Table 11 Communication
Challenges to integration Enablers to integration
Poor communication between PHC organisations (Wiese et al., 2011)
Lack of effective teamwork (Harris et al., 2005)
Lack of awareness/inclusion of PHC service organisations (Thorlby et al., 2012)
Lack of trust/mutual understanding (Powell Davies et al., 2010, Mur-Veeman et al., 2008)
Lack of transparency (Thorlby et al., 2012, Cumming et al., 2005)
Lack of clarity related to roles and
responsibilities, accountabilities and goals may lead to conflicts (Cumming, 2011, KPMG, 2008, Suchowersky et al., 2012, AGPN, 2009, Phillips, 2003, Kendall et al., 2012, Bouwen and Taillieu, 2004, Exworthy, 2008)
Open and frequent communication, with formal/informal links (Mattessich et al., 2004)
Multidisciplinary teamwork (Powell Davies et al., 2010, Divisions of Family Practice, 2009)
Clear, relevant (agreed) multifaceted strategy to foster integrated care from planning to
delivery(Jackson et al., 2007)
Clear decision-making processes (KPMG, 2008)
Engagement and ‘buy-in’ from relevant
stakeholders, including participation in decision- making (Cumming, 2011, Ling et al., 2012, General Practice Services Committee, 2012, Divisions of Family Practice, 2009)
6.6.2. Organisational culture
Prior positive relationships are beneficial to establishing and maintaining meso level integration (Table 12). Key enabling factors are access to adequate support for leadership and to foster champions. However, the key barriers are differences in priorities related to integrated care; and lack of strong leadership and management. Although flexibility and adaptability to change is essential, the literature commonly identified that the pace of change needs to be appropriate; and incorporating changes into existing infrastructure is an advantage.
Table 12 Organisational culture
Challenges to integration Enablers to integration
Differences in priorities (Powell Davies et al., 2010)
Lack of leadership and organisational development (Cumming, 2011)
Lack of management, authority (Mur-Veeman et al., 2008)
Lack of engagement with stakeholders (Harris et al., 2008, Checkland et al., 2012)
Lack of flexibility (Mur-Veeman et al., 2008)
Prior positive relationships facilitate integration efforts (Mattessich et al., 2004)
Support for managerial and clinical leadership and champions (Cumming, 2011, Ham et al., 2011, Ling et al., 2012)
Flexibility and adaptability in response to local needs and during period of change (Center for Community Health and Evaluation, 2008, Boyle, 2011, Mattessich et al., 2004)
Working with existing community collaboratives (Center for Community Health and Evaluation, 2008)
Appropriate pace of change, with multiple layers of participation (Mattessich et al., 2004)
Early planning to enhance sustainability (Center for Community Health and Evaluation, 2008)
6.6.3. System and structural arrangements
A defined population (enrolled, registered patients) is a common factor in successful models of integration in England and US (Table 13). Co-location of health services has been reported as both an advantage and disadvantage for integration. However, irrespective of physical co-location, meso level integration is facilitated when organisational boundaries are aligned; and contracts or agreements (formal or informal) are in place.
Differences in governance, administrative, procedural, budgetary and information systems; absence of an appropriate business model; and lack of adequate representation on governing bodies were identified as key system/structural barriers to effective integration.
Political climate and commitment to change is also an important enabler; but too much ongoing change, and lack of realistic timeframes, without opportunities to adjust, was described as disruptive, confusing and may lead to change fatigue.
Table 13 System and Structure
Challenges to integration Enablers to integration
Co-location may lead to attenuation of incentives and higher costs (Robinson and Casalino, 1996)
Health service organisation boundaries not aligned (Powell Davies et al., 2009, Mur-Veeman et al., 2008)
Different administrative systems, rules, regulations, budgets, processes, information systems and databases (Axelsson and Axelsson, 2006)
Lack of representation on governing bodies (Checkland et al., 2012, Harris et al., 2008)
Different modes of governance, lack of community governance and involvement in planning may promote competition rather than collaboration (IPAA, 2002, Thorlby et al., 2012, KPMG, 2008, Harris et al., 2008)
Separation of roles in planning, funding, service provision may lead to gaps or duplication of services (Cumming, 2011)
Ongoing changes in system and structure is disruptive and confusing (e.g. PCTs, CCGs) (Boyle, 2011)
Uncertainty about future changes (change fatigue) (Powell Davies et al., 2010)
Inadequate workforce to respond to changing needs of local population (Boyle, 2011)
Lack of business model to support integration (Harris et al., 2005)
Co-location and shared physical space enhances integrated care (Jackson et al., 2007)
Formal contracts/informal partnership agreements (Cumming, 2011, Goodwin et al., 2004)
Registered/enrolled patients (Ham et al., 2011, Larson, 2009, McCarthy et al., 2009b)
Common (agreed) care pathways(Jackson et al., 2007)
Shared multidisciplinary teaching (Jackson et al., 2007)
Expanded range of PHC providers and services offered (Pond et al., 2005)
Realistic timeframes, allowing adequate time and resources for collaboration and cooperation to occur (Cumming, 2011, Ham et al., 2011, Boyle, 2011)
Favourable political climate and political commitment to change (Cumming, 2011, Mattessich et al., 2004)
Protection from territorialism and competition between providers (Cumming, 2011)
Evaluation and regular review of reach and impact (Center for Community Health and Evaluation, 2008)
Rigorous shared accountability structures and performance regimens (e.g. VHA, ACOs, LHINs) (Curry and Ham, 2010, Miller, 2009, KPMG, 2008)
Practitioners working to the limit of their licenses maximise quality and cost (e.g.
