Integrated care in Europe: description and comparison of integrated care in six EU countries
International Journal of Integrated Care, 6 November 2003 - ISSN 1568-4156
Book review
Integrated care in Europe: description and comparison of integrated care in six EU countries
Edited by A van Raak, I Mur, B Hardy, M Steenbergen, A Paulus
Maarssen: Elsevier Gezondheidszorg, 2003, pp 208,
ISBN 90 352 2605 4
I.N. Fabbricotti

The integration of health care, social care and other related services has become a universally accepted and pursued strategy in modern health care systems, in order to improve the delivery of health care. However, the development of integrated care has proven to be a difficult task. The aim of this book is to provide its readers with insight into the challenges and problems that six European countries face in pursuing their integration strategies, as well as the solutions they have chosen. The purpose of the book is to draw lessons from these experiences by describing, comparing and confronting them with a theoretical model. The editors claim that the lessons are useful for health care practitioners (policymakers, managers, health care professionals) as well as for academics.

In the introductory chapter, the relevance and purpose of the book are described along with an outline of some characteristics of integrated care. The editors state that with the ageing of the population setting in, the number of service users with complex and multiple demands increases. In many countries it has become widely acknowledged that resolving the fragmented delivery of health care is of utmost importance in order to respond to the growing demand of these service users in a cost effective and demand focused manner. Therefore, many European countries have chosen to integrate healthcare delivery. By doing so, many similar and different inhibiting and promoting factors are encountered, that should be dealt with. Some of these are due to the specific institutional context in which these countries operate, while others are related to cultural, interpersonal, knowledge-based and power-related characteristics of the different parties involved. The editors assume that a systematic examination of the development of integrated care in these countries will help to make better decisions.

In the following six chapters, experts from Finland, Sweden, Austria, Spain, The Netherlands and England describe the integration of care in their country. Every country is described along the same dimensions: The main characteristics of each country's care system (care sectors, legal and financial arrangements and policy), the nature of integrated care (target groups, health care organisations, professionals and services, organisational features of integrated care) and the promoting and inhibiting factors (legislative, financial, cultural and structural). With a case description in every chapter, the integration of care is further illustrated and made more vivid. Both the Finnish and the Austrian case, entail a description of an ICT-project. The Swedish authors present an account of a conducted research on the so-called ‘chain of care’ concept. Some regional, local and national innovations are described in the case presented from Spain. In the Dutch case, the focus is on the impeding influence of the lack of commitment and trust in a network of providing and facilitating parties. The main focus of the English case is on projects aimed at integrating the fragmented care for elderly with dementia. In a reflective final paragraph, the countries’ integrated care activities are evaluated and some prospective comments are made on the future of integrated care.

Every chapter contains valuable information on ongoing political debates and health care reforms by focussing on the division of authority between territorial levels (the national state, the region, the municipalities) and purchasers and providers. Attention is also given to inter-organisational arrangements (e.g. protocols and multidisciplinary teams), the importance of commitment and support, conflict and competition, and the assessment, provision and monitoring of integrated care activities. Taken together, the empirical chapters provide a well-documented and comprehensive description of the system characteristics and the nature of integrated care in the six European countries. However, because all systems are described along a multitude of similar dimensions, there is an inherent danger that each paragraph will read as yet another enumeration of factors and facts. Moreover, the principal emphasis on the features of integrated care and the health care system, is made at the cost of a more action-oriented analysis of underlying sociological dynamics, i.e. the games that the involved stakeholders play and the relationships between causes and effects. Hence, an analysis of the inter-relatedness of all of the mentioned factors is missed. This is also the case in the first part of the concluding Chapter 8.

This final Chapter 8, the authors offer a comparison of the six systems, along the same dimensions as the ones in the preceding chapters. The authors conclude that the main similarity in the system's structures is their fragmentation. Even though different in their own kind, this fragmentation is due to the tremendous number of participating stakeholders and existing legislative, governance and organisational arrangements. Many system differences, on the other hand, result mainly from the degree in which the countries’ health care system has been historically derived from the Bismarck model or the Beveridge model.

