Arno van Raak

Integrated care: the impact of governmental behaviour on collaborative networks

Integration of care is necessary to secure the most appropriate match of the individual demands and the organisational and professional supply. Although this is a basic assumption of all the people involved in health and social care, the magnitude and persistence of obstacles to integration is a common problem in most European countries. In this article, we will explore the role of the Dutch government in the complex interplay of forces around the development of integrated care, within networks of collaborating health and social care agencies. By analysing the behaviour of the Dutch government, we will argue that, in principle, the authorities can play a facilitating role here. For several reasons, however, the government appears not to be able to adequately stimulate the establishment of integrated care arrangements. Examples of such ineffective governmental behaviour are measures with contradictory effects and the adoption of a traditional public finance perspective of comprehensive planning. Our conclusion is that, where local networks play a dominant role in integrated care delivery, the most effective governmental steering should be tailored steering, including a mix of specific steering measures suitable to specific local circumstances, combined with more general steering measures, like financial stimuli, based on legislation.

Understanding the feasibility of integrated care: a rival viewpoint on the influence of actions and the institutional context.

There is in Europe growing awareness that the delivery of integrated care is required to meet the demands of an increasing number of patients with multiple problems. It is also clear that the provision of integrated care is difficult to achieve. As yet, the debate about the circumstances enabling or hindering provision is not settled. The objective of this article is to generate more knowledge on this issue. It is often assumed that the feasibility of integrated care provision is caused by characteristics of the legislation, the financing system and other aspects of the institutional context. Here it is argued that these characteristics are relevant but not decisive. Based on empirical evidence from the Dutch case a rival viewpoint is presented, suggesting that it is the commitment of the actors involved, their support, and the way developments are being managed, that make the difference. Following presentation of the evidence, the implications of the findings for integrated care policy are discussed.

The influence of institutions and culture on health policies: different approaches to integrated care in England and The Netherlands

The concept of integrated care has assumed growing importance on the policy agendas both in England and The Netherlands and elsewhere. It is characterized as health and health care-related social care needed by patients with multi-faceted needs. This article compares policy approaches to integrated care in England and The Netherlands. Differing political strategies and conditions for integrated care correspond to the dissimilarities in the institutional structure and culture of their health care systems. Health care systems are understood as specific national and historical configurations. We review the last decade’s relevant policy processes, using the concepts of hierarchy, market and network. The state health care system in England relies mainly on hierarchical steering, thus creating tight network structures for integrated care on the local level. The Netherlands, with its health care system in a public-private mix, has set incentives for voluntary, loosely coupled and partly market-driven cooperation on the local level. Implications for success or failure are mixed in both configurations. Policy recommendations have to be tailored to each systems’ characteristics.

A New Theoretical Model for Cooperation in Public Health Settings: The RDIC Model

The Resource Dependence Institutional Cooperation (RDIC) model was constructed from four combined theories: network, organizational behavior, resource dependence, and new institutional. The authors developed the model in an effort to better understand cooperation in public health settings, and tested its validity in two different types of networks related to occupational health. Two qualitative studies were performed in the Netherlands. The first study included 11 respondents dealing with the sickness absence of 4 employees. The second study included 11 respondents from 5 organizations involved in developing sickness absence policy. Document analyses and semistructured interviews were performed. The results indicate that the RDIC model coincided with empirical patterns of cooperation in both types of networks. Though they recommend further empirical research, the authors conclude that the model appears to be a valid instrument for understanding cooperation. They assert that the RDIC model can facilitate the management of cooperation in various public health settings.The Resource Dependence Institutional Cooperation (RDIC) model was constructed from four combined theories: network, organizational behavior, resource dependence, and new institutional. The authors developed the model in an effort to better understand cooperation in public health settings, and tested its validity in two different types of networks related to occupational health. Two qualitative studies were performed in the Netherlands. The first study included 11 respondents dealing with the sickness absence of 4 employees. The second study included 11 respondents from 5 organizations involved in developing sickness absence policy. Document analyses and semistructured interviews were performed. The results indicate that the RDIC model coincided with empirical patterns of cooperation in both types of networks. Though they recommend further empirical research, the authors conclude that the model appears to be a valid instrument for understanding cooperation. They assert that the RDIC model can facilitate t...

