Imagine a 74-year-old woman with diabetes, heart failure, and a hip that needs replacing. In a good European hospital, she will see skilled doctors, each focused on their own specialty. The endocrinologist handles her blood sugar, the cardiologist looks after her heart, and the orthopaedic surgeon will take care of her hip. But no one oversees her overall care. She is the only one who goes to all three appointments, sharing her story from one doctor to the next, even though she is the least prepared to do so.
This is not just a coordination problem waiting to happen. It is how things usually work. That is why I want to focus on a difficult point: coordinated care is the agreed solution in European health policy, but these kinds of consensus solutions rarely work. Everyone uses the term, but few actually change what matters.
Everyone already agrees
This is worth sitting with, because it is easy to mistake agreement for progress.
The OECD has spent years explaining that ageing populations and chronic disease need care joined up across the whole pathway, not delivered in disconnected episodes. The data behind that is not subtle. Generalists now make up fewer than three in ten physicians across the OECD, the GP share has fallen by more than a fifth in several countries in under two decades, and patients reliably report that the parts of the system do not talk to one another.
None of this is contested. When a minister stands up and promises "integrated, patient-centred, coordinated care," there is no opposing camp making the case for fragmented, doctor-centred, disjointed care. Everyone is already on the same side.
Everyone agrees. Almost no one succeeds. The distance between those two sentences is the whole subject of this article.
What the brochures leave out
If commitment were enough, the results would be visible by now. They are not.
When researchers went back and reviewed the systematic reviews of integrated care, hoping to learn what actually works, they found something deflating. In a 2023 review in BMC Health Services Research that covered 22 separate systematic reviews, the programmes were so unlike one another, and the results so inconsistent, that no clear pattern emerged. Some reviews found real benefits. Others found no difference at all against ordinary care. The one thing everyone most wanted to know, which specific ingredients make integrated care work, was simply not identifiable from the evidence.
The European track record says much the same. A 2014 study in Health Affairs compared integrated-care efforts in Germany, the Netherlands and England using the same method for all three. The results were mixed across the board. Some clinical and process measures improved, provider satisfaction rose, but patient experience improved in some places and was unchanged or worse in others. The Dutch disease-management model managed the rare trick of significantly increasing costs.
The English pilots are the most telling detail. Planned hospital admissions fell, exactly as designed. But emergency admissions actually rose compared with the control group. The programme succeeded in moving activity around the system without reliably preventing the crises it had been built to prevent.
Sweden is the cleanest cautionary tale of all. It made its healthcare waiting-time guarantee statutory in 2010, has strengthened it since, and has poured billions of kronor into shortening the queues, including fresh money in this year's budget. According to the European health observatory's account, that guarantee has never once been met. And when one Swedish region built a digital registry to track waits in real time, researchers later found that clinicians frequently did not use the data it produced. The tool existed. The behaviour did not change. Nothing followed.
A programme can carry every fashionable feature, every dashboard and every coordinator, and still change nothing.
Why the money is the hinge
It is worth being concrete about why funding decides so much of this.
Under fee-for-service, the dominant model across most of Europe, every actor is paid for the activity they personally deliver: the consultation, the scan, the procedure, the admission. Nobody is paid for the only thing the patient actually wants, which is the problem resolved using as few of those steps as possible. In that world, coordination is unpaid overhead. It is the single task on which no one's income depends, which is precisely why it is the task that quietly gets dropped.
You can run all the workshops you like about working together. If the cheque still arrives for activity and not for resolution, the system will keep optimising for activity.
What the exceptions did differently
So it is worth looking hard at the few places that did move the numbers, because they share something, and it is not the org chart.
Gesundes Kinzigtal, in southwest Germany, is the case people keep returning to. What made it work was not a smarter pathway diagram or a bigger coordination team. It was the money. A regional management company, the local physicians' network, and two statutory insurers signed a shared-savings contract that made them financially co-responsible for the health of the enrolled population, roughly 33,000 insured people. If that population got healthier and the cost of its care came down, they shared in the savings. For the first time, the incentive pointed at the outcome rather than the volume of activity.
Look at what that bought at the patient's level. Each member chooses a "doctor of trust" who agrees shared health goals with them and stays responsible for their care across the whole system. Someone, finally, owns the case. The model has run since 2005 and been externally evaluated for over a decade, which is more than almost any of its imitators can claim.
That single design choice did what years of pathway redesign elsewhere had not. It gave someone a real reason to own the whole patient, not just the slice that carried their specialty's name.
This is the part the sector keeps walking past. Coordination is not an activity you bolt on. It is a consequence of accountability you create. Where nobody is on the hook for the resolved case, "coordination" quietly decays into more meetings, more referrals, and a thicker file that still travels in the patient's own handbag.
The two things that have to change
In practice, almost every programme that works has done two unglamorous things, and almost every one that fails has skipped at least one.
- Someone owns the case. Not a step in it. The whole of it, from the unanswered question to the closed loop. Today that owner is usually the patient, by default, which means there is no owner at all.
- The money follows resolution, not activity. A queue can shrink while patients give up or go private; the count improves and the person does not. The honest unit is the resolved case: opened, routed, treated, closed, with a record that follows the patient instead of the other way round.
Attach a coordinator to a system that still pays per appointment and per procedure, and you have not added capacity. You have added cost, a new job title, and a fresh layer of admin around the same broken journey.
The only question that matters
The question is not whether to coordinate. That debate ended years ago, and coordination won, on paper, everywhere.
The question every health leader should be made to answer is narrower and far less comfortable:
Have we changed who is accountable for the patient, and how that accountability is paid? Or have we drawn a nicer diagram and called it reform?
If it is the diagram, we already know how the story ends. We have the receipts.
Next week, the money. Europe is not, on the whole, underfunding its health systems. It is misrouting them. And the waste already sitting in plain view on the books would more than pay for the fix.
Sources
- OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studies, OECD Publishing, Paris. On the falling generalist share and patient-reported gaps in coordination.
- Rohwer A. et al. (2023), "Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review," BMC Health Services Research 23:894. doi.org/10.1186/s12913-023-09894-7. On heterogeneity and the missing evidence for effective components.
- Busse R., Stahl J. (2014), "Integrated Care Experiences and Outcomes in Germany, the Netherlands, and England," Health Affairs 33(9). doi.org/10.1377/hlthaff.2014.0419. On mixed results, rising Dutch costs, and the English emergency-admission finding.
- Hildebrandt H. et al. (2010), "Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract," International Journal of Integrated Care. See also the 10-year INTEGRAL evaluation: Schubert I. et al. (2019), BMJ Open 9(1):e025945. doi.org/10.1136/bmjopen-2018-025945.
- European Observatory on Health Systems and Policies (2023), Health Systems and Policy Monitor: Sweden. eurohealthobservatory.who.int. On the statutory waiting-time guarantee never being met.
- Stockholm School of Economics (2024), research summary, study published in Information and Organization. hhs.se. On clinicians not using the waiting-time data the registry produced.
Part 2 of a four-part series. Part 1 covered the foundation. Part 3 covers the economics of misrouted care.