Secondly, they state that although the importance of integrated care is expressed in the health care policies of all the countries under examination, the extent to which these political ambitions have been implemented and propagated differs in many important ways. Sub-national variation seems to be only apparent in the bigger countries. Similarities between countries are to be found in the providers and services that are involved in integrated care. In all countries, moreover, integrated care seems to be focussed mainly on the chronically ill elderly. Finally, many countries use organisational tools such as multidisciplinary teamwork, case management, protocols and ICT. The main differences between the countries are to be found in the points of entry and assessment. In every country there seem to be more constraining than facilitating factors and the inhibiting factors even increase with every step taken in the integration process. Despite all the barriers, every country believes that the development of integrated care will proceed.

Does this comparison give us a better understanding of the choices we have when we are developing and implementing integrated care in practice? The answer is twofold. Even though the similarities and differences between the countries are summarised in an almost perfect way and therefore give insight into alternative arrangements, it is mostly just that. You now know what the countries do and don't have, but you still wonder what the impact of all these are on the process and outcome of integrating care. In order to shed more light on this matter and to help readers assess their own configuration, the authors introduce a theoretical framework from a configurational theoretical perspective. The model is comprised of the concepts of structure, power and culture. All authors state that the division of power between government and society is not the decisive factor for the development of integrated care. The relative power that professionals have does however greatly impact the integration of care. They also state that in countries with an individualistic culture integrated care is developed more than in countries with a collectivist culture.

Unfortunately, the theoretical model presented by the authors has very little surplus value as an analytical and explanatory tool. The conceptualisations of structure, culture and power are too global to be of any analytical help and it remains unclear how these concepts derive from or can be applied to the described integration of care in the six countries under examination. It almost seems as if the authors have developed the model independently of the data gathered.

Finally, the authors present the lessons that can be learned. The authors suggest, firstly, that policymakers should make an analysis of the structure, power and culture of their own national configuration in order to make a better choice between competing strategies and to anticipate the problems they are likely to encounter. Secondly, policymakers should engage in, and learn from, cross-national comparisons. Thirdly, in order to be able to deal effectively with professional resistance, the authors offer health care managers a list of beneficial interventions that can be undertaken. The fourth lesson is directed to the European Union, which, according to the authors, should develop more knowledge and a better understanding of the impact that national configurations have on integrated care. The final lesson is that integrated care demands a goodness-of-fit between the instrumental and organisational tools that are being used and the specific national configuration in terms of structures and culture. The authors then present several tools that may help political entrepreneurs and health care practitioners to create a shared vision of integrated care, viable structures, responsiveness and trust, and tools to develop the necessary skills and expertise. A checklist in the appendix can further help managers with their integration strategy.

Does this study fulfil its ambition? As has been said above, the aim of this book was to provide lessons and a learning experience by comparing the development of integrated care in different health care systems. After reading the conclusions the reader is left with some disappointing feelings. In three out of five concluding lessons, the authors essentially do nothing more than recommending that the involved actors undertake the analysis by themselves. Even though the authors do make some comparative and instructive comments, no clear comparative analysis of facilitating and constraining factors is made. Much is left to the reader's own imagination and analytical capabilities. What kinds of solutions are most feasible in different configurations and why this is the case are questions that remain unanswered. The authors state that

those who expected this study to provide them with ready-made solutions could be disappointed

and that

insights and tools are offered but the readers themselves have to decide which knowledge and tools to add to their-tool-kit, which fit in with the characteristics of their own configuration

but even with this said, as a reader you cannot help but feel that the book does not completely live up to the expectations the authors seem to have instilled.

One reason for this could be that the book is written for a very broad audience. According to the editors, policymakers, managers, care providers and academics should all be provided with information they seek and deem relevant. True, the book does provide every group with interesting information, but to really satisfy all targeted groups, a much more in-depth comparative analysis of different aspects of integrated care on different system-level aggregates should have been made. Secondly, the emphasis tends to be mainly on the system characteristics. Policymakers, executive managers and academics that focus their studies on international comparisons will therefore benefit the most from the book. The paragraphs on organisational features, co-ordination mechanisms, tools and influencing factors contain valuable information for middle managers and health care professionals, but although valuable and instructive, they also have a less prominent place.

In sum, the book's added value is mainly in its elaborate description of integrated care in different countries. The authors can be applauded for these well-structured and well-written descriptions. Readers are provided with a tremendous amount of interesting and important information. However, unfortunately, the book does not satisfactorily enhance our understanding of the relation between different system characteristics and the promoting and inhibiting factors for integrated care, nor does it help us understand how we can undertake and use comparative analysis ourselves to make better decisions. Although this book has descriptive value, its analytical and explanatory value, therefore, remains limited.