[Health care] governance is like a greased watermelon — slippery and hard to grasp. It provides few opportunities for clear conceptual and empirical assessment.1
Governments, communities and health professionals are looking to new ways of delivering high-quality health care services as traditional “silo” models struggle to deliver appropriate care for an ageing population with a high prevalence of chronic disease.2 Difficulties in addressing power-sharing, funding, care models and an absence of relationship between organisations have been identified as significant barriers to such new approaches.
Integrated care requires a change in focus, from health services delivered by separate units to care that can be provided across organisations for a community or patient group. It requires general practices, hospitals, community services and consumer organisations to form effective long-term working relationships and to move beyond the occasional informal partnership to a serious commitment to integrated health care delivery. This strategic re-adjustment must be matched by a commensurate shift in inter-organisational management and governance.3,4,5
Integrated governance describes the formal relationship between organisations that allows them to manage deliverables, risk and process through collaborative business approaches.6 Integrated structures may exist between government agencies and across levels of government (local, state or federal) and/or the non-government sector.6 A key challenge for these emerging partnerships is managing the interaction between different modes of governance, which at some points may generate competition and at others, collaboration,7 and which lead to inherent difficulties in sustaining successful relations among diverse partners.8
Here we discuss the best available evidence on how the principles of integrated governance may be applied in the Australian health care context, focusing on improved community health outcomes and appropriate potential models to achieve them.
Using the methodology developed by Oliver et al,9 we conducted a systematic review and key informant interviews in an integrative process.
Our review identified studies published between 1990 and 2006 that described and evaluated models of integrated governance for health care delivery. We included studies describing a sharing of management and funding delivery services across two or more health care institutions. To ensure that the research was only informed by studies involving governance frameworks that were sustainable in the longer term, we excluded studies that had been sustained for less than 12 months.
Databases searched included the Cochrane Library database, MEDLINE, EMBASE, CINAHL, the Primary Health Care Research and Information Service, the Australian Public Affairs Information Service, the World Health Organization Library Database, the National Primary Care Research and Development Centre Library database, Science Citation Index, the Canadian Health Services Research Foundation database, and the Scientific Information for Policy Support in Europe database.
Search terms included words or phrases relating to governance, integration, collaboration, coordination, organisation and health services management. The search strategy is described on the Australian Primary Health Care Research Institute (APHCRI) website.10
We used a hierarchical strategy, so that studies from Australia, New Zealand, the United Kingdom, Canada and The Netherlands were identified first. We also reviewed the reference lists of retrieved studies and review articles for further relevant studies.
Two reviewers independently assessed citations for potential relevance to our review and extracted data and assessed quality using a standardised data extraction form. Any discrepancies were resolved by consensus. The principal outcome of interest was the effect of models of health care on clinical outcomes and sustainability. However, given that most evaluations would not be of sufficient duration or power to test such an outcome, our review focused on the following outcomes:
The composition of health care services delivered;
The governance structure or contractual relationship between parties, including factors such as accountability; and
The barriers and enablers associated with sustained models of governance.
We assessed the risk of bias in each of the studies using checklists appropriate to their study design. We included descriptive, qualitative and quantitative studies. The results were synthesised narratively.11
We also interviewed key informants to explore known integrated governance models currently operating in the Australian health care environment and additional activity not identified in our systematic review. The informants also identified the context for successful integrated governance approaches in the Australian health care setting.10
The search strategy identified a total of 3145 abstracts and titles, of which 16 studies met the inclusion criteria (Box 1). Further details about these studies are available from the APHCRI website.10
Box 1
Process of systematic review
The 16 models of integrated governance in health care described four models from Australia, two from Canada, five from the UK and five from the United States. All of the studies were evaluations of the process of integrated governance and service delivery structures, rather than of the effectiveness of the service. The evaluations included case reports, surveys and qualitative data analyses. Nine studies addressed policy change (eg, the UK National Health Service modernisation agenda), four addressed business issues (eg, partnering to add value), and three addressed issues of clinical integration (eg, care coordination of aged patients with complex conditions). The relationship between these drivers was not examined. The studies described both governance structures and enablers of or barriers to the process of integration (Box 2). All systematic review findings were supported by findings from the interviews with key informants.
