Journal of Integrated Care

Integration as a scientific paradigm

Axel Kaehne,
Article information:
To cite this document:
Axel Kaehne, (2017) "Integration as a scientific paradigm", Journal of Integrated Care, Vol. 25 Issue:
4, pp.271-279, https://doi.org/10.1108/JICA-07-2017-0023
Permanent link to this document:
https://doi.org/10.1108/JICA-07-2017-0023
Downloaded on: 16 December 2017, At: 04:30 (PT)
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

References: this document contains references to 40 other documents.

To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 34 times since 2017*
Users who downloaded this article also downloaded:
(2017),"Looking down the right end of the integration telescope", Journal of Integrated Care, Vol.
25 Iss 4 pp. 234-236 <a href="https://doi.org/10.1108/JICA-07-2017-0024">https://doi.org/10.1108/
JICA-07-2017-0024</a>
(2017),"Shifting the balance of care…and making the money add up", Journal of Integrated Care, Vol.
25 Iss 4 pp. 256-264 <a href="https://doi.org/10.1108/JICA-06-2017-0015">https://doi.org/10.1108/
JICA-06-2017-0015</a>

Access to this document was granted through an Emerald subscription provided by emerald-
srm:387340 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald
for Authors service information about how to choose which publication to write for and submission
guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company
manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as
well as providing an extensive range of online products and additional customer resources and
services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the
Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for
digital archive preservation.

*Related content and download information correct at time of download.

 The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/1476-9018.htm

Integration as
Integration as a scientific paradigm a scientific
Axel Kaehne paradigm
EPRC, Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK

Abstract 271
Purpose – Integration is policy, practice as well as object of systematic investigation. What we do not know is
whether or not integration can be understood as a science. In his book The Structure of Scientific Revolutions,
Thomas Kuhn formulated a notion of (natural) sciences based on the emergence of commitments amongst a
community of scientists to a set of logics, model and exemplars. He called this a paradigm. The purpose of this
paper is to assess the scientific nature of integration by perceiving it as a paradigm in Kuhn’s sense.
Design/methodology/approach – The paper proceeds by conceptual reflection through matching existing
components, theories and exemplifications of integration to Kuhn’s model of a scientific paradigm. Integration
is understood broadly, either vertical or horizontal, and located within the practical domains of policy
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

formulation, policy implementation and evaluation research. The nature, scope and depth of group
commitments amongst students and practitioners of integration receive particular attention in line with
Kuhn’s social interactionist approach.
Findings – Employing Kuhn’s notion of paradigm in the context of integration highlights the fundamental
tension between integration efforts and integration outcomes. Whilst integration defines itself in
contradistinction to professional boundaries and fragmentation, the paper argues that it fails to develop a
strong theoretical and empirical foundation for a robust and stable group commitment. The reason is that the
key motivational force that may create a stable group commitment amongst those engaged in integration,
the patient perspective, remains outside the integration paradigm. This leaves integration as a practice and
policy model underdeveloped, mainly paradigmatically illustrated by singular exemplars and rooted in
aspirational policy vocabulary, while clustered around a near dogmatic belief that working together between
services must lead to improved quality of care. To become a scientific paradigm the group commitment
in integration would have to coalesce around a clear ontology (symbolic generalisations), epistemology
(models of knowledge) and manifestations in practice (exemplars).
Research limitations/implications – At present both the ontology and epistemological foundations of
integration practice and research are insufficiently clear. This hampers the development of integration
practice as well as a better understanding of how to evaluate integration outcomes. Future studies should
focus on the depth, nature and subject of group commitments to assess whether integration is a viable
candidate for scientific paradigm or an assorted construct of policy aspirations.
Originality/value – The paper questions the rigour and trajectory of integration practice, policy and
research. It identifies a tension at the centre of the field between group commitments to scientific exemplars
(case studies) and symbolic generalisations, encapsulated in the desire to improve patient care. The notion of a
scientific paradigm thus helps to re-frame the discussion about research and practice in integration.
Keywords Integration, Evaluation, Integrated care, Paradigm
Paper type Conceptual paper

