Insights: Integrated Care

Bridging the gaps in joined-up care

The promise of integrated care is well understood: better patient outcomes, more efficient use of NHS resources and a more coordinated care journey across services. But as new digital tools reshape health and care, are systems adapting quickly enough? Owen Hughes reports
12 March 2025

Integrated care is supposed to make patient journeys seamless. Yet for many patients and providers, the reality often falls short of ambition.

According to a September 2024 report by NHS Confederation, most integrated care system (ICS) leaders are optimistic about their progress, with 77% confident that they are improving population health outcomes.

However, the report also points to the myriad obstacles facing a truly joined-up health and social care system, from workforce shortages, data sharing and interoperability challenges to the ever-looming spectre of funding.

One contributor to this report noted that shared care records have not provided the boost to integration that many had hoped for. Barriers like fragmented IT systems, the continued reliance on ‘pull’ rather than ‘push’ data environments and a lack of structured real-time data have made it difficult for clinicians to access the right information at the right time. These challenges often lead to inefficiencies and wasted resources at the cost of better care.

But there are encouraging signs of progress. AI-powered solutions are beginning to help extract meaningful insights from unstructured records, providing clearer patient summaries and improving care coordination. Meanwhile, the push for open data standards and value-based care models is fostering a more joined-up approach to healthcare delivery — albeit gradually.

Clearly, ICS leaders have their work cut out for them. Then again, nobody said it would be easy.

Produced in association with

Part 1

Tackling sticking points in care coordination

Much of the stickiness in integrated care – and healthcare delivery more broadly – stems from coordination challenges at key transition points. This happens when key information about an individual’s care isn’t shared with the appropriate teams as they move through the system.

Linda Vernon, head of digital empowerment at Lancashire and South Cumbria Integrated Care Board (ICB), feels that there is currently an overemphasis on how healthcare data is captured and stored rather than making it accessible for real-time patient navigation.

Vernon, who leads the ICB’s digital citizen portfolio and also sits on Digital Health’s ICS Digital Council, believes that the focus should be on ensuring patients can move through the system as smoothly as possible and that clinicians can access the correct information when needed, regardless of where the patient enters the system.

Referring to her 13 years of experience as a musculoskeletal advanced practitioner at Blackpool Teaching Hospitals NHS Foundation Trust, she says: “When I was clinical, a lot of our challenges were around referral. We used the phrase ‘inappropriate referrals’: they were appropriate for somewhere, but they didn’t quite meet the needs of our service.

“If we had the right flow systems in place, it wouldn’t matter where the patient landed because they would end up fairly promptly in the right place to see the right person.”

Our connected care record is valuable but much of the data is unstructured PDFs. Structured data would bring it to the next level

Linda Vernon

Vernon says artificial intelligence (AI) and automation tools can help match patients to services more efficiently. However, she points out that doing so requires structured, real-time data in connected care records, which existing systems lack.

“Our connected care record is valuable, but right now, much of the data is unstructured PDFs. Clinicians love it, but structured data would bring that to the next level with service data so that we can try to match people to the right services,” she says.

Steve Wightman, managing director, health and integrated care at The Access Group, suggests that shared care records have not been the solution to integrated care that many hoped they would be.

A key issue stems from the fact that care teams aren’t getting real-time updates of critical information. Instead, they are forced to go searching for it in different systems, resulting in wasted resources and communication gaps.

“The system still works entirely on a ‘pull’ basis. Nobody works on a ‘push’ basis, where you’re being notified of things you need to do or be aware of,” Wightman says.

“A community nurse recently told me they turned up [at a patient’s home] and spent two hours trying to find out where this person was and whether they were safe. Eventually, they were informed that that the individual was at an outpatient appointment in the hospital.

“Even within hospitals, integration doesn’t happen. When someone misses a pre-op, there should be an alert so the team can decide whether to keep them on the list or replace them in advance. Right now, that doesn’t happen, and we lose theatre capacity because of last minute issues that should have been flagged earlier.”

Another key issue is data overload in shared care records.

“What’s happened is we’ve put masses of data into the shared care record to a point where some trusts are saying to us that it’s almost become unusable and that they have to spend half an hour reading shared care record summaries to get a feel for what’s going on with the individual,” Wightman says.

Pritesh Mistry, fellow, digital technologies at The King’s Fund, suggests that the issue the NHS faces as it moves towards integration is as much about managing the sheer volume of data in IT systems as it is about capturing it.

“We are absolutely at a point where, as soon as you start connecting up different records, you’re going to end up with more data than a clinician can look at in a consultation,” Mistry adds.

To prevent this becoming a burden, smarter tools will be needed to help digest and make sense of the data being captured. Simply having access is not enough, says Mistry — systems will need to be designed to surface contextually-relevant information to the right people.

“[The NHS] will need to do a bit of catch up on how that structured data should be accessible to a clinician, to a patient, to a caregiver, at that moment in time that is actionable, relevant and useful for that individual. And that’s going to be context-dependent,” he adds.

