Integrated care is advocated as an effective way to improve outcomes for people with chronic disease or complex needs [1, 2]. However, much of the evidence is based on small scale studies or in specific care groups [3, 4, 5, 6, 7] and evidence of country wide large scale system change is lacking [8, 9, 10]. Recently, several regions have applied realist evaluation  and designed mixed methods studies to understand what works in scaling up integrated care [12, 13, 14, 15, 16].
This article reflects on progress of large scale, system wide reform of health and social care in Scotland since 2015. It does not purport to be an independent academic evaluation. Rather, it presents the experience of expert stakeholders in developing and implementing national policy for integrated health and social care and a critique of the related enablers, barriers, and impacts. The content draws on a documentary review and analysis of published reports conducted in 2019 by the International Foundation for Integrated Care’s hub in Scotland (IFIC Scotland) for the European Union funded Scirocco Exchange project (https://www.sciroccoexchange.com/). Synthesis was undertaken by experts with different perspectives drawn from IFIC Scotland’s multi-sector Reference Network https://integratedcarefoundation.org/ific-scotland-3. Thus, it blends both the reference and reflective quality paradigms of integrated care research .
Discussion of enablers and barriers is framed around the nine conceptual pillars proposed by the International Foundation for Integrated Care . These pillars map to the building blocks for integrated care developed by the European Commission  and operate across the macro, meso and micro levels of integrated care . The impacts of system change are based on publicly available national and local data that relate to the Quadruple Aim of improved population health, enhanced quality of care, better care and provider experience, and more cost –effective care .
As a devolved nation within the United Kingdom (UK), the Scottish Parliament has legislative powers across a wide range of policy areas including health and social care . Policy for the National Health Service (NHS) in Scotland is the responsibility of the Scottish Government and funding is resourced through a block grant from the UK Treasury. Fourteen territorial NHS Boards are responsible for planning and providing healthcare for their local population, accountable to Scottish Ministers, the Scottish Parliament and ultimately the electorate. The Convention of Scottish Local Authorities (COSLA) provides political leadership on behalf of Scotland’s 32 local councils who directly provide or commission a wide range of services including social work and social care. Around 80–85% of local authority funding comes from the Scottish Government in the form of a block grant.
The Scottish population is projected to grow from approximately 5.4 million in 2014 to 5.7 million by 2039 . By then, one in four people (25%) are expected to be over 65 years compared with 14% in 1983 . The prevalence of chronic disease in Scotland increases with age, from 25% of adults aged 16–24 to 77% of those aged 75 and over . Around one in five people (20%) in Scotland have multimorbidity and its prevalence is 38% higher in the most deprived decile compared to the least deprived areas . The onset of multimorbidity occurs 10–15 years earlier in deprived areas compared with more affluent areas, particularly multimorbidity that includes a mental health disorder .
Integrating health and social care has long been a policy ambition in Scotland [22, 28]. Faced with demographic, workforce, and financial challenges, in 2011 the Christie Commission  proposed four priorities for reform of public services:
The Reshaping Care for Older People (RCOP) programme , an early policy response to Christie, brokered collaboration between health, social care, housing, third sector and independent providers. Between 2011 and 2015, around 1% of the annual healthcare and social care budget for older people was ring-fenced as a Change Fund to be used for local transformation. The programme helped to generate support for services to be jointly planned, financed, and delivered across the whole system . Highland, in the north of Scotland, was the first area to press for radical reform and a partnership agreement between Highland Council and National Health Service Highland was established in 2012 under existing legislation . Known as the Lead Agency Model, NHS Highland took responsibility for planning, resourcing, and delivering adult health and social care services. In a reciprocal arrangement, the council became the lead for children’s services.
Faced with the scale of the required reforms, by 2011 there was cross party agreement that ambitious new legislation, strategies, and policies would be required . Widespread engagement, both national and local, fostered strong support for a shared vision and values for integration: better health and well-being outcomes through care and support at home and closer to home designed around what matters to people and communities [22, 32, 33, 34]. Macro level engagement with senior leaders from healthcare, local government, housing sector, voluntary organisations, and independent care providers was followed by dialogue with local health and social care organisations, professional bodies, care regulators and trade union representatives. A series of ‘town hall’ conversations across the country heard the voices of local citizens, family carers and the workforce. The extensive dialogue built a movement for change with strong and enduring support for the ‘why’ of integration. However, the details of the ‘what’ and the ‘how’ were less clear.
New legislation to integrate health and social care was introduced through the Public Bodies (Joint Working) (Scotland) Act 2014 . This required shadow arrangements to be in place by April 2015 and governance to fully integrate services by April 2016 through one of two models: Lead Agency (as described for Highland) or a Body Corporate Model. In the Lead Agency model, the lead agency becomes the “Integration Authority” for specific services and the accountability rests with the relevant Chief Executives and Finance Directors. With the exception of Highland , all others areas chose a Body Corporate Model where the NHS Board and corresponding local authority (or local authorities where the NHS Board interfaces with more than one local authority) delegate responsibility for planning and resourcing services to new Integration Authorities (IA) [22, 28, 35]. Thirty IAs were established as distinct legal entities, each operating under the direction of their Integration Joint Board (IJB) comprising non-executive members of the local NHS Board, elected members from the local authority and clinical, Third sector and community representatives. Two new senior posts of Chief Officer and Chief Finance Officer for each IA provide a single point of management for integrated services and related budget. The absence of an overly prescriptive approach was generally perceived as a virtue, allowing a degree of emergence to agree on the scope and details of the local organisational model.