Background
Since the publication of Kuhn’s book The Structure of Scientific Revolutions, the debate about
paradigms has had a prominent place in debates about the history of science. Although Kuhn
formulated his thesis about revolutionary change in science in view of prominent patterns in
the natural sciences, his work also influenced thinking in the social and applied sciences.
Over time, the term paradigm took on an expansive meaning and became a symbol for an
irrational dimension within the rational enterprise of science. Kuhn himself later disavowed
any narrow application of his thesis to natural sciences (Brad Wray, 2011) and social and
applied sciences increasingly made use of his theory of change. What got lost as his work took
on a narrative and discursive function within various disciplines was that the term paradigm
actually had a clear heuristic purpose in Kuhn’s original work. Kuhn saw himself engaging in
deductive work, seizing on the explanatory capacity of the term paradigm and using it to Journal of Integrated Care
explicate patterns in the history of science. Vol. 25 No. 4, 2017
pp. 271-279
It is this heuristic function that will be of particular interest in this paper. The paper © Emerald Publishing Limited
1476-9018
gives credence to Kuhn’s claim that the notion of a paradigm can elucidate regularities in the DOI 10.1108/JICA-07-2017-0023
 JICA history of science and can make sense of future developments. The field of application in
25,4 this paper is integration as an arena of interest for policy makers, researchers and
practitioners. Integration is understood broadly encompassing vertical and horizontal,
cross-sectoral as well as intraprofessional practices. This heterogeneity presents
considerable challenges using Kuhn’s thesis in the present context. Yet, I will argue that
employing his concept of a paradigm yields important insights into issues that have
272 plagued integration studies. The paper is thus conceptually experimental. It assesses the fit
of the concept of paradigm to the investigative field of integration by matching existing
theory and conceptual models to Kuhn’s theory of change. Appraising the extent to which
integration conforms to the contours of a paradigm, it will hopefully become clear which
tools we need to employ to explore integration, be it as a programme or an evaluation study.
This may raise the question why the notion of a paradigm should tell us anything new
about integration? What makes Kuhn’s concept so compelling over others to examine
integration as a practice, a scientific theory and a development model for service
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

improvement? Why not continue to develop ever more sophisticated models of what
integration is and try to evidence their specific components within the practice domain?
After all, initial work on this has been encouraging (Valentijn et al., 2013).
The answer, revealing the heuristic promise of paradigm within the integration field, lies
in the interplay between scientific modelling and the production of evidence. Integration has
long struggled with a poor evidence base. Whilst there are excellent examples of integration
programmes where patient outcomes have improved, the field has been plagued by the issue
of attributability. Evaluation methods have often failed to pinpoint exactly which
component has contributed to programme outcomes. The magnitude of the challenge
becomes clearer when we ask what would happen if we could attribute the improvement in
the health or care outcomes within a service improvement programme to the integration
element. Unless it would be a matched controlled study, improving outcomes through
integration does not rule out the possibility that any other type of service improvement
programme may have produced similar results (Kaehne, 2016). In other words, integration
as a service development process operates in a crowded place. It has to demonstrate its
impact on patient outcomes vis-à-vis regular service practices as well as routinely and
constantly changing services. Since health care and its adjacent care fields are in constant
flux through incessant policy formulations and organisational and inter-organisational
dynamic relationships, goalposts for judging the success of integration programmes above
and beyond general service improvements are continually moving.
The resultant evidence problem for integration has so far been approached as one of
insufficient sophistication of existing models. But, with the help of Kuhn’s paradigm, I will
show that our commitment to integration as a practice, a scientific approach and a theory of
service improvement is rooted not in empirical science but in a change of discourse, a move
in normative debates around the relationships between professions and patients. Integration
thus appears part of a wider trend to adopt a patient-centred perspective. The difficulty
arises that integration, however, remains an inter-professional endeavour, not a patient
orientated one. The thrust of our commitment is thus misdirected at professional
co-ordination when it should be patient focused. It is this tension between what we think we
do when we integrate services and what we want to achieve that creates conceptual and
empirical uncertainty in all integration domains, practice, research and policy.

Kuhn’s paradigm of scientific theory

Kuhn’s concept of a paradigm has several functions in the theory of science. His starting
point is that scientific consensus is rooted in a group commitment of scientists to a set of
theories, logics and exemplars. Where and when scientists fail to commit themselves,
the consensus breaks down and a new consensus emerges. The second thrust of his work,
 however, is to explain how and why scientists sometimes revoke their commitment to a Integration as
particular theory and re-commit themselves to another. This second part of his paradigm a scientific
model goes to the heart of scientific rationality as regulatory principle of science. This is where paradigm
critics described Kuhn as a provocateur challenging the rational foundations of science.
At closer inspection, Kuhn’s argument is more nuanced. His claim is not that commitments
to scientific theories are entered into randomly or arbitrarily but that decisions about which
theory to support are partly influenced by the values scientists holds. He comes to this 273
conclusion when analysing the to and fro between scientists during theoretical debates. What
struck him most about these debates, Kuhn writes, was the fact that the relevant data and
information that supported either theory was often widely available to all discussants.
Contrary to popular belief, Kuhn argues, new theories are not formed as new data emerge but
new theories become more likely to be supported as scientists gradually converge on new
emphases and new interpretations of existing data (Kuhn, 1977). What was previously
disregarded as irrelevant suddenly becomes significant. Kuhn gives various examples of this
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

