1) The document discusses various definitions of integration, including coordination of individual patient care, joined up services at an organizational level, and a single system for needs assessment, commissioning, and service provision. 2) There is evidence that integration can provide benefits by improving care coordination and aligning incentives, as seen in integrated models like MCOs and coordinated systems for older adults. 3) Successful integration requires organizational structures to guide collaboration, multidisciplinary teams, provider networks, and incentives to encourage shifting services to less intensive levels of care. However, fully integrating all services for all people is difficult to achieve.

1. Setting the Context
Chris Ham
University of Birmingham

2. Definitions
• Integration is often used to describe a
solution to the problem of fragmentation
• ‘The term ‘integration’ has taken on a wide
range of meanings…as it can signify
anything from the closer coordination of
clinical care for individuals to the formation
of MCOs that either own or contract for a
wide range of medical and social support
services’ (Leutz, 1999)

3. Definitions (2)
• Integration and coordination
• Coordination is often used to refer to
joined up care for individual patients
• The importance of care coordination is
increasingly recognised – see recent work
by OECD and by Bodenheimer
• Integration is usually used at a meso or
macro level e.g. to refer to Kaiser-like
organisations, and partnership working

4. Definitions (3)
• ‘In its most complete form, integration
refers to a single system of needs
assessment, service commissioning,
and/or service provision’ (Integrated Care
Network)
• Vertical/virtual integration
• Provider integration – partial or total
• Clinical/service/organisational
• Integration of commissioning and provision

5. Q.1
• How are we using the term integration in
our discussions and in the DH pilots?

6. The Evidence
• Naomi’s paper brings much of the evidence
together
• More recent work confirms there are benefits
from integration (Enthoven at NT in May)
• This work draws on the experience of MCOs in
the US
• There is also good evidence from other systems
e.g. Europe and Canada on integration of older
people’s services (HSMC paper)

7. Characteristics of MCOs
• Multispecialty group practice
• Team work
• Defined populations
• Aligned incentives
• Medicine-management partnership
• IT/EMR
• Accountability to stakeholders
(Shortell and Schmittdiel, 2004)

8. Characteristics of integrated
services for older people
• Organisational structures to guide
integration
• Multidisciplinary team care with case
management
• Organised provider networks
• Incentives to promote downward
substitution of services
(Kodner, 2006)

9. Leutz’s 5 laws of integration
• You can integrate all of the services for
some of the people, some of the services
for all of the people, but you can’t integrate
all of the services for all of the people
• Integration costs before it pays
• Your integration is my fragmentation
• You can’t integrate a square peg in a
round hole
• The one who integrates calls the tune

10. Q.2
• If integration brings benefits but is not
easy, then how and where do we start the
journey in England?

11. Different routes to integration in
England
• Primary care reaching into hospitals to move
services closer to home (Epsom)
• Partnership between PCTs and NHSFT and
their clinicians (Birmingham/Solihull)
• Specialist moving out of hospital to develop an
integrated diabetes service in the community
(Bolton)
• Partnerships between health and social care
e.g. Care Trusts
• Specialist networks e.g. cancer and heart
disease

12. Different routes (2)
• Vertical integration as in Kaiser is at one
extreme (likewise the Scottish and NZ
structures)
• The US has many other examples – looser and
virtual – that may be more relevant
• Multispecialty practice and aligned incentives
appear to be critical
• The history of the medical profession in England
and current health reform incentives present a
major challenge

13. Q.3
• What incentives would help to promote
integration?
• What would encourage GPs and
specialists to bridge the divide?
• What is the role of IT/Connecting for
Health in supporting integration?
• Does there need to be choice and
competition between integrated systems?