Karsten Vrangbæk

Patient reactions to hospital choice in Norway, Denmark, and Sweden.

This article is a comparative study of three Scandinavian countries--Norway, Denmark, and Sweden--all of which have provided the individual patient with extensive rights to choose the hospital where he/she wishes to receive treatment. In the paper, we present an analysis of the utilization of the opportunity to choose between hospitals in these three countries. The analysis addresses two questions: (i) How many patients are exercising the right to choose between hospitals in these countries and who is making use of this opportunity? (ii) How can we explain the observed utilization pattern? The results of the study reveal clear similarities between the three countries and suggest that few patients have actually chosen their hospital. However, a gradual increase can be observed over the years. Few formal, legislative, or economic barriers exist for patients. Instead, limited knowledge amongst patients regarding reforms, combined with insufficient support from GPs and limited information, can explain why few patients choose to receive care outside of their local region.

Public Values and Public Service Motivation: Conceptual and Empirical Relationships

The literatures on public values (PV) and public service motivation (PSM) both address whether public service delivery is driven by something more than self-interest. They have developed separately, although they can benefit from insights developed by the other, and this article discusses conceptual and empirical relationships between them. Based on a survey of 501 public managers, we find that PSM and PV are associated empirically, but not in a manner allowing total integration. The conceptual discussion reveals how the two concepts cannot be totally separated, as values can be motivating and motivation is often oriented toward something desirable (e.g., values). This suggests that neither total separation nor integration is a fruitful strategy. Given that the concepts are related, the literatures may benefit from more awareness of the conceptual overlaps and differences.

Choice policies in Northern European health systems

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitts suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice.

Health policy in Denmark: leaving the decentralized welfare path?

In this article, we investigate developments in Danish health care policy. After a short presentation of its historical roots, we focus on the decades after the administrative reform of 1970, which shaped the current decentralized public health care system. Theories of path dependency and institutional inertia are used to explain the relative stability in the overall structure, and theories of policy process and reform are used to discuss gradual changes within the overall framework. Although comprehensive reforms have not taken place in Denmark, many gradual changes may pave the way for more radical changes in the future. The political climate currently seems to be more favorable toward structural reform than in the past.

Public Value Dimensions: Developing and Testing a Multi-Dimensional Classification

Further integration of the public value literature with other strands of literature within Public Administration necessitates a more specific classification of public values. This article applies a typology linked to organizational design principles, because this is useful for empirical public administration studies. Based on an existing typology of modes of governance, we develop a classification and test it empirically, using survey data from a study of the values of 501 public managers. We distinguish among seven value dimensions (the public at large, rule abidance, balancing interests, budget keeping, efficient supply, professionalism, and user focus), and we find systematic differences between organizations at different levels and with different tasks, indicating that the classification is fruitful. Our goal is to enable more precise analyses of value conflicts and improve the integration between the public value literature and other parts of the Public Administration discipline.

Patient empowerment and the introduction of hospital choice in Denmark and Norway.

This article provides a critical analysis of the introduction of hospital choice in Denmark and Norway. The two Nordic cases provide evidence from public integrated health systems that may be compared to the current implementation of choice in other countries such as England. We use the theoretical concepts of institutional structure, historical legacies, and situational factors to analyze the translation of the general choice idea into a specific health policy design in Denmark and Norway. The results of the study show that even if there are many similarities between the two countries, there are also significant differences. In Denmark the initial implementation of choice was adjusted to the dominant policy objectives of macroeconomic control through regional planning, while in Norway the chosen solution reflects a more limited concern for expenditure control and a greater willingness to experiment. Timing and differences in the relative strength of the decentralized actors are important explanatory factors. Theoretically, this article provides some insights into the problem of introducing policies that contradict existing traditions, norms, and values. It addresses issues of policy design and the relationship between ideas, historically developed institutions, and situational factors, including actor constellations and interests.This article provides a critical analysis of the introduction of hospital choice in Denmark and Norway. The two Nordic cases provide evidence from public integrated health systems that may be compared to the current implementation of choice in other countries such as England. We use the theoretical concepts of institutional structure, historical legacies, and situational factors to analyze the translation of the general choice idea into a specific health policy design in Denmark and Norway. The results of the study show that even if there are many similarities between the two countries, there are also significant differences. In Denmark the initial implementation of choice was adjusted to the dominant policy objectives of macroeconomic control through regional planning, while in Norway the chosen solution reflects a more limited concern for expenditure control and a greater willingness to experiment. Timing and differences in the relative strength of the decentralized actors are important explanatory factors. Theoretically, this article provides some insights into the problem of introducing policies that contradict existing traditions, norms, and values. It addresses issues of policy design and the relationship between ideas, historically developed institutions, and situational factors, including actor constellations and interests.