The Chief Officers have two sets of leadership accountabilities: (i) to the IJB for strategic leadership, and (ii) to the NHS Board and local authority for operational leadership [22, 28, 35]. Chief Officers and IJB Chairs are responsible for building the effective relationships, collaboration, trust, and openness to challenge that are key requirements for successful leadership and management of integrated care [36, 37, 38, 39]. Effective system leadership for large scale change must be distributed, operating at all levels, and involve people who both use and provide care and support [40, 41]. At a macro level, the Ministerial Strategic Group  which predated the legislation continues to provide valuable high level national strategic direction and leadership for integration. At the meso level, Health and Social Care Scotland (https://hscscotland.scot) was established by Chief Officers as a national learning network to build a social movement for change and to share good practice. However, significant turnover in Chief Officers, IJB Chairs and in senior NHS, local government, and civil servants since 2016 has challenged relational continuity [43, 44].
At the point of care delivery, effective integrated care is heavily influenced by culture, trust and relationships between professionals from different teams, care setting and sectors [45, 46]. A series of coaching and collaborative action learning programmes have attempted to address these human factors . A new Masters programme ‘Leading People-centred integrated care’ was introduced by the University of the West of Scotland in 2018. Both of these initiatives target mid-career community health and care professionals and partners from third sector and strive to build leadership capability and enable succession planning. However, to date there has been limited engagement of professionals from acute hospitals in the national and local integrated care development programmes. This raises concerns about the need to further strengthen relationships between community and acute services.
Recognition of the benefit of understanding the relationships between costs, activity and variation for different population groups to inform joint strategic planning and commissioning led to the development of an Integrated Resource Framework . More than £9.4 billion in health and social care resources are now directed by IAs with approximately 70% of this funding delegated by the NHS and 30% by Local Authorities . However, in 2019, most IAs recorded deficits or requested additional funding from their National Health Service Board, local authority or the Scottish Government .
Provision of social care is acknowledged as an important contributor to current overall health and social care cost pressures. Free personal social care for people aged over 65 years, first introduced in 2002  was extended in 2019 to adults with degenerative neurological conditions. For both care groups, domestic services, day care or the accommodation element of care home costs may be chargeable. While Adult Social Care was the focus of a rapid, wide ranging independent review launched in 2020, the report of the review recommends some changes in the membership of IAs and in processes for commissioning services and care .
A strong focus on what matters to people and communities has been central to policy on integration in Scotland [22, 31, 34, 35]. Efforts to embed personal outcomes in practice have largely focused on re-orienting conversations at the point of care to achieve outcomes identified through shared decision making [53, 54, 55]. New integrated Health and Social Care Standards seek to improve personalisation and outcomes across all health and care providers . Empowerment, co-production and personalisation are further supported by legislation that places a statutory duty to offer choice in how people are assessed and receive their social care or support,  and by a human rights-based Carers Charter and legislation . IAs are tasked with involving the public, people who use services, politicians, and professionals in local service redesign. There are examples of good practice in engagement and co-design but also concerns over examples of tokenistic consultation and limited public involvement [32, 44, 59, 60].
Scottish policy has a strong commitment to outcomes and asset-based approaches [61, 62]. Health and Social Care Scotland’s Statement of intent signalled a commitment to develop new alliances to create more sustainable compassionate and caring communities . The Long Term Conditions Alliance, established in 2009 as a national intermediary for a range of health voluntary organisations, was reformed as the Health and Social Care Alliance Scotland (the ALLIANCE https://www.alliance-scotland.org.uk/) to amplify the voice of over 3,000 voluntary sector organisations and associates as partners for integration. Their analysis of progress in fostering new alliances cited continuing organisational, cultural, and financial challenges  but also many examples of successful asset-based initiatives . Examples include: Community Links Practitioners  who work alongside primary care to support people living in challenging circumstances or facing loneliness, mental health problems, addictions or debt to draw on individual and community assets; strength based collaborative care and support planning ; national and local support for self-management ; and social prescribing initiatives .
Integration has not changed the regulatory framework or accountabilities for professional practice, but national guidance describes clinical and care governance for integrated working . The National Workforce plan  set out commitments to develop the right workforce skills and capacity. Implementation of this plan is largely work in progress, but a critical step was the introduction of a new General Medical Services contract for general practitioners , supported by additional investment in primary care of £250 million to 2021/2022 . The new contract introduces new roles in primary care for community mental health professionals, community link workers, pharmacists, and advanced nursing and allied health practitioners to improve access and quality of care for individuals and communities . The independent review of social care is expected to make some recommendations on workforce capacity and capability, the vital role of the third sector, and the ‘wicked’ issue of parity of pay and conditions between social care and healthcare workers .
The vital contribution of improvement support for large scale change cannot be overstated. Between 2006 and 2016, improvement support for integrated working was provided by the Joint Improvement Team, a multi-sector improvement partnership overseen by senior representatives of the Scottish Government, NHS Scotland, COSLA, Third Sector, Independent providers and the Housing Sector [31, 34]. From 2016, in an attempt to rationalise improvement support for health and social care, the Scottish Government commissioned the established national healthcare scrutiny and improvement organisation, Healthcare Improvement Scotland, to extend their portfolio to integrated health and social care. With hindsight, changing well established implementation support relationships to IAs may have been an additional challenge at a time when relational continuity, trust and organisational memory were critical. Examples of improvement in primary care and community services are reported in several publications [39, 44, 75] and at https://hscscotland.scot/resources/.
Scotland’s Digital Health and Care Strategy  promotes technology enabled care solutions such as Home and Mobile Health Monitoring, Near Me Video Enabled consultations, Digital Platforms and Telecare initiatives. A Strategic Portfolio Board provides oversight of investment and support and has engaged advice from global experts, industry and academia . The digital health and care delivery programme helped build readiness for rapid innovation and adoption of digital solutions in response to Covid-19. Notably an improvement approach underpinned the unprecedented scale up of Near Me video enabled consultations . The approach has been well received by patients, carers, family and professionals .
