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Defining Pooled’ Place-Based’ Budgets for Health and Social Care: A Scoping Review


Davide Tebaldi ,

Research Associate, Health Organisation, Policy & Economics (HOPE), Centre for Primary Care and Health Services Research, University of Manchester, Oxford Road, Manchester M13 9PL, GB
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Jonathan Stokes

Research Fellow, Health Organisation, Policy & Economics (HOPE), Centre for Primary Care and Health Services Research, University of Manchester, Oxford Road, Manchester M13 9PL, GB
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Introduction: Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target ‘places’, broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches.

Methods: We initially conducted a scoping review, a systematic database search (‘Medline’, ‘Embase’, ‘Econ Lit’ and ‘Google Scholar’) complemented by further snowballing for academic and ‘grey literature’ publications (1995 – 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.

Results: Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.

Conclusion: Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

How to Cite: Tebaldi D, Stokes J. Defining Pooled’ Place-Based’ Budgets for Health and Social Care: A Scoping Review. International Journal of Integrated Care. 2022;22(3):16. DOI:
  Published on 13 Sep 2022
 Accepted on 23 Aug 2022            Submitted on 18 Jan 2022


The lack of integration of budgets across the health and social care sectors is a potential barrier to better-integrated care [1, 2, 3]. When there are two or more providers of different services to an individual (‘user’), those services interact to define the overall benefit to the user and indirectly influence each provider’s contribution to the health and social care system [1, 4]. For example, inappropriate social care capacity will affect the user’s well-being and increase the risk of hospital admission (and possibly the cost) [5]. Equally, hospital care that reduces impairment may reduce future social care costs. The productivity of each provider is closely interdependent, and not considering this joint production of patient outcomes might represent a unique missed opportunity for the health and care systems [5, 6, 7, 8].

In theory, pooled budgets could incentivise each organisation to consider outside of their very own ‘slice’ of budget activity. This could help sectors achieve shared goals more efficiently, for instance, by avoiding the duplication of services [9]. Therefore, in theory, pooled budgets are more likely to consider and produce holistic outcomes for the populations they serve. However, while several theories on the potential benefits of pooling budgets on health outcomes and service use exist [2, 9, 10, 11, 12, 13], the vast majority of which are based on the economic concept of the agency theory, less convincing empirical evidence supports this theoretical prediction [2, 10, 14, 15]. The agency theory predicts [2] that given the interdependencies between the health and social care sectors described above, it is unlikely that rewarding each provider separately for each package of care they produce will result in the best achievable health outcomes for patients. This is because in a single agency relationship each individual provider will have incentives to economise and thus to achieve the lowest cost of delivery consistent with its own goals. An alternative approach could be to align different providers incentives by tying them together financially with a single capitated budget covering both health and social care for each individual covered. In such a scenario, in absence of asymmetric behaviour and assuming a common governance and regulatory framework between providers, this kind of gaming behaviour should cease to exist. However, several systematic reviews summarised the effectiveness of pooled budgets [1, 2, 3, 4, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28] and, overall, despite some positive results, the evidence they produced remains sparse and still surrounded by numerous uncertainties [2, 3, 29, 30, 31, 32]. These uncertainties related to pooled budgets in the empirical evidence are partly due to several nebulous implementations of the concept, with a high degree of heterogeneity [2, 3]. What is more, the available academic literature has not been able to describe this heterogeneity [2, 10] entirely, a first step to unpack ‘what works, in which circumstances and for ‘whom’. For instance, there is some evidence of unintended consequences associated with the implementation of pooled-budget initiatives such as premature discharging and increased risk or readmission but, overall, there is also a current lack of emphasis on what the role of the macro environment might be and on potential unintended consequences [2]. Therefore, there is a need to clarify how real-world examples of pooled budgets have been practically implemented internationally.

Furthermore, addressing this descriptive gap seems increasingly important, given the shift from early integrated care models, which were highly focused on a small number of high-cost/-risk individuals [33, 34], to the more recent approaches which aim to target ‘places’ [31, 35], broader geographically defined populations and towards incentivising more preventative, proactive care [36]. This shift is happening globally [35]. In England, for example, this change is clear from the Vanguard ‘New Care Models’, aimed at maximising the value for patients by promoting better integration between health and social care organisations [37], in line with the NHS long term plan, a comprehensive programme which was designed to tackle the growing demand for health and social care services [31, 38, 39, 40]. The aforementioned change is also clear from the most recent reform of Integrated Care Systems (ICSs) [40], inspired by US Accountable Care Organisations, which aims to promote partnership of organization to deliver better joined up health and social care services. A recent White Paper related to ICS reform, published by the Department of Health and Social Care, highlights the importance of a place-based care system to deliver this change. It also announced a sizeable legislative change to remove barriers for more efficient joint working between the NHS, local government, community health services, and voluntary organisations at local and system levels [41]. Arguably, the pooling of budgets has increasingly become a political choice to align incentives among different partners forming the health and social care system. This political choice explicates either through national policies [6] or regional/local initiatives e.g. MESO-level integration [42]. This review addresses these gaps by scoping the available literature for practical examples of pooled budgets between health and social care, establishing critical criteria upon which to describe and differentiate these examples, and, among current examples, identifying which of them could be considered a whole ‘place-based’, pooled budget approach.


Several reasons contributed to adopting the scoping review methodological framework [43, 44, 45]. Firstly, the heterogeneity, complexity and frequent lack of clarity in the description and definition of ‘pooled place-based budgets’ required a flexible and exploratory approach that can be difficult to achieve with a more traditional narrow-focused systematic review [43, 44, 45, 46, 47]. Secondly, the available literature around the topic is sparse and with a lot of the budget description occurring in the grey literature, such as reports, policy statements, and other non-academic sources [9, 35, 36, 48, 49, 50], which demanded a more malleable approach able to incorporate evidence from a wide variety of different sources [46, 51]. Thirdly, this research aimed to map conceptual boundaries and provide working definitions for ‘pooled place-based budgets’ rather than answering a specific pre-defined research question, such as whether these interventions effectively achieved better-integrated care.

Following the latest guidelines for conducting scoping reviews, the present study was developed in six stages, described below: (i) Identifying the research question, (ii) Identifying relevant studies, (iii) study selection, (iv) charting the data, (v) collating, summarizing, and reporting the results, (vi) consultation [44, 46, 47].

Identifying the research question

To answer the main research question of what constitutes pooled place-based budgets, we first had to define a set of sub-questions against which the examples of pooled budgets identified in the literature were extracted and initially described. These were:

  1. Which budgets are being pooled? e.g., single services vs multiple services
  2. How much of the total budget is being pooled?
  3. At which population level? e.g. national, regional or neighbourhood level
  4. Is the budget fully place-based? i.e. is it allocated based on a geographical determination
  5. Does the macro-environment e.g. a set of economic, demographics, natural and social factors/condition that exists in a specific geographical area, affect the primary structure or boundaries and implementation?
  6. What are the reported intended and unintended consequences?

