Bernard J. Mohr - Designing Integrated Care Ecosystems: A Socio-Technical Perspective

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Health and care systems around the world are entering a period of transformational change as they must adjust to the new demands of socio-demographic trends related to ageing, chronicity and rising public health concerns. Integrated care has been put forward as one approach to respond to this growing complexity of need. By coordinating care and services around peoples holistic needs and focusing on more upstream and person-centred solutions to care, the hypothesis is that care experiences of service users may be improved, care outcomes enhanced, care utilisation patterns optimised, and ultimately result in more economically sustainable care providing higher value services.

It must be said that the evidence in favour of integrated care as a technology to support quality improvements in care systems is mixed. There are many excellent case examples around the world that demonstrate what might be achieved, especially if one takes a population health-based approach to system design. However, there are also many examples of integrated care programmes that have not been able to meet their objectives and/or of promising developments and pilot programmes that have withered and died after but a few years of life. For many reasonspolitical, financial, professional, cultural, informational, temporalintegrated care programmes are too often characterised by an inherent fragility in their design. The result is an inability for integrated care projects to move beyond small-scale innovations and the subsequent cycles of integrated care activity that do not build effectively on previous iterations of innovation.

Such observations are despite the fact that most of the building blocks to what makes an effective integrated care system are generally well known. Over the past decade, research has begun to yield many new and promising frameworks and models to guide our thinking, some of which are presented in this book. These recognise that success in integrated care design requires simultaneous action at different levels. For example, in engaging and empowering services users through a range of person-centred strategies, to building effective approaches to care coordination across complex professional and organisational settings via the development of new teams and networks. Organisational and systemic integration is also needed to align key elements such as funding, accountability, governance and performance assessments. Softer issues such as shared norms and values and/or the ability to communicate data and information effectively with the support of new technologies act as catalysts to such capabilities. The variables at play are numerous.

However, despite an understanding amongst such work that integrated care is a complex service innovation with many moving parts, implementation science is currently weak in this area and so our understanding of how to design and manage systems of complexity is poor. For the system designer, this presents an acute problem, not just because we know that success in integrated care design is as much dependent on local contexts and relationships between key actors as it is on the technical components of care delivery. To achieve success, the reality is that leaders and managers do not have a set of architectural blueprints from which to draw, only a set of principles that need a high degree of skill to be turned into effective and context-specific solutions. Without a better understanding of the complex dynamics of integrated care systems, then it remains likely that implementation failures will persist.

This edited volume by Mohr and Dessers seeks to bring new insights into this debate by introducing the reader to the theory of Socio-Technical Systems (STS) Design to create a more comprehensive and effective framework when thinking about the design of complex systems such as integrated care. Its specific contribution is to take the theory of STS Design and examine how this might be applied to ecosystems. Since the key characteristic of integrated care programmes involve a highly complex web of variables working across micro-, meso- and macroscales and in specific local contexts, then the visualisation of them as ecosystems is appropriate to the point. Through bringing together many case examples of national, regional and local approaches to integrated care design and delivery, the book highlights how the ecosystem lens can bring great insights to the system architect and therefore how STS Design might prove to be a highly promising route to bridging our current gap in thinking.

The road ahead for leaders and managers around the world in leading the process of transformational change is likely to be a long and arduous one, at least if history is anything to go by. A greater theoretical appreciation in how to design and implement integrated care solutions effectively is needed together with frameworks that help to guide such thinking in practice. This book is important since it challenges traditional linear or modular thinking and begs us to embrace a better understanding of the complexity around us and the tools that might be used to navigate it.

Aspirational Beginnings