accepted and implemented effectively.
Integrated structures are designed to enable common goals to be realised more effectively. From a user-oriented or client-centred perspective (which is taken throughout this resource book), the basic goals to be promoted by integrated structures are:
These goals have to be translated into specific ‘things to do’ and ‘outcomes to be realised’. Since the situation in national, regional or local care systems differs widely (for example, compare the NHS reform in the UK with the adaptation of the Scandinavian model to changing needs, the introduction of personal care budgets in the Netherlands or the development of care centres in Greece), there is not one set of outcomes that will indicate the achievement of more integration and better performance.
In practice, it is crucial to have a relative improvement – relative, that is, to the concrete situation and the resources at hand. But it is also important that there is an explicit agreement on a limited set of concrete and observable outcomes. This is essential for establishing a consensus about ‘being on the right track’ towards integrated care in the organisation.
When you discuss goals with partners, be prepared to talk about concrete, achievable and achieved outcomes.
Integrated working can make a difference at a number of levels, some of which can be thought of as pressure points within the health and social care system – for example, within older people’s services the benefits might include:
Integration processes that help organisations deliver these outcomes include:
Source: Peck et al (2000)
When looking at models of integration, one can find a wealth of initiatives, projects, innovations, re-organisations and other experimental arrangements in the field of integrated care.
The first lesson to note is that there are no models that can be transferred readily to other contexts, but that there are some basic organisational principles or strategies of designing for more integration, and there are also solutions adapted to sometimes very specific local situations. In trying to identify relevant options, one may distinguish models of integration by their degree or intensity of integration – in other words, the extent to which the partners connect their activities by linkages, co-ordination or contract (see Leutz 1999). In fact, the degree of integration does not tell us very much about the character of the relationships. Organisation theory reminds us that the principles underlying these connections can be different in important ways.
The second lesson, therefore, is that the usual classifications that order models of integration on a continuum (with ‘no integration’ at one end and ‘full integration’ on the other) are not very helpful. There is not just one solution for every problem of integration, and sometimes a closer look may reveal that less, rather than more, integration is the answer. Typically, different strategies of integration and networking are called for in different problem situations.
Managers of integrated social and health care need to realise the complexities of this area and have to learn the ‘management of dualities’ (Pettigrew and Fenton 2000). Managers of innovations must pursue more or less mutually exclusive goals in theory, and must reconcile them in practice, in a fair and optimising way. And in practice, we find very different strategies and arrangements establishing reliable relations with partners in the care system (see Smith Ring and van de Ven 1992, Hudson 2003, Williamson 1985, Walsh 1995, Woods 2002).
Looking for relevant ‘dualities’, we first consider the two options on which relations can be based:
The first option – trust versus contract – seems relatively straightforward, although contracts certainly can be more or less formal and binding, and can also require trust. In the second option, the reference to some higher authority means that the transactions are determined more or less by a shared commitment to goals or values, and entail some way of being accountable to some controlling third party, as will become clearer below.
Combining these options, we can identify four models of integration between agencies or organisations in care systems:
These are explained below.
This model regulates the usual business relations between partners. Market models are valued for their openness, flexibility, innovativeness and optimal allocation of resources. However, they tend to be ineffective in providing collective goods such as public health or prevention, in realising social justice, or in protecting underprivileged persons, such as those who are poor, frail or elderly. Their focus on individual interests of care providers is often in conflict with care integration for the benefit of the clients.
These business relations rely primarily on contracts rather than trust. They do not expect a shared higher authority or to share values with the partners, although contracts are backed up by a legal and sanctioning system. Examples of market relations can be found in purchaser–provider models in the Netherlands, Germany and the UK, which typically emphasise the role of the client as a consumer (Kodner 2003).
In this model, care provision of an organisation is established ‘under one roof’. The organisation may also be a state organisation if the state or municipality provides integrated services. Hierarchies have the advantage of being able to establish an effective management and bind their members (employees) by contracts to the pursuit of their goals (in this case, the goals of integrated care). They do not have to rely on trust since they exercise control under a clear ‘higher authority’ defined by the goals of the enterprise.