The places we live in and the wider determinants of health have a powerful impact on outcomes [80, 81]. The Scottish Index of Multiple Deprivation 2020  provides granular data on these determinants for data zones of around 800 people in 6,976 neighbourhoods. The interactive tool can be used by IAs to identify where people experience disadvantage across different aspects of their lives in order to target health and care resources to local areas with greatest need. However, understanding of population health and prioritisation of targeted investment for specific localities remains relatively underdeveloped. Investment in local analytical expertise and population health management data and tools is supporting leads for strategic planning and commissioning to better meet the needs of local populations . Data Sharing Agreements specify who can get access to data, for what purpose, and set out the process for authorisation and any restrictions .
Published reports note positive progress in collaborative working and encouraging evidence of impacts, albeit with significant local variation in the pace and scale of progress [39, 42, 44, 64, 65]. Since 2017, national scrutiny bodies have undertaken detailed joint inspections in eight IAs (27%) to review leadership, performance and strategic planning and commissioning processes and outcomes. Scotland’s National Performance Framework  describes the outcomes and indicators that track progress in achieving Scotland’s national purpose, values and ambitions. IAs produce annual reports on indicators for nine national health and wellbeing outcomes . These indicators draw on routinely recorded hospital and community data and on regular national surveys of care experience. National health and care data and data linkage systems offer ways to measure the impact of the reform, in particular through analysis of key trends over time. To appreciate these trends in the context of an ageing population, it is possible to consider how trends over the decade might have looked (‘expected’) in the absence of transformational change.
Emergency hospital admissions, a sentinel system level indicator, have risen annually . The trends for people aged 65 and over admitted as an emergency, indexed to 2008/09 (prior to the RCOP programme) and presented by broad length of stay, are shown below (Figure 1). The analysis reveals a 56% increase by 2018/19 in the number of older people admitted for urgent assessment who return home within hours or after one overnight stay. The trend for stays of between 8 and 14 days rose by only 7% over the period with virtually no change since 2012/13. The number of older people staying 15 days or more has been largely static since 2008/09, whilst decreasing slightly in 2018/19.
Further perspective on changes over the decade can be gained by comparing an ‘expected’ trend, adjusted for the changing age profile of the population since 2008/09, alongside actual trends. The first example here shows such a comparison for use of acute hospital beds by older people following emergency admission. The gap between the actual and the expected use of beds (‘emergency beddays’) has increased year by year since 2008/09. The number of emergency beddays used during 2018/19 (2.8 million) is considerably less than ‘expected’ (3.5 million) based on projection of the 2008/09 rate (Figure 2).
The number of people aged 65+ in long stay hospital care has markedly declined since 2008/09 and their beddays used reduced from 472,000 in 2008/09 to 229,000 in 2018/19 (Figure 3).
When days spent in long stay hospital care are combined with acute hospital stays, the actual bed days for people aged 65+ in 2018/19 are 27% lower than the population adjusted trend would have suggested. Notably, this gap between actual and expected has not been accompanied by an expansion in long term residential care . The same comparative approach reveals the gap between actual and expected numbers of long-term care home residents has also grown – the number of age 65+ long-stay residents at March 2019 (30,418) is 20% lower than would have been expected based on 2009 rates (Figure 4).
The complexity and heterogeneity of integrated care make evaluation and attribution of economic impact difficult . However, Figures 2–4 demonstrate a significant shift to care at home, avoiding institutional care costs and releasing resource for investment in community health and care support and services. One way to appreciate the scale of the shift from the previous balance of care is to present the 2018/19 figures above as ‘daily averages’. This method suggests around 10,000 more people aged 65+ were living at home each day in 2018/19 than ‘expected’ (Figure 5).
Allied with a 6% reduction in emergency bed days for all adults (2014/15 – 2018/19), this shift has enabled a managed and proportionate disinvestment in hospital bed capacity while bed occupancy remains stable .
Multiple complex interventions have contributed to achieving this shift . Evidencing the contribution of specific interventions is not an exact science. Routine national collection of data has been principally focused, to date, on acute healthcare and, more recently, has included linkable data from statutory social care services . The impact of community interventions such as intermediate care, reablement and third sector support for wellbeing has been more difficult to assess at a national level. The full potential of linkable information from routinely collected general practice data has yet to be realised in Scotland.
One notable exception is availability of data on Anticipatory Care Planning (ACP), a person-centred approach that encourages practitioners to work with patients, carers and families to express their preferences and goals for future care. From 2008, national support for ACP built on innovation in a single General Practice  and has incrementally enabled spread to cover 5% of the population by February 2020. This focus on ACP has contributed to a modest increase in the time people spend at home or in a community setting in the last six months of life [92, 93]. Following further rapid scale up during the Coronavirus pandemic, by October 2020 around 20% of primary care clinical records included an electronic summary of the patient’s anticipatory care plan that is routinely shared with out of hours and acute care providers.
The value of qualitative information on outcomes for people, families and communities is widely recognised but is not easily tracked at a national level. Academic evaluations of specific initiatives, for example of the Links worker programme , the House of Care early adopters  and of a compassionate community in one IA , highlight many examples of improved personal, relational and community outcomes. A standardised national survey of Health and Care Experience is sent every two years to a random sample of citizens . It seeks to capture their experiences of accessing and using local healthcare services and of receiving care, support and help with everyday living and caring responsibilities. Data from the 2017/2018 Primary Care Health and Care Experience survey suggests good levels of communication but a need for greater continuity and coordination of primary care (Figure 6).
In the most affluent areas of Scotland men experience 23.8 more years of good health and women and additional 22.6 years compared to the most deprived areas . Integration of health and social care has had little impact on these systemic inequalities.
