Inter-agency services in England and The Netherlands

Health Policy 48 (1999) 87 – 105 www.elsevier.com/locate/healthpol

Inter-agency services in England and The Netherlands A comparative study of integrated care development and delivery Brian Hardy a,*, Ingrid Mur-Veemanu b, Marijke Steenbergen c, Gerald Wistow a a

Nuffield Institute for Health, Uni6ersity of Leeds, Clarendon Road, Leeds, LS2 9 PL, UK Maastricht Uni6ersity, Faculty of Health Sciences, Department of Health Organization, Policy and Economics, PO Box 616, 6200 MD c, The Netherlands c Schakels Consultancy, PO Box 13041, 3507 LA Utrecht, The Netherlands

b

Received 27 August 1998; accepted 25 May 1999

Abstract In England and the Netherlands there is much comparable experience in developing and delivering integrated services, provided by different health care agencies to people with multiple care demands. The achievement of integrated care provision in such cases appears to be very difficult and laborious in both countries. This article may be considered a first step in exploring the reasons for this and in developing a framework that is not context specific, as a contribution to a more generally applicable analysis of obstacles to integration and the means for overcoming them. After analysing the English and Dutch health and social care systems and their development in recent decades, we conclude that basically there are clear system similarities which are hindering the integration of services, for instance the predominant complexity of the system with a lot of stakeholders having different roles, tasks, interests and power positions. We have identified common mechanisms that play a dominant role in both systems; not only the social, economic and political context, but also the local context, the legal context and funding streams. Other relevant factors are the procedural and structural arrangements at different system levels and the collaborative culture and tradition. The way these mechanisms work in practice, however, is different for England and the Netherlands, due to system differences. In the Netherlands for instance there is a clear

* Corresponding author. Tel.: + 44-113-233-6354; fax: +44-113-233-6348. 0168-8510/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 5 1 0 ( 9 9 ) 0 0 0 3 7 - 8

88

B. Hardy et al. / Health Policy 48 (1999) 87–105

emphasis on bargaining in the context of non-hierarchical structured networks, whilst in England hierarchies and the interplay between hierarchies, markets and networks play a more dominant role. In spite of the differences and problems in both countries we have found a similar recognition of interdependence and willingness to pursue integration of services for multi-problem patients. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Integrated care; Multi-problem patients; Interagency-services; System-comparison

1. Introduction The necessity for integrated care is becoming broadly recognised due to a considerable increase, in Western Europe, in the number of chronically ill patients with multiple care demands — often older people with, for example, coronary heart disease, diabetes or psychogeriatric problems. Such patients have long term needs for different services, like in- or out-patient hospital care, district-nursing, GP support, domiciliary care, physiotherapy and social support. ‘Integrated care’ is considered here to be a coherent set of products and services, delivered by collaborating local and regional health care agencies. Integrated care is required when the services of individual health care agencies do not cover all multi-problem patients’ demands. Care agencies then have to look for partners who can organize and deliver the care that they alone are unable to give [1,2]. Subsequently, they have to coordinate their activities in order to ensure that the ‘right’ services are available at the ‘right’ time, because patients require assessments of needs and provision which are not distorted by the organisational context and which are ‘simultaneous’ and ‘sequential’, i.e. care which secures liaison or linkages within and between the health and social care systems, so that service users can, first, receive comprehensive, multi-agency, packages of care at any particular point in time and, second, can move across or through the systems for different types and levels of care. Although awareness of the necessity of integrated care is growing, its achievement is another matter. For example, a recent official report in England identified insufficient integration between health care agencies as a recurring theme in reviews of services for older people and stressed the need for far greater inter-agency collaboration and communication [3]. The situation in the Netherlands is similar. A recent report on home care agreed that whereas ‘‘coordination between hospitals, homes of the elderly, GP’s, housing facilities, social work etc. is indispensable…up to now, health care services are insufficiently integrated’’ [4]. These recent statements echo the message of virtually all official guidance in both countries over the last two decades. Indeed, this theme of integration has become a dominant one across Europe, and also at the level of the European Community [5]. Why does the achievement of integrated care appear to be so difficult? Are there any general mechanisms that can be identified which affect the development of integrated care, including the facilitating and impeding factors? From the literature we know, for instance, that domain dissensus within and between organisations and professions is not uncommon and that integrated care development results in many