Identifying relevant studies

We searched the published and grey literature for examples of pooled health and social care budgets. We included qualitative and quantitative studies and adopted a three-stage search strategy. In the first stage, we systematically searched relevant databases, including Medline, Embase, EconLit, and Google Scholar, by combining synonyms of “pooled budget”, “place-based budget”, and similar words related to the broad concept of integrating funds for health and social care. It is worth noting that Google Scholar was specifically included in the systematic search strategy for its ability to effectively capture the majority of the relevant grey literature on a topic of interest by simply using a single search facility rather than a plethora of individual websites [52]. As previous research has found, Google Scholar was able to retrieve a substantial amount of the relevant grey literature on a specific topic of interest [52]. Therefore, we hoped that the inclusion of this database would also be able to identify the relevant international grey literature on pooled health and social care budgets. The initial search strategy was tailored to identify exclusively existing review studies since we were aware of at least ten systematic reviews that had already examined financial mechanisms to promote inter-sectorial action for health, including pooled budgets. We identified further review articles from the grey literature by searching among the relevant databases of independent charities in the field of health and social care, the King’s Fund, the Social Care Institute for Excellence (SCIE) and the Health Foundation, all British institutions but with an interest in providing international evidence and examples for integrated care and other health and care system reforms. Secondly, we conducted a hand-search among the list of references identified within relevant reviews for the primary studies of interest. Finally, we attempted to identify any examples not included in the previous reviews through a further ‘snowballing search’ [53]. According to this approach, we iteratively searched for additional materials we had identified as included (e.g. qualitative studies providing more detail when a primary study identified was quantitative with fewer details of the budget itself) and additional examples referenced within included primary studies. This last stage allowed the flexibility to include primaries studies that, for various reasons, might not have been included among the records previously identified [53]. All the extracted articles were stored on the reference managing software Endnote X9. As follow the complete list of inclusion and exclusion criteria:

Inclusion criteria:

  • Academic publications and non-peer-reviewed literature describing practical examples of previously separate budgets forming a ‘new’ pooled budget, as defined by Mason et al., 2015, i.e. each partner contributes to a common fund for spending on agreed projects and services to achieve shared outcomes. This definition does not imply that one of the partners must have been formerly focused on healthcare alone and the other on social care alone.
  • The ‘new’ pooled budget is used to finance and/or provide, at least, health and social care services. Services of any scope, a single service or a broad set.
  • Only articles with sufficient details to determine whether the pooled budget initiatives were practically implemented in the ‘real-world’ setting. Consequently, the articles must contain evidence that the ‘new’ budget as described above was directly used to finance and or provide, at least, health and social care services.
  • English Language.
  • Only studies published after 1995, given that the interest in how pooled budgets can promote intersectorial action for health, can largely be traced after that period.
  • Evaluation (quantitative, qualitative, or mixed methods studies) available in the literature.

Exclusion criteria:

  • Schemes that exclusively integrated non-financial resources, e.g. staff, facilities, equipment or know-how.
  • Schemes where the management and accountability for the pooled budgets remained entirely separate, e.g. aligned budgets, lead commissioning.
  • Sources lack details to determine whether the pooled-funding initiative passed the planning stage.
  • Guidelines for how to implement pooled budgets (however, relevant primary sources were sourced in this case, where available).
  • Articles that did not have, as their primary focus, the description of pooled budgets arrangements.
  • Articles with insufficient information to determine whether they meet the inclusion criteria.

Study selection

The attention was on the component and definition of ‘pooled’ and ‘place-based’ budgets for health and social care, focusing on the uncertainties related to the main research question. We concentrated on programmes or interventions that passed the planning stage and for which an evaluation, from the academic or non-academic literature, was already available.

Mapping the data

Based on the literature’s initial screening, we iteratively developed an extraction template to classify the key characteristics of the examples of ‘pooled budgets’ and facilitate the comparison across their different components. As a result, we extracted the following information from the selected references included in the final qualitative synthesis:

  • Title of the publication.
  • First author and year
  • Study design
  • Country
  • Country health system type [54]
  • Target population
  • Description of the budget
  • Whether the pooled budget is also place-based, i.e. geographical component
  • Summary of the study findings

Collating, summarising and reporting the results

We analysed and reported the information from the selected studies to map the existing literature on ‘pooled’ and ‘place-based’ budgets for health and social care. We first reported the results from the search and screening, described above. We then summarised the main characteristics of the examples of pooled budgets that satisfied our list of selection criteria in a table. Subsequently, the summary information was analysed thematically according to each sub-question, shown above, and reported separately in two different subsections of the main results. The first subsection defines how the international examples of pooled budgets were described across the key domains in the literature. The last subsection focuses more on specific case study examples most consistent with the concept of ‘place based’ budgets. These case studies were intended to add more description of the specific cases of the ‘place based’ budgets, although there were too few examples to overly-generalise in relation to the research questions for these specific cases.


Finally, an initial report containing a summary of the preliminary findings of the current review was presented on two different occasions to local policymakers within the Greater Manchester devolved health and social care region with policymakers giving general feedback on the suitability of the findings in terms of policy applicability (details in the appendix).


Figure 1 shows the flowchart diagram for the systematic search and screening of the included review studies. The initial database search identified 381 peer-reviewed academic studies. A further 11 grey-literature reports were retrieved. In total, 392 articles were identified at this stage. After 23 duplicates were removed and a further 40 records were retrieved by hand searching the selected references, one author DT proceeded to the title and abstract screening of the remaining 415 records. Therefore, the last count of 61 papers was eligible for full-text screening. Among these 61 records, 48 did not meet the inclusion criteria and were removed. Thirteen review studies satisfied all the inclusion criteria and were therefore included in the final qualitative synthesis [1, 2, 3, 4, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 28].

Flowchart diagram of the study selection process for the systematic search
Figure 1 

Flowchart diagram of the study selection process for the systematic search.

We then identified and classified the relevant international examples of pooled budgets by looking directly at the sources of primary studies within the reviews. A total of 24 primary studies were identified at this stage [6, 9, 10, 18, 22, 29, 32, 42, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88]. Subsequently, the additional ‘snowballing’ search identified a further 12 primary studies [7, 15, 59, 69, 70, 71, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98]. Thirty-six primary studies were therefore included in the final synthesis (see Figure 2) [6, 7, 10, 11, 23, 29, 32, 42, 51, 55, 56, 57, 58, 59, 60, 62, 63, 64, 66, 67, 68, 69, 70, 71, 83, 90, 91, 92, 93, 94, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118].

Flowchart diagram of the study selection process for the further ‘snowballing’ search
Figure 2 

Flowchart diagram of the study selection process for the further ‘snowballing’ search.

Ten broad categories of pooled budget models across seven countries were identified (see Table 1). However, the description of the models was often generic and not reported in detail regarding their practical implementation elements. For example, it was not always straightforward to retrieve information about the size of the budget and if it was composed of additional or existing funds. Furthermore, very few examples could claim to be entirely place-based. Out of the ten broad examples of pooled budget initiatives, only three described a population-based approach.

Table 1

Summary of the models included in the final qualitative synthesis.


1. Australian Coordinated Care Trials (ACT) [32, 66, 72, 73, 74, 75]. Australia National Health Insurance
Regulation: State
Financing: State
Provision: Private
Population size: ~5000 participants for each of the nine trials.
Population description: Patients with complex healthcare needs
Monetary size: Capitated budget of 0.50 to 5 Australian dollars per participant per day depending on which sites.
Existing/Additional funding: Additional
Service included: a broad set of services.
No Study Design: Randomised controlled trial
Summary of findings: cost-neutral and the mean quality of life did not improve.

2. SIPA (System of Integrated Services for Aged Persons) [9, 18, 22, 68, 73, 83, 84, 85]. Canada National Health Insurance
Regulation: State
Financing: State
Provision: Private
Population size: 606 participants
Population description: elderly persons.
Monetary size: capitated budget of $400 per patient per year.
Existing/Additional funding: Additional
Service included: a broad set of services
No Study Design: Randomised controlled trial
Summary of findings Accessibility increased, no significant difference in hospital services utilisation or costs.

3. The Program of All-inclusive Care of the Elderly (PACE) [76, 77, 78, 79, 80, 81, 119, 120] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: 651 participants.
Population description: frail elderly persons
Monetary size: capitated budget.
Service included: a broad set of services
No Study Design: A cross-sectional time-series
Summary of findings: Decreased hospital admission rates and hospital length of stay.

4. The British Columbia Model [61, 86, 87, 121] Canada National Health Insurance
Regulation: State
Financing: State
Provision: Private
Population size: regional model
Population description: frail elderly persons
Monetary size: n/a
Existing/Additional funding: additional
Service included: broad set of services
No Study Design: Cost-minimisation analysis
Summary of findings: No difference in life satisfaction.

