Editorial: Tolerating risk in integrated care

Citation

Kaehne, A. (2024), "Editorial: Tolerating risk in integrated care", Journal of Integrated Care, Vol. 32 No. 2, pp. 117-118. https://doi.org/10.1108/JICA-04-2024-097

As the most important conference for integrated care in Europe is closing its doors in Belfast, any observer cannot help but be impressed by the enormous amount of knowledge, expertise and evidence we have accumulated since integrated care first appeared on the radar of health care researchers, academics and practitioners. However, looking over the admirable array of papers and posters one may also wonder what the future has in store for the field.

Undoubtedly, integrated care is here to stay, as a field of investigation, an approach to care practices, and, more recently, as a fertile area to apply concepts of implementation science. In essence, there have always been at least two types of integrated care. In terms of policy, there is ae top-down way to do integrated care, mandated by central or regional government to form partnerships or collaborative working practices. Alternatively, there is a bottom-up attempt to create smooth(er) transitions for patients as they move between services. The latter differs from the former in terms of original impetus, motivational resources for staff, as well as available funding. Whilst both are a variety of health service innovations, bottom-up integrated care initiatives are more likely to be aligned with patient-centred care, often located in care micro-systems. They are also more likely to impact on patient outcomes although the evidence remains difficult to read.

For those integrated care programmes that are introduced top down, mandated by policy directives or central diktat, frontline staff and patients are less likely to be affected by or, in fact, motivated to implement them. The favoured mechanism of top-down integration remains organisational changes such as mergers of hospitals with community care organisations or close partnership agreements with shared funding arrangements at their core. Their prime territory is meso- or macro-systems of care, with little in the way of evidenced direct impact on patient care outcomes.

There are, of course, well-known exceptions to this rule, the most famous of which probably the integrated care provision based on population health provided by Kaiser Permanente or the programmes in Kinzigtal (Germany). They combine macro-organisational integration with a clear focus on micro-system impacts, i.e. improvements to patient outcomes.

Yet, the majority of integrated care programmes remain small-scale despite generating a burgeoning mountain of evidence that, following a disruptive transition period, they improve working conditions for staff and, ultimately, patients.

Whilst the organisational and policy perspective throws light on some interesting aspects of care integration, more recent work employing implementation science approaches highlights the role of innovation and its disruptive quality for staff and patients. If you think about it, innovation is actually a pretty unlikely thing to occur in a highly routinised and standardised environment such as health and social care. Care routines provide certainty and stability of expectations, as well as guarantee compliance with patient safety standards and agreed levels of quality of care for patients.

In other words, change carries risks, which staff are unlikely to take on unless they are convinced that there is a better, more efficient, safer and, yes, equally routinised world of practice awaiting them. Also, working under conditions of constant uncertainty can have a demoralising and demotivating effect.

It is these risks of change we may not talk enough about when we wonder why integrated care initiatives encounter so much resistance from many sides. The profound impact of risk on care practices in times of change is not a new insight. The leadership literature as well as management studies have long pointed out that uncertainty is a key feature of innovation and change that needs to be controlled, kept in check or proactively hedged. The question is how can we enable health care systems that are programmed to avoid risk to be more open to innovation and change, which create inherent uncertainties for everyone involved.

This brings me to my most recent clinical quality visit to my local hospital. What struck me most during the nightly round-through of wards with my colleagues was the unrelentless emphasis on reducing risks to patient care. To be fair, there were also some info boards on the ward walls where patients had articulated their views on services. But most of the conversations as well as most of the ward documentation focused on one thing: how to avoid risks to patient care quality, or, if they do occur, how to mitigate them. This may just be a feature of our overly litigated and under-resourced national health system in England, where nurses and medics fear nothing more than sanctions based on malpractice, near misses or the like. But, interestingly, the peril of risk also prompts nurses, midwives and medics to preempt any potential risk to patient care.

One significant effect I noticed was that care options, which may increase patient choice, remained unused or unexplored. In the maternity ward, the birth pool room was cluttered with furniture, clearly indicating that it was not offered as a viable option to pregnant mothers. When asked, the lead midwife explained that pregnant women “in our area” never really opted for this, so they use the room as a storage space now.

You may say that this has little to do with integrated care. But I would argue that it tells us something about an important systemic barrier to innovation and change. There is a system-induced reluctance to accept risks underpinned by a sanction-orientated surveillance and monitoring oversight regime, which is matched by a tendency amongst staff to pre-empt and forestall potential risks originating from more patient choice. Choice means more uncertainty and less routine, something that nurses, midwives and medics are programmed to intuitively avoid. As long as we accord such prominence to the notion of risk in our health care system, we may struggle to embrace integrated care innovation fully