Beyond the Clinical Silo: What Italy’s Reform of ‘Shared Administration’ Teaches the UK Third Sector​

The crisis in health and social care is a persistent shadow over the United Kingdom, yet the search for sustainability often feels trapped in a cycle of short-term funding and reactive policy. However, a landmark 2024 OECD analysis of home-based integrated care provides more than just data; it offers a strategic roadmap. Focusing on Italy’s systemic reforms, this international study reveals how moving beyond “service-based” care toward a “person-centred” model is the only viable path forward for societies facing a demographic reckoning. For UK charity leaders and trustees, the “so what?” is transformative. This analysis suggests we are moving into an era where the Third Sector shifts from being a peripheral provider of niche services to a central partner in “shared administration.” As we navigate our own NHS and social care bottlenecks, Italy’s journey from fragmentation to integration offers both a cautionary tale and a blueprint for a cohesive, community-driven ecosystem.

The Landscape of Dependency: A Global Demographic Shift

In an age defined by declining fertility and unprecedented life expectancy, the strategic definition of “dependency” has moved from a clinical niche to a central pillar of social policy. The OECD’s 2024 “Core Story” identifies a critical global transition: we are no longer merely treating acute episodes but managing long-term, complex needs within the home. This shift requires a “bio-psycho-social” approach, grounded in the International Classification of Functioning, Disability and Health (ICF), which views disability not just as a medical condition but as a social construct resulting from the interaction between individuals and their environment.

However, a significant barrier remains the “polymorphous” nature of care definitions. In Italy, this manifests as a rigid divide between Assistenza Domiciliare Integrata (ADI), which is predominantly short-term healthcare, and Servizio di Assistenza Domiciliare (SAD), which focuses on social support. The OECD reveals a “smoking gun” for fragmentation: only 7% of elderly ADI beneficiaries also receive SAD. This lack of overlap reveals a system that treats clinical and social needs as entirely separate entities. For the UK, the lesson is clear: without a unified definition of dependency that synthesises health and functional limitations, our services will remain siloed, preventing a truly holistic response to the individuals we serve. This theoretical tension leads directly to the practical challenges of how such complex systems are governed.

From Fragmentation to Shared Administration: The Governance Model

For the UK’s Third Sector, the OECD analysis signals a fundamental move from being mere contractors to becoming essential pillars of “multilevel governance.” At the heart of this shift is the concept of “Shared Administration,” formalised in Italy’s Third Sector Code (specifically Article 55). This provides a radical blueprint where the state and charities collaborate as equals to identify community needs and design interventions.

The strategic value for charity leaders lies in the distinction between “co-programming” and “co-design.” Co-programming allows charities to sit at the table to identify community needs and allocate resources before a service is even commissioned. Co-design follows, focusing on the specific implementation of projects. These participatory tools empower charities to influence public policy at the root, rather than simply bidding for rigid, pre-defined contracts. Furthermore, Italy’s establishment of the Inter-ministerial Committee for Policies in Favour of the Elderly (CIPA)—which is notably chaired by the Prime Minister—highlights a “whole-of-government” approach. For UK advocacy, this underscores the necessity of moving care strategy into the heart of government, such as the Cabinet Office, to ensure care is treated as a fundamental societal priority rather than a departmental burden. This high-level coordination is the prerequisite for supporting the “boots on the ground”—the workforce.

The Invisible Backbone: Bridging the Formal and Informal Workforce

A resilient care system requires a workforce strategy that recognises the “invisible backbone” of the sector: the informal caregiver. The OECD contrasts the “Formal Sector” of nurses and GPs with the millions of family caregivers who provide the vast majority of support. In Italy, nearly 14% of the population provides informal care, yet they often lack the professional recognition or training needed to function as part of an integrated team.

The strategic bottleneck is the “compartmentalisation of training.” Contractual and legal barriers often prevent professionals from expanding their duties, while siloed education pathways mean that doctors, nurses, and social workers rarely train together. This prevents the person-centred approach that modern care demands. As a best-practice comparison, we should look to Austria’s “Community Nurse” pilot project. This model redefines the nurse as a community anchor who supports both the elderly and their families, bridging the gap between clinical health and social well-being. For charities, there is an urgent need to move away from unmonitored monetary disbursements, which risk fueling “black markets” for care, and toward robust support measures: respite care, psychological support, and integrated training. Transitioning from a supported workforce to an effective system, however, requires the right digital infrastructure.

The Digital Divide: Interoperability and the “Social Record”

Data interoperability is the “critical frontier” for charities trying to demonstrate impact and coordinate with the NHS. The OECD highlights a significant gap between the “Computerised Social Record” (CSI), which tracks social interventions, and the “Electronic Health Record” (FSE), which tracks clinical data. Interestingly, the analysis notes that Italy’s FSE is actually ahead of many OECD countries in terms of technical and operational readiness, yet the social sector continues to lag behind, creating a digital disconnect that hinders patient care.

To bridge this divide, the sector must look to international models that prioritise patient empowerment through data. Key best practices include:

• Finland’s Kanta System: A gold standard for centralised, secure data management that integrates both public and private services, giving individuals full control over their own health and social information.
• The UK’s Federated Data Platform: Noted for fostering collaboration between hospitals and social care, this platform aims to optimise resource management while safeguarding privacy.
• Catalonia’s Integrated Agency: A model for merging health and social budgets and information systems to ensure data informs every level of policy planning.

For the Third Sector, the “Social Record” must become as robust and interoperable as the health record to ensure non-clinical needs are not lost. This digital integration sets the stage for the most innovative frontier of holistic health: social prescribing.

Beyond Medicine: Social Prescribing and the Link Worker

Social prescribing represents a fundamental shift in care philosophy: moving from “what is the matter with you” to “what matters to you.” By addressing the social determinants of health—isolation, housing, and nutrition—this model connects patients to community and charity resources as a primary form of treatment.

The “Link Worker” acts as the connective tissue in this model, removing the psychological and interpersonal barriers that often prevent the most vulnerable from accessing support. The OECD analysis indicates that this role is vital for “equity in service access,” leading to measurable outcomes such as reduced hospital admissions and the preservation of individual autonomy. While the US focus often remains on basic needs like food and housing, the UK’s personalised care model is recognised internationally for its holistic scope. For charities, social prescribing is a powerful validation of their core work, positioning community activities—from vocational training to arts and crafts—not as “extras,” but as essential components of health.

Conclusion: A Forward-Looking Strategy for the Sector

The OECD’s 2024 analysis confirms that the future of care is integrated, person-centred, and community-led. For the UK charity sector, the path forward requires an authoritative embrace of “Shared Administration” to claim a seat at the policy-making table. We must move beyond being a safety net and become the architects of a new system.

The long-term significance of this revolution cannot be overstated. We are moving toward a world where the distinction between “health” and “social” care becomes obsolete. UK charity professionals should keep a close watch on strategic metrics of success: the transition toward Single Access Points (PUA) as a unified gateway for services, and the implementation of the Unified Information System of Social Services (SIUSS). These are the markers of a system that truly puts the person first. The tools for transformation—from co-design to social prescribing—are already within our reach. The imperative now is to use them to build a care system that is as resilient as the people it serves.