Hierarchic models play an ambiguous role in care systems. On the one hand, we find that larger organisations and mergers are promoted to achieve more integration – especially in rather fragmented market systems. For instance, the discussion on managed care in the United States and on care trusts in the UK demonstrates such hopes for more efficiency and quality by integrated organisations with strong elements of hierarchy (see Goodwin et al 2003 and Wernet 1999). In some situations, such as in Germany or Austria, new larger organisations are expected to bridge and break up existing barriers between traditional parts of the care system – in other words, between the health and social care systems (see Pelikan et al 1998, Schaeffer 1998). On the other hand, we find criticisms of hierarchical structures, because they are considered to imply too high a degree of centralised power and bureaucracy (for a Finnish example, see Sinkkonen and Jaatinen 2003).
This model establishes a preferred and stable relationship allowing for an integration of exchanges and activities on an operative level based on ‘recurrent contracting’ (see Smith Ring and van de Ven 1992). Here, ‘co-orientation’ means that people or agencies are clearly orienting their activities to partners in a network, but that the relations may not be very strong, and membership in the network may be changing relatively easily. Between partners in the care system, this implies the development of durable relationships on the basis of recurrent co-ordinated transactions – for example, the co-ordination between hospital and community care to provide a ‘seamless’ discharge management. This co-ordination may be considered a necessary first step or a key towards (more) integrated care.
Important networks in the care system that would come under the category of ‘co-orientation networks’ include the wider network of community care – especially networks of social work, and the informal care network or the ‘life world’ of the client. Another important case is the situation in less professionalised care systems, such as in the southern Mediterranean, or in new Eastern European care systems, where informal support and fragmented care systems are still prevalent (for a Spanish example, see Rico et al 2003).
Co-orientation networks are based on trust, although some relations may not require high levels of commitment. This is because the relations do not typically involve a formal reference to higher values and are not subjected to controlled accountability. Partners essentially keep their independence.
This model of co-operation, also known as ‘relational contracting’ (see Smith Ring and van de Ven 1992) involves some agreement on basic values and a strong reliance on trust. Co-operative networks tend to be the preferred option in the realm of integrated care. They might even be considered an essential element of the philosophy of integrated care. However, the precise characteristics of this ‘culture of trust and co-operation’ vary widely between different countries and different professional sectors, so the conditions for co-operative networks vary.
In central European care systems, such as the Netherlands, Germany and Austria, the ‘third sector’ of not-for-profit organisations and voluntary associations plays a systematic role in care provision. There has also developed a rather strong tradition of non-profit non-governmental organisations (NGOs) in the care sector and of their co-operation with the state or municipalities. These traditions are still very influential and provide a basis for trust and shared value commitments for the ‘common good’, although in recent years the co-operation has been structured increasingly on market principles (Dahme and Wohlfahrt 2000, Schaeffer 1998).
In modern, market-oriented societies, co-operative networks typically need support from the ‘higher authorities’ of the state, region or municipality to command sufficient influence and legitimacy. Both types of networks can be looked at as ‘integrated networks’ in the terminology suggested here. The main choices – in this perspective – are then between markets, hierarchies, and networks. The choice between markets and hierarchies, on the one hand, and types of integrated networks, on the other, will depend on how far the local or regional ‘culture of trust’ supports co-orientation and co-operation.
The four models described above can be further characterised by strategies of coping with, or sharing risks, overleaf. Basically, strategies can be distinguished based on trust, power, knowledge or exchanges (of money, goods and services). The strategies can be combined with the basic models to form the options in Table 3 (see also Smith Ring and van de Ven 1992).
Considering care systems, each of the four models favours very different options:
It is important to note that reliance on knowledge is ambivalent in two ways. First, knowledge is power and it can be used by managers and professionals to pursue an ‘optimising’ of processes in their specific interests. But then, a reliance on knowledge creates an openness towards ‘knowledge communities’ (institutions of education and research), which accounts for the innovative potential and an orientation toward evidence-based quality standards. Typically, co-operative networks have some research or higher education institution among their membership because relying on knowledge can mediate between interests and provide for better solutions.
