Ashgate Publishing, 2004, pp 499,
ISBN 0 7546 4196 1
This volume is an invaluable resource for those seeking comparative information on the policies and practices for the provision of integrated health and social care for older people across nine European countries. It results from the first phase of the PROCARE research project funded under the EU Fifth Framework Programme and prefaces a second phase currently being completed.
Nine chapters providing the detail for the specific countries, each written by a local research team and supplemented by vignettes of good practice examples, are preceded by two overview chapters. The introductory chapter by Kai Leichsenring seeks to address core issues—different understandings of integrated care, different strategies for its achievement, and the impact of the varying national contexts. This discussion has value well beyond the specific context of provision for older people, rehearsing the variety of definitions and bravely attempting a characterisation of the participating countries according to eight key concepts, ranging from the whole system approach being promoted within the UK to the emphasis on person-centred practice in the Netherlands and Denmark and on what is termed transmural care in Finland, integration across residential and domiciliary services. Together with the exploration of different components of integration—care management, strategies for intermediate care, needs assessment and joint planning, user choice, integration of professional cultures, care-friendly communities, support for informal (family) care, quality management—this distillation from the specifics of different national strategies and from the detail of almost 50 pilot or mainstream projects begins to address the elements which may be seen as fundamental to the development of a theory of integrated care.
This is the goal for the second overview chapter, by Andy Alaszewski, Jennie Billings and Kirstie Coxon. In practical terms they address four key areas: an identification of the need for and the barriers to the provision of integrated care for older people in Europe; a discussion of the alternative definitions of integrated care which highlights the importance of a person-centred approach; an exploration of the alternative strategies for overcoming the barriers to integrated care; and a critical examination of alternative approaches to the evaluation of integrated care. This chapter is perhaps best regarded as ‘work in progress’: it outlines the building blocks with which those seeking to devise a theory of integrated working for older people are juggling. It highlights the particular challenges associated with the management of ill health in older people in a context where ageism may be prevalent, it underlines the complex organisational and financial environments within which integration is sought, it explores integration within the framework of the structure, process and outcome model developed by Donabedian, and it suggests key markers, for example social inclusion, against which the progress towards integrated care might be evaluated. The specification of outcome measures through which the impact of integrated working can be assessed is essential; without such evidence the argument for integrated working remains one of assertion rather than certainty. Six somewhat embryonic approaches to such assessment of integration are sketched.
The remaining chapters provide, country by country, a wealth of detail on legal, structural and financial frameworks, on contrasting policy emphasis and on practice initiatives—and also on emerging commonalities. The Integrierte Gesundheits-und Sozialsprengel (Integrated Health and Social Care Districts) of Austria, the Danish Skaevinge project offering 24 hour integrated health and social care, the Laatuvanttu discharge project in Finland, the St-Martin d'Hères Coordination Gérontologique in France and the KAPI in Greece all provide fascinating detail of models for integration. But all the national chapters offer a concise and accessible portrait. On a personal note, writing from Scotland, I would like to have seen more acknowledgment within the UK chapter of the policy divergence post devolution, particularly stark in this arena. Indeed this chapter might more accurately have been titled England, thereby removing a number of inaccuracies generated by extrapolating from England to the broader UK.
There would have been scope within this study for further systematic comparison and classification across the different nations, perhaps one might say for further ‘integration’ of the data. A collaboration across nine sites is, however, no mean achievement and the editors should be commended. The provision of health and social care for older people, ‘one of the most prominent shortcomings in European health and welfare systems’ (p. 10), presents one of the key opportunities—and challenges—for the integrated working agenda. If the second phase of this project, detailed case studies of model ways of working, can proceed to the identification of a robust and sustainable strategy for service delivery it will be a major advance.