Structural Reform in Denmark, 2007–09: Central Reform Processes in a Decentralised Environment

Abstract This paper investigates the policy process leading to the rapid and somewhat surprising introduction of a major structural reform in Denmark in 2007. The reform reduced the number of regional and local authorities and changed their responsibilities and financing. The research question is why a reform of this magnitude and scope was introduced in a Scandinavian country at this point in time in spite of previous failures and in spite of likely resistance from actors with vested interests in the existing structure? The article explains the initiation of the reform by a rare opening of a window of opportunity due to a number of contextual factors. Once the window was opened the process changed to one of opportunistic pursuit of institutional and personal interests. Skilful management of the reform process by central actors was important for getting the decision through possible resistance points.

Public Sector Values in Denmark: A Survey Analysis

Abstract The issue of public sector values has been increasingly important in public sector reform debates in Europe in the past decade. While there is much debate over values and normative basis there is limited empirical evidence on value profiles and value changes. This article aims to address such limitations by presenting data from a major survey based study of value orientations at all levels in the Danish public sector. The article investigates the following questions: How do public managers perceive values in the public sector? Can we construct value profiles for the public sector or parts of it? Two related hypotheses are suggested. First that it is possible to identify a set of values that is regarded as important by almost all public managers and second that these value profiles are reflected in value orientations and perceptions regarding staff skills and motivation.

Value Dynamics: Towards a Framework for Analyzing Public Value Changes

This paper presents a preliminary framework for analyzing how values in the public sector change over time. The specific dynamics are conceptualised as three types of change mechanisms: a teleological, a conflictual and a value-internal change mechanism. Choice of governance systems – hierarchy, clan, network or market - is an example of designing control systems to promote particular values. Another change mechanism is rooted in conflicts between values and the actors carrying these values leading to various organisational responses. Finally, influenced by basic properties of a value changes may follow several distinct patterns such as life cycles, pendulum dynamics, enlargement of scope, refinement and turbulence. The possible outcomes of value dynamic processes are basically changes in value configurations: crowding out, sedimentation, the core-periphery hypothesis, division of labour, and re-interpretation. The paper uses examples from a Danish context, but argues that the value dynamics identified have a more universal scope.

Reshaping public accountability: Hospital reforms in Germany, Norway and Denmark

The article contributes to the literature on multi-level welfare governance and public accountability in the context of recent European hospital reforms. Focusing on the changing dynamics between regional and central governance of hospitals in Germany, Norway and Denmark, we raise concerns about the reshaping of traditional public accountability mechanisms. We argue that, triggered by growing financial pressures, corporatization and professionalization have increasingly removed decision-making power from regional political bodies in hospital funding and planning. National governments have tightened their control over the overall trajectory of their hospital systems, but have also shifted significant responsibility downwards to the hospital level. This has reshaped public accountability relationships towards more managerial or professional types embedded within multi-level forms of governance. Points for practitioners Our study may be taken to suggest that if reforms are responses to policy pressures, the accompanying changes in accountability relationships and arrangements in turn contribute to altering the pressures and constraints that form the context for administrative, managerial and professional work. As reforms in Norwegian, Danish and German healthcare contribute to corporatization, centralization and economization, there is reason to expect that what officials are held accountable for, and how, is also likely to change and to accentuate the span between policy aims and actual managerial and professional performance.