process of shifting loyalty. The main motivator, however, is always the same. It is an
adjustment in what a scientist considers to be relevant or irrelevant within a given context.
It is not new data that lead to theory development, but re-interpretation of existing data that
leads to relinquishing one for another theory. For Kuhn, values that inform this choice are
doing the work when scientists change their theoretical allegiance.
This argument has often been criticised as opening the floodgates to epistemological
relativism. That, however, overinterprets the role values play in Kuhn’s argument. Values
are not the final arbiter for adopting a theory amongst a scientific community. They guide
the emergence of a consensus about a prevailing theory or a novel one emerging.
Any theory, Kuhn emphasises, needs to demonstrate its utility within the ruff and tumble of
scientific work. It needs to have explanatory (predictive) power. Kuhn sketches
five attributes that make a useful theory: accuracy, consistency, scope, simplicity, and
fruitfulness or utility. Values themselves are thus not sufficient to discriminate between two
theories and to create a consensus. Yet, values have a heuristic function as they allow
scientist to “see situations as like each other” (Kuhn, 1977, p. 190), hence assist in
determining which data are relevant to a given theoretical debate. Kuhn links his discussion
about the role of values in theory emergence and theory change to the notion of persuasion
and a shared vocabulary, something we will come back to in the paper.

Integration as paradigm
The first question that arises in the present context is why integration should be understood
as a paradigm at all. After all, integration is not a scientific theory. It is a practice for
professionals engaged in health care delivery, a policy formulated to guide organisational
changes, and an object of study for researchers and evaluators in health care and public
management studies. Integration therefore straddles three domains, be they disciplinary,
practical or conceptual. Within each domain integration is governed by different principles
and working assumptions. So why speak of it as one singular paradigm?
The answer lies in the propensity of Kuhn’s paradigm to extent to other sciences, including
applied sciences. Whilst the notion of a paradigm was originally intended for the natural
sciences, Wray revealed that Kuhn gradually moved away from such a purist approach
(Wray, 2011). At the time of his article The Essential Tension (Kuhn, 1977), paradigms came to
mean any group commitment within any scientific endeavour, including applied sciences.
This would include policy analysis, policy implementation and the evaluation of policies.
Yet although this opens up the possibility of a general applicability of Kuhn’s paradigm to
any one of the integration domains, why should the field in its entirety seen as a paradigm?
This question takes us to the nature of applied science in health care where findings from
studies are supposed to inform policy and programme development just as they are thought to
 JICA influence implementations of service improvements. This hand in glove approach is only
25,4 possible if the fundamentals are similar, first and foremost the terminological foundations.
And, I would argue, this is the case with integration as a practice, a policy and a research
object. All domains operate with similar (though vague) conceptualisations of what
integration is. Practice, policy as well as research are based on assumptions and models that
they share. That is in contradistinction to other areas of science, where, for example, the laws
274 of thermodynamics are based on logics or mathematical cogency.
It is a particular characteristic of applied science that genesis, utilisation and appraisal of a
specific concept or model can be captured through a shared group belief in the concept itself.
The difference to pure sciences is one of extent and depth. Whereas in the natural (and social)
sciences the group commitment does not extend beyond a narrow group of theorists, allowing
a wider community of scientists to put it to use without being part of the group itself, in
applied sciences, and in particular in integration studies, the group committed to a particular
unifying theory or approach is relatively small, yet includes the community of practice.
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