5. Accountable Care Organisations (ACOs)[11, 15, 26, 35, 96] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: Various sizes. More than 750 ACOs in the U.S. serve around 20 million people.
Population description: All the insured individuals in that specific geographical area
Monetary size: Capitated budget under a contractual arrangement with an insurer.
Existing/Additional funding: Service included: a broad set of services
No Study Design: Various evaluations (both qualitative and quantitative).
Summary of findings: mixed findings: mixed

ACO example: Kaiser Permanente [9] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: 8.7 million people in eight regions.
Population description: All the insured individuals in that specific geographical area
Monetary size: Capitation payment.
Existing/Additional funding: Existing
Service included: broad set of services.
No Study design: Various evaluations (both quantitative and qualitative)
Summary findings: one of the top-performing health systems in the U.S.

ACO example: The Veterans Health Administration (V.A.)[9, 88] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: Regionally based.
Population description: older people
Monetary size: Capitation payment.
Existing/Additional funding: Existing
Service included: broad set of services
No Study design: Various evaluations, both quantitative and qualitative
Summary findings: Reduced hospital bed days by 55 per cent

ACO example: Geisinger Health System [9] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: 2.6 million people
Population description: People with high healthcare needs
Monetary size: Bundled payments
Existing/Additional funding: Existing
Service included: a broad set of services
No Study design: Various evaluations, both quantitative and qualitative
Summary findings: increased productivity and patient satisfaction.

6. Gesundes Kinzigtal [58, 59, 71, 90] Germany Social Health Insurance
Regulation: Societal actors
Financing: Societal actor
Provision: Private
Population size: ~35,000
Population description: nearly half of the 69,000 residents of the Kinzigtal region
Monetary size: shared savings contract based on (virtual) capitated budget
Existing/Additional funding: additional
Service included: a broad set of services.
Yes Study design: Propensity Score Matching
Summary of findings: reduction of 2.5 years in mortality rate.

7. The Arizona Long-Term Care System (ALTCS) [122, 123] United States Private Health System
Regulation: Private
Financing: Private
Provision: Private
Population size: all the individuals in a given geographical area.
Population description: patients at high risk of institutionalisation.
Monetary size: capitated budget
Existing/Additional funding: additional
Service included: a broad set of services.
No Study design: computer simulation with survey data.
Summary of findings: decreased nursing home utilisation

8. Better Care Fund (BFC) [8, 29, 124, 125, 126, 127] England National Health Service
Regulation: State
Financing: State
Provision: State
Population size: 14,362,968
Population description: All the patients ehad any planned or emergency hospital admission in the two financial years before the first adoption of the BCF.
Monetary size: £5.3 billion in 2015/16, and£5.8 billion in 2016/17 for a total of £11.1 billion over the two years.
Existing/Additional funding: existing funds
Service included a broad set of services
No Study design: ordinary least squares (OLS) regression and quasi-experimental methods (difference indifference).
Summary of the findings: no effects on secondary care use for the whole population. Increased use of bed days increased in the short-term by 0.164 (4.9%) per patient per year

9. Norrtalje [42, 55, 56, 57] Sweden National Health Service
Regulation: State
Financing: State
Provision: State
Population size: 65,000.
Population description: Residents of Norrtalje
Monetary size: Capitated budget. Up to 5% of the local authorities’ budget.
Existing/Additional funding: Existing funding
Service included: broad set of services.
Yes Study Design: Pilot, qualitative.
Summary of findings: Improved coordination but no cost reductions nor improvements in health outcomes.

10. Eksote [128] Finland National Health Service
Regulation: State
Financing: State
Provision: State
Population size: 132,000.
Population description: Residents of EKSOTE region
Monetary size: 550 million €
Existing/Additional funding: Existing funding
Service included: all social and healthcare services
Yes Study Design: various studies both qualitative and quantitative.
Summary of findings: avoid necessary visits and optimized hospital admission

Health system country context

The vast majority of the international examples of pooled budgets are from private insurance-based health systems. For example, much of the evidence comes from the nearly a thousand examples of Accountable Care Organisations (ACOs) in the U.S. [9, 11, 12, 15, 16, 17, 19, 23, 26, 35, 51, 85, 97, 100, 118, 122, 123, 129, 130, 131, 132, 133]. However, more examples of initiatives to integrate budgets for health and social care are also emerging from Social Insurance/National Health Systems, both in Europe [6, 7, 8, 9, 33, 35, 36, 42, 48, 49, 50, 55, 56, 57, 58, 59, 62, 63, 68, 71, 90, 94, 98, 99, 101, 103, 117, 134] and worldwide [4, 9, 11, 15, 16, 17, 19, 23, 26, 35, 51, 61, 66, 74, 75, 77, 79, 80, 81, 83, 85, 86, 87, 97, 121, 129, 131, 132, 133, 135, 136, 137, 138, 139]. The health system in place in the country where pooled health and social care budgets were implemented seemed to have played a potential role in shaping their form. Initiatives from insurance-based systems appeared to be more oriented towards the provision side (e.g. expanding services delivered towards social care within given budgets), where reforms in National Health Systems involved changes mostly on the funding side (e.g. joining once separately dedicated health and social care budgets to commission services).

Target population

This review identified two broad categories of pooled budget models. Mostly, pooled budgets targeted a specific sub-population, often people with high healthcare needs [8, 9, 32, 33, 35, 48, 49, 50, 61, 66, 68, 69, 70, 74, 75, 77, 79, 80, 81, 83, 85, 86, 87, 95, 121, 122, 123, 133, 135, 136, 137, 139]. In fewer instances, they served an entire population living in a pre-determined geographical area, i.e. ‘place-based’ pooled budgets [42, 55, 58, 59, 71, 90]. Although often cited as examples of ‘place-based budgets’ [8, 9, 35, 36], ACOs in the U.S. cover defined geography of the integrated provider, but only the insured fragment of that geographical population [11, 15, 19, 35, 140]. Norrtalje in Sweden and Eksote in Finland (both with a National Health Service) were the only example of fully ‘place-based’ budgets identified [42, 55]]. However, these models covered a relatively small populations, roughly 65,000 in each local authority area in the case of Norrtalje [42, 55] and the 132,000 residents of the South Karelia region in the case of Eksote [128]. A hybrid example is represented by Gesundes Kinzigtal, operating what it calls a ‘population-based’ model across half a rural region in the Kinzig Valley in Germany (with a Social Insurance model) [58, 59, 71, 90].

General structure

Where reported, there was wide variation in the broad aspects we were able to measure, including monetary size [32, 79, 83, 90], whether the budget came from existing [11, 15, 26, 74] or additional funds [32, 58, 75, 90], and the range/comprehensiveness of services covered [32, 42, 55, 56, 57]. However, in most cases, the budget appeared to be calculated based on population size [18, 68, 83], sometimes with additional variable elements determined by payment type, like fee-for-service or bundled payment [9, 35].


We found considerable variation in the range of outcomes reported across the various examples of pooled budgets identified in Table 1. Health outcomes included life satisfaction [61], mortality morbidity and quality of life. In addition, some models reported detailed intermediate clinical outcomes. These included blood pressure, cholesterol and BMI, a measure of secondary care use such as length of in-hospital stay [75], the number of hospitalisations/home hospitalisation [68, 83], delayed discharge and nursing home days [68, 83]. Among the non-health outcomes, cost per patient [66, 86]. In some instances, identifying unmet healthcare needs was an unintended consequence of pooled budgets [15, 29]. Other unintended consequences of studies, in PACE, for example, found that some programmes denied access to those with psychiatric or substance abuse problems (‘cream skimming’) [120].