Second, as the term ‘professional culture’ indicates, the knowledge of a profession consists not only of ‘evidence-based’ scientific knowledge but also of visions, paradigms, unquestioned concepts and procedures, practical experiences, and even disciplinary folklore. Such a culture may, in fact, be a ‘closed’ sub-culture or an enclave, and the sub-cultural knowledge can create considerable barriers to integration across boundaries (see Goodwin et al 2003). The prime example in integrated care is the split between the cultures of medical care and social care.
|
Basic models of integration
|
Markets
or individualistic contracting |
Hierachy
or integrated organisations |
Co-orientation networks
or weakly connected networks |
Co-operative networks
or strongly connected networks |
|---|---|---|---|---|
|
Risk-coping strategies
|
|
|||
|
Power
|
Decentralised power, moderate accountability by contracts
|
Centralised power, high accountability
|
Decentralised (low) power, low accountability
|
Low central power based on consensus, high accountability to shared goals |
|
Exchange
|
Unrestricted flow of decentralised exchanges based on prices and competition
|
Restricted flow of goods and services based on central goals and controlling
|
Open flow of goods and services based on recurrent contracting or ‘norms of reciprocity’
|
Restricted flow of goods and services based on ‘fair’ agreements, sharing of benefits and risks |
|
Trust
|
Low reliance on trust, balancing of individual interests, open membership
|
Low reliance on trust, dependence on loyalty, clearly defined membership
|
Reliance on trust, selective membership and relations with (low, moderate) commitments or risks
|
High reliance on trust on strategic level, commitments covering high risks, controlled membership |
|
Knowledge
|
High reliance on innovation for competitive advantage
|
Low reliance on innovative knowledge, administration of confirmed knowledge
|
Moderate reliance on knowledge, domain-specific operative innovations, traditions of good practice
|
High reliance on knowledge, innovation, if shared culture ‘open-scientific’ rather than ‘closed-ideological’ |
Partners in all model situations have to cope with risks and to decide with whom they want to share risks, and with whom they do not and in which way they accept responsibility and accountability. Partners will agree to regulations and make commitments that they consider necessary to achieve their goals, but they will also try to avoid levels of integration and hierarchy, which they consider unnecessarily restrictive and limiting of their choices. Integration is expected to limit risks and increase benefits, and this has to be reflected in the objectives and procedures of an integrated structure.
From the perspective of professionals, some problems might have to be solved by specialists in special institutions. This is also true from the perspective of the clients, who will consent to greater restrictions to their freedom of choice if the risks for their health are high. So they will favour the restrictions of institutional care in a hospital when they are vulnerable. But then, some openness and integration with other networks might be necessary for better care outcomes. For example, hospitals are undergoing considerable change under the impact of more client orientation – in other words, by allowing ‘rooming in’ (for example, allowing mothers of sick children to stay with them overnight) and ‘reaching out’ (for example, providing rehabilitation services at home, which benefits health care).
These reflections on risks highlight the importance of the clients and the nature of their problems:
The terms ‘low risk’ and ‘lower qualification’ are a matter of social and political definition. This also poses the more general problem of who has the right, and the responsibility, for deciding on which risks are considered high or low, who carries the risks, and who is accountable. The legal framework does not typically provide sufficient guidance. Some health risks (such as accidents) or social risks (such as unemployment) may be very high, but they may or may not be adequately recognised by support systems, insurances, or society at large. Care providers have to cope with the fact that the term ‘low risk’ usually refers to circumstances that can be treated by someone with a lower professional qualification, offering lower prestige, and the fact that their roles can often be substituted by informal care – the characteristic situation of not-for-profit organisations in social and health care. This fact tends to make the coverage of ‘low risks’ under-financed and unattractive for the services.
Including family relations in integrated care creates special challenges, since they are a special network embedded in community networks or life worlds, and supporting both types of client. Family relations are not chosen to cope with risks (whether one chooses to use them or not), but they are a resource nevertheless because their traditional values predispose members to see carrying burdens and high risks as a matter of fate, love or solidarity. But these family traditions are changing. In modern society, while these relationships are strong in some cases or local cultures, in others they are not. Family relations may also form a sub-cultural enclave, which creates barriers to co-operating with the care system, as with some religious traditions the oppose medical treatments.
Integrating services for both types of clients, or for clients with changing levels of problem severity over their care paths, can be expected to produce difficult integration problems and to require great flexibility in service provision. This is especially the case when the distribution of risks and responsibilities is seen to be unjust, and the effectiveness of the accountability system is questioned. The issues of accountability and control can be raised by:
So the choice of a model of integration should be guided by the types and levels of risks and responsibilities that have to be distributed or shared, and by the accountability procedures required.
