In almost every country of the world there are problems of fragmentation and a lack of continuity in services for frail older people and other groups with complex, multiple needs (for examples see Glasby 2004 for a summary; see also Banks 2004; Leichsenring and Alaszewski 2004; Nies and Berman 2005). Almost irrespective of language, culture, structure, context and funding, there are different services responsible for different aspects of service provision and with different financial and regulatory systems, roles and responsibilities, and organisational and professional cultures. Making sense of this in a way that leads to joined up and well-organised experiences for service users and their families is a difficult political, managerial and practical task. Put simply, people do not live their lives according to the categories we create in our welfare services, and any holistic response to health needs will have to link to and be coordinated with the responses of other agencies if it is to be successful.
In pursuit of more effective inter-agency working, a number of countries have sought to develop more formal partnerships between local organisations. These tend to share a number of characteristics such as a focus on a particular at risk group and a defined catchment area, overall responsibility for arranging and/or delivering comprehensive services, the active involvement of primary care services and a focus on multidisciplinary teamwork at ground level. Such an approach is a powerful idea and intuitively seems like a sensible way forward. In theory, such integration could lead to more seamless services, user-centred care, an emphasis on prevention and rehabilitation, greater continuity of care, improved access to services, more integrated primary and secondary care and a reduction in inappropriate service use. However, key concerns include the difficulty of combining medical and social models and the risk of acute care (and the high cost of such services) distorting priorities.
There is a range of different models in different countries – each with strengths and limitations. Examples include the Program of All-Inclusive Care for the Elderly (PACE) and Social Health Maintenance Organisations