Historical or existing budgets

The present review identified two broader categories of pooled health and social care budgets. On the one hand, we found examples of initiatives where historical budgets lines were pooled together to co-finance health and social care services, e.g. the UK’s Better Care Fund [8] or Norrtalje in Sweden. On the other hand, we found evidence of models/systems of care that expanded the range of service offered based on pre-existing historical budgets, e.g. ACOs or Gesundes Kinzigtal. For example, ACOs are increasingly shifting their boundaries beyond the traditional definition of healthcare by providing services that align more closely with social services. As above, in the former case, the initiative’s focus was more oriented to the funding side. In the latter, the change mainly happened on the provision side, expanding preventative services offered.

The following sections focus on three illustrative case studies of the closest ‘place-based’ examples identified above, illustrating macro-system differences.

The Norrtalje Model, Sweden – an example in a National Health Service

In 2006, Norrtalje, a local authority north of Stockholm in Sweden, implemented a single organisation-administered pooled budget for all health and social care for the entire population of circa 65,000. The pooled budget initiative entailed creating a new, single integrated provider organisation that became in charge of delivering the totality of health and social care services. In addition, a joint political board formed by twelve members, six from the local municipalities and six from the county, was to administer the entire organisation, including the right to appoint and dismiss the integrated care provider’s chief executive officer (CEO). What is more, this new organization retains funding responsibilities for the entire population of Norrtaelje and therefore it can be considered an example of a fully place based budget.

Before implementing the reform, the legacy system included the Stockholm county council providing owned and tax-funded primary care and hospital specialist care. Except for two independent family practices, all healthcare personnel were salaried employees of the county council. The Norrtalje local authority, on the other hand, owned and funded local social care, operated a public nursing home, and contracted private home care services. The result was simplified from the previous 40 different contracting agreements between payers and providers to contracting only the integrated organisation through the single pooled budget.

According to a qualitative study [55], fears over the closure of a local hospital were a key motive for implementing the organisational/financing changes in the first place and, as may occur in many relatively small and isolated regions, there is a local spirit that allowed for and drove change – in this case it was known as the Norrtaelje spirit [42]. However, the administrative and pooled budget changes alone were insufficient. Additional barriers such as different working cultures concerns over work boundaries and autonomy, perceptions of extra coordination work still had to be overcome with subsequent projects. The study also reported implementing both organisational/pooled funding changes simultaneously to the service delivery would have faced capacity issues, so they were implemented in phases. Introducing the economic changes also brought much additional administration, having to meet national and county requirements and proving to regulators that the new distribution adhered to the rules for each traditional budget, plus the financing rules of the new integrated joint commissioning board. All considered, it took over five years for any qualitative improvement to patient experience and outcomes to be reported.

Eksote, Finland – an example in a National Health Service

Established voluntarily in 2008, all the nine municipalities in the South Karelia region in Finland decided to form a joint municipal federation called EKSOTE [128]. Starting from 2010, this new organization, in charge of the whole population budget of €550 million, became responsible for all social and healthcare services in the region. As was the case in Norrtalje, this budget was entirely allocated based on geographical determination, and thus can be considered fully ‘place based’. The services covered by this new established budget include but are not limited to hospital and family services, rehabilitation services, oral and mental healthcare, social services for adults, and special services for the disabled. Eksote is administered by a regional management organization with direct management links with local service providers. The latter pay Eksote a monthly fixed sum. If these financial assets are not sufficient to cover service provisions, Eksote municipal federation cannot ask for additional funds, and it needs to mark a bookkeeping deficit. More specifically, Eksote organization includes Council, an Administrative Board and an Advisory Board of municipality managers. The Council retains the highest decision-making power, including appointing the administrative board and approving financial plans and budgets. Its members are elected from representatives of the municipal councils of the participating municipalities. In addition, an activity-based reimbursement system is in place in Eksote, where providers receive additional resources if they make improvements, such as reducing hospital admission or receiving a penalty otherwise. The underlying principle behind this reimbursement system is to introduce competition across providers to reward high-value care for the region’s residents. To date, some promising examples of integrated services are emerging from Eksote. For instance, the rehabilitative home care service supported independent living by providing multidisciplinary interventions at the older person’s home. As a result, it decreased healthcare and social services utilisation over 24 months compared to usual care, according to the findings of a recent randomized controlled trial [141].

Gesundes Kinzigtal, Germany – an example in a Social Health Insurance

Gesundes Kinzigtal–“Healthy Kinzig Valley” is an integrated care system located in the Kinzig Valley, south-western Germany [59]. The regional for-profit healthcare management company Gesundes Kinzigtal GmbH administers the whole health care budget for nearly half of the 69,000 residents of the Kinzigtal region. It is a joint venture between health management private for-profit company OptiMedis AG (1/3 of the total shares) and physician Medizinisches Qualitätsnetz—Ärzteinitiative Kinzigtal (literally, Medical Quality Network—Physicians Initiative Kinzigtal), a network of physicians which holds 2/3 of the total shares. A population-based approach, which covers a whole range of health service and beyond for the all the people living in defined geographical area e.g. the Kinzig Valley involves a close collaboration between various actors, including hundreds of providers, general practitioners, specialists and hospitals. Additionally, Gesundes has agreement with local authorities and local private providers, e.g. gyms, sports clubs and self-help groups, to expand the range of services offered beyond the ‘traditional’ health sector by including more preventative and social services. For example, they experimented with a service called ‘Social case management which was supported by social workers and offered support to people with complex social problems and addictive disorders [12].’ Therefore, Gesundes Kinzigtal GmbH is accountable for the entire health care service budget for people of all ages and care needs.

Gesundes Kinzigtal GmbH fosters collaboration with pharmacies, health and sports clubs and local governments. People living in the Kinzigtal valley are insured under one of the two participating sickness funds (which determines population membership within the region). At the heart of the Gesundes Kinzigtal GmbH lies a financial mechanism that aims to improve the margin for the contracting sickness funds. More in detail, the difference in costs sustained by the sickness funds taking part in Gesundes Kinzigtal GmbH and a benchmark calculated by standardising the average costs across all of the (over 100) sickness funds in Germany. This mechanism has been named ‘Virtual Budget’ because Gesundes Kinzigtal GmbH does not directly reimburse providers, but on the contrary, they continue to be reimbursed by their usual sickness fund [58]. However, if a sickness fund spends less for a patient insured with Gesundes Kinzigtal GmbH than it receives from the pool, Gesundes Kinzigtal GmbH will share the difference. A recent evaluation shows, Gesundes Kinzigtal GmbH, achieved a 2.5 years reduction in the mortality rate for those enrolled in the integrated care program [59].


Summary of the findings

The findings from the scoping review identified very few practical examples of successfully implemented pooled budgets that covered a whole geographical population rather than a population segment. Despite the mapping exercise establishing a considerable number of models of pooled budgets (n = 10) which spanned more than 20 years across seven different countries, the scarcity of information and variability which accompanied their description made it complex to compare them in full. Furthermore, the only three ‘place-based’ examples identified were from localised geographical areas where the macro-environment in which these models have been implemented is likely to have played a significant role in shaping their implementation. For example, the strong sense of community in Norrtalje and the Kinzig Valley (each with a total population of circa 60,000) appears to have acted as a crucial enabler for establishing the pooling of budgets given that both areas have broadly similar geographical characteristics and they both share a non-strictly urban location. Arguably, it would have been different (and probably more difficult) to implement similar radical changes in the way health and social care services are managed and organized in other settings with more open environments, a much larger population, as well as a completely different demographic profile. Furthermore, out of the 22 social and healthcare counties in Finland, only Eksote appeared to have shifted for organizing health and social care services from municipal to a regional level and still for a relatively small population size too. As such, it perhaps represents a unique case rather than the norm. Therefore, the replicability of these models outside of their specific context could be limited.

