Integrated care in a National Health Service: better horizontal than vertical for general practice?

Abstract

The concept of integrated care (IC), nowadays commonly adopted across the world, implies a positive attitude towards addressing fragmentation of services provided inside health systems.1 Striving for combining parts to form a whole, IC has undoubtedly laudable aims for patients, especially for ageing chronic patients with both physical and cognitive problems, the major current challenge of health systems in highly developed countries.2 Indeed, a comprehensive IC should now encompass the coordination of health and social services to achieve continuous care across organizational boundaries, overcoming the still existing mismatch between the increasing burden for chronic conditions from the demand side and the provision of services centred on acute care from the supply side. Conceptually, IC can be either horizontal or vertical, like in any else supply chain.3 The former occurs when IC is applied to various services delivered at the same organizational stage (e.g. hospital services), the latter when IC brings together services delivered at different stages (e.g. hospital and general practice services in health care). In its turn, vertical integration can be either forward (e.g. acute care with postacute care downstream) or backward (e.g. community care with acute care upstream). Systemically, the Beveridge-type public health services such as the English and Italian health systems (with universal coverage and mainly funding from general taxation) are expected to be more effective in achieving IC than the Bismarck-type statutory health insurances such as the German and French health systems (with almost universal coverage and funding from mandatory social contributions).4 In fact, the latter have, by default, many more stakeholders than the former, and it is challenging to involve all players in IC interventions when some of them have financial interests which run counter to the desired aims and may lead to moral hazard.5