Integrated care cannot flourish with broken windows.

Integrated care is an important item in policy notes of governments [1] and advisory committees [2]. The question is why it is not already practised everywhere. Multidisciplinary work and continuity of care are so self-evident and normal that both should be a natural part of the everyday care practice. Why is that not the case?

The theory of the broken windows can explain much of the low incidence of integrated care. This theory of the criminologists (Kelling and Coles [3]) states that the incidence of crime depends more on the context than on personal characteristics of the criminal such as sex, age, race, education and cultural background. The theory got its name from the metaphor of a house with one broken window. When this window is not repaired, soon a second window will be broken. Then ordinary citizens become criminals by stealing everything valuable from the house. Basing their policy on this theory, the New York Police and New York Transit Authority lowered the incidence of serious crimes from 626,182 in 1992 to 355,893 in 1997 [4]. The new approach started in the subway and after its success it was expanded to the whole of New York. Each subway train was immediately repaired and repainted. Graffiti were removed during the night after discovery. Simultaneously, a zero tolerance policy was introduced with severe penalties for passengers who continued to demolish the trains. As a result, most of the passengers started to behave as good citizens. Total crime diminished, as the above mentioned figures indicate.

My experience is that many providers of integrated health care work in a context with ‘broken windows’, e.g.:

Registration and information systems are poor and don't give enough feed back to professionals.

Information and communication technology (ICT) functions too slowly for professionals and the installed software do not fit to daily clinical practice.

Task descriptions, the allocation of responsibilities and the remuneration systems for professionals do not reflect daily practice.

A shortage of ancillary staff, equipment and consulting rooms exists

The financial incentives for the professionals are old-fashioned: they stimulate production instead of quality.

Buildings are too old and too small with sometimes real broken windows.

Because of these shortages professionals do not become criminals. However, they do lose their standards learned in classrooms and skills labs.

When basic conditions for professionals are not fulfilled, when their ‘windows are broken’, integrated care can not flourish.

An intermediate policy step is ‘repairing the broken windows’. It would be better to stimulate integrated care of professionals through:

Creating information systems which are friendly and useful for professionals

Creating easily accessible electronic medical records and safe internet applications for communication between professionals

Contracting ancillary staff which can take over routine activities of professionals

Introducing financial incentives which stimulate continuity of care and a multidisciplinary approach

Modernising old buildings, also in old neighbourhoods, making professional work safe and comfortable.

After this step, the floor is open to introduce multi-disciplinary protocols and organisational structures. Those professionals who refuse them, have to meet a zero tolerance policy, as was first invented in the New York subways.

Guus Schrijvers Professor in Public Health, Editor in Chief IJIC