As mentioned in the introduction of this study, pooled budget funds entail the creation of a single administrative, legal, and organisational system in order to align providers’ incentives and overcome agency problems in the way health and social care is organised and delivered. Therefore, as the path dependency [142] theory also suggests, implementing these changes may be context dependent on a series of contingencies that have occurred in a specific place at a particular point in time. Another set of initial conditions might have produced different outcomes. This has been well documented in the case of Norrtalje, for example, where the integrated system/pooled budget funds met the administrative, legal and organizational system and tradition embedded in the macro-environment but it might also apply to the other two examples of place-based budgets outlined in this review to a certain extent.

Study findings concerning the wider literature

A direct comparison of the findings from the present review with the previous studies on the subject is complex because none of these studies examined pooled budgets specifically. Instead, they focused more generally on financial integration [2, 3]. In addition, even when we retrieved the primary source of information for the models included in our mapping exercise, the wide heterogeneity in how these models were described made comparisons very difficult. As a result, there is a need for more detailed reporting on the specifics of these budgets when they are rolled out to facilitate potential cross-learning. We have attempted to provide an initial framework for this reporting to facilitate this in future reports.

Strengths and limitations

Adopting a scoping review methodology benefitted this study as the method allowed us to map the literature concerning pooled place-based budgets for health and social care. This literature mapping provided a more precise overview of what pooled place-based budgets are and what conditions might be possible. Furthermore, the flexibility of its approach made it possible to identify models not included in previous reviews, e.g. from the grey literature. While we aimed to be comprehensive in our approach, likely the search strategy did not identify all publications relevant to the subject area. However, the two additional ‘snowballing searches’ in the academic and grey literature strengthened our findings.

Additionally, some models we identified in the search are potentially relevant but did not meet our “sufficient details to determine whether the pooled budget initiatives were practically implemented” inclusion criteria, or were examples where accountability of previously separate budgets remained in place with separate partners (so, not strictly a ‘pooled budget’). Some of these, for instance, were extensive nationwide centralised reforms as in Scotland or New Zealand [143, 144]. These centralised reforms deserve further exploration, particularly in terms of potential to incentivise pooled budget innovations, but were out of scope for this review where we focused on those already implemented and described at ground level.

Finally, as we were primarily interested in the descriptions of the budgets themselves, we did not assess the risk of bias of the studies included in the final synthesis, which means equal weight was given to academic and non-academic literature. This indicates that the results of the effectiveness outcomes reported should not be over-interpreted; we were interested in which outcomes were being evaluated at all.

Implications of the findings for practice and research

An overarching element of a truly ‘place-based’ approach appears to be a close provider overlap with the selected commissioning geography. This might, theoretically, be easier to achieve in a national health system, as seen in Sweden and Finland, where geographical populations can be a planning focus rather than patient self-selection to multiple insurers. One of the other themes of successful implementation of pooled budgets, in the examples of Sweden and even ACOs in the U.S. above, seems to be the simultaneous simplification of the provider landscape into a single/integrated group. Partly, this might quell powerful ‘losers’ as funding flows are changed, usually attempting to shift activity and costs away from large hospitals towards smaller community providers. Without this, it seems alignment of geographical footprints might be, at least, a prerequisite. This might be a problem in some contexts. For example, the NHS outlines primary care networks (PCNs) as a crucial part of ‘place’ in England. Still, a recent analysis of PCN geographies showed “all practices had joined a single PCN in [only] three [of the] commissioning regions” [145]. ‘Ideal’ size of PCNs was set at 30–50 K compared to the circa 250 K commissioning geographies in place at the time, so perhaps not too surprising but with probable implications for contracting and coordination. It becomes more complicated to deal with multiple contracts without this overlap, for example, potentially contracting for proportions of the total population to whom the provider provides its services.

An overarching element that denotes place-based approaches is focusing on proactive care, e.g. prevention, rather than reactive care, e.g. acute and hospital care. However, to the best of our knowledge, at present this is a theme which is relatively under-researched. One of the theoretical foundations behind the pooling of budgets stems from their ability to generate savings while maintaining the same level of quality. As described in the insurance literature, the larger the risk pool, the more predictable and stable the spending is. However, we could not identify any study that evaluated whether this is the case. Furthermore, a key limitation in any literature search is time-lag, which however cannot be resolved in the current paper. In this sense, given the importance of the topic a possible step for further research would be to conduct prospective case studies, with interviews of managers of these case studies to elicit further detail on the way pooled budgets are constructed and implemented. Finally, we did not find any study describing interventions in low/middle-income countries. To conclude, as it often the case when implementing radical organizational reforms there may be unintended consequences associated with them. However, information of the possible unintended consequences associated with the vast organizational changes found in the examples identified by this review were lacking and further research is needed in this direction, as well as to bring together more generalised learning for place based pooled budgets once more studies exist.


This article reviews practical international examples of pooled health and social care budgets, successfully implemented and evaluated in real-world settings. We investigated further these examples to assess which of them are consistent with the concept of a place-based approach. Two significant conclusions can be drawn from the current research. Firstly, very few examples were fully place-based and covered all the needs of a whole pre-defined geographical area. Secondly, despite their relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Additional File

The additional file for this article can be found as follows:


Search strategy. DOI:


Ph.Dr. Monica Andersson Bäck at University of Gothenburg Department of Sociology and Work Science The Department of Sociology and Work Science, University of Gothenburg (, Sweden.

One anonymous reviewer.

Funding Information

This research was funded by the National Institute for Health and Care Research – Applied Research Collaboration Greater Manchester (NIHR ARC-GM). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

JS was also supported by an MRC fellowship (MR/T027517/1).

Competing Interests

The authors have no competing interests to declare.


  1. Cameron A, Lart R, Bostock L, Coomber C. Factors that promote and hinder joint and integrated working between health and social care services: a review of research literature. Health & social care in the community. 2014; 22(3): 225–33. DOI: 

  2. Mason A, Goddard M, Weatherly H, Chalkley M. Integrating funds for health and social care: An evidence review. Journal of Health Services Research and Policy. 2015; 20(3): 177–88. DOI: 

  3. McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T, et al. Financing intersectoral action for health: A systematic review of co-financing models. Globalization and Health. 2019; 15(1) (no pagination)(86). DOI: 

  4. 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 Services Research. 2018; 18(1): 350. DOI: 

  5. Forder J. Long-term care and hospital utilisation by older people: an analysis of substitution rates. Health Economics. 2009; 18(11): 1322–38. DOI: 

  6. Hudson B. Ten years of jointly commissioning health and social care in England. Int J Integr Care. 2011; 11 Spec Ed(Special 10th Anniversary Edition): e005. DOI: 

  7. Humphries R. Integrated health and social care in England – Progress and prospects. Health Policy. 2015; 119(7): 856–9. DOI: 

  8. Humphries R, Wenzel L. Options for integrated commissioning: beyond barker. King’s Fund; 2015. 

  9. Curry N, Ham C. Clinical and service integration. The route to improve outcomes London: The Kings Fund; 2010. 

  10. Goddard M, Mason AR. Integrated care: a pill for all ills? International journal of health policy and management. 2017; 6(1): 1. DOI: 

  11. Addicott R, Shortell SM. How “accountable” are accountable care organizations? Health care management review. 2014; 39(4): 270–8. DOI: 

  12. Kocot SL, Dang-Vu C, White R, McClellan M. Early experiences with accountable care in medicaid: Special challenges, big opportunities. Population Health Management. 2013; 16(SUPPL.1): S4–S11. DOI: 

  13. Goodwin N, Smith J. The evidence base for integrated care. Slidepack. Available at: html. (accessed on 13 December 2011); 2011. 