But what is the content of the integration paradigm? What is the level of contestation
within its scientific community? And how did it come about? These questions will shed light
on the nature, the scope and depth of group commitment that underpin the field of
integration. They may also reveal some of the difficulties of how integration can be further
developed and, ultimately, whether or not and how it can be challenged.
If we had to sketch a brief historical narrative of integration studies, Leutz’ article on the five
laws on integration in health care may be taken as a useful starting point (Leutz, 1999). His paper
is one of the most cited and still acts as a benchmark for conceptual discussions about what
constitutes integration. Reading his article it becomes clear that his five laws are little more than
maxims. Yet, they may reasonably operate as a set of tenets that define the boundaries of the
field as well as spell out some of the main parameters of integration practice. Leutz is acutely
aware how deeply integration is embedded in the wider health care context, in an organisational,
social behavioural as well as individual sense. His main claim is that where integration genuinely
occurs it may lead to improved patient outcomes. Yet he is also cognisant of that fact that
integration is perhaps drawing on a large reservoir of health research, with elaborate models
such as the one developed by Donabedian (Busetto et al., 2016; Willis et al., 2016).
This interaction between existing health care research and integration studies has
always been a fertile one. As the conceptual debate on integration took off, the field gained
increasing sophistication by drawing on established health care approaches. Students of
integration can now make use of an elaborate conceptual instrumentarium, including the
rainbow model of integration (Valentijn et al., 2013, 2015), distinctions between micro, meso
and macro levels of integrating efforts, as well as ideas about the underlying epistemology
of integration, mainly centred around the question of attributability in evaluation studies
(Douthwaite et al., 2003; Montenegro et al., 2011; Gibson and Segal, 2015; Kaehne, 2016).
Whilst theories and concepts of integration have emerged that resonate with the wider health
research agenda, integration also retained a disciplinary and methodological heterogeneity. This
ecumenical approach to how integration is being investigated largely stems from a lack of
clarity where and how integration actually occurs. For a start, it can be problematised as a part
of the dynamics between organisations and individuals. LeGrand’s theory of self-perception
encapsulated in the terms of knaves and knights (LeGrand, 2006) may stand paradigmatically
for this type of research. His apt charaterisations of individual motivations of professionals
operating in health care settings structure the field between patients and medical professionals
as consumers and providers of care. Others have developed instruments to measure the
diffusion of novel procedures within organisations and the normalisation of practices
(Hill and Hupe, 2003; Greenhalgh et al., 2004; Nolte et al., 2016). And, last but not the least,
public management studies have contributed perspectives on conditions of governance and
regulatory oversight (Rummery, 2006; Davies, 2009; Coleman et al., 2014).
 The relationship between organisations has also received sustained attention from Integration as
scholars. Axelrod’s work on complexity and inter-organisational dynamics may be mentioned a scientific
here paradigmatically (Axelrod, 1997). On the side of inter-subjective integration, where paradigm
individuals interact with other individuals, social behaviour scientists have conducted studies
using Q methodology to analyse self-perception and subjectivity, complementing some of the
work that social network analysts do when focusing on connections within or between
organisations (Glendinning et al., 2001; Huerta et al., 2006; Provan and Milward, 2006; 275
Goodwin, 2008; Dickinson et al., 2013). In addition, there has also been a cluster of work
around the status differentials between professionals and the perception of professional
boundaries (Sanders, 2000; Axelsson and Axelsson, 2006; Hall et al., 2006; Fisher and Elnitsky,
2012). Despite this methodological heterogeneity of integration research and its symbiotic
relationship with health care research in general, it is one abstract general belief that sustains
and underpins practice as well as evaluation and research. Just like all health care studies,
integration studies commonly subscribe to the belief that working together, or integrating
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