B. Hardy et al. / Health Policy 48 (1999) 87–105

89

transaction costs [6 – 12]. In this article we will explore these questions in respect of England and the Netherlands, because in both countries there is much experience with more and less successful initiatives of developing and delivering integrated care. We will also consider which problems may be identified from the Dutch and English experiences. In both countries responsibility for the development and delivery of integrated care is spread across a complex array of organisations and functions at central, regional and local levels of governance, with no single locus of accountability for policy formulation, funding and implementation. These services can be conceived of as overlapping/interlocking systems operating around both vertical and horizontal axes of collaboration. The vertical axis comprises relationships between centre and locality while the horizontal axes comprise relationships between organisations at the same level, whether central, provincial, regional or local. Our ultimate purpose is to develop a framework which is not context specific and may, therefore, contribute to a more generally applicable analysis of obstacles to integration and the means for overcoming them. This article can be considered the first step in achieving this goal. Below, we describe first the English case. We will outline the principal features of the system along the vertical and horizontal axes, as far as they are relevant to the development and delivery of integrated care, including the principal barriers to integrated care management. Next we similarly discuss the Dutch case. Subsequently we will compare both cases by addressing similarities and differences between England and the Netherlands. Our conclusions can be considered a first step in identifying mechanisms which, more generally, impede or facilitate the development and delivery of integrated care to multi-problem patients.

2. The English case

2.1. Principal features of the UK health and social care systems 2.1.1. The 6ertical axis In England, health and social care are the principal services for people with multiple care demands; but other services which are important for the delivery of integrated care are housing and social security.1 At national level in England these services are, however, the responsibility of separate government departments. Although health and social care are the responsibility of the Department of Health the two services operate within a framework of central-local relationships which are constitutionally separate. This is crucial to the problems of integrating separate health and social care services at local level. 1

There are important differences in the range and responsibilities of organisations in the constituent parts of the United Kingdom, i.e. in Scotland, Wales, England and Northern Ireland [13], but in this paper we are focusing, for the sake of simplicity, on the situation in England.

90

B. Hardy et al. / Health Policy 48 (1999) 87–105

Health care is largely provided through a centrally funded and managed national health service (NHS). The underlying principles of the NHS were set down in the Beveridge Report of 1942, which advocated the establishment of a comprehensive, universally available, publicly financed health care system [14]. This system was implemented in 1948. The Secretary of State for Health has direct strategic and operational management responsibilities for the NHS. Although many of those responsibilities are delegated to local health authorities, these have been dominated by government appointees (especially their chairmen) and the effect of reforms to NHS management during the last decades has been to strengthen the powers of the centre by ‘‘introducing for the first time a clear and effective chain of management command running from districts to the Secretary of State’’ [15]. The vast bulk of funding for the NHS (some 85%) is from general taxation and services are provided free at the point of delivery. The remainder of the service’s funding comes from charges for medicines, dental and ophthalmic services together with an earmarked element of National Insurance (social security) payments. However, no contribution requirements are necessary and health care is available to all on the basis of need. The national budget for health care is allocated to local health authorities through the regional offices of the NHS Executive according to a national weighted capitation formula. With the introduction of the internal market in 1991, District Health Authorities bought services from self governing public hospital trusts, community health services and even private hospitals. At the same time, general practitioners were able to volunteer to have transferred to them part of the health authority’s budget and become direct purchasers for their clients of hospital and other services, not necessarily in line with agreed health and local authority priorities. This internal market is being dismantled by the current Labour government. Social care services differ from the NHS in two important respects. First, there is and always has been a proportionately larger role for the voluntary and private sectors, such as private residential and nursing homes, in providing social care services, even though much continues to be funded by the public sector. About 80% of net expenditure derives from national taxes and the remaining fifth is provided through a local property-based tax, though central government effectively sets an upper limit (or ‘cap’) on the level of each local authority’s annual expenditure. Moreover, most social care services are means-tested with charges being based upon the level of capital assets as well as income. The second, and more important difference from the NHS is that responsibility for the purchase, provision and regulation of social care lies with the social services departments (SSDs) of local authorities, which are directly elected, in contrast with nominated health authorities. However, whilst not having the same direct line of funding, accountability and management control that exists in the health service, local authorities are not wholly autonomous units of government: although politically accountable at local level they operate within a national framework of statutory powers and obligations. One consequence of these different funding arrangements is that the boundary between health and social care services, which is inherently difficult to define,

