Policymakers and local system leaders face a challenge in finding ways of designing and delivering the hospital to community agenda. 

While there is good evidence about what it takes to integrate health and social care, knowledge about how best to co-ordinate primary and secondary care is in much shorter supply. To address this, The Health Foundation commissioned the International Foundation for Integrated Care (IFIC) to identify the most promising models of co-ordination between primary and secondary care from around the world. The five care models picked out by IFIC, which focus on the management of chronic conditions, provide valuable lessons for care commissioners and providers in England.

The first lesson is trust and strong relationships between the different organisations and professionals involved is essential. This is demonstrated by the Leuven Care Ecosystem in Belgium, a care model focusing on the care of patients with diabetes. The success of this model is built on a long legacy of effective partnership working between GPs and hospital specialists around the management of patients with complex needs. Without the mutual trust and respect that this partnership engendered, the Leuven model might have struggled to take root in the way it has. What this shows is the importance of protecting time and space for relationships to develop and not placing excessive demands on cross-organisational services at a point when the participants are still getting to know each other.  

System leadership also matters. National and local leaders need to speak with one voice and ensure there is a consistent and sustained policy commitment to care co-ordination. This gives those commissioning and delivering co-ordinated care services the confidence and stability they need to build and embed their interventions.

An example of this is the Catalan ProPCC (Programme to People with Complex Chronic Conditions) system, which focuses on community-based management of people with complex care needs. Since 2011, the region has had a clear focus on delivering co-ordinated care and launched a succession of programmes to realise this ambition. Reimbursement mechanisms and outcome measurement and accountability frameworks that are aligned with this goal have also been put in place.  

Attention should be paid also to working practices, norms and skills required to deliver care coordination. A common challenge here lies in the communication between the members of multidisciplinary teams working in different organisations.

Most projects that feature in our research have put in place effective measures to deal with this problem. For instance, the ProPCC teams facilitate bespoke meetings with primary care centres, specialist community services and hospital specialists. Maintaining these open communication channels allows them to decide and enact the most suitable management plans, while building working relationships between providers in the system.  

Of equal importance is the presence of professionals skilled in operating across boundaries. Community nurses are one such professional group. In the Irish Caredoc Community Intervention Teams programme, community nurses co-ordinate patient management and provide acute care at home. Their work has a crucial part to play in avoiding hospital admissions and enabling the early discharge of people with chronic diseases. Community nurses are uniquely placed to liaise with all members of the multidisciplinary team and lead on patient care. Investing in such roles is key to the delivery of sustained co-ordinated care.  

The final ingredient is funding. No model of co-ordinated care can survive for long without adequate resources to secure the long-term involvement of participants. This is illustrated by the Australian Keeping Well programme. This model, which focuses on the care of older patients at risk of hospitalisation, was preceded by the failed co-ordination programme, Wellnet. In Wellnet's case, the misalignment of funding incentives between primary and secondary care precipitated its demise,  highlighting the importance of adjusting funding flows and incentives to realise the promise of care coordination. For care coordination to be delivered at scale and be sustained over time, careful consideration needs to be given to the strategic and operational behaviours and skills, coupled with the resources and personnel needed to translate the policy ambition into practice.

Perhaps the most critical skill though, and the one that may be hardest to master, is the ability to align and co-ordinate these disparate enablers of co-ordinated care, and fashion them into a coherent and mutually-reinforcing whole. This is key to achieving the integrated, neighbourhood-based service the Government has committed to delivering.