Ingrid Mur-Veeman

How to manage the implementation of shared care ‐ A discussion of the role of power, culture and structure in the development of shared care arrangements

The Dutch health care sector has become familiar with innovation of care delivery in order to meet the changing demand of the steadily ageing population, in need of complex care. Innovations often concern the implementation of shared care models, implying collaboration and substitution of care. Whereas ageing is a European-wide phenomenon, the development of such new care arrangements can be observed not only in The Netherlands, but also in the UK, Scandinavia, Italy and other countries. In this article we discuss the implementation of shared care, with the help of three concepts: power, culture and structure. We discuss the role of these factors from the view that shared care can be considered as inter-professional working within a network context. The central question is how structure, culture and power can offer change managers a starting-point for improving their innovative capacity. To illuminate our discussion we make use of a number of event-descriptions from five Dutch shared care projects. Also, we give some practical recommendations for change managers.

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.

Diagnosis of sustainable collaboration in health promotion – a case study

BackgroundCollaborations are important to health promotion in addressing multi-party problems. Interest in collaborative processes in health promotion is rising, but still lacks monitoring instruments. The authors developed the DIagnosis of Sustainable Collaboration (DISC) model to enable comprehensive monitoring of public health collaboratives. The model focuses on opportunities and impediments for collaborative change, based on evidence from interorganizational collaboration, organizational behavior and planned organizational change. To illustrate and assess the DISC-model, the 2003/2004 application of the model to the Dutch whole-school health promotion collaboration is described.MethodsThe study combined quantitative research, using a cross-sectional survey, with qualitative research using the personal interview methodology and document analysis. A DISC-based survey was sent to 55 stakeholders in whole-school health promotion in one Dutch region. The survey consisted of 22 scales with 3 to 8 items. Only scales with a reliability score of 0.60 were accepted. The analysis provided for comparisons between stakeholders from education, public service and public health.The survey was followed by approaching 14 stakeholders for a semi-structured DISC-based interview. As the interviews were timed after the survey, the interviews were used to clarify unexpected and unclear outcomes of the survey as well.Additionally, a DISC-based document analysis was conducted including minutes of meetings, project descriptions and correspondence with schools and municipalities.ResultsResponse of the survey was 77% and of the interviews 86%. Significant differences between respondents of different domains were found for the following scales: organizational characteristics scale, the change strategies, network development, project management, willingness to commit and innovative actions and adaptations. The interviews provided a more specific picture of the state of the art of the studied collaboration regarding the DISC-constructs.ConclusionThe DISC-model is more than just the sum of the different parameters provided in the literature on interorganizational collaboration, organization change, networking and setting-approaches. Monitoring a collaboration based on the DISC-model yields insight into windows of opportunity and current impediments for collaborative change. DISC-based monitoring is a promising strategy enabling project managers and social entrepreneurs to plan change management strategies systematically.

THE REFORM OF HOSPITAL CARE IN THE NETHERLANDS

OBJECTIVES This article provides a short overview of the structure of hospital care in the Netherlands. It discusses a number of hospital reform programs that have been started since the early 1980s and others more recently proposed. Attention has also been given to the potential impact of hospital reform. METHODS Descriptions of hospital structure, planning, financing, payment of medical specialists, and hospital workforce and services provide a context for a discussion of current hospital reform programs. Trends in hospital care delivery, strategic management, and internal organization are examined. RESULTS The relationships between the hospital and other health-care providers, health insurers, employers, and patients are found to have a significant impact on the future of the hospital. The interconnections of these four factors will help form the basis for an understanding of ongoing hospital change. CONCLUSIONS Hospital care has been subject to rapid change during the last two decades, as hospitals become centers for acute specialized medical care. This development has important consequences for the position of hospitals in the health-care delivery network, as they become one of a number of providers in a more integrated delivery system. It should be noted that the changes in hospital care cannot be understood as the results of a single reform program, but rather as the result of a long series of reform efforts.

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.

Governmental promotion of co‐operation between care providers: a theoretical consideration of the Dutch experience

Throughout Europe, there is an increasing number of independently living chronically ill patients who suffer from multiple and complex health problems. Several organisations which, individually, are not able to deliver all of the necessary services to these so‐called multiple problem patients, are involved in providing for their care. In countries like Sweden, the UK and The Netherlands, national governments consider co‐operation between providers to be essential in meeting the demands of these patients. In order to promote co‐operation, governments must know why and how particular relationships between providers come about. We argue that the nature of (resource) dependencies that are conditioned, shaped and secured by institutions determine the characteristics of these relationships. Using Dutch data, we illustrate the effect of legislation and government policies on dependencies and relationships. We indicate how government policy makers can shape dependence that is favourable to co‐operation.