B. Hardy et al. / Health Policy 48 (1999) 87–105

91

determines the extent to which individuals may be liable to contribute to the costs of their own care.2 Looking at the English system for health and social care we can, therefore, see a complex system, largely resulting from this health and social care split. This is one of the most important features of the system, giving rise to several major difficulties for the integration of care services. First, the different lines of political accountability can lead to differing and sometimes conflicting policy perspectives regarding health and social care respectively. Second, separate budgets for health and social services are, in themselves, a barrier to integration and they create incentives for each service to shift costs onto the other [16]. Third, there is a potential conflict between controlling costs and improving service systems. Finally, a remarkable feature of the English system is its hierarchical character, especially in health care, but also, although to a lesser extent, in the social care sector. In the case of health care this derives from a combination of direct lines of command from central government down to providers and financial flows from central government via regional offices, district health authorities and GP fundholders to providers.

2.1.2. The horizontal axes There have long been criticisms of the lack of integration between central government departments in England, including the Department of Health’s failure to co-ordinate its health and social care functions [8]. This lack of integration has been acknowledged and addressed in recent years, with the publication of a succession of joint circulars of advice and guidance to health and local authorities and joint working between the regional arms of the NHS Executive (see below) and the Social Services Inspectorate (SSI) [17]. Notwithstanding such initiatives, day-today coordination at the centre remains problematic. At regional level, until 1996, there were eight separately constituted, non-elected, Regional Health Authorities (RHAs) in England: their Chairmen were appointed by the Secretary of State. It was through these RHAs that the centre managed District Health Authorities. RHAs were abolished in April 1996 and replaced by much smaller regional offices of the NHS Executive, the headquarters of which is within the Department of Health. In the case of social care there is no comparable executive branch directly managing the service at regional level. Instead the regional 2 While the allocation of funds between social services functions is not generally prescribed by the government, the major source of growth for social services in recent years has come from a specific grant which is made up of resources transferred from the social security system (and, therefore, not new money in the system of care overall). However, the sums involved have been substantial: by 1996/1997, it was equivalent to one third of all social services expenditure before the transfer began in 1993/1994. This specific grant is also significant as one of the cornerstones of the current, far-reaching, changes in the funding and delivery of services for older people outside hospital settings. It originates in a huge, unplanned and uncontrolled expansion of social security funding for residential and nursing home places in the independent sector (£10m in 1978 and £2500m in 1993). Such payments were based on a test of financial means but not of the need for care. Under the NHS and Community Care Act of 1990, however, local authorities have been responsible since 1993 for assessing such needs and using the transferred resources accordingly.

92

B. Hardy et al. / Health Policy 48 (1999) 87–105

SSI has both an inspectorial and policy guidance function—i.e. an indirect management role — in relation to local authority social services departments. This inspectorate has increasingly sought, in its organisational structure and practice, to match the NHS Executive and its Regional Offices. At local level, the horizontal axis may be analysed in respect of structure, stakeholders and interdependencies. In respect of structure, the absence of shared boundaries (co-terminosity) between health and local authorities has historically been seen to be a major barrier to integration. Although most boundaries were designed to be coterminous in 1974, many no longer are after successive reorganisations in both the NHS and local government. The latest proposals for reorganisation of the health service once again refer to ‘‘the benefits of coterminosity’’ in respect of proposed Primary Care Groups and Social Services [18]. Our previous research has shown, however, that structural co-terminosity does not guarantee integration of either planning or service delivery [9,12,19,20].3 Since the early 1990s, the number of stakeholder interests has been increased, notably by the introduction of quasi-markets in health and social care and the attendant growth in the number of independent sector providers, especially in the social care sector. A particular complexity in the NHS concerns primary health care. Since the inception of the NHS in 1948, general practitioners (GPs) have continued to retain their self-employed status rather than become NHS employees. The barriers to integration which this has created were exacerbated by the previous government’s introduction of GP fundholding. Some domiciliary nursing services are provided as part of integrated primary care teams organised around GP practices. Others, however, are organised on a neighbourhood basis around specific geographical localities. Social workers may be either geographically or hospital based but all are employed by local authority social services departments. Domiciliary social care has historically been provided by the same departments but is increasingly supplied through the private and not-for-profit sectors [21]. Finally, the local horizontal axis is characterised by the existence of a number of crucial interdependencies between different stakeholders and forms of provision. Interdependencies arise principally, but not wholly, at the boundaries of different organisational domains (hospitals, primary care, domiciliary care, residential and nursing care): for example, patient records, referrals to hospitals and successful discharge from them [22 – 24]. Moreover, those responsible for assessing need (e.g. GPs and social workers/care managers) are dependent on the availability of sufficient services, of an appropriate quality and in an appropriate location. Similarly, just as users depend on the ‘right’ services being available at the ‘right’ time and place, so 3 In previous government-funded research, undertaken for the Department of Health, we examined integration between health and social care organisation in contexts of varying inter-organisational complexity. In some cases health and local authority boundaries were co-terminous, in others one local authority might contain within its boundaries (or have overlapping its boundaries) several health authorities. In principle it might be expected that co-terminosity would lead to more effective coordination. In practice we found this apparently crucial structural factor does not guarantee effective coordination. It is certainly a facilitating factor but equally crucial are the organisations’ abilities and willingness to collaborate (see Ref. [9]).

