Fragmented care remains a critical issue in health systems, leading to significant gaps and poor outcomes. This article highlights real-world consequences and the inefficacy of current patchwork solutions, exposing the gap between policy intent and practical impact. An urgent shift to integrated, people-centred care is needed, embracing social determinants of health, learning health systems and collective leadership. While pockets of excellence exist, sustainable transformation requires valuing and investing in the counterforce: co-creation, relational reciprocity and radical collaboration. This is our path to transformation – supporting the necessary conditions and capabilities for whole systems change.

Addressing Fragmented Care Is Long Overdue

Fragmented care has been a standing focus of the quality agenda for decades, yet it continues to persist in every corner of the health ecosystem, leaving profound gaps (CIHI n.d.; IOM 2001; Starfield et al. 2005).

This is not a theoretical problem; we know this because of the countless stories that serve as undeniable evidence that our systems are not working: an aging parent navigating multiple care providers to manage a chronic illness while their caregiver struggles with isolation; a youth left with no access to critical mental health services not knowing where to turn without disposable income to pay for private care; a person you pass on the street facing precarious housing and unmet palliative care needs, without the basic dignity of food security.

Everyone has a story – whether personal or one you have witnessed – where the impact of fragmented care has led to significant consequences. People working within our systems often go to heroic efforts to fill in the gaps with patchwork solutions and workarounds to make things work for patients. This approach is neither effective nor sustainable.

This is the everyday consequence of a disjointed array of healthcare and social care providers within our systems, which are not built for connection or for supporting all the social determinants that make people healthy – those factors that are necessary to improve well-being and population health (Bell et al. 2023; Varner et al. 2024).

The Healthcare Quarterly series on the future of quality, “It Is Time for Health Quality 5.0: Are You Ready?”, has identified fragmented care as one of the most pressing problems for health systems around the world (Thompson 2023). I note that when combined with other major challenges such as the workforce crisis and the lack of co-creation, the consequences of not addressing fragmented care are amplified (Thompson 2024a, 2024b). Advancing integrated care cannot exist in a vacuum.

The lack of integration reverberates at every level, affecting individuals, families and communities – at best resulting in poor experiences and at worst, causing physical and mental harm.

Reflecting on the Global Momentum Toward Integrated Care

We have known for decades that our outdated, transactional and medically focused health systems are inadequate to meet the needs of people and communities (CMA 2010).

In 2024, Canada marked the 50th anniversary of “A New Perspective on the Health of Canadians,” in which Canadian minister of national health and welfare, Marc Lalonde, highlighted the profound impact of social factors, such as housing, food security and social connection, on health and well-being (Lalonde 1974).

Since its release, both the Canadian and the global population have doubled, and calls to advance integrated care and population health have echoed worldwide (Stein et al. 2022). Of particular significance in Canada was the 2000 publication “Towards a Canadian Model of Integrated Healthcare” by Peggy Leatt, George H. Pink and Michael Guerriere, marking a pivotal moment – 25 years ago (Leatt et al. 2000). Over the past decades, many of us around the world have started down a path to transformation, embracing innovation, reimaging the systems, structures and mindsets that define healthcare today and implementing various initiatives, advancing us toward the quintuple aim (Nundy et al. 2022).

As the first article in the Quality 5.0 series highlights, it is imperative that we adopt a learning health systems approach to generate and translate this high-quality evidence into practice to advance integrated care and population health (Reid et al. 2024; Thompson 2023). This approach enables continuous improvement and scaling of initiatives, continually growing and refining the evidence related to the why, what and how to advance integrated people-centred care. This evidence speaks to the increasing momentum and traction of various approaches in both strategic, top-down initiatives and community-driven, bottom-up innovations (Wodchis et al. 2020).

To meet the escalating needs, we have seen the emergence of new roles in the health system, such as patient and system navigators and peer support workers, all designed to help individuals to navigate complex systems and connect seamlessly to the health and social services they need (Dumbrell et al. 2024).

Strengthening primary healthcare, social medicine and social prescribing is emerging as a top priority in many health systems, now recognized as fundamental to advancing integrated care and population health (Scarpetti et al. 2024). The purpose is to better integrate social determinants of health into care delivery. The increase in models of team-based care through primary care networks, such as in the movement seen in Canada, as well as increased neighbourhood approaches to care, such as in the Netherlands, aim to better partner care delivery with community organizations, public health and social services to improve outcomes; they are investing in upstream care delivery through health promotion, disease prevention, chronic disease management and population health management (Bosdijk et al. 2023; Philpott 2024).