  14. Farmer SA, Casale PN, Gillam LD, Rumsfeld JS, Erickson S, Kirschner NM, et al. Payment reform to enhance collaboration of primary care and cardiology a review. JAMA Cardiology. 2018; 3(1): 77–83. DOI: 

  15. McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early Performance of Accountable Care Organizations in Medicare. New England Journal of Medicine. 2016; 374(24): 2357–66. DOI: 

  16. Conway SJ, Himmelrich S, Feeser SA, Flynn JA, Kravet SJ, Bailey J, et al. Strategic Review Process for an Accountable Care Organization and Emerging Accountable Care Best Practices. Population Health Management. 2018; 21(5): 357–65. DOI: 

  17. Kaufman BG, Spivack BS, Stearns SC, Song PH, O’Brien EC. Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review. Medical Care Research and Review. 2019; 76(3): 255–90. DOI: 

  18. Beland F, Hollander MJ. Integrated models of care delivery for the frail elderly: International perspectives. Gaceta Sanitaria. 2011; 25(SUPPL. 2): 138–46. DOI: 

  19. Blackstone EA, Fuhr JP. The economics of medicare accountable care organizations. American Health and Drug Benefits. 2016; 9(1): 11–8. 

  20. Cai C, Runte J, Ostrer I, Berry K, Ponce N, Rodriguez M, et al. Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses. PLoS medicine. 2020; 17(1): e1003013. DOI: 

  21. Gupta N, Ayles HM. Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review. European Journal of Health Economics. 2019; 20(9): 1303–15. DOI: 

  22. Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: A synthesis of the evidence. International Journal of Geriatric Psychiatry. 2003; 18(3): 222–35. DOI: 

  23. Liu JL, Brook RH. What is Single-Payer Health Care? A Review of Definitions and Proposals in the U.S. Journal of General Internal Medicine. 2017; 32(7): 822–31. DOI: 

  24. Myint CY, Pavlova M, Thein KNN, Groot W. A systematic review of the health-financing mechanisms in the association of southeast asian nations countries and the people’s Republic of China: Lessons for the move towards universal health coverage. PLoS ONE. 2019; 14 (6) (no pagination)(e0217278). DOI: 

  25. Petrou P, Samoutis G, Lionis C. Single-payer or a multipayer health system: a systematic literature review. Public Health. 2018; 163: 141–52. DOI: 

  26. Wilson M, Guta A, Waddell K, Lavis J, Reid R, Evans C. The impacts of accountable care organizations on patient experience, health outcomes and costs: a rapid review. Journal of Health Services Research and Policy. 2020; 25(2): 130–8. DOI: 

  27. Baehr A, Holland T, Biala K, Margolis GS, Wiebe DJ, Carr BG. Describing Total Population Health: A Review and Critique of Existing Units. Population Health Management. 2016; 19(5): 306–14. DOI: 

  28. Maslin-Prothero SE, Bennion AE. Integrated team working: a literature review. International journal of integrated care. 2010; 10. DOI: 

  29. Stokes J, Lau Y-S, Kristensen SR, Sutton M. Does pooling health & social care budgets reduce hospital use and lower costs? Social Science & Medicine. 2019; 232: 382–8. DOI: 

  30. Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of Case Management for ‘At Risk’ Patients in Primary Care: A Systematic Review and Meta-Analysis. PLOS ONE. 2015; 10(7): e0132340. DOI: 

  31. Morciano M, Checkland K, Billings J, Coleman A, Stokes J, Tallack C, et al. New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis. Health Policy. 2020; 124(8): 826–33. DOI: 

  32. Segal L, Dunt D, Day SE. Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model. Health Policy. 2004; 69(2): 215–28. DOI: 

  33. Rand Europe E, Young LLP. National Evaluation of the DH Integrated Care Pilots. Rand Health Q. 2012; 2(1): 8. 

  34. Stokes J, Checkland K, Kristensen SR. Integrated care: theory to practice. Journal of Health Services Research & Policy. 2016; 21(4): 282–5. DOI: 

  35. Ham C, Alderwick H. Place-based systems of care. A way forward for the NHS in England. London: The King’s Fund; 2015. 

  36. Alderwick H, Ham C, Buck D. Population health systems: going beyond integrated care. King’s Fund; 2014. 

  37. Office. NA. Developing new care models through NHS vanguards: National Audit Office; 2018. 

  38. NHS. The NHS Long Term Plan. NHS; 2019. Available from: 

  39. Alderwick H, Dixon J. The NHS long term plan. BMJ. 2019; 364: l84. DOI: 

  40. NHS. Designing integrated care systems (ICSs) in England. National Health Service report, available at; 2019. 

  41. DHSC. Integration and Innovation: working together to improve health and social care for all 

  42. Bäck MA, Calltorp J. The Norrtaelje model: a unique model for integrated health and social care in Sweden. International journal of integrated care. 2015; 15. DOI: 

  43. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005; 8(1): 19–32. DOI: 

  44. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implementation Science. 2010; 5(1): 69. DOI: 

  45. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology. 2018; 18(1): 143. DOI: 

  46. Lockwood C, Tricco AC. Preparing scoping reviews for publication using methodological guides and reporting standards. Nursing & Health Sciences. 2020; 22(1): 1–4. DOI: 

  47. Peters MDJ, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis. 2020; 18(10): 2119–26. DOI: 

  48. provision Htbbtauttdcc. Social Care Institute for Excellence (SCIE); 2019. 

  49. Ham C, Heenan D, Longley M, Steel DR. Integrated care in Northern Ireland, Scotland and Wales. Lessons for England London: The King’s Fund; 2013. 

  50. Mrinska O. Integrating Health and Social Care Budgets; 2010. 

  51. Hatef E, Lasser EC, Kharrazi HHK, Perman C, Montgomery R, Weiner JP. A population health measurement framework: Evidence-based metrics for assessing community-level population health in the global budget context. Population Health Management. 2018; 21(4): 261–70. DOI: 

  52. Haddaway NR, Collins AM, Coughlin D, Kirk S. The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching. PLOS ONE. 2015; 10(9): e0138237. DOI: 

  53. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review – a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy. 2005; 10(1_suppl): 21–34. DOI: 

  54. Böhm K. Classifying OECD healthcare systems: a deductive approach; 2012. 

  55. Øvretveit J, Hansson J, Brommels M. An integrated health and social care organisation in Sweden: creation and structure of a unique local public health and social care system. Health policy. 2010; 97(2–3): 113–21. DOI: 

  56. Allebeck P. Mapping Household-Based Health Security–The Case of Sweden. Social Theory & Health. 2008; 6(1): 60–73. DOI: 

  57. Hultberg E-L, Glendinning C, Allebeck P, Lönnroth K. Using pooled budgets to integrate health and welfare services: a comparison of experiments in England and Sweden. Health & Social Care in the Community. 2005; 13(6): 531–41. DOI: 

  58. Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract. International journal of integrated care. 2010; 10: e046–e. DOI: 

  59. Busse R, Stahl J. Integrated care experiences and outcomes in Germany, the Netherlands, and England. Health affairs (Project Hope). 2014; 33(9): 1549–58. DOI: 

  60. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997; 45(2): 223–32. DOI: 

  61. Hollander MJ, Chappell NL. A Comparative Analysis of Costs to Government for Home Care and Long-term Residential Care Services, Standardized for Client Care Needs. Canadian Journal on Aging/La Revue canadienne du vieillissement. 2007; 26(S1): 149–61. DOI: 

  62. Kodner DL. Whole-system approaches to health and social care partnerships for the frail elderly: an exploration of North American models and lessons. Health Soc Care Community. 2006; 14(5): 384–90. DOI: 

  63. Landi F, Onder G, Russo A, Tabaccanti S, Rollo R, Federici S, et al. A new model of integrated home care for the elderly: impact on hospital use. J Clin Epidemiol. 2001; 54(9): 968–70. DOI: 

  64. Moran N, Glendinning C, Stevens M, Manthorpe J, Jacobs S, Wilberforce M, et al. Joining up government by integrating funding streams? The experiences of the individual budget pilot projects for older and disabled people in England. International journal of public administration. 2011; 34(4): 232–43. DOI: 