While few disagree with the vision for integration, national progress has often seemed slow and piecemeal [39, 42, 43, 44, 64]. As implementation requires careful alignment of many policies and support mechanisms with significant interdependencies, it is not surprising that there has been an ebb and flow of progress over time and across the country. One factor has been significant turnover in the first cohort of Chief Officers and IJB Chairs and by changes in key personnel in Ministerial, policy and senior NHS management posts [43, 44].
Implementing major reform after a prolonged period of austerity has proven challenging. Now the economic context is even more volatile and uncertain as a result of Coronavirus. However the pandemic has undoubtedly demonstrated what can be achieved by working together across organisational and sectoral boundaries: better local collaboration, greater ability to pivot and enhanced capability to facilitate key infrastructure and practice changes at unprecedented speed. Facing stark health and economic challenges from the pandemic , IAs and NHS Boards must further strengthen their alliances with community partners and the third sector to improve lives and opportunities through a stronger focus on prevention, early intervention and targeted action on the wider determinants of health.
Progress on addressing inequalities in Scotland has been elusive, in common with many countries . Relative inequalities have widened over the last 10 years and life expectancy at birth remains relatively poor and has not improved since 2012. Some argue this requires reimagining local governance beyond health and social care . Although there seems little appetite for further structural change in Scotland’s public bodies, there is growing recognition of a need to strike the right balance between centrally directed organisations such as the NHS and flexible arrangements for local delivery through strong horizontal integration with community partners. A Blueprint document from local government  affirms the need to accelerate progress on integration and includes proposals for the next phase of reform. Several strategic actions are already underway, including the introduction of legislation to adopt the European Charter for Local Self Government  in Scots’ law. This aims to guarantee political, administrative and financial independence for Local Authorities along with new powers to raise and set taxes and make spending decisions based on local priorities and economic realities.
Linked with this is a commitment to reinvigorate the relationship between Public Health and Local Government to improve and protect community wellbeing, particularly for vulnerable populations who have experienced greater disadvantage from the health and economic impacts of Covid-19. Public Health Scotland’s Strategic Plan 2020–2023 sets out four priority areas of action where collaboration with local government on wider determinants of health will be critical . These priorities are: Covid-19 response, recovery and renewal; understanding and influencing the economic, social and emotional factors that create good relationships and mental wellbeing, and eliminate discrimination and stigma; use of data and intelligence to understand the unique needs of Communities and Place to improve health and wellbeing in communities that experience the worst outcomes; and identifying and supporting evidence based actions to address poverty and improve child health.
Various published insights on Scotland’s integration story describe critical issues of leadership, culture, workforce, difficulties with demonstrating impact and managing a challenging financial context [22, 31, 39, 44, 64, 65, 102, 103]. From analysis of these reports and reflecting on our accumulated wisdom as expert stakeholders collaborating in developing and implementing this policy reform for over a decade, we offer five key lessons for other systems considering similar reform:
Published reports note positive progress in collaborative working and high level national data demonstrate encouraging evidence of impacts from this policy reform. Only time will tell if the potential can be fully realised in order to scale up and sustain these early gains. Notably, even ‘standing still’ in performance over the last five years has been a significant achievement given the economic challenges, increasing system demands and complexity of care needs. However, important questions remain unanswered. Could the early progress achieved through the RCOP programme  have been sustained and spread to other care groups without introducing new legislation? Is there any difference between the outcomes realised through the two models of integration (Lead Agency vs Body Corporate)? While there has been national scrutiny of progress [28, 43, 44], there has been little in-depth academic research on observed changes in local processes, relationships and cultures over time.
Experience from Covid-19 to date has demonstrated what can be achieved by working together across organisational and sectoral boundaries: better local collaboration, greater ability to pivot and enhanced capability to facilitate key infrastructure and practice changes at unprecedented speed. Careful reflection and analysis of this experience will be required to understand why this was the case and what were the respective contributions of people, communities, processes, structures and technologies in creating the conditions to enable rapid change. The Researcher in Residence model  could be a very useful vehicle for rapid, real-time and action-orientated research to understand the important opportunities for transformation in this turbulent period . This insight will be critical to strengthen alliances with community partners for population health to improve lives and opportunities for all.
In unprecedented times and in an uncertain and rapidly evolving political, economic and health and social care landscape, there is one certainty: Scotland’s integration story will continue to unfold.
Ana M Carriazo MD PhD, Senior Advisor, Regional Ministry of Health and Families of Andalusia, Spain.
Dr Axel Kaehne, Reader Health Services Research, Medical School, Edge Hill University, UK.
The authors have no competing interests to declare.
Briggs AM, Valentijn PP, Thiyagarajan JA, Carvalho IA. Elements of integrated care approaches for older people: a review of reviews. BMJ open. 2018; 8(4): e021194. Available from: https://bmjopen.bmj.com/content/8/4/e021194. DOI: https://doi.org/10.1136/bmjopen-2017-021194
Borgermans L, Marchal Y, Busetto L, Kalseth J, Kasteng F, Suija K, et al. How to improve integrated care for people with chronic conditions: Key findings from EU FP-7 Project INTEGRATE and beyond. International Journal of Integrated Care. 2017; 17(4): 7. DOI: https://doi.org/10.5334/ijic.3096
Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: A systematic review of UK and international evidence. BMC Health Serv Res. 2018; 18(1). DOI: https://doi.org/10.1186/s12913-018-3161-3
Looman WM, Huijsman R, Fabbricotti IN. The (cost-) effectiveness of preventive, integrated care for community-dwelling frail older people: a systematic review. Health Soc. Care. Commun. 2019; 27(1): 1–30 Available from: https://pubmed.ncbi.nlm.nih.gov/29667259/
Liljas AEM, Brattström F, Burström B, Schön P, Agerholm J. Impact of Integrated Care on Patient Related Outcomes Among Older People – A Systematic Review. Int J Integr Care. 2019; 19(3): 1–16. DOI: https://doi.org/10.5334/ijic.4632
Martínez-González NA, Berchtold P, Ullman K, Busato A, Egger M. Integrated care programmes for adults with chronic conditions: a meta-review. Int J Qual Heal Care [Internet]. 2014 Oct; 26(5): 561–70. DOI: https://doi.org/10.1093/intqhc/mzu071
Goodwin N, Dixon A, Anderson G, Wodchis W. Providing integrated care for older people with complex needs. Lessons from seven international case studies. London: The King’s Fund; January 2014. Available from: https://www.kingsfund.org.uk/publications/providing-integrated-care-older-people-complex-needs.