B. Hardy et al. / Health Policy 48 (1999) 87–105

93

service providers depend on each other to ensure that inappropriate demands are not placed on them and that resources are used as cost effectively as possible, without gaps or duplication. The above description of the three horizontal axes shows a third feature of the British health and social care sectors: considerable complexity, with an extensive and varied number of interdependent organisations and stakeholders—across the statutory and non-statutory sectors—with different interests and different powerdependency relationships.

2.2. Principal de6elopments and barriers to integrated care in England Joint planning between health and local authorities has been required by central government in England since 1974. Yet, by the end of the 1980s there was considerable criticism of its slow progress and limited achievement [9,25,26]. Indeed, the centre’s approach to integration during the 1970s and 1980s was famously described as ‘‘the discredited refuge of imploring collaboration and exhorting action’’ [26]. As a result, the 1990 NHS and Community Care Act was intended to create a ‘‘new framework of stronger incentives and clearer responsibilities’’ [15]. With the introduction of this Act, the localities became increasingly involved in managing processes in the health and social care system. The Act introduced quasi-markets into the fields of health and social care based on a separation of the responsibilities for the purchasing and providing functions of both health and local authorities. Although there are some significant differences between these health and social care quasi markets [27]4 there is an important similarity in that these authorities, as traditional unified hierarchies, are required to manage these markets via the development and management of increasingly complex inter-organisational networks. They thus have to utilise a range of integrating mechanisms, appropriate to each of these three forms of governance: administrative orders in respect of hierarchies; contracts in respect of quasi-market relations and trust and cooperation in managing network relationships. As we have noted elsewhere, these recent changes posed health and local authorities the dilemma of reconciling the collaborative imperative with a new competitive imperative, implicit in market relationships [28]. In practice, the previous Conservative government was soon urging authorities to recognise the benefits of collaboration with their providers as well as competition between providers. Collaboration between purchasers was also encouraged through joint commissioning, or purchasing [29]. In addition, the government subsequently introduced a number of specific requirements, most notably that health and local authorities should sign agreements about their respective responsibilities for hospital discharge and continuing care. What is important is not merely the existence of steering instruments (in this case a legal 4 Notably that the provider side in the NHS is still predominantly within the public sector (and there are considerable political problems about privatising supply) whereas in social care, on the other hand the supply side is increasingly within the independent sector (it is now the major provider of nursing and residential homes and provides 44% of domiciliary care).

