Integrated Care aims to join up our health and social care services, to deliver patient care that is safe, timely, efficient and as close to home as possible. Integrated care improves quality and outcomes and puts the patient experience at the centre of everything we do. It means changing the way that care is provided, so that people with complex needs can live healthier and more independent lives.

Clinical Design and Innovation is leading a large-scale programme of work to develop a system of integrated care within our health and social care services. This is a long-term programme of change and improvement for our health and social care services and will involve people at every level of the health service working together to create improved experiences and outcomes for the people in our care.

Integrated care has the patient perspective as an organising principle of service delivery. It is based on the principles of illness prevention, patient empowerment, multi-disciplinary cross-service care planning and delivery, where all health and social care services work together to provide a flexible network of care responsive to the changing needs of patients and their families. Achieving this will involve public and private providers, patient groups, clinicians and the voluntary sector – indeed, all healthcare stakeholders.

Integrated care is not a new concept and arises from the consequences of fractures in systems and delivery that allow individuals to ‘fall through the gaps’ in care – e.g. primary/secondary care, health/social care, mental/physical health care. The need to address fragmentation in health system is increasing as more people live longer and with complex co-morbidities. Integrated care is most effective when it is population-based and takes into account the holistic needs of patients.

“Integrated health service delivery comprises the management and delivery of health services such that people receive a continuum of health promotion, health protection and disease prevention services, as well as diagnosis, treatment, long-term care, rehabilitation, and palliative care services through the different levels and sites of care within the health system and according to their needs” (adapted from PAHO, 2011).

The WHO has provided a framework including five inter-dependant strategic directions to support people-centred and integrated health services with key actions (WHO/HQ, 2015).

1. Empowering and engaging people
2. Strengthening governance and accountability
3. Reorienting the model of care
4. Coordinating services
5. Creating and enabling environment