NHS reforms: the five laws of integrated care

The listening exercise is over and the results are in; the NHS Future Forum insists integrated care must underpin how health and social care is delivered – and they are right. But do we really understand what this means, and what it implies?

As our recent event on the role of integrated care highlighted, the true meaning of the term 'integrated care' remains elusive. It is the equivalent of the psychologist's ink-blot test – meaning different things to different people – enthusing some, threatening others, bemusing many.

Most can agree that integrated care is person-centred, bringing together formerly fragmented and sub-optimal services to significantly improve the quality and experience of care to individuals. Research shows that there are many different ways of doing this, and that – where implemented appropriately – patient experiences and care outcomes can improve significantly.

However, history tells us just how difficult it is to turn the concept of integrated care into an operational reality: most of the schemes that promoted integrated care in the past have perished, and only a few very good examples have stood the test of time.

To explain some of the reasons for this is it is worth going back to examine the 'five laws' of integrated care developed by Walter Leutz following his observations of the process in the UK and USA. These laws contain enduring truths.

Law 1: You can’t integrate all of the services for all of the people

The fundamental questions here are: who you should target for integrated care? and what intervention is the most effective to use? Get the answers wrong and the result will often be unnecessary or uneconomic. For example, case management is a labour-intensive approach that is unlikely to be cost effective unless it is targeted accurately. Much of the evidence in the UK shows there remains a steep learning curve to getting this right.

Law 2: Integration costs before it pays

Costs are unavoidable, but savings are not assured. There is an element of risk in integration, and this has never sat well with the risk-averse culture in health and social care (let alone in the current financial environment). As a result, and on the basis that it's far better to risk someone else's money rather than your own, many integrated care schemes remain limited to grant-funded and/or small-scale pilots with no real sustainable commitment behind them.

Law 3: Your integration is my fragmentation

Even if a manager implicitly recognises the benefits of integrated care, they may feel it undermines or fragments their role. By its very nature, the process of integrated care requires strong leadership and skilful handling to broker the partnerships required to make it work. This is why so much research in this area focuses on the development of social capital to foster a common vision for change, and why financial inducements or enforced accountabilities alone can often commercialise relationships rather than promote collegiate working.

Law 4: You can't integrate a square peg into a round hole

All integrated care is local and no one model can be effectively prescribed. Whereas the problem to resolve may look similar, (say, reducing re-admission rates to hospitals because step-down care is inadequate), the approach to solve it must be adapted to meet local circumstances. Hence, integrated care is not a solution that can be implemented wholesale or imposed from on high. It must be built from the bottom up, driven by local ownership, within a system that rewards this.

Law 5: The one who integrates calls the tune

Integrated care has largely been the business of providers and has not necessarily reflected the values of patients and communities. Indeed, in many cases, dominant professional elites can emerge, reflecting their own values and interests above others. Effective integrated care networks need skilled managers to broker a common path between partners that have competing interests. True 'coalitions of the willing' are rare.

There is a clear need for a more integrated health and social care system. Yet making integrated care work locally has been variously described as 'pushing a boulder uphill' or 'swimming against the tide' due to the inherent difficulties in the process.

Much of the success of the government's integrated care project will therefore rest on consistent system leadership at the top to turn this tide and support local innovation. Revisions to the Health and Social Care Bill mean that integrated care should be explicitly promoted, potentially providing the stimulus towards this enabling environment. A window of opportunity has been created that is too important to miss.

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#499 Tricia Woodhead
Health Foundation Quality Improvement Fellow 2010 and consultant radiologist
Weston Area Health Trust

I am provoked to ask 'where is the patient in all of this'. Nick's observations of the reputation for integration is concise. A quick google of the definition generates the phrases 'unified whole' and 'harmonious'. Perhaps this is where the confusion arises, what is harmonious or unified for organisations may not be so for the patient and their family. If we are tasked with redesign of care so as to integrate we must have patients and families at the table. Their perspective of good integration should be the benchmark. I anticipate that work the Kings Fund, Health Foundation and others are supporting will make this very clear to providers and commissioners. International centres of excellence in integration (parts of Sweden and the US Mid West) have included patients in all their decision making for some time. We should learn from them.

