An Overview of Progress and Potential in Health System Integration in
Canada
Prepared by John Marriott and Ann L. Mable
Prepared for:
Health Services Division
Health Care Strategies and Policy Directorate
Health Policy and Communications Branch
Health Canada
November 2002
Past Progress and Future Potential in Health System Integration
in Canada
Executive Summary
What is health system 'integration' about, and what progress
has been made in this area in Canada and elsewhere? Themes and models
of integration, long a characteristic and a tool of diversified industries
and organizations, have been adapted to health systems, to bring closer
together different (sectoral) elements of system resources, to enhance
control mechanisms and focus organizations on the people they serve. As
reported by Chernichovsky (1995) "the emerging dominance of integrated
models and reforms promotes system efficiency and consumer satisfaction
rather than a particular doctrine. Consequently it denotes efforts to
combine the comparative advantages of public systems (equity and social
[macro] efficiency) with the comparative advantages of competitive, usually
private systems (consumer satisfaction and internal [micro] efficiency)
in the provision of care." In Canada, the particular promise of
integration in general is the potential to overcome historical inefficiencies
implicit in the fragmented chimney or 'stove-pipe' configuration
of system resources. Canada has a rich and credible experience with integration
as an early participant in the exploration and design of integrated models
for health care. (Ham and Brommels 1994, Health Canada 1993, Griffith,
Sahney and Mohr 1995, Marriott and Mable 1997).
The purpose of this paper is twofold: to update and assess developments
in health system integration in Canada and other countries, and to enhance
and improve the level of understanding of concepts, models and their potential
implications for Canada. The report is geared for use by federal, provincial
and territorial governments. It analyses the topic and status of health
system integration, blending input from theoretical and empirical research
as well as Canadian and international experience (the United States, The
Netherlands, the United Kingdom, New Zealand, and Australia). The methodology
involved a review of information on integration and associated topics,
including 'grey' literature, published and unpublished reports,
and draws from the authors' own work and resources in this area.
For a variety of reasons, terms and notions of 'integration'
have become unclear through undisciplined use. As a result, there are
various interpretations of what integration means, and the considerable
array of 'integration' activities undertaken may not necessarily
reflect considerable integration. This paper provides a framework for
defining integration terms and models, proposing a simplified typology
for organizing and clarifying a review of the major integration models
and approaches. To understand the status, progress and untapped potential
of integration in Canada, it is important to understand: (1) the models
and approaches, and (2) the experience in Canada with rostered full integration
models, a story increasingly pertinent, in view of other countries'
development of these models.
Countries have explored five major models and approaches to integration,
as presented in the typology, including: the rostered 'full integration'
organization, the geographic regional organization, the integrated delivery
system model, primary health care reform, and voluntary collaborative
initiatives of otherwise independent entities (presented within the rubric
of 'integration' of services). Each of the models and approaches
has a predominant point of emphasis, respectively, a rostered population,
geography, providers, primary health care, and voluntary collaboration,
reflecting varying levels of integrative capacity. These distinguish and
differentiate, in terms of shaping mission, orientation and capacity (operational
characteristics, service responsibilities, ways of addressing the population
served, the relationships established between organization and providers
and governments, etc.). Each holds different implications for government
policy. Experience to date seems to show that integrated models and approaches
hold answers to systemic questions at many levels. Further, if enabled
to pursue options fully, integrated organizations embody solutions to
system problems, and mechanisms to address system goals, to change old
sectoral patterns of fragmented services.
The implications of integration trends put the focus on rostered full
integration models, geographic regional models and primary health care
reform (incorporated within or contracted for by the larger integrated
models). While efforts toward primary health care and collaborative initiatives
promote integrative behaviour, they don't go far enough to address
or rationalize systemic resources. As well, issues associated with the
US-based integrated delivery system model make it unfeasible and unfitting
in the Canadian environment. With respect to the larger organizational
constructs, the international experience reflects a predominant trend
away from command and control configurations toward integrated organizations
that combine responsibility and funding. The policy focus has been on
introducing, refining or transforming organizational models of integration,
with the functional integration occurring within or associated with these
organizations. The larger steps taken in recent years' reform by
Canada and the countries reviewed, can be summarized as follows:
The US moved more directly toward development of Health Maintenance
Organizations, while other countries (except Australia) explored various
forms of 'command and control' geographic regional authorities,
began to experience problems with them, and moved to change and refine
them, moving toward structures and features implicit in rostered models.