94

B. Hardy et al. / Health Policy 48 (1999) 87–105

requirement to collaborate) but the extent to which it is reinforced by incentives to comply or ultimately by sanctions in the event of non-compliance. The danger is that the climate created by the use of sanctions would not be conducive to fostering the local ownership, commitment or trust without which joint agreements will fail. The current Labour government has made further steps in urging greater collaboration and partnership between health and local authorities. The 1997 NHS White Paper [30] sets out six key principles underlying the government’s proposed changes, the third of which is ‘‘to get the NHS to work in partnership by breaking down organisational barriers and forging stronger links with local authorities, the needs of the patient will be put at the centre of the care process’’. This key principle springs from the government’s damaging criticism of the previous internal market in which, it has argued: ‘‘there was little strategic co-ordination. A fragmented NHS has been poorly placed to tackle the crucial issue of better integration across health and social care. People with multiple needs have found themselves passed from pillar to post inside a system in which individual organisations were forced to work to their own agendas rather than the needs of individual patients’’. This internal market ‘‘forced NHS organisations to compete against each other when it would have made better sense to co-operate. In the new NHS, co-operation will replace competition’’. Thus the government has proposed that ‘‘a new statutory duty of partnership [be] placed on local NHS bodies to work together for the common good’’: a duty which ‘‘will extend to Local Authorities’’. Whatever the forms of governance in which health and local authorities are operating, the foundation for collaborative behaviour is a recognition by the various parties of their power-dependence relationships. In other words, the stimulus for joint working — for integration—between any two or more organisations is a recognition of the need to bargain for and to exchange needed resources: constitutional-legal (juridical), organisational, financial, political or informational [31,32]. Whatever the form of governance there will always be some stakeholders with greater power than others. In markets, for example, there are tendencies towards monopoly and in the case of health and social care quasi-markets some evidence of monopsony. In terms of hierarchical relationships between central and local tiers of government, there is an asymmetry in terms of the centre’s potential for ultimate coercion: the centre can mandate collaboration and integration though not necessarily guarantee it in practice since the regional and local tiers of government or administration upon which it relies for implementation have the capacity to modify, delay and even obstruct. Notwithstanding the fact that successive government expectations for wide ranging integration of local service planning have been extremely demanding, at an operational level there are nevertheless examples of successful inter-organisational coordination. Indeed, the ‘successes’ we have studied—jointly managed projects or services — involved the most complex of inter-organisational contexts and forms of coordination [9]. Even these successful projects were inherently fragile and vulnerable to a number of problems which threaten the sustained development of all such joint projects. Because of such vulnerabilities, joint schemes need to be treated by their ‘parent’ organisations as fragile plants needing careful protection until they have taken organisational root [9].

B. Hardy et al. / Health Policy 48 (1999) 87–105

95

The laborious work and modest successes result from several serious and persistent barriers to collaboration at all levels of the system. As indicated in Box 1, they include structure, procedures, finance and legitimacy at system and institutional level as well as the professional self-interest at the operational level. We would hypothesise that these barriers and threats to integration apply in a wide variety of service contexts — within and outside the public sector—and in many countries.

3. The Dutch case

3.1. Principal features of the Dutch health and social care system 3.1.1. The 6ertical axis Health and social care in the Netherlands evolved as a hybrid of church-based, non-profit foundations and private providers of individual and professional help. Historically the supply side functioned as an independent, self-regulating system,

Box 1. Principal barriers to integration.

96

B. Hardy et al. / Health Policy 48 (1999) 87–105

with the emphasis firmly on curative medical care as opposed to preventive medical care [33] or social care. Until the 1970s, the role of central government was limited to guaranteeing the continuity and autonomy of the system, with little active intervention. The gradual but steady growth of state intervention, by introducing financial and planning legislation, by formulating a huge number of policy measures and by launching a number of policy plans regarding the whole system [34], is an important aspect of the modernisation of the Dutch care sector. Health and social care is financed through various funding sources. About 10% of the total health care bill is paid for out-of-pocket, by the patient. Another 10% is paid by the government, with funds raised through taxation. The remaining 80% of health and social care expenditures are covered by insurance premiums, of which 65% come from the statutory social health insurance schemes and 15% from private insurance [35]. The Sickness Fund scheme (Sickness Fund Act (ZFW) 1964) offers statutory health insurance to all citizens whose income does not exceed a certain ceiling. These funds cover acute care and are managed by the statutory Sickfunds. Funding is from premiums paid by employers and employees and people on social security support. The Exceptional Medical Expenses Act (AWBZ) from 1967 is a true national insurance scheme which covers the entire population. This collective fund, paid for by social premiums, was created to protect people from the specific risks of chronic illness and invalidity. Thus, employers and users’ contributions, including private premiums to commercial insurance companies for citizens with an income beyond the Sickness Fund ceiling, are the financial sources for the bulk of health and social care services, which in the Netherlands—unlike the UK—are not strictly separated. Instead, the principal distinction is between acute and long-term care. Because of the funding system the insurers play a major role in financing health and social care services. However, they play only an advisory role in the planning process, the responsibility for which lies with central government, with also an advisory role for provincial and local authorities. This administrative arrangement implies a de facto institutional separation between finance and planning in health care. Equally important is that care providers, which can be conceived of as the bottom of the vertical axis, are subject to different financial regimes and planning legislation, which is a major obstacle to cooperation between providers. Box 2 shows the division of financial regimes across the different providers. When looking at the vertical axis of the total health and social care system in the Netherlands, we can observe a complex system, comprising a combination of elaborate government regulation, on the one hand, and the mainly private/statutory provision of financing and health care facilities on the other. Thus, planning and finance are separate processes. Policymaking and policy implementation occurs in a fragmented power structure, which since the late 1980s is complicated by government endeavours to introduce market-like arrangements [36]. This high level of complexity and fragmentation is the first noticeable feature of the Dutch health and social care system. Second, in respect of funding and financing, there is a split between acute and long-term care, which is a major obstacle for providers under different financing regimes (ZFW or AWBZ) to coordinate and/or substitute their

