The integration journey can be difficult; the number of stakeholders, complexity of implementation and significant change required to processes and practice present numerous challenges for integration leaders.
Some of the main pitfalls highlighted in the literature on integration include:
integrating services without identifying the reasons for their underperformance and evaluating all options for improvement
integrating organisations without considering changes needed at all levels of health system including individuals and teams
unexpected consequences of change
poor engagement of stakeholders throughout developing and implementing integrated programme.
Even after the point of integration, further challenges can affect the successful delivery of the integrated care vision. Barriers to delivering the benefits of integrated care during implementation may include, for example:
absence of commitment to integration among healthcare providers
conflicting interests among the organisations providing healthcare
insufficient resources to develop the integrated service
inadequate mechanisms of payments or reimbursement between organisations
poor exchange of information on patient health records between healthcare professionals
poor coordination of care across the integrated service
insufficient focus on patients’ needs and wishes when planning and delivering care
moving care to primary care without preparing and up-skilling the workforce
tensions between healthcare professionals because of uncertainties over their new roles and responsibilities, misunderstandings over priorities in care, and resistance to change.
Integrating diabetes care across different professions, services and organisations in Oxfordshire was bound to encounter some challenges. Indeed, we have faced a number of difficulties that have delayed implementation of the new integrated service. This prolonged and sometimes bumpy journey has given the programme team a deeper understanding of established ways of working and the complexity of providing services across organisations.
Working in a changing environment
The NHS environment is constantly changing. New local and national healthcare priorities may provide opportunities and impetus for integration projects if the specialty area falls under the policy remit, but may create challenges if it does not. This can be especially challenging if the integration project has originated as a bottom-up movement affecting one specialty in times of huge transformation.
Even a programme that is well into the advanced stages of development may be hindered if it is not aligned with new policies. This was the case in Oxfordshire, where the local Sustainability and Transformation Plan seemed to promise financial or organisational support for integration, but at the same time disrupted the programme timeframe and consumed resources, resulting in confusion within the team.
Making decisions
Another challenge we experienced was a lack of clarity regarding decision makers and decision influencers in each stakeholder organisation. This is crucial as the right people need to be informed and convinced about the value of integration.
Personnel changes
Several changes in key personnel, both clinical and managerial, have impacted the integration project and set back the timescale. Maintaining continuity of the programme when key people leave and new people join the team, has been a challenge; it takes time for new team members to get up to speed, grasp the vision, and understand their role and purpose in the team. Integration is a long-lasting process that constantly changes, and keeping stakeholders fully engaged over time will always be difficult.
Further reading
Miller R, Brown H, Mangan C Integrated care in action. A practical guide for health, social care and housing support. 2016. London: Jessica Kingsley Publishers.
Hussain S., Dornhorst A. Integrated care-taking specialist medical care beyond hospital walls. A report to the Royal College of Physicians Future Hospital Programme. 2016. London: RCP. Link
Frontier Economics. Enablers and barriers to integrated care and implications for Monitor. A report prepared for Monitor. 2012. London: Frontier Economics. Link