#501 John Kapp
Social Enterprise Complementary Therapy Co,

Patients want treatments that cure their conditions. Polls show that 3 out of 4 patients want complementary therapy to be free on the NHS, because they know from experience that it works. There are 6 complemenarty therapies that are NICE-recommended, and patients have the statutory right to them under the NHS constitution, yet the waiting time for them on the NHS is thousands of years. for how the integration of complementary therapy into the NHS could transform public health and halve statistics by 2016, at less cost to the taxpayer.

#502 Kathy Torpie
Keynote Speaker and Author In The patient Voice

The enduring truth of these five laws apply to most attempts at any kind of major organizational or social change. As such, they lead me, as a psychologist and long term patient to the following conclusions about how to respond to these laws as a guide post rather than as a barrier..

Law 1: You can’t integrate all of the services for all of the people
Therefore, rather than NHS choosing WHO to target for integrative care, it seems to make more sense to promote integrative care and invite communities, who are interested and willing to commit from the onset, to choose for themselves whether they want to be involved. Without that kind of buy in and ownership from the participants, any major change is unlikely to succeed

Law 2: Integration costs before it pays
That is why NHS would take responsibility for marketing the potential benefits of integrative care in order to get the buy in necessary for the community to accept the risks for an idea that it believes in and fully owns from the start. The community would be fully supported, rather than "led" from the top

Law 3: Your integration is my fragmentation
This is true if integration is imposed from the outside on a community that does not already have a strong sense of shared values and a commitment to sharing power and responsibility to realize shared goals

Law 4: You can’t integrate a square peg into a round hole

Law 5: The one who integrates calls the tune
That is why the people 'calling the tune' should be the community that chooses integrative care for themselves. The role of the government should be to promote integrative care, to educate the public abut the benefits and to guide and support those communities who choose this approach for themselves rather than "manage" them from the top down

By "community" I refer to representatives of all key stakeholders, including medical professionals and management, social services, local government, patients and their families.

#503 Alida Farmer
Service Development Manager

At last someone has gone back to Leutz and the excellent document put together by the Integrated Care Network! Totally agree about the role of service users and communities. I believe that integration can be commissioned - sure it's about cultural change and leadership, but working with partners across sectors, through proper procurement, CAN make it happen - with clear outcome frameworks

#506 Richard Ward
GP Practice manager

Where to begin...
Perhaps then we should focus not on the difficulties of integration but more on solutions to make it work. So thanks Nick for setting out a framework
Law 1: How should we target scarce resource into an integreated approach to get biggest benefit to patients? Some suggestions / examples would help.
Law 2: Who do we need to re-assure / encourage to be less risk averse? How have these problems been overcome in successful ventures?
Law3: How can we re-assure the "gate keepers" who see integration as a loss of power... Stop re-organising?
Law 4: Relate some examples of "bottom up" systems working
Law5; Balance is required. patient and community opinion about priorities is valid, but it is only part of commissioning / procuring / providing appropriate services
So, less on the difficulties, more on solutions and for goodness sake establish a shared learning system to make sure we aren't all left to invent the proverbial wheel!

#507 Dr Paul Worthington
Programme Manager
Hereford PCT

Putting aside John Kapps own statistics (which inspire a whole host of methodological questions), I'm most intrigued by his claim that bringing complementary therapies into the NHS could 'halve statistics by 2016'. I'm all in favour of less and more focused data, but this does seem a claim too far...........

#508 Alan Moore
Manager in General Practice

Law 2 really should be Law 1 - and the major hurdle before moving on to any others. ALL change costs - and the previous Government spent billions and still did not realise this fundamental. The present Government needs to learn the same lesson as well. Integration is a good idea and is patient-centred but if not properly funded will just be another expensive idea that raises public expectations, places extra unsustainable burdens on the NHS and won`t work. The only achiv=evement might be that it will waste more money.

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