It is not well known or documented that Canadians (in Ontario, Quebec,
B.C. and Saskatchewan) explored rostered integrated organizations prior
to most other countries (except the US). Ontario launched the Group Health
Centre in Sault Ste. Marie, and the subsequent Comprehensive Health Organization
(CHO) program, policy and model development in communities across the
province.
- Canada looked at the rostered full integration model Comprehensive
Health Organization early on, but in a subsequent wave of deconcentration
and devolution, most provinces moved quickly into command and control
regional models (despite problems and reforms in other countries), which
became the predominant focus, to the present.
- Canada did not complete the launch of CHOs, but rather invested considerable
resources in the focus on RHAs and sectoral reform, involving hospital
restructuring and primary health care reform.
- Meanwhile, as various forms of HMOs were evolving in the US, some
publicly funded systems began to explore the features and dynamics of
rostered integrated organizations, which also spurred changes in regional
organizations, as follows:
- Some moved to rostered organizations and away from regional organizations
(e.g. Sickness Funds in The Netherlands).
- Some developed rostered organizations in stages (e.g. GP Fundholders
to Primary Care Groups and now Primary Care Trusts in England).
- The responsibilities of regions were changed to accommodate the
shift to rostered organizations (e.g., the regional purchaser-provider
split, to remove service provision, and subsequently, the removal
of contracting, repositioning both functions (with attendant responsibility
and funding) into the independent rostered organizations).
- Australia did not move to regions at all, but is presently exploring
underlying elements of integrated approaches to managing a full
continuum of care, in its Coordinated Care Trials.
- Finland is making cautious refinements to regions (Municipalities)
regarding such mechanisms as citizens' right of choice of
physician and organization.
- New Zealand is still making adjustment to its regional authorities,
and had been exploring full integration organizational models (e.g.
including for the Maori), but with recent government changes, their
present status is unclear).
- With primary health care initiatives in particular, Canadian efforts
have come back full circle (beginning with 'full' CHO models,
to regional models, to focussed (e.g. hospitals) sector reform to horizontally
integrated primary health care initiatives) to explore models and approaches
to cross-sectoral integration.
- Given interest in the steps taken in England, and recognition of
the potential to build from a base of primary health care, there is
renewed effort to move toward integrated organizational models in a
staged approach.
These steps have taken place as other countries take direct action in
response to systemic issues and needs. In summary, countries have moved
away from command and control structures, and ahead with development of
rostered 'full integration' models, and have removed or simplified
the structures and roles of regional organizations. Canada is already
restructuring its regional organizations. Prior efforts to examine and
develop rostered integration models, while becoming stalled by circumstances,
nonetheless produced significant 'hands on' experience at
all levels. That experience is reflected in present system reforms, as
initiatives work to move back toward the key features of full integration
models (roster, capitation funding, an array of services, multi-disciplinary
providers, integrated information systems, etc.). Primary health care
in particular demonstrates its potential to 'grow' toward
full integration, as had been envisioned in the Victoria Report, explored
by the CHO program, and demonstrated in England, with the development
of fully vertically integrated Primary Care Trusts. As other countries'
efforts produce additional experience with the rostered models, Canada
is strongly positioned to renew its efforts to achieve more extensive
health system integration.
Recent provincial and national reform initiatives in Canada reflect
a generally optimistic trend. Some of both the national and provincial
initiatives explored explicit models and approaches to integration. The
National Forum on Health looked specifically at models, including full
integration and regional models, and international experiences. The Kirby
Senate Committee endorsed the notion of internal markets, and significantly,
a phased in approach to developing what would essentially be a full integration
organization, modelled on steps taken by the GP Fundholders to current
PCTs of England. The Health Transition Fund promoted 'hands on'
exploration of methods, including primary health care initiatives which
looked at elements such as rosters and capitation, and 'integrated
service delivery' projects, which remained predominantly at the
level of voluntary collaboration or functional integration. The Primary
Health Care Transition Fund magnifies the focus on primary health care
and its integration with other parts of the health care system, to encourage
permanent and sustainable change. The Clair Commission demonstrated specific
interest in consideration of more vertically integrated organizational
models, although it supported and reinforced regional models presently
in place. Its focus on Integrated Service Networks suggests a direction
toward more fully integrated models, with per capita funding and rosters.