With this in mind, Access is working on offering AI-generated summaries via its Access Intelligent Care Platform (AICP) to help care professionals surface key information about a person’s care.

“To be able to present just a short AI summary of everything that’s going on with that patient record is so powerful [to] give you a feel of what’s happening,” says Wightman.

Part 2

Realigning funding to population needs

Jerry Clough, vice president of integrated care at Optum UK, believes that value-based care with joined-up data at its heart is key to transforming patient pathways and population health outcomes.

Clough argues that the NHS already has a strong foundation for population health management because it is free and universally accessible. However, he believes that the NHS’s historical reliance on transaction-based funding models, such as Payment by Results, has created an imbalance whereby funding is prioritised for hospitals instead of primary care and preventative interventions.

This may have worked in the past, but today’s NHS is dealing with a very different patient population, says Clough. “The presenting condition the NHS is now facing is people with multiple long-term conditions who are also turning up on waiting lists.”

According to Clough, a core challenge in shifting to value-based care is ensuring that payments are tied to meaningful patient outcomes rather than just service volume.

Moving investment upstream is more cost-effective because it prevents patients from becoming acutely unwell, preventing hospital admissions and saving critical resources. But without reliable data integration across different care settings, it’s difficult to fairly distribute funding to services that prevent hospital admissions in the first place, says Clough, leading to different care services operating in isolation rather than in unison.

“What value-based care is trying to get at is: how do we pay for the value that any provider in this system could help us create? Technology, and data and analytics can support this – showing where there is a healthcare need. Technology can also show when patient outcomes have been improved, and therefore where value has been created.”

Clough adds: “Focusing on prevention mean that healthcare providers are paid for the value they create. If spending £1,000 on prevention means that £10,000 is saved further down the line, why wouldn’t you do that?”

Since 2022, Optum has been working with Lincolnshire ICB to explore how population health management can support targeted, proactive care. The initiative, using Optum’s Pathfinder PHM Analytics platform, has enabled the ICB to assess the impact of new interventions and ensure that resources are allocated based on population needs, rather than historical spending patterns.

Mistry says that aligning funding with better patient outcomes is a step in the right direction. However, he cautions that measuring success purely through system-wide efficiencies risks overlooking the impact on patient care and staff well-being.

If you focus on measuring what’s easy, then you might miss some of the things that are important for patients and staff

Pritesh Mistry

“I think it’s important to consider what you’re measuring, because if you take just a system perspective, then you might lose [sight of] patient experience and patient outcomes,” he says.

“If you focus on measuring what’s easy, then you might miss some of the things that are important for patients and for staff. Your incentives and your measures are important, but they need to be considered carefully as well.”

For example, while automation could potentially alleviate pressures in primary care, Mistry warns that this may not necessarily translate to better care if the approach doesn’t account for the demands placed on clinicians.

“If you implement some technology that automates some of the workflow and releases a bit of capacity for GPs so they have more time, but that time is used for more appointments [and] the GP is going to be more fatigued by the end of the day – are they really giving the care that they could give?”

Part 3

Breaking down data and governance silos

A key part of Vernon’s work involves creating a single directory of services using the Open Referral UK data standard, which aims to ensure that accurate and up-to-date service information is accessible across education, social care, primary care and voluntary sectors.

This approach is designed to address a long-standing problem: directories of services are often created with short-term funding, only to become outdated and underused. By maintaining a single, system-wide version of the truth, information can remain accurate and reliable, reducing duplication and ensuring that clinicians, social care teams, and community support services can access and trust the same data.

However, open standards that could support this, such as Open Referral UK are still not being used as extensively as they should be, and Vernon argues that a stronger push from the centre is needed.

“I think that will give us more strength to mandate that data is available for multiple purposes. Now that we have secure data environments and a federated data platform, we want to ensure that data from EPRs and other clinical systems is collected once, managed by the system and perhaps even by the individual.”

Yet for these efforts to have a lasting impact, Vernon stresses that system providers must do their part. “NHS England really needs to mandate suppliers to adopt open data standards so that that information can be made visible in their products,” she says.

Mistry argues that the challenges facing integrated care are a reflection of entrenched ways of working rather than purely technological shortcomings.

“Even though there’s a requirement for people to collaborate across organisations, it doesn’t necessarily mean that people behave in that way just yet,” he says.

“Technologies will have been purchased from a siloed perspective of what the organisation needs, as opposed to what needs to sit around an individual and around a pathway. So you get siloed technologies, and that exacerbates the interoperability challenges that the NHS has faced.”

While he is ultimately optimistic about the outlook for integrated care, Mistry suggests ICS leaders face a considerable undertaking. “ICSs have got a lot to do,” he adds.

“Technology can really improve how care is delivered; it is massively beneficial. We could really realise some of the productivity gains by reducing some of the waste in the healthcare system.

“But they need good leadership; they need leaders that can bridge between digital experts and clinical experts and operational staff; that are able to champion technology and protect the budgets. That then makes it more likely that we can progress.”

A Digital Health Intelligence Insights report in association with Optum UK and The Access Group