which has seen age-related and long-term chronic illness replace communicable disease as the biggest challenge that health systems must now address. Today, more than half of the growing numbers of people aged over 65 in Europe are living with more than three chronic conditions, with about one-fifth having five or more concurrent health problems. This shift means that the economic burden of age-related chronic illness now represents between 75-80 per cent of health care expenditure, a figure that is also expected to rise. The ability to find a way to sustain health outcomes and quality of care within limited financial resources has become the greatest of challenges.

Current health and care systems, especially in Europe, are ill-equipped to meet the future challenge as they have over many years developed systemic and institutional structures that focus on cure rather than care. As a result, most countries have begun the search for structural or technological solutions that embrace new and more integrated care models that place the emphasis on preventing ill health, supporting self-care, delivering care closer to people’s homes, eliminating waste and duplication, and reducing the reliance on hospitals and long-term care institutions. The hypothesis to integrated care is that care experiences and outcomes for people can be improved without adding to costs, and there is enough evidence from around the World to suggest this is indeed possible.

However, the bad news is that integrated care is mightily difficult to achieve in practice since it requires partners in care to effectively ‘let go’ their sovereignty (e.g. over budgets, governance rules and quality targets) in order for a collective approach to be agreed. In most cases it is rare that new ‘integrated care organisations’ result and in reality is some form of ‘networked’ model emerges with various degrees of joint commitment. As a consequence, many integrated care schemes lack agreement on whether and how their collective performance should be judged and it is quite rare to find managerial agreements that tie partners to a quality improvement process. As a result, not enough attention is paid to measuring and benchmarking quality with most innovations happening as an ‘act of faith’ and dependent on the values and leadership held by the professionals involved. echo

Understanding the change management process to achieve integrated care is not well advanced, so international research projects such as Project INTEGRATE (www.projectintegrate.eu) are seeking a better understanding. Given what we already know, we might predict the following principles needed for this:

• A focusing on changing behaviours and cultures – integrated care is as much sociological as technical;
• A common vision and narrative with shared aims;
• Strong and respected leadership plus the time and energy to drive integrated care forward;
• Finances and governance rules that align to desired outcomes;
• Care delivery systems that must be restructured (e.g. less hospital, more primary care);
• A commitment to continuous quality improvement linked to measuring outcomes and investing in research

Nick Goodwin will be presenting a lunchtime session on Tuesday, 15th October 2013 during ISQua's International Conference, titled 'Improving care outcomes whilst controlling costs? The rise of integrated care as a global strategy in health reform'.  Further information on this session and all other sessions taking part during our conference can be found on our website - https://www.isqua.org/conference/edinburgh-2013/programme-outline.