work practices ought to improve outcomes. It is here that Kuhn’s notion of a paradigm can
elucidate the nature and extent of the group commitment that encompasses all three groups,
the practitioner, the policy maker and the researcher. It is to this question that we now turn.
Kuhn argued that group commitments extent to at least three dimensions. First, symbolic
generalisations, second, models of understanding, third, to a set of exemplars. Symbolic
generalisations in natural science often amount to little else than mathematical formulae such
as Ohm’s law (I ¼ V/R). In the case of integration symbolic generalisations are different. They
are the most general assumptions made that are the sine qua non of the field. Without these,
the field would not be able to operate. Within integration, it is the notion that if people work
together (integrate their practices) they will produce better quality of care (or improve working
relations). The depth and the scope of that notion varies within the different groups of
professionals, yet the fundamental assumption remains valid. Integrating, so the premise
goes, ultimately produces better care. Kuhn’s argument is that this symbolic generalisation
orders the field of evidence. It acts as a regulatory principle for our selection of data, what we
consider to be relevant or irrelevant within any given context. Note that, as mentioned above,
a key function of the symbolic generalisation is to sift through and assess the relevance of
existing data and information. It constructs a hierarchy of relevance between different types
of information. The symbolic generalisation operative within integration studies is thus a
discriminating criterion for what matters to us as integration scholars.
This reveals the Achilles heel and, ultimately, the fragility of the scientific commitment
amongst scholars. Whilst our assumption that integration produces better quality of care
orders the field and constructs a hierarchy of evidence, given the difficulties with the
attributability of impact mentioned above, this assumption also renders the field impervious
to the possibility that services may improve without integration. The core principal
commitment of integration scholars thus turns out to be schismatic rather than unifying.
Moving to Kuhn’s heuristic domains of models and exemplars, the models of
understanding proliferate within integration studies. They have reached considerable levels
of sophistication epitomised by the rainbow model or a taxonomy of integration (May et al.,
2009; Rumbold and Shaw, 2010; Valentijn et al., 2013, 2015). In contrast, exemplars of
integration remain curiously isolated and singular in nature. Cases of successful integration
are often quoted but usually based on impressionistic case studies and anecdotal support
from practitioners who testify to the effect that integration efforts have had on previously
underperforming services. What remains unclear is whether any other type of service
improvement programme would have equally produced these or even better results. Robust
comparative studies with tight controls are rare in the field of integration.
Those working in the field of integration, therefore, do have a stock of exemplars, refer
to a symbolic generalisation, as well as operate with highly elaborate conceptualisations.
 JICA They thus meet all three requirements of group commitment, even though the scope and depth
25,4 of commitment to each criterion varies between individual members. The key question in
Kuhn’s notion of a paradigm, however, was: how did they get here? Kuhn’s paradigm was not
just a theory about the infrastructure of that group commitment. It was above all, a thesis about
how, when and where this commitment developed in contradiction to any other commitment.
Let us turn first to the question of where integration developed as a group commitment.
276 As a policy commitment this question is easy to answer. The policy of integration
emerged from dissatisfaction with professional boundaries and barriers between micro or
macro systems of care, some of them cutting across professional sectors. The key trigger for
this change was silo working. Professionals were seen to work well within their own
professional remit yet, as patient care required cross-sectoral input, the quality of working
outside professional frontiers gained importance. As a novel theory integration, however,
was not formulated to replace non-integrative practices. The counterpoint to integration was
professional practices that were based on claims to exclusive practice domains. This was
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

part of the standardisation and harmonisation of practice, the holy grail of professionalism
(Lawton and Parker, 1999; Kaehne and Catherall, 2013; Evans et al., 2016). As practitioners
harmonised their training and practice, they formulated exclusive work terrains regulated
by specific principles, values and maxims. How does this standardisation of practice relate
to the emergence of a new paradigm of work, integration?
Recall that Kuhn’s argument was about the values guiding scientists in selecting existing
data and information. The change that occurs within the community of practitioners, policy
makers and researchers is not brought about by new empirical insights. Instead it is a shift
in perspective, a change in the hierarchies of relevance associated with existing data and
knowledge. For integration, the key perspectival shift was one from professions to patients.
What animated professionals to “see situations like each other” was a growing awareness
that professionalisation had improved the status and working practices between
themselves, but had failed to improve the quality of care for patients. The value
generating a change of perspective was, thus, a reappraisal of who benefited and ought to
benefit from improved work processes. In a sense, integration was predicated on
(re)articulating the patient perspective. The exemplar of good practice and model for this
was person-centred work. Or, to cast it in Kuhn’s terminology, it was person-centred
vocabulary and person-centred care as policy imperatives that persuaded professionals to
shift from a sole commitment to professional standards to patient-centred perspectives as a
benchmark for quality of work (Felce, 2004; Kaehne and Beyer, 2014; Ross et al., 2015).
There was a collective recognition that professional separation based on standardisation
of professional practice, whilst critical for professional status and identity, became a barrier
to what now appeared important: improvement to patient care.