Willis CD, Riley BL, Stockton L, Abramowicz A, Zummach D, Wong G, et al. Scaling up complex interventions: insights from a realist synthesis. Heal Res Policy Syst [Internet]. 2016 Dec 19; 14(1): 88. Available from: http://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-016-0158-4. DOI: https://doi.org/10.1186/s12961-016-0158-4
Greenhalgh T, Papoutsi C. Spreading and scaling up innovation and improvement. BMJ [Internet]. 2019 May 10; 365: l2068. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.l2068. DOI: https://doi.org/10.1136/bmj.l2068
Plsek PE, Greenhalgh T. The challenge of complexity in health care. Br Med J. 2001; 323(7313): 625–8. DOI: https://doi.org/10.1136/bmj.323.7313.625
Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review – a new method of systematic review Art. 12, page 12 of 15 Goderis et al: Evaluating Large-Scale Integrated Care Projects designed for complex policy interventions. J Health Serv Res Policy [Internet]. 2005 Jul 4; 10(1_suppl): 21–34. Available from: https://journals.sagepub.com/doi/10.1258/1355819054308530. DOI: https://doi.org/10.1258/1355819054308530
Nurjono M, Shrestha P, Lee A, Lim XY, Shiraz F, Tan S, et al. Realist evaluation of a complex integrated care programme: Protocol for a mixed methods study. BMJ Open. 2018; 8(3). DOI: https://doi.org/10.1136/bmjopen-2017-017111
Stokes T, Atmore C, Penno E, Richard L, Wyeth E, Richards R, et al. Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand. BMJ Open. 2019; 9(3): 1–8. DOI: https://doi.org/10.1136/bmjopen-2019-030076
Goderis G, et al. Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium. Int J Integ Care. 2020; 20(3): 12, 1–15. DOI: https://doi.org/10.5334/ijic.5435
Read DMY, Dalton H, Booth A, Goodwin N, Hendry A, Perkins D. Using the Project INTEGRATE Framework in Practice in Central Coast, Australia. Int Journal Integ Care. 2019; 19(2): X: 1–12. DOI: https://doi.org/10.5334/ijic.4624
Kirst M, Im J, Burns T, Baker GR, Goldhar J, O’campo P, Wojtak A, Wodchis WP. What works in implementation of integrated care programs for older adults with complex needs? A realist review. Int J for Quality in Health Care. 2017; 29(5): 612–24. DOI: https://doi.org/10.1093/intqhc/mzx095
Van Kemenade EA, Van der Vlegel-Brouwer W. Integrated Care: a definition from the perspective of four quality paradigms. Journal of Integrated Care. 2019; 27(4): 357–367. DOI: https://doi.org/10.1108/JICA-06-2019-0029
Lewis L, Ehrenberg N. Realising the true value of integrated care: Beyond COVID-19. Oxford: International Foundation for Integrated Care; 2020. [cited 2020 Oct 22]. Available from: https://integratedcarefoundation.org/realising-the-true-value-of-integrated-care-beyond-covid-19.
European Commission. Tools and Methodologies to Assess Integrated Care in Europe. Report by the Expert Group on Health Systems Performance Assessment. 2017; 15. Available from: https://ec.europa.eu/health/sites/health/files/systems_performance_assessment/docs/2017_blocks_en_0.pdf.
Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J of Integ Care. 2013; 13: e010. DOI: https://doi.org/10.5334/ijic.886
Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient. Ann Fam Med. 2014; 12(6): 573–6. DOI: https://doi.org/10.1370/afm.1713
Taylor A. New act new opportunity for integration in Scotland. Journal of Integrated Care. 2015; 23(1): 3–9. Available from: https://www.emerald.com/insight/content/doi/10.1108/JICA-11-2014-0041/full/html. DOI: https://doi.org/10.1108/JICA-11-2014-0041
National Records Scotland. “Projected Population of Scotland (2014-based).” Edinburgh; 2015. Available from www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-projections/population-projections-scotland/2014-based.
National Records of Scotland. Registrar General Annual Review; 2018. Available from: https://www.nrscotland.gov.uk/files//statistics/rgar/2018/rgar18.pdf.
The Scottish Government. Scottish Health Survey 2017: volume one – main report. Edinburgh; 2018. Available from: https://www.gov.scot/publications/scottish-health-survey-2017-volume-1-main-report/.
McLean G, Guthrie B, Mercer SW, Watt, GC. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract. 2015; 65(641): e799–e805. DOI: https://doi.org/10.3399/bjgp15X687829
Barnett K, Mercer S, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of Multimorbidity for Health Care, Research, and Medical Education: A Cross-Sectional Study. The Lancet; 2012. Available from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext.
Audit Scotland. What is integration? A short guide to the integration of health and social care services in Scotland. Edinburgh: Audit Scotland; 2018. Available from https://www.audit-scotland.gov.uk/uploads/docs/report/2018/briefing_180412_integration.pdf.