In integrated organisations and networks, different partners and professions with a range of interests co-ordinate their activities and co-operate for the common goal of integrated care. ‘Stakeholders’ are actors or agencies who have an interest in the goals, processes and outcomes of integrated care, and who can significantly influence the available alternatives and the outcome of interventions.
Stakeholders are also potential partners in a concerted initiative for integration. Important stakeholders in integrated care typically include:
Additionally, it should be recognised that interests of stakeholders are represented by lobby associations on different levels.
For a helpful manager’s checklist’, see the appendix in van Raak et al (2003).
The service user as a stakeholder may play four different roles:
A strategy for care integration must start with a thorough analysis of the local and regional stakeholders in the social and health care system, to identify potential initiators, supporters and opponents of integration. Depending on the influence and position of the initiators, they can choose a stakeholder strategy:
All strategies have to face the fact that integration requires and creates a new centre of influence or power. This holds whether an existing organisation is expanded, the internal governance structure of a network has to be developed, or existing networks are to be influenced or managed more effectively from outside (in other words, by the state). Resistance by stakeholders is the ‘natural’ reaction.
The external management of networks is an especially demanding task since it has to manoeuvre between the strategies for organisations and for networks (more...).
Members of an integrated network tend to perceive this management of networks as management by an external stakeholder (see Goodwin et al 2003). Therefore, ‘management of trust’ is essential.
To decide on which model is appropriate, it is necessary to analyse the local structure of stakeholders to identify supporters of integrated care, and to set incentives to encourage professionals to co-operate.
The philosophy of integrated care especially favours co-operative networks, as explained earlier. But summarising the lessons from a decade of health care reform in Europe, one analysis reaches an ambiguous conclusion:
It is therefore necessary to experiment with the design of integrated organisations, as well as with integrated networks, to find the appropriate mix that fits the local circumstances.
Designing integrated organisations is typically top-down. A kind of strategic alliance with an agreement on central goals and values is negotiated at the start, and the partners consolidate this into an integrated organisation ‘under one roof’. The process of the design itself will follow a strategy applying the principle of optimising.
Integrated care organisations can use different strategies to develop (see Pelikan 1998), including:
Typically, the resulting integrated organisation is internally structured into relatively independent units specialising in different types of services (such as social, health or rehabilitation services). So the distinction between an integrated organisation and an integrated network is not clear cut in practice. The important elements of integrated organisations are integrated management, pooled budgets, and the degree to which contracts between partners are exclusive.
The focus in the design of integrated organisations is on containing costs and achieving quality through improved co-ordination and integration of services. Concepts of managed care typically try to achieve both these goals, although they are frequently seen as opposing objectives, but this is not necessarily the case. In fact, integrating services to enhance care quality often does increase costs for the extra effort, although in the long run it may reduce them. So, cost containment in one given area may be a prerequisite to free up sufficient resources for innovative integration. In addition, placing the organisation in a stronger position in negotiations with financing agencies (such as the state or insurance companies) may be a goal.
A managed care strategy should combine knowledge and technologies, the economies of scale of larger organisations, lower transaction cost, the pooling of budgets, common infrastructures, and research and development capacities to organise integrated care ‘under one roof’. It is basically a strategy of optimising, so that different interests are balanced within the organisation through hierarchies and contracts.
Reviews of managed care and care trusts provide experiences with integrating partners (see Wernet 1999, James and Miles 2002, Bailyn and Miller 2001). In view of these experiences, the following design rules are suggested as checklist for practice. These rules should be observed beyond the management strategies applicable to any viable enterprise.
A special emphasis should be placed on the final point in the checklist: client orientation. The client’s personal, informal support network – as well as their wider community – are no more than co-orientation networks, in the terminology introduced above. So the interface and interrelations between the organisation and the life world of the client become a very difficult problem for integrated organisations following an essentially different ‘logic’ based on hierarchy and contracts, while the ‘logic’ of informal support is based on trust and norms or reciprocity. The problem is reflected in the differences between social and health care, since to be effective in its mission social care typically has to develop more ‘open’, trust-oriented structures and advocacy roles on behalf of the client.
