Managing healthcare is challenging. In most European countries, the national health systems have several complexities, bureaucratic idiosyncrasies, continuous organizational and technological growth, as well as a long history spanning over 70 years (1). Organizations, such as national health services, need to be restructured when they undergo significant size changes, especially as they reach over 40 years of existence, which is precisely the stage most are reaching. According to Drucker, when an organization exhibits these characteristics, “it has outgrown its policies and its rules of behavior. If it continues in its old ways, it becomes ungovernable, unmanageable, uncontrollable” (2).

Integration of care is emerging as a tool for health sector reform around the world (3–7) to improve system efficiency and effectiveness, population health outcomes, continuity of care, as well as access to healthcare, both primary and secondary (3–7).

There are several integrated care models, and their rationale and value vary according to its contexts. However, integrated care models can be comprehended as a set of structures and practices shaped by contextual factors. Their aim is to unify inputs, delivery, management, and organization of health services under a single management scope (3, 7–11). Often, it is also antithetical to fragmented and episodic care, which has also been dubbed “Healthcare Archipelago.” In its latter definitions, integration of care is associated to a people-center and user-led health system (8, 12).

The concept of integrated care primarily originates from systems theory, which views organizations as hierarchical structures with interconnected parts (7). As organizations become more complex and decentralized with specialization, quality of care may suffer. Pursuing the integration of these specialized structures can therefore lead to increased efficiency and healthcare quality (7, 13).

The gains in efficiency and effectiveness can occur in multiple aspects. Integration can lead to less duplication and waste, more flexible service provision, and better coordination and continuity of care. It can encourage more holistic and personalized approaches to health needs, especially for complex patients such as older individuals and those with multiple chronic diseases (4, 7).

Integrated care is also considered a strategy to increase continuity of care, with an emphasis on prevention and disease management. This is achieved by shifting the focus of care to the community and primary care, instead of the hospital, and even changing how accident and emergency departments in hospitals operate (14).

Specific areas present a compelling rationale for integration, such as the cases that demand synergies between social care and healthcare. Integration can significantly impact discharge times from hospitals and overall quality of care in specific cases, such as the ones related to mental illness, palliative care, older adults, and children. For example, integrating health and social care reduced the length of hospital stay by 32% in a study involving patients with serious mental illness (15).

Worldwide efforts are being made to increase the integration of care in different formats, ranging from complete integration of the organizations responsible for health and social care to small efforts in decentralized service-delivery networks (6).

Integrated care can take many different forms and dimensions and can be either vertical or horizontal. Horizontal integration applies to providers or groups operating at the same level (e.g., groups of primary health centers). Vertical integration involves bringing together different levels on the hierarchical structure under one management umbrella (e.g., secondary and community care) (4, 8) aiming to provide a continuum of primary, acute, and post-acute care within a single organizational structure. In vertical integration, the governance, planning, and resourcing of care are carried out by the same organization. This approach is expected to improve service coordination and facilitate a better progression of services across the patient care spectrum (6, 8, 16).

Supported by the previous experience with vertically integrated healthcare organizations in Portugal and best practices from the literature, the Portuguese National Health Services (NHS) Executive Board (EB) is implementing a novel approach in vertical integration. The purpose of this article is to present an overview of the literature and the efforts being done in the Portuguese NHS. Thus, the article aims to contribute to the global discussion on the practical implementation of integration of care, in the context of a health system strongly supported by a national health service.

Integration of care has promising results in reducing length of hospital stays (4), enhancing patient satisfaction (4, 14), increasing perceived quality of care, and enabling access to services (14), both in European and global settings.

Despite that, the effectiveness of integrated care initiatives hinges on a multitude of factors. There is a need for a careful orchestration of the interconnected elements, each contributing to the overarching goal of enhancing healthcare delivery and improving patient outcomes. These factors include:

While integration efforts hold theoretical benefits, their implementation results vary in both benefits and expected disadvantages. Hence, focusing on specific contexts and implementation methods is crucial.