Discussion
The paper adopted Kuhn’s notion of a scientific paradigm and applied it to the emergence
of integration as a policy, practice and object of investigation. I argued that scholars of
integration possess a range of exemplars, models as well as symbolic generalisations that
may be sufficiently articulated for a group consensus. The core commitment at the centre of
integration, however, presents scholars with methodological and empirical difficulties: the
claim that integration produces better care as opposed to any other form of care delivery.
The reason this remains problematic lies, so I argued, in the fact that the emergence
of the integration paradigm originates in a shift of understanding of what constitutes
improved quality of care. This change occurred where standardisations of practice
were seen as insufficient to bring about better patient care outcomes. It was exemplified
in the formulation of person-centred patient care. Yet, as integration retains an improvement
 trajectory directed at professionals, it fails to extend its group commitment to Integration as
patient-centred practice. Integration thus remains an incomplete scientific paradigm. a scientific
If integration is not a mature scientific paradigm, what is it? Future studies need to investigate paradigm
the epistemological, ontological and theoretical foundations of integration. To use Kuhn’s
language, what do people commit to when they formulate, practice or investigate integration in
real world contexts? To make it a scientific paradigm, the group commitments require a quality
of convergence on models, symbolic generalisations and exemplars that reinforce and underpin 277
the group’s practices and logics. At present, it appears that the group’s founding principle feeds
on an aspirational belief (integration leads to better quality of care), sustained by a normatively
charged vocabulary (patient outcomes improve when working together).
To strengthen the paradigm character of integration, the group commitment needs to
encompass symbolic generalisations that possess sufficient accuracy, consistency, have broad
scope, feature simplicity, and hold promise of utility. At present, there is no established
consensus amongst students of integration what this entails. So the central task for
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

future research is to reveal the nature, scope and motifs for paradigmatic commitments that
regulate integration as a practice, policy and research. There are some recent approaches in
social science that may be particularly suitable for these investigations. Realist evaluation
may be one of them claiming to reveal the assumptions people make when they develop,
implement and assess service programmes (Pawson et al., 2004; Greenhalgh et al., 2011;
Rycroft-Malone et al., 2012; Astbury, 2013; Kaehne, 2016).

Conclusion
Kuhn’s concept of scientific paradigm is useful to assess the basic commitments and logics of
those with an interest in integration as policy, practice and object of investigative study.
Seen through the prism of the scientific paradigm, integration turns out to be incomplete with
symbolic generalisations poorly supported by isolated singular exemplars, drawing on a
heterogeneous body of modelling. The key tension in integration studies is that the normative
goal (improving patient care) is weakly grounded in empirical exemplars. A narrative
reconstruction of how integration emerged through the transition from one paradigm to the
next appears to suggest that the main motivational force committing practitioners and
scientists to integration has been a reappraisal of the relative relevance associated with
professional standardisation as opposed to patient-centred care. Since patient-centred care is
rarely manifested as a primary outcome in models or exemplars of integration, there remains a
contradiction at the heart of the paradigmatic group commitment to integration. Scholars of
integration can chart this contradiction and ultimately rectify it, by mapping the nature, scope
and depth of the various group commitments to integration and by encouraging practitioners
and researchers to pivot integration policy, practice and research to the patient perspective.

References
Astbury, B. (2013), “Some reflections on Pawson’s Science of Evaluation: a Realist Manifesto”,
Evaluation, Vol. 19 No. 4, pp. 383-401, doi: 10.1177/1356389013505039.
Axelrod, R.A. (1997), Complexity of Cooperation: Agent-Based Models of Competition and Collaboration,
Princeton University Press, Princeton.
Axelsson, R. and Axelsson, S.B. (2006), “Integration and collaboration in public health – a conceptual
framework”, International Journal of Health Planning and Management, Vol. 21 No. 1, pp. 75-88.
Brad Wray, K. (2011), “Kuhn and the discovery of paradigms”, Philosophy of the Social Sciences, Vol. 41
No. 3, pp. 380-397, doi: 10.1177/0048393109359778.
Busetto, L., Luijkx, K.G., Mathilda, A., Elissen, J., Johannes, H. and Vrijhoef, M. (2016), “Context,
mechanisms and outcomes of integrated care for diabetes mellitus type 2 : a systematic review”,
BMC Health Services Research, pp. 1-14, doi: 10.1186/s12913-015-1231-3.
 JICA Coleman, A., Checkland, K., Segar, J., McDermott, I., Harrison, S. and Peckham, S. (2014), “Joining it up?
25,4 Health and Well-being Boards in English Local Governance: evidence from Clinical
Commissioning Groups and Shadow Health and Well-being Boards”, Local Government
Studies, Vol. 40 No. 4, pp. 560-580, doi: 10.1080/03003930.2013.841578.
Davies, J. (2009), “The limits of joined up government: towards a political analysis”, Public Administration,
Vol. 87 No. 1, pp. 80-96, doi: 10.1111/padm.12048.
Dickinson, H., Glasy, J., Nicholds, A., Jeffares, S., Robinson, S., Sullivan, H. and National Institute
278 for Health Research and Service Delivery and Organisation Programme (2013),
“Joint commissioning in health and social care: an exploration of definitions, processes,
services and outcomes”, Department of Health, London.
Douthwaite, B., Kuby, T., Van De Fliert, E. and Schulz, S. (2003), “Impact pathway evaluation:
an approach for achieving and attributing impact in complex systems”, Agricultural Systems,
Vol. 78 No. 2, pp. 243-265, doi: 10.1016/S0308-521X(03)00128-8.
Evans, J.M., Grudniewicz, A., Baker, G.R. and Wodchis, W.P. (2016), “Organizational capabilities for
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