Geisinger) (Maeng et al., 2012)
6.6.4. Information technology and resources
The key enablers in information technology and use of resources pertain to access to shared data, information and resources (Table 14). Investment in IT infrastructure and technical support facilitates data collection, data sharing, decision support systems and dissemination of materials, including guidance on how to integrate and foster strong engagement with other stakeholders.
Attention to IT privacy and security are also important elements for developing and maintaining trust. Inconsistency in definitions and lack of valid measures of integration were identified as barriers to evaluating performance.
Table 14 Information Technology Resources
Challenges to integration Enablers to integration
Lack of shared information leads to under- or over-servicing (Wiese et al., 2011, Cumming, 2011)
Lack of technical support within each
community (Center for Community Health and Evaluation, 2008)
Inconsistency in cost definitions and quality measures (Fisher et al., 2012)
Lack of valid measures of integration to assess performance (Strandberg-Larsen and Krasnik, 2009)
Difficulties collecting appropriate data at population and service level (AGPN, 2009)
Inadequate use of data and research evidence (Innvær et al., 2002, Nutbeam, 2004)
Potential violation of anti-trust laws (ACOs) (The United States Department of Justice, 2011)
Availability and alignment of adequate shared resources, experiences and skills (Powell Davies et al., 2010, Jackson et al., 2007, McCarthy et al., 2009b, KPMG, 2008, Ling et al., 2012)
Standardised procedures, tools, and central advisory group (McCarthy et al., 2009b, Boyarsky and Parke, 2012)
Investment in IT allows effective data sharing, decision support tools and dissemination of information and resources (Curry and Ham, 2010)
Compatible IT and information transfer system (Jackson et al., 2007, Ling et al., 2012)
IT resources to access information and enable reporting requirements (KPMG, 2008)
Electronic medical records and high performing information systems (Larson, 2009, Curry and Ham, 2010, Maeng et al., 2012, McCarthy et al., 2009b)
Ensuring IT privacy and security of data (Cumming, 2011)
Appropriate collection and use of data to inform improvements (New Zealand Ministry of Health, 2006, Ham et al., 2011)
Guidance on techniques to facilitate
engagement and development of partnerships (Local Health Integration Network, 2010a).
6.6.5. Funding arrangements
Funding arrangements that are complex, insufficient, inflexible, provisional, or lead to competition and conflict are common barriers to integration efforts worldwide (Table 15). Similarly, high start-up costs, or perverse incentives that lead to over-servicing or patient ‘dumping’ are problematic. In contrast, some form of capitation or universal funding; and adequate establishment and
maintenance funding to support integration were common enablers in the research literature.
Table 15 Funding arrangements
Challenges to integration Enablers to integration
Partial funding arrangements lead to lack of coherence and make links more difficult to establish and maintain (Cumming, 2011, Ham et al., 2011)
Complex funding arrangements are confusing (General Practice Services Committee, 2012, Shinto, 2010)
Insufficient funds to offer comprehensive health to all (e.g. VHA) (Curry and Ham, 2010)
Competing funding arrangements may lead to conflict (Kendall et al., 2012)
Fixed budgets that do not allow for
collaboration capacity (e.g. community health organisations) (Powell Davies et al., 2009)
Funding to support partnerships not sustained (McDonald et al., 2007)
High start-up and maintenance costs (e.g. ACOs) (FTC and the Department of Justice, 2011)
Perverse incentives may lead to over-servicing;
or patient ‘dumping’ (e.g. US HMOs)
Capitation and universal funding(National Health Committee, 2000); and salaried providers (Larson, 2009, Fisher et al., 2012, Enthoven, 2009, Zhou et al., 2010)
Adequate establishment funding and support for partnerships and administration to maintain them, particularly to achieve long-term goals (Cumming, 2011, New Zealand Ministry of Health, 2006, Center for Community Health and Evaluation, 2008)
Financial incentives aligned with organisational goals (Curry and Ham, 2010)
Episode-based payments encourage good quality, comprehensive, integrated care (Ham et al., 2011)