B. Hardy et al. / Health Policy 48 (1999) 87–105

97

Box 2. Dutch health care providers and their funding sources.

services for the sake of integrated care. Third, the vertical axis described above is not unambiguously hierarchical; there is no direct line of legislative/regulative command simultaneously with full control of financial flows by the same (governmental) institution.

3.1.2. The horizontal axes At the central level, policy-making for people with multiple care demands extends beyond the Ministry of Health, Welfare and Sport. The planning of nursing homes, for example, is clearly determined by financial, employment and economic concerns, articulated by the Ministries of Finance, Social Affairs and Economic Affairs. Moreover, macro economic policy considerations obviously dictate the availability of financial and other resources in the health and social care sector. Furthermore, it is worth noting that national representative provider and health insurance associations, the employer and employee associations influence governmental policymaking by advising (which is a formal role), lobbying and negotiating.

98

B. Hardy et al. / Health Policy 48 (1999) 87–105

Provincial and local governments operate in some respects as autonomous policy-makers and in others mainly as the implementing agency of national policy programs. Their role in health care is limited. Whereas provincial government is involved in hospital and nursing home planning, as an advisor to the Ministry, the activities of local government focus upon public health and health related social work. Both provincial and local authorities do have some juridical (legal) steering instruments in the care field, relying on legislation. The regional /local level, which, again, will be analysed in respect of structure, stakeholders and interdepencies, is dominated by local insurers, regional cooperating bodies (often foundations), local authorities, providers and local patient/consumer organisations. For the sake of integrated care development and delivery they shape policy and service networks, like strategic alliances [37]. Providers taking part in such strategic alliances retain their own responsibilities and juridical autonomy: their interrelationships are regulated by contracts. The alliances increasingly have been developed as so-called transaction networks, addressing one or more clearly defined tasks — such as consultation with diabetes patients or a shared provision of day care facilities to people with learning disabilities—with all partners contributing to this common activity. Whenever such networks are developed as a common project, i.e. with clearly formulated common aims to be attained within a certain fixed time span, special officials, such as a project director, are often appointed to take care of initiating, structuring and steering collaborative activities. Such project managers are typically controlled by a board of deputies from the organisations and professions involved. The network providers can be said to be highly interdependent in a number of complementary ways. First, in terms of the transfer of patients: this is important in delivering integrated care to people with complex health and social problems, because they are constantly moving between providers. Second, in respect of the transfer of information, especially patient data and information on treatment. Finally, primary care providers in particular are in need of the transfer of expertise on specialist and technological care. Besides these complementary interdependencies, however, more competitive interdependencies can be observed. These derive from partially overlapping task-domains, which are often a source of domain struggles, with conflicts and debates resulting from different views and interests operating in market-like situations. Ultimately, the providers’ strategies and interactions determine the success or failure of collaborative activities. Central government stays at a distance. It cannot rely on direct sanctions that compel the local parties to cooperate. Instead, it can only make use of incentives and stimuli, deriving from legislation and policy measures. An example here is the use of the Hospital Provisions Act, which enables the Ministry to push the providers to cooperative arrangements or even merger negotiations. Other examples include financial subsidies to local networks. In addition, civil servants, when communicating with separate providers, often try to put them under pressure to develop collaborative arrangements for the sake of integrated care delivery. There are few effective direct linkages between the centre and the localities and thus little direct accountability. It is the local networks which provide the vehicle through which

B. Hardy et al. / