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Theoretical generalisation provides the basis for tackling problems of service complexity, fragmentation and disrupted care pathways.

Recent mental health service transformation in Wales, United Kingdom, has been stimulated by a policy programme underpinned by person-centred recovery values. This paper offers analysis informed by the perspectives of Niklas Luhmann and other noted theorists to examine escalating service system complexity related to this transformation. Analysis builds upon the findings of a qualitative study employing thematic discourse analysis of talk of people with mental illness and associated workers.

In total, three themes were constructed in participants' talk: “Competing versions of recovery”, “Misaligned service expectations” and “Disrupted care pathways.” Recovery may be understood as a form of moral communication and autopoietic meaning-making activity, according to Luhmann's radical constructionist epistemology. This has the potential to generate competing versions of recovery, a key contributor to escalating complexity.

Findings could be developed further by continued investigation of the relationship between recovery implementation and service fragmentation.

A more judicious, balanced policy-implementation may cultivate optimal conditions for recovery pluralism by avoiding polarisation towards either top-down, policy-based recovery implementation or a proliferation of approaches at the grassroots level. Findings have implications for healthcare settings beyond the scope of mental healthcare, given the prevalence of person-centred care internationally.

A simplistic view of recovery implementation should be challenged. Recovery should not be considered a “magic bullet” for mental healthcare delivery. Haphazard recovery-implementation may have detrimental effects of escalating complexity, service fragmentation and disrupted care pathways.

This paper aims to: analyze the challenge of health services fragmentation; present the attributes of integrated health service delivery networks (IHSDNs); review lessons learned on integration; examine recent developments in selected countries; and discuss policy implications of implementing IHSDNs.

A literature review, expert meetings, and country consultations (national, subregional, and regional) in the Americas resulted in a set of consensus‐based essential attributes for implementing IHSDNs. The analysis of 11 country case studies on integration allowed for the identification of lessons learned.

Studies suggest that IHSDNs could improve health systems performance. Principal findings include: integration processes are difficult, complex, and long term; integration requires extensive systemic changes and a commitment by health workers, health service managers and policymakers; and, multiple modalities and degrees of integration can coexist within a system. The public policy objective is to propose a design that meets each system's specific organizational needs.

The analysis presented in this paper is qualitative.

Some policy implications for implementing IHSDNs are presented in the paper.

The research and evidence on integration remains limited. The paper expands the knowledge‐base on the topic, presenting lessons learned on integration and recent developments in selected countries, which can support integration efforts in the region.

The US prison population has recently reached an all-time high, with women representing the fastest growing subpopulation. Correctional health-care system in the USA remains fragmented and nonuniform in practice, particularly in women’s health care, with poor transitions between incarceration and release. This study aims to examine the qualitative health-care experiences of women while incarcerated and their transition into the community health-care setting. Additionally, this study also examined the experiences of a subset of women who were pregnant while incarcerated.

After obtaining institutional review board approval, adult, English-speaking women with a history of incarceration within the past 10 years were interviewed using a semi-structured interview tool. Interview transcripts were analyzed using inductive content analysis.

The authors completed 21 full interviews and identified six themes that were both the most significant and most novel: “feeling stigmatized and insignificant,” “care as punishment,” “delay in care,” “exceptions to the rule,” “fragmentation of care” and “obstetric trauma and resilience.”

Women face numerous barriers and hardships when accessing basic and reproductive health-care services while incarcerated. This hardship is particularly challenging for women with substance use disorders. The authors were able to describe for the first time, partially through their own words, novel challenges described by women interacting with incarceration health care. Community providers should understand these barriers and challenges so as to effectively reengage women in care upon release and improve the health-care status of this historically marginalized group.

This article aims to describe the thinking behind MASSE, a project in Finland that helps address the fragmentation of care and patient journey disruptions for long-term care. It outlines the conceptualization of an information technology (IT)-assisted solution and presents preliminary findings and research problems in this ongoing project.

The project employs a service engineering and design science approach with the objective of addressing chronic and multimorbid patients in specialized multiprovider environments. It does this by applying information and communication technologies and organizational design. The project has been a cocreative effort with ongoing interviews and workshops with various stakeholders to inform the conceptualization of a solution, an intermediary step before the implementation phase.

Patient journey disruptions occur when caregivers do not know what to do in specific situations. A potential solution is a virtual care operator (VCO) with a personalized patient card that would enable service ecosystem actors to integrate and coordinate their tasks. This article presents the basic design principles of such a solution.

Conceptual ideas and preliminary results only indicative.

Systemic integration efforts like those ongoing in Finland can benefit from the VCO concept encouraging a more collaborative way of thinking about integrative solutions and opening up new avenues of research on business implications and ecosystem strategies.

The VCO concept answers to the continuity of care, the rising costs of health care and the growing numbers of patients with chronic disease and multimorbidity whose care remains fragmented and uncoordinated.

Taking an ecosystem approach to care integration and addressing interoperability issues are on the cutting edge of healthcare system transformation.

Managing patients in advanced age is complex, especially when it comes to multi-morbidities and polypharmacy. The purpose of this qualitative study is to investigate challenges, opportunities and potential solutions from a primary healthcare provider perspective.