We have also seen an increase in policy-led or place-based integrated care initiatives that cross all levels of the health system. These initiatives are created with the intent to establish shared governance and accountability to improve health and well-being outcomes, such as in the integrated care systems in England (Miller et al. 2021).

Together, these examples show how innovation, collaboration and commitment to shared goals are driving meaningful progress in integrated care. Despite these global efforts, we have yet to see real progress on the scale and sustainability of change.

These pockets of excellence remain just that – isolated pockets. This is not our sustainable operating model for achieving whole systems transformation.

Why Is Progress So Hard?

In our experience with systems change, two forces consistently grapple for dominance: the status quo and its counterforce.

The status quo keeps systems stagnant by maintaining our approaches for change that fail to achieve the transformational and sustainable outcomes we seek.

All too often, we default to focusing on structure, the constant reorganization of our health systems within their existing frameworks, believing that tinkering with structure will yield lasting improvements, or similarly, implementing incomplete or isolated policies or pilots and neglecting the relational and sustainable components needed for whole systems transformation.

Maintaining the status quo of pulling on the same levers of change leaves us in this oxymoron reality where things are constantly changing, yet nothing is changing at all. The overwhelming administrative tasks involved in implementing change make it even more complex, often preventing the achievement of intended outcomes. People are so focused on present urgent priorities that shared purpose is overshadowed or even lost. This is a complete disregard for the people-centred care principles we all aim to uphold.

A clear vision, and certainly the lack of a clear vision, does not provide a clear path, exposing a persistent gap between policy intent and practical impact. Leaders are caught in the present urgency and the time and resources needed to address today's crisis that foresight and reflection on sustainable change are lost.

The counterforce challenges the status quo – it questions, disrupts and reimagines. It champions enabling the conditions and capability we need for transformation, reinforcing the power of social capital: trust, relationships and belonging (Lee and Buhlman 2024). This approach values co-creation, relational reciprocity (Reiss-Brennan 2024) and radical collaboration, understanding that sustainable change emerges from shared purpose, collective leadership and equal partnership.

We witness this tension between the status quo response and the counterforce play out in boardrooms, policy-making circles, leadership committees and on the front lines of care. The stakes in this tension are high. The status quo cannot withstand today's population health crises and social injustices that persist in our communities. Without real change that enables collective progress toward improved outcomes, health systems risk collapsing under the weight of chaos.

How might we shift from an overemphasis on present activities and start to value and prioritize the counterforce? Imagine if enabling the conditions for transformation through collaboration, capability building and relational approaches became our standard way of operating.

So, What Is Coming? The Catalyst for Transformation

Bowie's “Tomorrow Belongs to Those Who Hear It Coming” (1977) reflects the notion that collective foresight and action are the powers we share to shape the path forward.

The call for integrated care has never been more urgent. Transformation requires more than intention or isolated initiatives – it demands bold action and collective leadership (Stein et al. 2021).

Our collective leadership and collaboration can break the cycle of reinventing the wheel each time an integrated care solution is needed, reinforcing the value to leverage, complement and adapt existing approaches and resources that build on decades of lived experience and evidence. This radical collaboration enhances our capability to learn and unlearn together for transformation – intentionally choosing partnerships over competition, optimizing not duplicating, for collective impact. This notion of shifting from ego to ecocentric is a reorientation from the context of our jobs or our organizations to the entire ecosystem and, fundamentally, the people and communities we serve.

The question is, how do we unlock this potential?

In Canada, we have high-quality assets at our fingertips that have been created to help close the transformation chasm. Taken together, they are powerful enablers for change. First, we need to increase awareness of what is already happening across these and help to ensure that people do not waste time, energy and resources reinventing the wheel. Second, we can all go further and faster if these initiatives converge. Convergence will not happen naturally, but when leaders of these national initiatives come together, the roles that each play can be amplified and collective impact achieved. With this also comes momentum, learning at scale and inspiring conditions for others to join the movement.

Let us look at a few outstanding Canadian assets that we think can be leveraged to advance integrated, people-centred care in new and exciting ways (Table 1).

We believe in the power of evidence, standards and collective learning to drive change. Health Standards Organization (HSO) standards are updated on a regular cadence, which provides an opportunity to incorporate what we have learned from the International Foundation of Integrated Care (IFIC) Canada, the emerging evidence from the Canadian Institutes of Health Research (CIHR) project and the experience from people around the world who are using the standard to transform their health systems. This is but one example of the power of convergence that can unlock the potential for us to activate transformation in real and meaningful ways.

Taking these first steps in establishing these assets to enable the agenda for change was necessary. While we have made progress, we know from learnings thus far that the fully enabled environment is needed for the transformational power we seek and we also know that the counterforce is lacking. Herein lies the opportunity and leverage point for convergence. The opportunity for collective impact.

Just imagine the possibilities if we converge and invest in connecting, adapting and sharing learnings across assets. Only by working together in this way can we achieve the meaningful transformation we all aspire to.

Imagining and patterning for our possible future

Through collective leadership, we can set a clear vision, develop realistic plans, measure progress, learn our way forward and celebrate successes together. This counterforce – co-creation, relational reciprocity and radical collaboration – is essential for transformation. It requires time, effort and commitment as the currency for change. Success depends on embedding these capabilities into the transformation agenda, ensuring that they are valued and credible alongside technical and structural components (Fooks et al. 2018).

There is a need for deeper expressions of accountability and deliberate action if we are to drive meaningful change or risk defaulting to the status quo.

What if we make a bold commitment today to embrace and uphold this counterforce, just imagine the possibilities of our future:

1. Just imagine no strategic plan exists without alignment across organizational and community partners through co-creation, embracing shared purpose and priorities.
2. Just imagine municipalities, public health and healthcare and social care organizations radically collaborating, aligned by shared goals and collective accountability to advance community well-being.
3. Just imagine learning and leadership opportunities are no longer isolated but integrated across education programs, services, organizations and sectors, unleashing the transformative power of collective learning and unlearning, capability building and system leadership.
4. Just imagine standards as dynamic and adaptive mechanisms, evolving as enablers of shared accountability, innovation and transformation across the health ecosystem.
5. Just imagine health systems and industry partners working together in equal partnership with communities to bring about sustainable transformation through innovation and collaboration.
6. Just imagine people's and communities' needs are not only met but their health and well-being flourish through inclusivity, co-creation and investment in community-led initiatives. Community partners and service organizations know each other and are designed to connect and interoperate.

This shift from the status quo to the possibility of our future reorients us all from an organization-centric to a people- and community-centric perspective. However, this shift requires more than the will of people; it demands tangible investment and action from everyone.

Just imagine a chief transformation officer or office with the soul of its mission and mandate to support the enabling conditions and build the capabilities that allow this to become the new way we operate – closing the chasm between what policy is intended to do and what actually happens on the ground, connecting across through shared purpose, collective leadership and mobilizing people as part of a movement for change (Evans et al. 2016). The counterforce presents a path of possibility and opportunity. It reimagines systems as ecosystems of connection, rooted in trust and relationships – elements as vital to transformation as any technical solution.

Taking Control of What Is Ours to Change

As leaders, opting out of the quality and transformation agenda is not an option; in fact, it is ours to enable. Bold leadership is necessary to create integrated and population health systems that serve all. It is essential to our collective future, and our actions must reflect that urgency.

In our journey, we have learned that change happens at the speed of trust. Our job now is to create deliberate spaces for co-creation, relational reciprocity and radical collaboration. Each of us holds a piece of the puzzle; no single organization can achieve meaningful progress alone. The challenge is in how we create the enabling environment and capability to bring the pieces together to form a cohesive whole.

This is of utmost importance. Not only is advancing integrated care and population health critical for the health and well-being of people and communities, but health is also a socio-political issue necessary to tackle the broader challenges we face today (Russell 2018). We must now name these challenges and bring them from the periphery into the mainstream.

The Quality 5.0 series names these broader societal challenges – climate change; equity; workforce crisis; safety; and fragmented care – which threaten our opportunity to flourish (Thompson 2023). Progress will lag if we continue to view these issues individually or in isolation – in fact, we cannot meaningfully address them unless we do so collectively.

Upholding the health and well-being of people and communities and advancing health for all is relevant no matter what the issue is – our strength is in connection and community.

Everybody has a story. Now is the time to unite our stories across the health ecosystem and mobilize a collective movement and path to transformation. Stay tuned for more conversations to be had.

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