Terry Young

Paradoxes facing the Integrated Care Systems: SCALE

This week in our series on the development of integrated care systems in England, we welcome a guest contribution from Professor Terry Young.

Terry brings a unique perspective from 16 years in industry designing devices and systems and 17 years as a Professor leading large multi-disciplinary research teams in healthcare, focussed around systems development, modelling and simulation. He combines a focus on transformation and organisational change with a deep understanding of the commercial value of digital technology and an extraordinary networking ability which sees him working with people from diverse backgrounds encouraging them to orientate their thinking around a common challenge.

To read other blog posts within this series, click on the link below.


Integrated Care Systems (ICS’s) represent a once-in a generation chance to redesign health services, so let’s step back.  Our predecessors weren’t stupid, so their legacy won’t be undone just by trying something different.

Graph depicting the scaling paradox

Let’s imagine we know exactly what good care is: should we deliver it through large or small facilities? As the chart shows, small facilities spread beyond most people’s reach are ineffective, while mega-health centres on every street corner are unaffordable.  This rules out two options: so should we try small and close together or large and far apart?.

There are good reasons to concentrate resources: staff work better when clustered with peers and centralised equipment can be shared. There are even social economies of scale so that organisations yield a 15% premium for each doubling of size. However, demand drives us the other way: we need care within reach and like to know who is diagnosing or treating us.

Thus, there is a scale paradox where provision and demand pull in opposite directions.

The primary/secondary care split tried to square this circle with services at different scales and the new paradigm of systems, places and neighbourhoods echoes traditional thinking.  However, each layer carries huge running and interface costs (money and delay).

Remarkably little has been written about other ways to trade-off the need to concentrate knowledge and capability against the spread-out nature of demand, so we highlight two: information systems and logistics.

The past year has transformed our on-line existence: we work with people we never meet properly from locations we never thought of as work and still save 10-20 hours/week on commuting. There are downsides, but we are profoundly different people. Applying such insights to the scale paradox, we now know we can run effective teams that need never share the same car park.  Not anymore.

Home delivery changed us, too. While health and other sectors have struggled, on-line grocers and retailers prospered hugely after some early hiccups and shortages. Millions of us don’t worry about getting stuff.  Not anymore. Logistics also reshapes the scale paradox. Distance disappears once you know a particular product or drug will be in the right place at the right time. Rapid transport, such as air ambulances, is not new in health but it would be folly to design any Integrated Care Systems without careful and radical attention to logistics.

Thus, while the Integrated Care Systems discussion has focused on policy, payment and place, two ubiquitous, almost invisible, revolutions are being neglected: information systems and logistics. One brings people together, and the other brings them what they need at just the right time.

Without either, no amount of structure, governance or funding can make an Integrated Care System work.


More useful information on integrated care systems can be found at

The Future Integrated Care Systems

We have 7 key insights to share with you from our work over many years in health and care. All developed through dialogue and engagement around clear vision. True systems leadership in action.

Our 7 key insights are;

  • Why, why, why? – Ensure shared clarity of purpose around the needs of patients and communities,
  • Dual purpose design – resourcing multiple purposes,
  • Mind the gaps – understanding and respecting difference,
  • Design Principles – translating strategic clarity,
  • Identify and manage the tensions – or they will manage you,
  • Make the right thing the easy thing – enabling processes, and
  • Build trust momentum – growing systems leadership.

Learn more by downloading our free E-Book here.

  • We will use the information provided here to keep you updated by email and email newsletters about our latest news. For further information on how we use your personal information, please see our Privacy Policy.
  • This field is for validation purposes and should be left unchanged.