Christie C. Christie Commission on the future delivery of public services. Scottish Government, 2011. Available from: www.gov.scot/publications/commissionfuture-delivery-public-services/.
Scottish Government. Reshaping Care for Older People: a Programme for Change 2011–2021. Available from: https://www2.gov.scot/Resource/0039/00398295.pdf.
Hendry A, Taylor A, Mercer S, Knight P. Improving Outcomes through Transformational Health and Social Care Integration – The Scottish Experience. Healthcare Quarterly. 2016; 19: 73–79. DOI: https://doi.org/10.12927/hcq.2016.24703
Mead E. In Amelung VS (ed.), Handbook of Integrated Care. 2017; 525–539. Springer. Available from: https://link.springer.com/chapter/10.1007/978-3-319-56103-5_32. DOI: https://doi.org/10.1007/978-3-319-56103-5_32
Scottish Government. Integration of Adult Health and Social Care in Scotland Consultation: Scottish Government Response. Edinburgh: Scottish Government; 2013. Available from: https://www.gov.scot/publications/integration-adult-health-social-care-scotland-consultation-scottish-government-response/.
Hendry A. Creating an Enabling Political Environment for Health and Social Care Integration. Int J Integ Care. 16(4): 7, 1–3. DOI: https://doi.org/10.5334/ijic.2531
Scottish Government. Public Bodies (Joint Working) (Scotland) Act 2014. Edinburgh: Scottish Government; 2014. Available from: https://www.legislation.gov.uk/asp/2014/9/contents/enacted.
Busetto L, Luijkx K, Calciolari S, Ortiz LGG, Vrijhoef HJM. Barriers and Facilitators to Workforce Changes in Integrated Care. Int J Integ Care. 2018; 18(2): 17, 1–13. DOI: https://doi.org/10.5334/ijic.3587
Timmins N. Leading for integrated care ‘If you think competition is hard, you should try collaboration.’ London: The King’s Fund; 2018. Available from https://www.kingsfund.org.uk/sites/default/files/2019-11/leading-integrated-care-summary.pdf.
Miller R, Stein KV. The Odyssey of Integration: Is Management its Achilles’ Heel? Int J Integ Care. 2020; 20(1): 7, 1–14. DOI: https://doi.org/10.5334/ijic.5440
Baylis A, Trimble A. Leading across health and social care in Scotland: Learning from chief officers’ experiences, planning and next steps. London: The King’s Fund; 2018. Available from: https://www.kingsfund.org.uk/sites/default/files/2018-07/Scottish_officers_full_final.pdf.
Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Large-system transformation in health care: A realist review. Milbank Quarterly. 2012; 90: 421–56. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-0009.2012.00670.x. DOI: https://doi.org/10.1111/j.1468-0009.2012.00670.x
Evans JM, Daub S, Goldhar J, Wojtak A, Purbhoo D. Leading integrated health and social care systems: Perspectives from research and practice. Healthc Q. 2016; 18(4): 30–5. DOI: https://doi.org/10.12927/hcq.2016.24553
COSLA & Scottish Government. Ministerial Strategic Group for Health and Community Care: Health and Social Care integration: progress review (Final Report); 2019. Available from: https://www.gov.scot/publications/ministerial-strategic-group-health-community-care-review-progress-integration-health-social-care-final-report/.
Scottish Parliament. Public Audit and Post Legislative Scrutiny Committee. Available from: [webpage on the internet]. [cited 2020 Oct 22]. https://www.parliament.scot/parliamentarybusiness/CurrentCommittees/101363.aspx.
Audit Scotland. Health and social care integration: Update on Progress; 2018. Available from: https://www.audit-scotland.gov.uk/report/health-and-social-care-integration-update-on-progress
Miller R. Crossing the Cultural and Value Divide Between Health and Social Care. Int J Integr Care. 2016; 16(4): 10. DOI: https://doi.org/10.5334/ijic.2534
Middleton L, Rea H, Pledger M, Cumming J. A Realist Evaluation of Local Networks Designed to Achieve More Integrated Care. Int J Integr Care. 2019; 19(2): 4. DOI: https://doi.org/10.5334/ijic.4183
NHS Education Scotland. Leadership and Management Programmes. [webpage on the internet]; 2020. [cited 2020 Oct 22]. Available from: https://learn.nes.nhs.scot/641/leadership-and-management-programmes/you-as-a-collaborative-leader/.
Public Health Scotland. Health and Social Care Integrated Resource Framework; 2019. Available from: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Publications/2019-11-26/2019-11-26-IRF-Health-and-Social-Care-Resource-Summary.pdf.
Scottish Government. Scottish Budget 2020-21; 2020. Available from: https://www.gov.scot/binaries/content/documents/govscot/publications/publication/2020/02/scottish-budget-2020-21/documents/scottish-budget-2020-21/scottish-budget-2020-21/govscot%3Adocument/scottish-budget-2020-21.pdf.
Audit Scotland. NHS in Scotland 2019; 2019. Available from: https://www.audit-scotland.gov.uk/nhs-in-scotland-2019.
Community Care and Health (Scotland) Act. 2002. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www.legislation.gov.uk/asp/2002/5/contents.
Scottish Government. Independent Review of Adult Social Care in Scotland; 2021. Available from https://www.gov.scot/publications/independent-review-adult-social-care-scotland/.
Andrews N, Gabbay J, le May A, Miller E, Petch A, Webber M. Story, dialogue and caring about what matters to people: progress towards evidence enriched policy and practice. Evidence & Policy; 2020. DOI: https://doi.org/10.1332/174426420X15825349063428
Personal Outcomes Network. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://personaloutcomescollaboration.org/.