Integrated networks can be designed top-down or bottom-up. The strategy essentially has to develop more effective structures of governance between partners. As stated above, managing networks from the outside is especially difficult, since the external agent has to exercise influence without an accepted position within the network. Special qualities of the manager as a negotiator and ‘boundary spanner’ (see Goodwin et al 2003) are decisive for success.
Integrated networks essentially consist of fair, balanced and well-organised arrangements, regulations, contracts between organisations or agencies on the basis of negotiations on central values and policies, leadership and decision-making, and the co-ordination and co-operation of care activities, and the evaluation and sharing of costs, benefits and risks.
Networking is an ‘art’, rather than a science or a technology with guaranteed success. The basic process is one of communicating and negotiating with other people. In obvious win–win situations in which everybody gains by co-operation, forming an organisation or network is either not necessary or not difficult, and requires only a clear contract to avoid conflict over the gains. In other words, the market usually takes care of it.
Integrated networks are knit together by implicit and explicit contracts, but they depend essentially on trust. In practice, negotiating typically starts because attempts to solve the problems through the pursuit of individual interest by all partners (market model) and statutory regulations (hierarchy model) have not produced solutions. Professional expertise and insight alone cannot produce the solutions either, because typically integrated care depends on knowledge from a range of different disciplines and practical spheres and accepting other people’s knowledge requires considerable trust.
In this situation, altruistic motivations or higher values are called for, to convey legitimacy to the initiative. Typically, voluntary or non-profit organisations are founded to establish a forum for discussion of the common cause and to address the problem. This is one reason why NGOs play an important role in many countries, and why integrated networks usually consist of a ‘welfare mix’ of statutory or state, private or market and NGO organisations. The rules detailed in the checklist below may be applied to design or improve networks.
Again, a special emphasis should be placed on the final point in the checklist – client orientation. Co-operation in integrated networks typically develops in a situation of open community networks that have close relationships with the life world of clients. These networks are a valuable resource, but they can present difficulties in strategies emphasising a more managerial culture and professionalism in the pursuit of quality in integrated care. Telling examples of this problem can also be found in other fields of social policy, such as in networks on crime, disorder and drug prevention. (For examples, although with a somewhat different analytical framework, see Goodwin et al 2003.)
Some additional rules or strategies are important in practical networking. These are detailed in the following checklist.
Three types of role in organisations and networks are vital for the success of integrated care: entrepreneurs, stakeholders, and care professionals. Unfortunately, in most systems the clients do not (yet) have an influential role.
All literature on the success and failure of integration initiatives testifies to the fact that successful initiatives depend on individuals who identify with the goals, and invest their capacities, skills, influence and enthusiasm in the project. If these people stop being involved (or are dismissed), the project will seriously suffer or fail. This positive influence does not usually come from one single person but from a dedicated team that unifies vital functions, such as leadership, expertise, public relations, network integration and established influential connections. Innovation depends on entrepreneurs, and on their recognition, respect and support from partners inside and outside the initiative.
Entrepreneurs fit into the stakeholder category, but there are also other actors and agencies that have to be supportive, qualified and resourceful. An initiative cannot usually select these actors, but has to accept them as given. But across the care system at large, it is vital that entrepreneurs find stakeholders in all fields, and on all levels, who are willing and competent to support and co-operate. In practically every project report that has a more personal tone, there are phrases such as ‘If it had not been for that particular person in that agency (whether a ministry, administration, political party or labour union board), this would not have happened’. Integration depends on a culture of support for integration.
Comparisons of integrated care in Europe (Jarvelin 2002, Mur-Veeman et al 2003) reveal that relatively similar problems of care integration can be found in all the countries. This phenomenon can be explained by the fact that, to some extent, the problems and solutions are produced by the care system itself – especially by the professionals in Europe, who share a relatively similar education and play a decisive role as stakeholders in the social and health care system.
So, strategies and structures that are designed to set incentives for professionals to co-operate and support integrated care are crucial to the success of care integration. These strategies include:
There are many factors that might pose barriers to initiatives of integrated care. Frequently these are rooted in the history and structure of the specific care system or region, so there are no more general barriers than there are general solutions. Each situation has to be analysed in its own right. Thus, in this section we emphasise only some important aspects already referred to in the ‘design rules’ checklists (pp 44–48).
