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Scotland 26. – 27. April 2015

Helge Ramsdal

Østfold University College

Never-ending Reforms - Collaboration in Health and Social Care in Norway

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«Collaboration in mental health care»

«The health and social care system»

20 % of work force in health and social services

Scandinavian traditions: «the profession state»

Modernisation: quality, cost efficiency, equality – from NPM to NPG

Challenges:

- Demographic changes

- Complexity – wicked problems (mental health, addiction, poor immigrants, …..

•

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The Norwegian welfare state

• Pop.: 5 mill.

• A «municipal» welfare state: – 430 local authorities, «general» municipalities in charge of medical services,

elderly care, mental health, social services incl. housing (and much more).

• 19 counties: – Reduced role in health and social policies. Since 2002: public health issues

• State: – In charge of specialised services/hospitals since 2002, co-funding local

services, national guidelines etc.

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Norway health and social policies - the context

The steering problem no. 1: Vertical coordination

– State and municipalities - state funding, local implementation.

But: 400 to 400.000 pop.

The steering problem no. 2: Horizontal integration

- Coordination of sectors, services, agencies, professionals at local levels.

But: local authority organisation models vary substantially

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Never-ending reforms to obtain better integration and coordination:

1) NAV reform 2000: Labour, Insurance, Social services, integrating state and municipal social welfare services.

«One door» to all welfare services.

2) The Mental Health reform: 1999 – 2009: «A failure in all services» - focus on coordination of hospital and municipal services.

3) The Hospital Reform 2002:

Specialised health services/hospitals transfered from counties to state responsibility, regional and hospital authorities – the «NHS» NPM design.

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3) The Coordination Reform: «Proper treatment at the right place and right time» - 2009 – 2017

Problems:

•More people are falling ill,

•population is ageing,

•more people need help for longer periods,

•more diseases are treatable with new technology, and the queues are lengthening for specialist health care services.

Challenges:

•Patients’ needs for coordinated services are not being sufficiently met.

•In the services there is too little initiative aimed at limiting and preventing disease.

•Population development and the changing range of illnesses among the population.

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Measures - Key steps for proper treatment

Key step 1: A clearer role for the patient

•Patient pathways to «permeate» all services

•Contact point for the patient

•Review of the statutory framework –patients’ rights

Key step 2: New role for municipalities in future

•Future municipal tasks

•Binding system of agreements between municipalities and health authorities

•Reinforcing preventative health work

•Better medical services in the municipalities

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Measures cont.

Key step 3: Financial incentives

•Municipal co-financing

•Municipal responsibility for patients ready for discharge

•Increased financial framework of the specialist health care services

Key step 4: Enabling the specialist health care services to apply their specialised competence more

•Administrative systems

•Competence

•Pilot hospitals

Key step 5: Facilitating better-defined priorities

•National Health Plan

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3) The Coordination Reform – steering instruments

• Legal measures – «The idea of the new municipality» - e.g. abandoning the «professions’ protocol» and organization of local services – local «medical centres».

• Formal agreements between hospitals and municipalities on coordination related to e.g. diagnosis groups – patient pathways.

• Financial – municipal co-funding of hospital services

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Four issues:

1. The Collaboration reform as a political steering innovation: - «new governance», or?...

2. «Patient pathways» - «scientific-bureaucratic medicine», or?...

3. Welfare technology (municipal care) – an «innovation journey», or?...

4. Preventive health care/public health - new methodologies for implementing well-known policies, or?...

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1. The Collaboration reform as a political steering innovation: - «new governance», or?...

• The traditional reform design models of the Scandinavian welfare states (1945 – ca.1990) – mix of hierachic, detailed steering instruments

• A transition period: centralization and de-centralization – «the new municipality» (mental health reform and the hospital reform) (1990- 2000)

• The Collaboration reform – new governance/WOG? A «direction» reform – indirect steering instruments - dialogues

• Empirical studies on reform design (mix of steering instruments)

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Collaboration reform - a «new governance» reform ?

Four research topics:

1) The Reform design – mix of steering instruments – will «new governance» approaches improve vertical coordination or will we see new schisms between municipal and hospital services?

2) The «process perspective» on coordination – what are the consequences of implementing patient pathways?

3) The introduction of welfare technologies in municipalties – will it reduce the need for care personell – more need for collaboration and coordination?

4) The strengthening of public health strategies - will new social engineering methodologies work?

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«Hierarchical design» «Dialogic design»

Clearly defined operational goals ambiguous and non-operational goals

Clearly defined target group No clearly defined target group

based on legislation based on circulars, memos, etc.

earmarked funding funding through block grants

vertical management structures horizontal management structures

Unambiguous knowledge of cause-effect uncertain knowledge base

profession maintains knowledge no profession or many professions

state requirements for local implementation no local implementation agency specified

agencies by the state

Comparing four health reforms

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Health Centre HVPU Psych. Coordination

Legislation yes yes no yes

Clearly defined goals yes yes no no

Ideological basis yes yes no no

Scientific-professional

basis yes no no no

Prof. compentence

required yes no no no

Earmarked funding yes yes yes no

Local design of actions

and services required yes no no no

Unambiguous

knowledge base yes yes no no

Vertical manage-

ment structures yes yes yes no

Local polit/admin imple-

mentation agencies yes no no no

Planning required no yes yes no

References

Ramsdal, Helge: From hierarchical steering to dialogic governance? An analysis of four welfare state reforms in Norway, in: Barroso, J. and L.M. Carvalho (eds.): Knowledge and Regulatory Processes in Health and Education Policies. EDUCA, Lisbon 2012. (Ch. 3, pp. 89 – 131).

Ramsdal, Helge and Mona. J. Fineide: Les défis de la réforme de la santé mentale. L’expérience de la Norvège (The Challenge of Mental Health Reform – Experiences from Norway). Revue de Sociologie de la Sante nr. 34, 2011 Autumn

Ramsdal, Helge, Mona J. Fineide: Clinical Pathways as regulatory tool in Mental Health Policies. Report on Regulations in Health Policies in Norway, KnowandPol, Project n° 0288848-2 co funded by the European Commission within the Sixth Framework Program, October 2010, www.knowandpol.eu

The Coordination reform, English version:

http://www.regjeringen.no/upload/HOD/Dokumenter%20INFO/Samhandling%20engelsk_PDFS.pdf

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