integrating care: a review of measurement tools”, Evaluation & the Health Professions, Vol. 39
No. 4, pp. 391-420, doi: 10.1177/0163278716665882.
Felce, D. (2004), “Can person-centred planning fulfil a strategic planning role? Comments on Mansell &
Beadle-Brown”, Journal of Applied Research in Intellectual Disabilities, Vol. 17 No. 1, pp. 27-30.
Fisher, M.P. and Elnitsky, C. (2012), “Health and social services integration: a review of concepts and
models”, Social Work in Public Health, Vol. 27 No. 5, pp. 441-468.
Gibson, O.R. and Segal, L. (2015), “Limited evidence to assess the impact of primary health care system or
service level attributes on health outcomes of Indigenous people with type 2 diabetes:
a systematic review”, BMC Health Services Research, Vols 15/154, doi: 10.1186/s12913-015-0803-6.
Glendinning, C., Abbott, S. and Coleman, A. (2001), “ ‘Bridging the gap’: new relationships between primary
care groups and local authorities”, Social Policy and Administration, Vol. 35 No. 4, pp. 411-425.
Goodwin, N. (2008), “Are networks the answer to achieving integrated care?”, Journal of Health Services
Research and Policy, Vol. 13 No. 2, pp. 58-60.
Greenhalgh, T., Wong, G., Westhorp, G. and Pawson, R. (2011), “Protocol – realist and meta-narrative
evidence synthesis: evolving standards (RAMESES)”, BMC Medical Research Methodology,
Vol. 11 No. 115, pp. 1-10.
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. and Kyriakidou, O. (2004), “Diffusion of innovations
in service organizations: systematic review and recommendations”, The Milbank Quarterly,
Vol. 82 No. 4, pp. 581-629, doi: 10.1111/j.0887-378X.2004.00325.x.
Hall, I., Parkes, C., Samuels, S. and Hassiotis, A. (2006), “Working across boundaries: clinical outcomes
for an integrated mental health service for people with intellectual disabilities”, Journal of
Intellectual Disability Research, Vol. 50 No. 8, pp. 598-607.
Hill, M. and Hupe, P. (2003), “The multi-layer problem in implementation research”, Public Management
Review, Vol. 5 No. 4, pp. 471-490, doi: 10.1080/1471903032000178545.
Huerta, T.R., Casebeer, A. and Plaat, M.V. (2006), “Using networks to enhance health services delivery:
perspectives, paradoxes and propositions”, Healthcare Papers, Vol. 7 No. 2, pp. 10-26.
Kaehne, A. (2016), “Complexity in programme evaluations and integration studies: what can it tell us ?”,
Journal of Integrated Care, Vol. 24 Nos 5/6, pp. 313-320, available at: http://dx.doi.org/10.1108/
JICA-10-2016-0041
Kaehne, A. and Beyer, S. (2014), “Person-centred reviews as a mechanism for planning the post-school
transition of young people with intellectual disability”, Journal of Intellectual Disability Research,
Vol. 58 No. 7, pp. 603-613.
Kaehne, A. and Catherall, C. (2013), “User involvement in service integration and carers’ views of
co-locating children’s services”, Journal of Health Organization and Management, Vol. 27 No. 5,
pp. 601-617, available at: www.ncbi.nlm.nih.gov/pubmed/24341179
Kuhn, T.S. (1977), The Essential Tension. Selected Studies in Scientific Tradition and Change, University
of Chicago Press, Chicago, IL and London.
 Lawton, R. and Parker, D. (1999), “Procedures and the professional: the case of the British NHS”, Integration as
Social Science and Medicine, Vol. 48 No. 3, pp. 353-361. a scientific
LeGrand, J. (2006), Motivation, Agency, and Public Policy: Knights and Knaves, Pawns and Queens, paradigm
Oxford University Press, Oxford.
Leutz, W.N. (1999), “Five laws for integrating medical and social services: lessons from the
United States and the United Kingdom”, The Milbank Quarterly, Vol. 77 No. 1, pp. 77-110.
May, C.R., Mair, F., Finch, T., MacFarlane, A., Dowrick, C., Treweek, S., Rapley, T., Ballini, L., Ong, B.N., 279
Rogers, A., Murray, E., Elwyn, G., Légaré, F., Gunn, J. and Montori, V.M. (2009), “Development of
a theory of implementation and integration: normalization process theory”, Implementation
Science , Vol. 4, p. 29, available at: https://doi.org/10.1186/1748-5908-4-29
Montenegro, H., Holder, R., Ramagem, C., Urrutia, S., Fabrega, R., Tasca, R., Alfaro, G., Salgado, O. and
Gomes, M.A. (2011), “Combating health care fragmentation through integrated health service
delivery networks in the Americas: lessons learned”, Journal of Integrated Care, Vol. 19 No. 5,
pp. 5-16, doi: 10.1108/14769011111176707.
Downloaded by Göteborgs Universitet At 04:30 16 December 2017 (PT)

