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The Paradox of Integration Reform


There are some questions in public policy which have good answers. We can be pretty clear about how to pave roads, how to collect taxes and even have decent methods for teaching kids and catching criminals. That is not to say we can’t do those things incrementally better, and technology and human ingenuity can sometimes transform what we think we know.

But there are some areas of public policy where no-one truthfully has ‘the answer’. One such area is health and social care integration, which is currently the subject of an excellent seminar series by the School of Health in Social Science at the University of Edinburgh. The discussion I attended today highlighted hugely significant differences in context and approach in Norway, Scotland and England to similar challenges of integrating care and health. The complexity derives from many quarters – political, cultural, historical and financial. But at the heart is a desire by both policy makers and practitioners to make things better. At the seminar today, I was struck by the depth of passion from Scotland’s public servants – there is an aching desire to achieve improvement, but also some fear it might not quite deliver the solution much needed for patients, users, families, carers and citizens.

My sense is that reform, paradoxically, can create more retrenchment than change at some levels within the system. Because, crudely, everyone worries more about their jobs and professional identity immediately before, during and after a big change like this, the real purpose of integration – at the practice and consumer/citizen level – can be lost. When things settle down of course, there may be structures and finances in place which create better conditions for real integration, but it’s then we realise what we should have been focusing on in the first place.

I personally think the changes to health and social care in Scotland are sensible and positive. But they are not the answer to how to truly integrate health and social care. They perhaps reflect necessary conditions at a macro level. What matters now is whether they are infused with new thinking on professional collaboration and new conversations with users and patients which lead to real behavioural change on both demand and supply sides. For an insight to some of this thinking you may want to see our research report about residential care Home Truths. We are by no means decrying big structural reform, but we do think some of the basic people and practice dimensions can get a bit lost when everyone is fretting about their jobs and status. If we invested half the time and money in really understanding networks, changing behaviours and building trust, well, we might create something very special.

Before I get carried away,can I remind myself and you to be wary of the man or woman with the answer to health and care integration. They just haven’t found the right questions yet.

Alex Khaldi is Managing Director of IMPOWER. To contact him to discuss this blog please email or call 020 7017 8030.

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IMPOWER is an organisation driven by a social purpose. We are a values led consultancy dedicated to the reform of the public sector.



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