Not dissimilarly, The Fyke Commission combined use of positive overarching
terms of integration plus focus on regionalization reorganization, to
increase size of regions, with predominant focus on proposed Primary Health
Care Networks within regions, with some potential to integrate services
beyond primary care. The other three national and provincial reform initiatives
are broader in nature and focus. The Social Union Framework Agreement
and Health Accord set a context for increased integration, development
of primary health care, and generally progressive approaches. The Romanow
Commission is not yet finished its work, but has thus far offered some
positive endorsement of concepts of integration, with uncertain commitment
as to approaches or forms. At the provincial level, the Mazankowski Report
seems to hold implicit messages for the potential to develop vertically
integrated health organizations, depending on the direction they ultimately
choose to go.
While other countries forge ahead with rostered full integration models,
Canadian potential has not yet been fully realized. While integration
efforts reaffirm the good experience gained to date, they also expose
the need for greater 'national' coherence, to promote understanding
and progress. Canadian innovators at many levels face challenges complicated
by a reform environment which has obscured understanding of what has happened
and what is possible. Major barriers and facilitators that influence present
progress are the same as have been identified for some time. Three major
barriers have blocked progress in integration: misunderstanding of terms,
models and approaches; overlapping reform initiatives which obscure or
impede progress; and resistence to change – particularly within
bureaucracies. Even when Ministers support them, new programs or initiatives
face uphill fights to gain approvals to proceed, particularly where changes
in legal, legislative, financial, administrative or other parameters are
required. Other sectoral stakeholders combine their efforts with bureaucracies
that fund them, to extend resistence out to block promising, innovations.
Just the same, significant work has been achieved in Canada. Major facilitators
include strong leadership, political will, tolerance for pluralism and
provider support. Clearing the way for completion or refinement of foundational
work already begun in Canada to achieve more comprehensive integration
models will bring the system closer to achieving its stated goals.
Canada can elect to maintain the status quo, to 'let things ride'
with present reform initiatives, and deal with cost and other issues as
they arise, hoping to achieve greater effectiveness in care and cost-efficiency
in use of public resources. Present Canadians initiatives are trying to
incorporate important features and principles of the rostered 'full
integration' models, but without the removal of barriers, they too
may remain blocked by the same sectoral factors that have generally blocked
progress. The problem is that even if successful, present efforts will
only go so far, and none completes the task of incorporating or integrating
a continuum of care. This leaves important areas of system activity and
cost relatively unchanged, and does not rationalize the system in terms
of its maximum effect, and may utilize significant funds for initiatives
that remain in focussed areas. Rather than solving problems, this invests
more precious resources in perpetuation of the stovepipe structures, which
in the end may not improve care. Canada needs a defined direction at the
national level, and concerted action across Canada, to move the system
forward.
Governments should lift the level of their thinking to a 'full
integration model' perspective, to maximize opportunities for integration
of the Canadian health system. Initiatives focussed only at a lower level
of integration limit potential for progress. With medicare, Tommy Douglas
emphasized revamping the whole delivery system, not just parts. A system
that now calls for performance and results should actually operate in
keeping with its goals and principles. Accordingly, health organizations
and providers need to be enabled to actually operate in ways that integrate
and maximize health system resources. To revamp the system to achieve
its goals implies a commitment beyond 'integration' rhetoric,
to move away from sectoral stovepipes to proceed toward comprehensive
capability in health providers and organizations, with a more fluid and
flexible system to support them. The strategy would represent a positively
oriented approach, based on what is possible, with leaders and champions
in communities and governments ready and willing to innovate and move
forward. It would reflect tolerance for pluralism, allowing new organizations
to emerge from within the existing system. Support to enhance and facilitate
progress should come from the federal government, which has the opportunity
to explore organizational models within its area of responsibility, such
as for the First Nations and Inuit. If, as Roy Romanow (2001) indicates,
"The solutions are within our grasp" then the system should
actually operate in keeping with its goals and principles in a way that
moves forward – away from fragmented sectoral resources and toward
integrated organizations which can best harness them. This implies a commitment
to put the best possible models and mechanisms in place to benefit all
Canadians.
Marriott Mable
Wolfe Island, Ontario
K0H 2Y0
613-385-1647
marrmabl@kos.net
The views expressed in this report are those of the authors
and do not necessarily represent those of Health Canada
The Web site report contains the Executive Summary.
For further information contact:
Acute Care & Technology Unit
Quality Care, Technology, and Pharmaceuticals Division
Health Policy Branch
Health Canada
10th Floor, Brooke Claxton Building
Tunney's Pasture
Ottawa, Ontario K1A 0K9
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