Nolte, E., Frolich, A., Hildebrandt, H. (2016), “Implementing integrated care: a synthesis of experiences
en three European countries”, International Journal of Care Coordination, Vol. 19 Nos 1-2,
pp. 5-19, doi: 10.1177/2053434516655626.
Pawson, R., Greenhalgh, T., Harvey, G., Walshe, K. and ESRC (2004), “Realist synthesis:
an introduction”, working paper series, ESRC, London.
Provan, K.G. and Milward, H.B. (2006), “Health services delivery networks: what do we know and
where should we be headed?”, Healthcare Papers, Vol. 7 No. 2, pp. 32-36.
Ross, H., Tod Mary, A. and Clarke, A. (2015), “Understanding and achieving person‐centred care:
the nurse perspective”, Journal of Clinical Nursing, Vol. 24 No. 9, pp. 1223-1233.
Rumbold, B. and Shaw, E.S. (2010), “Horizontal and vertical integration in the UK: lessons from
history”, Journal of Integrated Care, Vol. 18 No. 6, pp. 45-52, doi: 10.5042/jic.2010.0652.
Rummery, K. (2006), “Partnerships and collaborative governance in welfare: the citizenship challenge”,
Social Policy and Society, Vol. 5 No. 2, pp. 293-303.
Rycroft-Malone, J., McCormack, B., Hutchinson, A., DeCorby, K., Bucknall, T., Kent, B., Schultz, A.,
Snelgrove-Clarke, E., Stetler, C., Titler, M. and Wallin, L. (2012), “Realist synthesis: illustrating
the method for implementation research”, Implementation Science, Vol. 7 No. 33, pp. 1-10.
Sanders, J. (2000), “A review of health professional attitudes and patient perceptions on ‘inappropriate’
accident and emergency attendances: the implications for current minor injury service provision
in England and Wales”, Journal of Advanced Nursing, Vol. 31 No. 5, pp. 1097-1105.
Valentijn, P.P., Schepman, S.M., Opheij, W. and Bruijnzeels, M.A. (2013), “Understanding integrated care:
a comprehensive conceptual framework based on the integrative functions of primary care”,
International Journal of Integrated Care, Vol. 13, p. e010, doi: 10.1192/bjp.bp.105.016006.
Valentijn, P.P., Vrijhoef, H.J.M., Ruwaard, D., Boesveld, I., Arends, R.Y. and Bruijnzeels, M.A. (2015),
“Towards an international taxonomy of integrated primary care: a Delphi consensus approach”,
BMC Family Practice, Vol. 16 No. 1, p. 64, doi: 10.1186/s12875-015-0278-x.
Willis, C.D., Riley, B.L., Stockton, L., Abramowicz, A., Zummach, D., Wong, G., Robinson, K.L. and
Best, A. (2016), “Scaling up complex interventions: insights from a realist synthesis”, Health
Research Policy and Systems, Vol. 14 No. 1, p. 88, doi: 10.1186/s12961-016-0158-4.

Corresponding author
Axel Kaehne can be contacted at: axel.kaehne@edgehill.ac.uk

For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com