Taking integrated care forward in Europe: a need for a strategic direction?
Over the past two decades an important demographic and epidemiological transition has taken place in Europe which has seen age-related and long-term chronic illness replace communicable disease as the biggest challenge that health systems must now address. This presents a significant problem since it comes at a time when health and welfare budgets are under pressure. The ability to find a way to sustain or even improve health outcomes within limited financial resources has become the greatest of challenges.
Current health systems in Europe, however, appear to be ill-equipped to meet the challenge as they have over many years developed systemic and institutional structures that focus on cure rather than care. As a result, most countries have begun the search for structural or technological solutions that embrace new and more integrated care models that place the emphasis on preventing ill health, supporting self-care, delivering care closer to people’s homes, eliminating waste and duplication, and reducing the reliance on hospitals and long-term care institutions.
In recent years, many national governments across Europe have accepted the narrative in favour of integrated care and have introduced policies or pledges to support it. Recent examples include The National Collaborative for Integrated Care and Support in England; Coordination reform in Norway; Care structure laws in Germany (Versorgungsstrukturgesetz); and care groups using bundled payments to manage chronic disease in the Netherlands. At a European-wide level, the quest for ‘action’ to accelerate the adoption of integrated care strategies is tangible, both in terms of investment in research such as Project INTEGRATE but also through commitments to collective action for integrated care via the impressive European Innovation Partnership on Active and Healthy Ageing. Being personally involved in both of these initiatives it is clear that the energy and commitment for change is high.
Nonetheless, in scanning across the strategies that have been taken forward, I cannot help but feel that not enough is being done to free-up care systems at a local level in a way that allows them to innovate and so provide care collaboratively. National strategies have tended to focus on three main strategies: structural reform, economic incentives (linked to outcomes), and legislative change. Yet, a key tendency of these approaches has been to centralise the administration and funding for integrated care, and/or to create specific pilot or demonstration projects. This has not allowed innovation towards new ways of working at the scale and pace required to meet future needs.
The truth is that integrated care strategies can never be successful if they are only mandated from above since the levers for change are limited. Those who have experienced first- hand how to make integrated care work, such as Ken Kizer who headed the successful transformation of Veterans Health in the USA, will tell you that care operates as a complex adaptive system, so change cannot be specified and controlled. Rather, small changes in critical elements of the system need to be leveraged to produce large change.
If strategies must be driven from the bottom-up, this will require the ability to develop and support a cultural and operational willingness for collaboration at a clinical and service level with the investment in the necessary capacity and capability to match. Engaging patients, carers and the wider community to become ‘fully engaged’ as co-producers of their own care is essential, yet undervalued. Attention to the future workforce so that multi-professional working is embraced is needed. Overall, caring for older people and meeting their complex needs should be a much higher priority than it is.
Attempting to recalibrate the way care is provided to meet such challenges will take considerable time and effort, but the burning platform created by the European economic crisis and combined with the changing demographics of disease has created a compelling case for change. Long-term political support and commitment will be essential to this, but unless these political strategies allow for innovation and new ways of working at the front-line then it will be an opportunity missed.
For Integrated Care (IFIC)