Integration or co-ordination – what’s in a name? : a critical appraisal of the application of integrated care in the context of real world clinical care delivery

Abstract

The current discourse regarding integrated care and its aspiration for a better, more accessible and responsive healthcare service is a worthy endeavour. There are growing examples across health care settings of where an integrated approach to care can improve patient outcomes and service user experience. Overall, from the perspective of the clinical organization, governance authority and those mandated to manage care, integration of care has many advantages. However, in the real-world expression of clinical care delivery, integration of care remains a topic of debate amongst healthcare professionals. This particularly applies to horizontal integration – integrating the care of a person with multiple conditions in a holistic person-centric manner – where the benefits to be gained are greatest but the challenges also greatest. What remains unclear is whether integrated care offers something new and potentially transformative beyond what may be considered good co-ordination of care, and more traditional shared care. Questions are raised in terms of who leads the integration of care, particularly where patients may require a shared model of care-giving between different clinical services with different clinical goals. Palliative and end-of-life care across the EU offers one example of this. Despite international direction from WHO and some excellent research and practice examples of integrated care programmes to expand palliative care beyond its cancer-orientated focus, the reality is that across the EU, palliative care remains cancer-focused with only minimal integration to the wider healthcare system. Despite a movement to advance early integration of palliative care supported by clear research evidence, late referrals and misunderstanding of palliative care beyond end-of-life seem to inhibit the opportunity to expand integrated care models. Further, the construct of health service delivery may challenge integration based on where the patient resides and who holds responsibility for their care. In the case of palliative care, shared care models of consultancy, rather than integration of services would seem to be the modus operandii in practice. In effect, how integrated care is perceived and understood remains unclear and the need for a debate on the meaning and impact of true integration within a healthcare system for transformative care planning and delivery is now warranted. In emerging models of advocacy for integrated care, such as the IFIC Framework, language and terminology themselves may be creating an unnecessary obstacle. Lead concepts such as ‘Professional Integration’ and ‘Organisational Integration’ appear to the practical outsider, including clinicians and operational managers, to be advocating changes to professional structures and accountability, and large-scale organisational change. Discussions in practical settings in different European locations have shown opposition to ‘professional integration’, but strong support for coordinated specialism within an integrated care plan. When bringing in significant changes to practice, it is desirable to avoid using terminologies which are threatening and misleading. This presentation will raise these critical debates from the perspective of the healthcare practitioner who is charged with adopting an integrated approach to care in their everyday practice and determine the reality of this new paradigm within healthcare beyond what may be considered a utopian ideal.