Petch A, Cook A, Miller E. Partnership working and outcomes: do health and social care partnerships deliver for users and carers? Health and Social Care in the Community. 2013; 21(6): 623–633. DOI: https://doi.org/10.1111/hsc.12050
Scottish Government. Health and Social Care Standards My support, my life. Edinburgh: Scottish Government; 2017. Available from: https://hub.careinspectorate.com/media/2544/sg-health-and-social-care-standards.pdf.
Scottish Government. Self-directed support strategy 2010-2020: implementation plan 2019–2021; 2019. Edinburgh: Scottish Government. Available from: https://www.gov.scot/publications/self-directed-support-strategy-2010-2020-implementation-plan-2019-21/.
Scottish Government. Carers’ charter: your rights as an adult carer or young carer in Scotland. Edinburgh: Scottish Government; 2018. Available from https://www.gov.scot/publications/carers-charter/.
Stewart E, Greer S, Erica A, Donnelly P. Transforming health care: the policy and politics of service reconfiguration in the UKs four health systems. Health Economics, Policy and Law. 2019 April; 12: 1–19. Available from: https://www.cambridge.org/core/journals/health-economics-policy-and-law/article/transforming-health-care-the-policy-and-politics-of-service-reconfiguration-in-the-uks-four-health-systems/6BC5FD0A0FA269EB74B7047F48CAD5C6.
Scottish Parliament. Are they involving us? Integration Authorities’ engagement with stakeholders. Edinburgh: Scottish Parliament; 2017. Available from http://www.parliament.scot/S5_HealthandSportCommittee/Reports/IA_report.pdf.
Coutts P, Brotchie J. The Scottish Approach to Evidence: A Discussion Paper. Alliance for Useful Evidence and Carnegie UK Trust; 2017. Available from: https://www.carnegieuktrust.org.uk/publications/scottish-approach-evidence-discussion-paper/.
MacLeod M, Emejulu A. Neoliberalism with a community face? A critical analysis of asset-based community development in Scotland. Journal of Community Practice. 2014; 22: 430–450. DOI: https://doi.org/10.1080/10705422.2014.959147
Health and Social Care Scotland’s Statement of intent. Available from: https://hscscotland.scot/media/spotlight/statement-of-intent-future-collaborative-conversations-and-five-essential-elements.html.
Dawn Griesbach. Health and social care integration: How is it for you? Views from the public sector; 2019. Available from: https://www.alliance-scotland.org.uk/wp-content/uploads/2019/05/Health-and-Social-Care-Integration-How-is-it-for-you-Views-from-the-Public-Sector.pdf.
Health and Social Care Alliance Scotland (the ALLIANCE). Let’s Talk about Integration; 2018. Available from: http://www.alliance-scotland.org.uk/blog/news/we-need-to-talk-about-integration/.
Smith M, Skivington K. Community Links: Perspectives of community organisations on the Links Worker Programme pilot and on collaborative working with primary health care. University of Glasgow; 2016. Available at: http://www.healthscotland.scot/media/1253/27362-community-links-evaluation-report-april-2016-cr.pdf.
Cook A, Grant A. From Fixer to Facilitator, Evaluation of the House of Care programme in Scotland. Matter of Focus; 2020. Available at: https://www.matter-of-focus.com/house-of-care-programme-in-scotland-evaluation-report/.
Health and Social Care Alliance Scotland (the ALLIANCE). Self Management. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www.alliance-scotland.org.uk/self-management-and-co-production-hub/what-is-self-management/.
Health and Social Care Alliance Scotland (the ALLIANCE). Developing a Culture of Health, The role of signposting and social prescribing in improving health and wellbeing; 2017. Available from: https://www.alliance-scotland.org.uk/wp-content/uploads/2017/10/ALLIANCE-Developing-a-Culture-of-Health.pdf.
Scottish Government. Clinical and care governance framework: guidance; 2015. Available at: https://www.gov.scot/publications/clinical-care-governance-framework/.
Scottish Government. The Health and Social Care: Integrated Workforce Plan. Edinburgh: Scottish Government; 2019. Available at: https://www.gov.scot/publications/national-health-social-care-integrated-workforce-plan/.
Scottish Government. GMS contract: 2018. Edinburgh: Scottish Government; 2017. Available from https://www.gov.scot/publications/gms-contract-scotland/.
The Scottish Government. Delivering the new GMS contract in Scotland: memorandum of understanding. Edinburgh; 2017. Available from: www.gov.scot/publications/delivering-the-new-gms-contract-in-scotlandmemorandum-of-understanding/.
Mercer S, Gillies J, Noble-Jones R, Fitzpatrick B. National Evaluation of New Models of Primary Care in Scotland. Glasgow: University of Glasgow; 2019. Available from: http://www.sspc.ac.uk/media/Media_645962_smxx.pdf.
Healthcare Improvement Scotland ihub. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://ihub.scot/improvement-programmes/.
Scottish Government. Scotland’s Digital Health and Care Strategy: enabling, connecting and empowering. Edinburgh: Scottish Government; 2018. Available from: https://www.gov.scot/publications/scotlands-digital-health-care-strategy-enabling-connecting-empowering/.
Scottish Government. Digital Health and Care in Scotland. Available from: https://www.digihealthcare.scot/wp-content/uploads/2018/04/25-April-2018-EXTERNAL-EXPERT-PANEL-REPORT-published.pdf.
Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. An opportunity in a crisis? BMJ. 2020; 368: m998 (Published 12 March 2020). Available from https://www.bmj.com/content/368/bmj.m998. DOI: https://doi.org/10.1136/bmj.m998
Scottish Government. Near Me Public Engagement: Public and Clinician Views on Video Consulting; 2020. Available from: https://www.gov.scot/publications/public-clinician-views-video-consultations-full-report/.
Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On. London: Health Foundation; 2020. Available from: https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on. DOI: https://doi.org/10.1136/bmj.m693
Naylor C, Wellings D. A citizen-led approach to health and care. Lessons from the Wigan Deal. London: King’s Fund; 2019. Available from https://www.kingsfund.org.uk/sites/default/files/2019-06/A_citizen-led_approach_to_health_and_care_lessons_from_the_Wigan_Deal_summary.pdf.
Scottish Index of Multiple Deprivation. Available from: https://simd.scot/#/simd2020/BTTTFTT/9/-4.0000/55.9000/.
Public Health Scotland. A Guide to Data to support Joint Strategic Commissioning and Needs Assessment; 2018. Available from: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/docs/Guide-to-Data-to-Support-HSCPs.pdf.
Public Health Scotland. Information Governance Framework. Available from: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Local-Intelligence-Support-Team/Information-governance/.
Scottish Government. Scotland’s Wellbeing – Delivering the National Outcomes; 2019. Available from: https://nationalperformance.gov.scot/sites/default/files/documents/NPF_Scotland%27s_Wellbeing_May2019.pdf.
Public Health Scotland. Core Suite of Integration indicators. Available from: https://beta.isdscotland.org/find-publications-and-data/health-and-social-care/social-and-community-care/core-suite-of-integration-indicators/.
Public Health Scotland. Acute Hospital Activity and NHS Beds Information. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www.isdscotland.org/Health-Topics/Hospital-Care/Publications/2019-11-26/Acute-Hospital-Publication/trend-data/#beds.
Public Health Scotland. Care home census for adults in Scotland. [webpage on the internet]. [cited 2020 Oct 22] Available from: https://beta.isdscotland.org/find-publications-and-data/health-and-social-care/social-and-community-care/care-home-census-for-adults-in-scotland/.
Rocks S, Berntson D, Gil Salmerón A, Kadu M, Ehrenberg N, Stein V, Tsiachristas A. The European Journal of Health Economics; 2020. DOI: https://doi.org/10.1007/s10198-020-01217-5
Public Health Scotland. Source Tableau Platform. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Health-and-Social-Care-Integration/Introduction/.
Baker A, Leak P, Ritchie L, Lee A, Fielding S. Anticipatory Care Planning and Integration: A primary care pilot study aimed at reducing unplanned hospitalisation. British Journal of General Practice. 2012; 62(595): e113–e120. DOI: https://doi.org/10.3399/bjgp12X625175
Finucane A, Davydaitis D, Horseman Z, Carduff E, Baughan P, Tapsfield J, Murray, S. Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care. British Journal of General Practice. 2019; 70(690): e20–e28. DOI: https://doi.org/10.3399/bjgp19X707117
Public Health Scotland. Percentage of End of Life Spent at Home or in a Community Setting. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://beta.isdscotland.org/find-publications-and-data/health-and-social-care/social-and-community-care/percentage-of-end-of-life-spent-at-home-or-in-a-community-setting/.
Barrie K, Miller E, O’Brien M, Hendry A. Compassionate Inverclyde Evaluation Reports; 2018. Available from: https://ardgowanhospice.org.uk/how-we-can-help/compassionate-inverclyde/
Scottish Government. Health and Care Experience Survey, 2019. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www2.gov.scot/Topics/Statistics/Browse/Health/GPPatientExperienceSurvey.
Scottish Government. Long-term monitoring of health inequalities. Edinburgh: Scottish Government, 2020. Available from: https://www.gov.scot/publications/long-term-monitoring-health-inequalities-january-2020-report/.
Scottish Government. Coronavirus (COVID-19): evidence gathered for Scotland’s route map -equality and Fairer Scotland impact assessment; 2020. Available from: https://www.gov.scot/publications/equality-fairer-scotland-impact-assessment-evidence-gathered-scotlands-route-map-through-out-crisis/.
Scottish Government. Local Governance review. Available from: https://www.gov.scot/publications/local-governance-review-analysis-responses-ask-public-sector-organisations-outline-alternative-arrangements-public-service-governance/pages/2/.
COSLA Blueprint for Local Government. 2020. Available from: https://www.cosla.gov.uk/__data/assets/pdf_file/0021/19551/LG-Blueprint.pdf.
Scottish Parliament. European Charter for Local Self Government (Incorporation) (Scotland) Bill. [webpage on the internet]. [cited 2020 Oct 22]. Available from: https://www.parliament.scot/parliamentarybusiness/CurrentCommittees/115604.aspx.
Public Health Scotland. A Scotland where everybody thrives. Public Health Scotland’s strategic plan 2020–23. Available from: https://www.publichealthscotland.scot/our-organisation/a-scotland-where-everybody-thrives-public-health-scotland-s-strategic-plan-2020-23/.
Fooks C, Goldhar J, Wodchis W, Baker R, Coutts J. Integrating Care in Scotland. Healthcare Quarterly. 2018; 21(3): 37–41. DOI: https://doi.org/10.12927/hcq.2018.25702
Dayan M, Edwards N. Learning from Scotland’s NHS. London: Nuffield Trust; 2017. Available from: https://www.nuffieldtrust.org.uk/research/learning-from-scotland-s-nhs.
Marshall M, Pagel C, French C, Utley M, Allwood D, Fulop N, et al. Moving improvement research closer to practice: the Researcher-in-Residence model. BMJ Qual Saf. 2014; 23(10): 801–5. DOI: https://doi.org/10.1136/bmjqs-2013-002779
Glasby J, Miller R. Ten lessons for integrated care research and policy – a personal reflection. Journal of Integrated Care. 28(1): 41–46. DOI: https://doi.org/10.1108/JICA-11-2019-0047