Integrated care: reach across, don’t dictate down

Cathy Fooks, President & CEO

There’s broad agreement that integrated healthcare serves patients better, eases the burden on caregivers and improves system accountability and efficiency. There are excellent examples of it in many countries and multiple efforts to create it here in Canada. Yet progress toward it remains frustratingly slow.

For that reason, The Change Foundation is working with partners from the University of Toronto — the Institute of Health Policy Management and Evaluation, the Health System Performance Research Network, and the Dalla Lana School of Public Health — to organize a series of discussions on accelerating integrated care.

Our idea was to create a kind of learning lab: over the meetings, the same group of Ontario health-system leaders would hear from experts on how integration is developing in other countries. Their responses to the first discussion would shape the second, and the third would build on that. We’ll have more complete articles coming out about the discussions, but I wanted to share briefly the gist of our September meeting.

Chris Ham, chief executive of England’s King’s Fund think tank, was our guest speaker at the first session. He opened his remarks by showing a video the King’s Fund uses to illustrate the concept of integrated care. It’s a useful primer, but by now the concepts of integrated care are well known, without being well-used.

That failure to spread, according to Ham, is because the vast majority of attempts to integrate care go about it the wrong way. Successful integrated care, he said, is fundamentally about people and their families and carers—how we can best meet their needs and how we can give them the skills required to focus on relationships. Our efforts tend to flounder because we forget that, and focus our energies on institutions, professions and jurisdictions, as Ham illustrated in this slide: 

Challanges slides_the kings fund

It was easy to recognize the point Ham’s slide was illustrating: we’ve all been part of the strategizing and planning the column of technical challenges represents. Our efforts to integrate healthcare often, perhaps usually, boil down to debates over affordability and territory.

In a strongly centralized, government-controlled system, that’s no surprise. Healthcare is structured around budgets and institutions. But that is Ham’s point: it should be about people. People are not technical challenges. And that’s why successful integration shifts the focus to the second column, relational challenges.

That simple list was clearly revelatory for the people at the meeting. The idea that we need to focus on systems and collaboration to transform healthcare is not new, of course. What caught people’s attention was Ham’s firm belief that government needs to “stay out of the way” and let local groups draw on and build relationships in order to make care work for the people in their area. More specifically, government should create the right environment to allow local organizations to come up with the right solutions for them based on their populations, culture and resources.

Ham’s recipe for success, based on what he’s seen so far, suggests integrated care cannot be introduced in a system-wide, top-down way. The best efforts he knows start small scale, in neighbourhoods or communities, perhaps serving as many as 30,000 to 50,000 people. Small enough, in any case, that providers are used to working together, and building links among services is not too unwieldy.

Ham’s first example of that small-scale personal approach was the remarkable shift to integrated care in the English retirement area of Torbay. Change there was triggered by a failing grade given to the town’s social services system by government inspectors, he said, but the change itself was not dictated by government; rather, local healthcare providers, led by family doctors, got together to improve their patients’ lives.

He also described how the District Health Board for Canterbury, the region surrounding Christchurch on New Zealand’s South Island, undertook radical changes to its care services beginning in 2007, when demand on the system was mounting to the point where it looked unsustainable.

Key to that success, Ham said, was Canterbury’s close-knit community, where people already knew and trusted each other. But it was also about true and meaningful engagement of those who would have to implement the change at the frontlines. He believes real change cannot be dictated or transactional — it must be bottom up and developed at the person-to-person level. I’d add that it must also involve patients and caregivers to be meaningful, which is an aspect of engagement Ham admits has often been neglected.

Ham added a caution as he described these successful examples of integrated care. Because it depends on relationships and local community reality, he said, there is no single right way to do it, and one community’s successful model cannot simply be grafted onto another community. We should not look for shortcuts.

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