The United Kingdom took a variety of approaches to care integration and has managed to improve provider experience through more responsive services, as well as reduce costs per patient per year (6, 13, 19, 20). Furthermore, patient waiting time and outpatient appointments may be reduced, and patient needs and preferences with regards to end-of-life care are met more often (14). Scotland, specially, found that vertical integration of health and social care can enhance patient outcomes, organizational efficiency, and patient experience (6). It also reduced delayed discharges – patients clinically ready for discharge awaiting post-hospital care and support (6).

Germany’s Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors in a specific region has also achieved considerable results. A decrease in mortality was measured 2.5 years after enrollment in the program, as well as decreased length of stay, improved patient and provider experience, and decreased cost per patient per year (13).

In the Netherlands, a bundled payments system, specific for certain chronic conditions reduced specialist care and enhanced patient and provider experience. However, it presented mixed results for clinical outcomes, mortality, and process indicators and increased costs due to its disease-oriented approach (13).

In the US, despite its predominantly private healthcare system, there are numerous attempts to implement integration of care in its various forms. A study on medication adherence rates found no average changes, yet health equity worsened, with significant declines in adherence among minorities, patients over 80 years old, and with greater comorbidities. This was explained as a decrease competition for Medicare beneficiaries and disruptions of services among hospital-physician integration (21). Despite that, even in these circumstances vertical integration has shown some benefits. In a systematic review of vertical integration and quality of care in the US, 6 out of 10 studies found that vertical integration was associated with higher quality of care (22) and vertical integration was associated with increased access to surgical care for vulnerable, low-income patients (23).

In Spain, the integration of 1 hospital and 7 primary care providers, the provision of cardiology care improved the quality of care related to ischemic heart disease, heart failure, and atrial fibrillation, when compared to usual cardiological care (24).

Overall, vertical integration is a promising avenue to increase patient-centered care while still increasing systemic efficiency and effectiveness. Furthermore, attempts with greater range are more promising than focusing only on one disease or group (13). While care integration typically enhances results and quality in health, vigilance is required to mitigate potential inefficiencies, especially when strategic alignment is not promoted (25).

Several pitfalls of vertical integration warrant consideration. There is a risk of price escalation instead of reduction, especially in contexts where vertical integration reduces competitiveness or when services and goods outside of bundled payments are involved in vertical integration (13, 26). Furthermore, various system attributes and market factors can influence the outcomes of vertical integration efforts. Those include changes in physician or healthcare team composition, patients’ health plans, market consolidation levels, payment policies, healthcare technology, and organizational practices (26). Addressing these complexities is crucial for optimizing the outcomes of vertical integration initiatives and mitigating potential adverse effects.

The literature lacks reports of vertical integration as extensive as Portugal’s NHS-wide approach. Partial experiments show positive effects on efficiency, effectiveness, and health outcomes. Nonetheless, it is important to consider the risks inherent in the model and ensure adequate support in terms of promoting the real integration of care. A health system-wide approach is needed, which includes the participation of both the government and society. Currently, Portugal is deciding to take this step forward, supporting the mobilization and engagement of institutions, professionals, and communities looking to the goal of achieving better health for all.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

FG-d-S: Conceptualization, Writing – original draft, Writing – review & editing. JuS: Data curation, Investigation, Writing – original draft, Writing – review & editing. MC: Writing – original draft, Writing – review & editing. RG: Investigation, Writing – original draft, Writing – review & editing. RV: Investigation, Visualization, Writing – review & editing. JoS: Writing – review & editing. AM: Writing – review & editing. RM: Supervision, Writing – original draft, Writing – review & editing. MM: Supervision, Validation, Writing – review & editing, Writing – original draft. HA: Writing – original draft, Writing – review & editing. AD: Writing – original draft, Writing – review & editing. FA: Validation, Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.