  65. Ware T, Matosevic T, Hardy B, Knapp M, Kendall J, Forder J. Commissioning care services for older people in England: the view from care managers, users and carers. Ageing & Society. 2003; 23(4): 411–28. DOI: 

  66. Battersby MW. Health reform through coordinated care: SA HealthPlus. BMJ. 2005; 330(7492): 662. DOI: 

  67. Mukamel DB, Peterson DR, Temkin-Greener H, Delavan R, Gross D, Kunitz SJ, et al. Program characteristics and enrollees’ outcomes in the Program of All-Inclusive Care for the Elderly (PACE). Milbank Q. 2007; 85(3): 499–531. DOI: 

  68. Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos A-P, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2006; 61(4): 367–73. DOI: 

  69. Baltaxe E, Cano I, Herranz C, Barberan-Garcia A, Hernandez C, Alonso A, et al. Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols. BMC Health Services Research. 2019; 19(1): 370. DOI: 

  70. Bower P, Reeves D, Sutton M, Lovell K, Blakemore A, Hann M, et al. Health Services and Delivery Research. Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT. Southampton, UK: NIHR Journals Library. Copyright © Queen’s Printer and Controller of HMSO 2018. This work was produced by Bower et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK; 2018. DOI: 

  71. de Bakker DH, Struijs JN, Baan CB, Raams J, de Wildt JE, Vrijhoef HJ, et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Aff (Millwood). 2012; 31(2): 426–33. DOI: 

  72. Gardner K, Sibthorpe B. Impediments to change in an Australian trial of coordinated care. Journal of Health Services Research & Policy. 2002; 7(1_suppl): 2–7. DOI: 

  73. Kodner DL. The quest for integrated systems of care for frail older persons. Aging Clinical and Experimental Research. 2002; 14(4): 307–13. DOI: 

  74. Masters S, Halbert J, Crotty M, Cheney F. Innovations in Aged Care: What are the first quality reports from the Transition Care Program in Australia telling us? Australasian Journal on Ageing. 2008; 27(2): 97–102. DOI: 

  75. Perkins D, Owen A, Cromwell D, Adamson L, Eagar K, Quinset K, et al. The Illawarra Coordinated Care Trial: better outcomes with existing resources? Australian Health Review. 2001; 24(2): 172. DOI: 

  76. Chatterji TP, Burstein NR, Kidder D, White A, Miller N. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration; 1998. 

  77. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing. Journal of the American Geriatrics Society. 1997; 45(2): 223–32. DOI: 

  78. Hayes KJ, Thorpe JH. New options to integrate care and financing for persons dually eligible for Medicare and Medicaid. Ann Health Law. 2012; 21(3): 561–614, i–ii. 

  79. Kane RL, Homyak P, Bershadsky B, Flood S. Variations on a Theme Called PACE. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2006; 61(7): 689–93. DOI: 

  80. Meret-Hanke LA. Effects of the Program of All-Inclusive Care for the Elderly on Hospital Use. The Gerontologist. 2011; 51(6): 774–85. DOI: 

  81. Mukamel DB, Peterson DR, Temkin-Greener H, Delavan R, Gross D, Kunitz SJ, et al. Program Characteristics and Enrollees’ Outcomes in the Program of All-Inclusive Care for the Elderly (PACE). The Milbank Quarterly. 2007; 85(3): 499–531. DOI: 

  82. Battersby M, Harvey P, Mills PD, Kalucy E, Pols RG, Frith PA, et al. SA HealthPlus: A Controlled Trial of a Statewide Application of a Generic Model of Chronic Illness Care. Milbank Quarterly. 2007; 85(1): 37–67. DOI: 

  83. Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006; 25(1): 5–42. DOI: 

  84. Bergman H, Béland F, Lebel P, Contandriopoulos A-P, Tousignant P, Brunelle Y, et al. Care for Canada’s frail elderly population: fragmentation or integration? Cmaj. 1997; 157(8): 1116–21. 

  85. Kodner DL. Whole-system approaches to health and social care partnerships for the frail elderly: an exploration of North American models and lessons. Health and Social Care in the Community. 2006; 14(5): 384–90. DOI: 

  86. Chappell NL, Dlitt BH, Hollander MJ, Miller JA, McWilliam C. Comparative Costs of Home Care and Residential Care. The Gerontologist. 2004; 44(3): 389–400. DOI: 

  87. Hollander MJ, Pallan P. The British Columbia Continuing Care system: Service delivery and resource planning. Aging Clinical and Experimental Research. 1995; 7(2): 94–109. DOI: 

  88. Wistow G, Waddington E. Learning from Doing: Implications of the Barking and Dagenham Experience for Integrating Health and Social Care. Journal of Integrated Care. 2006; 14(3): 8–18. DOI: 

  89. Henwood M, Hudson B. Individual budgets and personalisation: a new model for integration? Journal of Integrated Care. 2008; 16(3): 8. DOI: 

  90. Hildebrandt H, Schulte T, Stunder B. Triple Aim in Kinzigtal, Germany. Journal of Integrated Care. 2012; 20(4): 205–22. DOI: 

  91. McDaid D. Joint budgeting: can it facilitate intersectoral action. Governance for Health in All Policies. 2012; 111. 

  92. Glendinning C, Rummery K, Clarke R. From collaboration to commissioning: developing relationships between primary health and social services. Bmj. 1998; 317(7151): 122–5. DOI: 

  93. Hernandez C, Aibar J, Seijas N, Puig I, Alonso A, Garcia-Aymerich J, et al. Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment. Int J Integr Care. 2018; 18(2): 12. DOI: 

  94. Glendinning C, Coleman A, Shipman C, Malbon G. Progress in partnerships. Bmj. 2001; 323(7303): 28–31. DOI: 

  95. Hernandez C, Alonso A, Garcia-Aymerich J, Grimsmo A, Vontetsianos T, García Cuyàs F, et al. Integrated care services: lessons learned from the deployment of the NEXES project. International journal of integrated care. 2015; 15(1): e006–e. DOI: 

  96. McWilliams JM, Chernew ME, Zaslavsky AM, Hamed P, Landon BE. Delivery system integration and health care spending and quality for medicare beneficiaries. JAMA Internal Medicine. 2013; 173(15): 1447–56. DOI: 

  97. Muhlestein D, Saunders R, McClellan M. Growth of ACOs and alternative payment models in 2017. Health Affairs Blog. 2017. 

  98. Stokes J, Cheraghi-Sohi S, Kristensen SR, Sutton M. Work Package 2: Thick descriptions of-Salford Integrated Care Programme (SICP)/Salford Together; 2016. 

  99. Hudson B. Joint commissioning across the primary health care–social care boundary: can it work? Health & Social Care in the Community. 1999; 7(5): 358–66. DOI: 

  100. Malmmose M, Mortensen K, Holm C. Global budgets in Maryland: early evidence on revenues, expenses, and margins in regulated and unregulated services. International journal of health economics and management. 2018; 18(4): 395–408. DOI: 

  101. Glendinning C. Breaking down barriers: integrating health and care services for older people in England. Health Policy. 2003; 65(2): 139–51. DOI: 

  102. Hudson B. Circumstances change cases: local government and the NHS. Social Policy & Administration. 1998; 32(1): 71–86. DOI: 

  103. McDaid D, Oliveira MD, Jurczak K, Knapp M, Group M. Moving beyond the mental health care system: an exploration of the interfaces between health and non-health sectors. Journal of Mental Health. 2007; 16(2): 181–94. DOI: 

  104. Wilkins P. Accountability and Joined-up Government. Australian Journal of Public Administration. 2002; 61(1): 114–9. DOI: 

  105. Stokes J, Struckmann V, Kristensen SR, Fuchs S, van Ginneken E, Tsiachristas A, et al. Towards incentivising integration: A typology of payments for integrated care. Health Policy. 2018; 122(9): 963–9. DOI: 