One great barrier is the lack of a culture of trust that provides accepted values, regulations, organisational models and procedures for co-operation. Past conflicts in the local setting can build up this barrier and they have to be addressed and raised to common awareness.
Another barrier that is very influential – for instance, in the relationships between the social system and the health care system – is that of differences of professional culture and discipline, which hinder dialogue and understanding across the divide and make a constructive discussion about goals and means difficult.
Deeply ingrained in each country’s welfare system are more structural barriers resulting from the legal frameworks and incentive systems that promote the pursuit of individual interests and property rights at the expense of incentives for co-operation and collective benefits. These barriers are often difficult to overcome because the regulations typically cannot be changed by partners looking for more co-operation at the local level.
Most of the important factors supporting (or hindering) initiatives for integration have been mentioned in the design rules, so in this section we emphasise a few points again. The initiatives and interventions for integrated care should be embedded in a national programme for ‘integrated services for older people’ – which is, in fact, the title of a public programme and policy in the United Kingdom (see Audit Commission 2002). The development of integrated care in organisations and networks has to be supported by cultural, social and political changes throughout the social and health care system to provide a favourable ground for local or regional projects. Trust is an important feature that has to be based on widely accepted attitudes in favour of integration.
Especially for integrated networks, support must be available from experts, third-party agencies and financing programmes, which can provide guidance in network formation, mediate in case of problems and conflict, and provide financial resources, especially to overcome initial barriers. There also here needs to be guidance resulting from practical experiences. This type of support, with additional material, references and links and other useful resources including a report on projects in eight European cities (Goumans and Tamsma 2003) can be found on the EHMA website (see Web links).
Two factors are considered of special importance:
Another factor that deserves emphasis here, although it is dealt with in Chapter 12, is acceptance and implementation of modern information systems and technologies. Many, if not most, expectations of increased integration arise because in an information and knowledge society, there are simply more opportunities for integration. Without the corresponding technologies, such expectations must be frustrated (see also Dykes and Wheeler 1997).
It is also of great importance that projects and initiatives exchange their experiences and learn from each other. Integrated structures have to be communicating and learning structures. This is what the CARMEN network and this resource book are all about (see also Vaarama, Pieper eds 2004). However, when it comes to co-operation and networking, each local and regional situation is different. There are some principles and rules, such as those provided here, but there are no ready-made models. Integration models cannot be transposed to different contexts as easily as some of the other models in this resource book because they cannot be implemented within the relatively well-defined setting of the care process itself. They essentially reach out to other fields and partners. There is only one answer: find partners and start learning by doing!
Integrating organisations and networks is an art. There are no simple recipes and there is no substitute for learning and experience in practice. This holds also for basic choices between ‘top-down’ and ‘bottom-up’ strategies, or between integrating under one roof of an organisation or integrating partners in a network. But in an open society, the search for – and experimentation with – arrangements improving co-operation in integrated care is not only a demanding challenge, but also a rewarding opportunity. In an information society, we not only have rising expectations of co-ordination and integration – we also have more effective and efficient means of communication. And in an ageing society, we have to find innovative and sustainable solutions for a rising demand. Integrated care is a means to an end – not an end in itself. We should not lose sight of the central goal of improving the life quality for everyone involved, from the frail older people with needs for integrated care to those who care, both inside and outside the professional system.
Audit Commission (2002). Integrated Services for Older People. Building a whole-system approach in England. London: Audit Commission. Also available at: www.audit-commission.gov.uk
Bailyn S, Miller C (2001). Care Trusts: Opportunities, problems and actions. A digest of comments in professional journals (April 2000–01). London: Office for Public Management. Also available at: www.opm.co.uk
Dahme H-J, Wohlfahrt N eds (2000). Netzwerkökonomie im Wohlfahrtsstaat. Wettbewerb und kooperation im Sozial- und Gesundheitssektor (Network economy in the welfare state. Competition and co-operation in the social and health care system). Berlin: Edition Sigma.
Dykes P, Wheeler K (1997). Planning, Implementing and Evaluating Critical Pathways. New York: Springer.
Goodwin N, 6 P, Peck E, Freeman T, Posaner R (2003). Managing Across Diverse Networks of Care: Lessons from other sectors. Birmingham: Health Services Management Centre.