ABC: The Pathway to Comparison of the Costs of Integrated Care

In recent years, health care demand has become increasingly complicated and care has had to be integrated. The main reasons for this are a rising number of chronically ill patients and ageing of populations. Integrated health care is processual so there are continuous changes in care delivery; it incorporates many co–ordinating and co–operative activities which can produce uncertain outcomes; and activities are directed at delivering tailor–made care so there are no standardized or generalized outcomes. These characteristics mean that it is difficult to determine and compare the costs of different integrated care structures. This article argues that using Activity Based Costing (ABC) and integrated care pathways provides the best information possible for decision–making by health care managers, insurers, care suppliers and governments.

A Comparative Study of Dementia Care in England and the Netherlands Using Neo-Institutionalist Perspectives

In this article, the authors compare dementia care in England and the Netherlands. They used qualitative methods to explore recommended standards of service provision and perceived achievements in mainstream care. They found some similarities in recommended standards and in major shortcomings in mainstream services: notably, weaknesses of generic services in supporting patients and carers, and failure to achieve integrated care. Priorities regarding service provision differed. Whereas in England, a social model of care was used to encourage empowerment of both the person with dementia and the carer, Dutch care professionals focused more on “warm care concepts” and on support of the carer rather than the patient. The balance between community care and institutional care also differed. The authors used neo-institutionalist concepts to explore these similarities and differences as embedded in the (historically developed) structural and cultural contexts of the respective health and social care systems.

Integrated health care from an economic point of view

In many countries, health care reforms are being made with the purpose of stimulating actors to make economically sound decisions. Recent attempts in The Netherlands encompass the development and introduction of integrated health care arrangements. Since these arrangements are directly tailored to care demand, it is generally expected that integrated health care will enhance efficiency. This paper analyses whether a shift towards integrated health care actually represents a Pareto‐optimal change. An analysis of the consequences shows that care demanders, providers and informal care givers, to some extent and under certain conditions, can be expected to benefit from the introduction of integrated health care. Under long‐term considerations, the introduction of integrated care may be categorised as a potential Pareto‐improvement.

Can we make sense of multidisciplinary co-operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.

Integrated care management: applying control theory to networks.

Delivery of integrated care by interorganizational networks attracts much attention in Europe. Such care is required to meet the demands of multi-problem patients. Many efforts are made to establish networks. Often, established networks do not deliver integrated care. Managers must understand the background of this problem, in order to deal with it. The issue addressed here concerns behaviour control in networks of autonomous care-providing organizations. So far, publications have focused on behaviour control in single organisations. Based on empirical data we argue that, due to an essential distinction between networks and single organizations, behaviour control in the former should be approached differently. In addition, we discuss the implications of our findings for the management of integrated care delivery.

Shifting stroke care from the hospital to the nursing home: explaining the outcomes of a Dutch case

RATIONALE, AIMS AND OBJECTIVES Supply chains can contribute to better care for stroke patients and more efficiency. However, such outcomes are hampered when links in the chain are weak. The article aims to further the knowledge about the causes and possible improvements of weak links thereby using theory about rules for action and routines (action patterns). METHOD We executed a single case study of a chain of service delivery to stroke patients by a university hospital and a nursing home in the city of Maastricht, the Netherlands. Methods included document study, interviews, observations, process mapping, use of data matrices and performance of t-tests. RESULTS In the case, the care delivery process in the chain was redesigned to improve the flow of patients and to reduce the length of hospital stay. Length of stay was reduced. However, transfer of patients from the hospital to the nursing home was hampered. At this weak link in the chain, the redesign clashed with the routines of hospital paramedics who did not want to work according to the redesign. CONCLUSIONS The applied theory is useful to understand why a link in a supply chain is weak. Negotiations can be used to strengthen a link.