Background There is considerable opportunity to draw on other countries experiences to (better) understand the challenges facing the further development of innovative delivery systems and to identify ways to address them.

We analysed the governance and accountability arrangements that influence integration efforts in Italy, the Netherlands and Scotland, and examined how the Covid-19 pandemic has affected governance arrangements.

Methods Cross-country case analysis involving document review and semi-structured interviews with 35 stakeholders in 10 case study sites between October 2020 and April 2022. Sites were identified through document review and consultation with country experts. To maximise variation, we selected sites which have taken different approaches to integration and at different scales.

We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to structure our analytical enquiry.

Results Governance arrangements ranged from small scale bottom-up voluntary agreements between payers (health insurers) and providers in the Netherlands to top-down mandated regional integration care systems in Scotland.

We identified a disconnect between what national governments aspire to achieve and their own efforts to implement their vision of integrated care, resulting in blurred, and sometimes complex, lines of accountability. Study participants in all settings reported that policies, resource allocation and monitoring indicators were dominated by concerns about (acute) health care despite a commitment to health and social care integration.

The pandemic highlighted and exacerbated existing strengths and weaknesses of integrated approaches (or lack thereof) but was not perceived as a disruptor to the overall integration vision for health and care systems in any country. Instead, the need for cost control and efficiency savings was seen as the main driver and accelerator of integrated care policies.

Discussion Our findings suggest several ways by which government can better support integration efforts. Core will be the formulation of a unified, consistent, long-term national vision of health and social care integration across all tiers of the system. This needs to be combined with the flexibility and autonomy for local areas to be able to customise and adapt national policies to the local context.

Supporting new ways of working may require additional resources, and while the economic context is likely to remain challenging, a continued focus on cost control and efficiency savings is likely to fundamentally constrain what can be achieved and undermine the desired long-term system transformation. Continued dominance of acute health care may mean that integration efforts continue to only occur ‘at the edges’ rather than whole system change.