Fifty-seven participants joined in group discussions on challenges and opportunities of working with advanced age. Participants included general practitioners (GPs), practice nurses, students and administration staff working in ten general practices. A thematic analysis was developed, supported by NVivo software.

Poor lines of communication and fragmentation of services between differing levels of health care services available for older people were highlighted. This has implications for quality of care and equity of services. Participants also reported challenges in treatment and funding regimes.

The small sample size and regional nature of the study, along with the semi-structured nature of the group discussions and rigorous thematic analysis, indicate that this qualitative data is transferable, dependable, confirmable and credible. Comparing the views of tertiary and community services would be useful.

A range of potential strategies and solutions to the current fragmented services was offered by GPs. For example, adequately funded and staffed community-based health hubs; IT platforms enabling timely flow of patient information between primary and tertiary health providers and creation of medical, nursing and allied health roles aimed at improving synergy between GP and tertiary services.

Obtaining the perspectives of general practice highlights the challenges and complexities of caring for those in advanced age brings. These insights have not been previously been explored in-depth within this setting in New Zealand.

This paper provides a European overview of alternative approaches to integrated care for older people, drawing from a wider European project entitled PROCARE. It discusses the structural complexities that create the challenges in integrated care, compares and contrasts approaches to integrated care through a structure and process framework, and considers the place of person‐centred seamless care in European health and social care models.

The desirability of having a more flexible workforce is emphasised across many health systems yet this goal is as ambiguous as it is ubiquitous. In the absence of empirical studies in healthcare that have defined flexibility as an outcome, the purpose of this paper is to draw on classic management and sociological theory to reduce this ambiguity.

The paper uses the Weberian tool of “ideal types”. Key workforce reforms are held against Atkinson’s model of functional flexibility which aims to increase responsiveness and adaptability through multiskilling, autonomy and teams; and Taylorism which seeks stability and reduced costs through specialisation, fragmentation and management control.

Appeals to an amorphous goal of increasing workforce flexibility make an assumption that any reform will increase flexibility. However, this paper finds that the work of healthcare professionals already displays most of the essential features of functional flexibility but many widespread reforms are shifting healthcare work in a Taylorist direction. This contradiction is symptomatic of a failure to confront inevitable trade-offs in reform: between the benefits of specialisation and the costs of fragmentation; and between management control and professional autonomy.

The paper questions the conventional conception of “the problem” of workforce reform as primarily one of professional control over tasks. Holding reforms against the ideal types of Taylorism and functional flexibility is a simple, effective way the costs and benefits of workforce reform can be revealed.

The House of Commons Select Committee Report (1992), and more recently the Changing Childbirth report (1993), suggest that the lack of continuity experienced by women and professionals within the traditional system of maternity care is no longer appropriate nor desirable. Informs the reader how Scunthorpe Maternity Services had already recognized the need to reduce fragmentation and raise standards and how a strategy was developed, in response to these deficiencies, which planned to replace the traditional model of care with one of integrated team midwifery. Also describes the process undertaken in the transformation of services, highlights the impact of such changes on the midwives and midwifery practice and discusses developments for future consideration.

The purpose of this paper is to report the preliminary evaluation findings of an integration programme in the children’s health care sector in the North West of England. The programme was led by the local Clinical Commissioning Group (CCG) utilising a semi-autonomous working group model. It comprised horizontal and vertical integration. The evaluation reflects the emerging policy context of CCG leadership in the field of health care planning and commissioning.

The evaluation used a mixed method observational study design to obtain the views and opinions of stakeholders and measured their change over time. A series of initial semi-structured interviews was conducted with purposively selected key professionals in strategic positions to assist in designing a survey instrument. An online survey was launched at programme inception and repeated at five months. Respondents were members of five implementation working groups. Survey responses were subjected to a descriptive analysis and tests of correlation.

The data showed high levels of commitment and perceptions of shared vision and goals amongst respondents which were relatively stable over time. Responses also indicated that the programme was perceived to have a considerable impact on collaborative work but that this initial effect decreased over time. There were no significant attitudinal differences across sectors or professional groups.

The study demonstrates the strengths and weaknesses of the multi-agency working group model to implement change. Whilst confirming initial positive effects of integration programmes on collaborative work, over time this appears to wear off to be replaced by increased levels of skepticism amongst participants. The author findings have implications for service commissioners and service planners engaging in vertical or horizontal integration of children’s services.

The purpose of this paper is to contribute an Australian perspective to the debate on health system integration by identifying some key Australian challenges to integration, policy responses to enhance integration and potential insights from these for international policy makers, researchers and practitioners.

Drawing on the systems theory concept of entropy, the authors contend that there exist factors that contribute to system fragmentation. Whilst policy responses to these challenges are contextual, there are generalisable features worth exploring internationally.

The authors suggest that recognition of inherent system-based barriers is an important initial stage in moving towards integration. Whilst process and people factors are important contributors to integration, the political will to move in this direction is a necessary dynamic to energise the system through appropriate funding, incentives and governance structures.

The paper provides a fresh Australian perspective to the international discourse on barriers and opportunities to enhance health system integration.