  106. Stevens M. Individual budgets: on the launch pad. Journal of integrated Care. 2006; 14(6): 23. DOI: 

  107. Shammassian BH, Ahn A, Mukherjee D. Length of stay and disposition of patients undergoing elective spine surgery in Maryland: Impact of the global budget revenue program. Clinical Neurosurgery. 2019; 66(Supplement 1): 49. DOI: 

  108. Saliterer I, Sicilia M, Steccolini I. Public budgets and budgeting in Europe: State of the art and future challenges. The Palgrave handbook of public administration and management in Europe. Springer. 2018; 141–63. DOI: 

  109. Ragupathy R, Aaltonen K, Tordoff J, Norris P, Reith D. The effects of pharmaceutical cost containment on access to licensed and subsidized medicines under single payersystems in the United States, United Kingdom, Australia and Newzealand. Value in Health. 2011; 14(3): A14. DOI: 

  110. Peck E, Gulliver P, Towell D. Governance of partnership between health and social services: the experience in Somerset. Health & social care in the community. 2002; 10(5): 331–8. DOI: 

  111. Narayan AK, Harvey SC, Durand DJ. Impact of medicare shared savings program accountable care organizations at screening mammography: A retrospective cohort study. Radiology. 2017; 282(2): 437–42. DOI: 

  112. Kozlowska O, Attwood S, Lumb A, Tan G, Rea R. Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK. International Journal of Integrated Care. 2020; 20(4). DOI: 

  113. Hudson B, Curry N, Harris M, Gunn L, et al. Integrated care pilot in north west London: a mixed methods evaluation. Int J Integr Care. 2013; 13: URN:NBN:NL:UI:10-1-114735. International Journal of Integrated Care. 2011; 11(Special 10th Anniversary Edition). 

  114. Harlock J, Caiels J, Marczak J, Peters M, Fitzpatrick R, Wistow G, et al. Challenges in integrating health and social care: the Better Care Fund in England. Journal of Health Services Research & Policy. 2019; 25(2): 86–93. DOI: 

  115. Gavaghan M, Hertz D, Garfield S. Health economic modeling methods from an ACO provider perspective. Value in Health. 2013; 16 (3): A28. DOI: 

  116. Davey B, Levin E, Iliffe S, Kharicha K. Integrating health and social care: implications for joint working and community care outcomes for older people. Journal of Interprofessional Care. 2005; 19(1): 22–34. DOI: 

  117. Checkland K, Coleman A, Harrison S. When is a saving not a saving? The micro-politics of budgets and savings under practice-based commissioning. Public Money & Management. 2011; 31(4): 241–8. DOI: 

  118. Broffman L, Brown K, Bayley KB, Savitz L, Rissi J. Funding accountable care in Oregon: Financial models in two coordinated care organizations. Journal of Healthcare Management. 2016; 61(4): 291–302. DOI: 

  119. Lynch M, Estes CL, Hernandez M. Chronic Care Initiatives for the Elderly: Can They Bridge the Gerontology-Medicine Gap? Journal of Applied Gerontology. 2005; 24(2): 108–24. DOI: 

  120. Lynch M, Hernandez M, Estes C. PACE: Has It Changed the Chronic Care Paradigm? Social Work in Public Health. 2008; 23(4): 3–24. DOI: 

  121. Hollander MJ, Chappell NL, Prince MJ, Shapiro E. Providing care and support for an aging population: Briefing notes on key policy issues. Aging Clinical and Experimental Research. 2007; 15(3 Suppl): 1–2. DOI: 

  122. McCall N, Korb J. Utilization of services in Arizona’s capitated Medicaid program for long-term care beneficiaries. Health care financing review. 1997; 19(2): 119. 

  123. Weissert WG, Lesnick T, Musliner M, Foley KA. Cost savings from home and community-based services: Arizona’s capitated Medicaid long-term care program. Journal of Health Politics, Policy and Law. 1997; 22(6): 1329–57. DOI: 

  124. Authorities ACfL, England tNHSi, Wales. Means to an end: joint financing across health and social care: Audit Commission; 2009. 

  125. Comptroller, General A. Health and Social Care Integration. National Audit Office London; 2017. 

  126. Department of Health. 2017–19 Integration and BetterCare Fund/Policy Framework 2017 [cited 2020 December, the 17th]. Available from: 

  127. Forder JE, Caiels J, Harlock J, Wistow G, Malisauskaite G, Peters M, et al. A system-level evaluation of the Better Care Fund; 2018. 

  128. Tepponen M, Itkonen P. Case Study Finland, South Karelia Social and Healthcare District, EKSOTE. Springer International Publishing. 2021; 1169–84. DOI: 

  129. Done N, Herring B, Xu T. The effects of global budget payments on hospital utilization in rural Maryland. Health Services Research. 2019; 54(3): 526–36. DOI: 

  130. Jia JB, Lencioni R, Forman HP, Kim HS. Era of a Single Population-Based Payment to a Cancer Center: Delivering the Value of Interventional Oncology in Accountable Care Organizations. Cancer Journal (United States). 2016; 22(6): 423–6. DOI: 

  131. Davis K, Buttorff C, Leff B, Samus QM, Szanton S, Wolff JL, et al. Innovative care models for high-cost Medicare beneficiaries: delivery system and payment reform to accelerate adoption. The American journal of managed care. 2015; 21(5): e349–e56. 

  132. Anderson GF. Leadership in creating accountable care organizations. Journal of General Internal Medicine. 2011; 26(11): 1368–70. DOI: 

  133. Applebaum R, Straker J, Mehdizadeh S, Warshaw G, Gothelf E. Using High-Intensity Care Management to Integrate Acute and Long-Term Care Services: Substitute for Large Scale System Reform? Care Management Journals. 3: 113–9. DOI: 

  134. Glendinning C, Challis D, Fernández J-L, Jacobs S, Jones K, Knapp M, et al. Evaluation of the individual budgets pilot programme. Final Report York: Social Policy Research Unit, University of York; 2008. 

  135. Hébert R, Veil A, Raîche M, Dubois MF, Dubuc N, Tousignant M. Evaluation of the Implementation of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Québec. Journal of integrated care; 2008. DOI: 

  136. Hebert R, Raiche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2010; 65B(1): 107–18. DOI: 

  137. Hébert R, Durand PJ, Dubuc N, Tourigny A. Frail elderly patients. New model for integrated service delivery. Canadian Family Physician. 2003; 49(8): 992. 

  138. Billie ME, Letizia M. Serious Illness Conversations: A Case Management Quality Improvement Project. Professional case management. 2020; 25(4): 220–9. DOI: 

  139. Leung AC-T, Liu C-P, Chow NW-S, Chi I. Cost-Benefit Analysis of a Case Management Project for the Community-Dwelling Frail Elderly in Hong Kong. Journal of Applied Gerontology. 2004; 23(1): 70–85. DOI: 

  140. Fisher ES, Shortell SM. Accountable Care Organizations: Accountable for What, to Whom, and How. JAMA: the journal of the American Medical Association. 2010; 304(15): 1715–6. DOI: 

  141. Suikkanen SA, Soukkio PK, Aartolahti EM, Kautiainen H, Kääriä SM, Hupli MT, et al. Effects of Home-Based Physical Exercise on Days at Home and Cost-Effectiveness in Pre-Frail and Frail Persons: Randomized Controlled Trial. Journal of the American Medical Directors Association. 2021; 22(4): 773–9. DOI: 

  142. Auschra C, Sydow J. Path Dependence and Integrated Care. Springer International Publishing. 2021; 119–29. DOI: 

  143. Mead E. Scotland. Springer International Publishing. 2017; 525–39. DOI: 

  144. Cumming JM. Integrated Care in New Zealand. International Journal of Integrated Care. 2011; 11(5). DOI: 

  145. Morciano M, Checkland K, Hammond J, Lau Y-S, Sutton M. Variability in size and characteristics of primary care networks in England: observational study. British Journal of General Practice; 2020. DOI: