From the bottom up and other lessons from down under.

THE PREMISE OF LEATT, PINK AND GUERRIERE’S PAPER is that international experience with integrated healthcare can inform strategies for the establishment of integrated healthcare in Canada. The authors propose that based on international reforms, development of an integrated system of healthcare delivery for Canada can better meet the needs of consumers, improve quality of care and outcomes and decrease costs of service provision. A cynic might suggest that the most important global lessons to be learned are that consumers, when asked, cannot readily agree on the services they want or need (Robinson 1999); that purchasers have difficulty defining what will be purchased in terms that ensure quality outcomes (Maynard 1994; Propper 1995; Robinson 1999); and that the level of competition, the amount of central control and the financing methods may have a greater impact on cost control than integrated service delivery (Berwick 1996). Although integration and coordination of care delivery has logical appeal, as highlighted by Leatt et al. there is limited empirical evidence on the impact of integrated healthcare on either individual or community health outcomes or value for money in healthcare delivery. Michael Walsh, MD, MPA Chief Executive Officer, The Alfred Hospital, Prahan, Australia u