The benefits of HSI may be difficult to realise, even if major integration barriers are minimised. Weil's metastudy
of global integration initiatives11 indicated that there was limited evidence that integration actually worked
in either a financial or an operational sense. Over the last 30 years, many American studies have indicated that
HSI generally resulted in either modest economic savings or actual increases in health care costs
and insurance premiums. European studies also showed that integration produced negligible
improvements in efficiency or profitability. Moreover, a Canadian study indicated that HSI may not improve
clinical effectiveness. An earlier study into integrated organisations indicated that declining service quality may
be caused, in part, by particular leadership styles that delay problem-solving capabilities, deplete resources and
sap management morale