An Overview of Progress and Potential in Health System Integration in Canada
Prepared by John Marriott and Ann L. Mable
Health Services Division
Health Care Strategies and Policy Directorate
Health Policy and Communications Branch
Past Progress and Future Potential in Health System Integration in Canada
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involved a review of information on integration and associated topics, including 'grey' literature, published and unpublished reports, and draws from the authors' own work and resources in this area.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.
Wolfe Island, Ontario
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.
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