Box 2
Barriers to and enablers of integrated service delivery in health care
Three options for integrated health care governance appropriate to the Australian health context were identified from this approach (Box 3):
Box 3
Models of integrated health care governance
The creation of an incorporated body, with governance responsibility shared across integrating organisations and with pooled resource allocation capability for a given population or region. Examples of this type of model can be seen in Sunrise (NT) and North Wyong (NSW).10
An incorporated body established by integrating organisations, with its own funding pool and responsibility for defined areas of common business overlap between organisations.12 An example is the Advanced Community Care Association (SA).13
A formal and agreed governance arrangement between organisations to share resources by delivering services across a finite geographical area.14,15 This model is seen, for example, in Brisbane South Centre for Health Service Integration (Qld)16 and the Integrated Primary Mental Health Service (Vic).17
There is a significant and historic opportunity in the current Australian health care environment to promote sustainable integrated governance relationships focused on improved community health outcomes. Contemporary reforms to improve the health care system,2 such as the National Action Plan on Mental Health18 and the Australian Better Health Initiative,19 will require a far more significant ability to work productively between jurisdictions.
State governments are increasingly attempting to work with non-government organisations and the private sector to maximise scarce resources in the face of increasing health care demand. Such significant and ambitious integration agendas need to be underpinned by effective governance mechanisms that are appropriate to the undertaking, the stakeholders involved and the scale of delivery.
Our study highlighted local and international initiatives that have been sustainable in the area of integrated governance, and proposed three potential evidence-based governance approaches for consideration by organisations seeking to move towards integrated service delivery.
We found limited research on the effects of different models on clinical or health service outcomes. Our review was confined to studies involving governance that had been sustained for over 12 months, but it is possible that further lessons could be learned from studying programs that were sustained for shorter periods. Furthermore, the interviews with key informants revealed emerging local examples (not identified by our systematic review) of demonstrated links between strengthened integrated governance vehicles and improved local clinical/service outcomes. Further research is essential to develop a thorough understanding of the organisational variables that facilitate or impede integration of service delivery. The conduct of controlled studies, with predetermined outcomes of interest and particularly relevant to chronic disease treatment programs, would be particularly timely.
Despite these limitations, a number of potential governance models are described that fit within the current paradigm of Australian health care as viewed by our key informants. They allow government and health care organisations working in this area to identify and build upon an evidence-based framework that provides the best balance between risk-sharing and autonomy at the current time. Both our review and the key informant interviews identified local communities with the vision, leadership and commitment to extend health service integration as the logical starting point for more ambitious integrated governance regionally.
Abstract
Objective: To identify sustainable governance arrangements for health care organisations undertaking integrated health service delivery based on best available evidence.
Method: Systematic review of the literature (1990–2006), supported by key informant interviews as an integrative process.
Results: 16 studies met our selection criteria. All described enablers of and barriers to delivering integrated health services. We identified three models for integrated health care governance with a demonstrated ability to be sustained in the medium term. Common themes that emerged as the logical starting point for more ambitious integrated governance arrangements regionally were: the need for a clear separation between governance and operational management; and the need for local communities with the vision, leadership and commitment to extend health service integration. These themes were reinforced by interviews with key informants. Careful measurement of the process, impact and outcomes of such activities was often overlooked.
Conclusion: State governments are increasingly attempting to work with non-government organisations and the private sector to maximise scarce resources in the face of increasing health care demand. Ambitious integration agendas must be underpinned by effective governance mechanisms that are appropriate to the undertaking, the stakeholders involved and the scale of delivery.