Goumans M, Tamsma N (2003). Networks for Integrated Care at the City Level. Report on the City Network workshop, Newcastle, October 2003. Utrecht: Netherlands Institute for Care and Welfare (NIZW). Available at: www.ehma.org
Hudson B (2003). Governance and Integrated Care: Understanding and developing networks at the local level. Paper presented at the CARMEN workshop, Newcastle, October 2003. Available at: www.ehma.org
James R, Miles A eds (2002). Managed Care Networks: Principles and practice. Phoenix: Aesculapius Medical Press.
Jarvelin J (2002). Health Care Systems in Transition. London: WHO Observatory on Health Care Systems. Also available at: www.euro.who.int/observatory
Kodner DL (2003). ‘Consumer-directed services: lessons and implications for integrated systems of care’. International Journal of Integrated Care. Available at: www.ijic.org
Leutz W (1999). ‘Five laws for integrating medical and social services: lessons from the United States and the United Kingdom’. The Milbank Quarterly, vol 77:1, pp 77–110.
Mur-Veeman I, Van Raak A, Paulus A, Steenbergen (2003). ‘Comparison and reflection’, in Van Raak et al Integrated Care in Europe. Description and comparison of integrated care in six European countries. Maarssen: Elsevier Gezondheidszorg.
Naylor D, Iron K, Handa K (2001). ‘Measuring health system performance: problems and opportunities in an era of assessment and accountability’, in Measuring Up: Improving health systems’ performance in OECD countries. OECD conference. Ottawa: OECD.
Nies H, van Linschoten P, Plaisier A, Romijn C (2003). ‘Networks as regional structures for collaboration in integrated care for older people’. Paper presented at the International Conference on New Research and Developments in Integrated Care, 21–22 February 2003. Barcelona: Institute for Health Studies. Available at: www.ijic.org
Peck EW, Villeneau L, Crawford A (2000). Partnerships and Integrated Management in Mental Health. Briefing paper. London: King’s College London.
Pelikan JM, Gießler E, Grundböck A, Krajik K, (1998). ‘Das virtuelle Krankenhaus – Ausweg oder Königsweg für die Krankenversorgung der Zukunft?’ (The virtual hospital – solution or ideal path for health care provision in the future?), in Virtuelles Krankenhaus zu Hause – Entwicklung und Qualität von ganzheitlicher Hauskrankenpflege (Virtual hospital at home – development and quality of holistic home health care). Vienna: Facultas Universitätsverlag.
Pettigrew AM, Fenton E (2000). The Innovating Organisation. London: Sage Publications.
Rico A, Casado D, Sabes R (2003). ‘Situation in Spain’, in Van Raak et al, op cit.
Schaeffer D (1998). ‘Die Versorgung von akut kranken Menschen durch integrierte ambulante Versorgungsverbünde in Deutschland’ (The care for acutely ill persons by interated community service associations in Germany) in Pelikan JM et al, op cit.
Sinkkonen S, Jaatinen P (2003). ‘Situation in Finland’, in Van Raak et al, op cit.
Smith Ring P, van de Ven H (1992). ‘Structuring co-operative relationships between organisations’. Strategic Management Journal, vol 13, pp 483–98.
Vaarama M, Pieper R eds (2004). Integrated Care for Older Persons: European perspectives and good practices. Dublin: EHMA/STAKES.
Van Raak A, Mur-Vreeman I, Hardy B, Steenbergen M, Paulus eds (2003). Integrated Care in Europe. Description and comparison of integrated care in six European countries. Maarssen: Elsevier Gezondheidszorg.
Walsh K (1995). Public Services and Market Mechanisms. Competition, contracting and the new public management. Basingstoke: Macmillan.
Wernet St P ed (1999). Managed Care in Human Services. Chicago: Lyceum.
Williamson O (1985). The Economic Institutions of Capitalism. New York: Free Press.
Woods KJ (2002). A Critical Appraisal of Accountability Structures in Integrated Health Care Systems. Available at: www.dph.gla.ac.uk
www.ehma.org – The European Health Management Association, which managed the CARMEN network, the group that produced this resource book. CARMEN publications and other materials can be found via the EHMA website or by emailing info@ehma.org.
www.integratedcarenetwork.gov.uk a UK government website providing a forum and guidance for researchers and practitioners of integrated care.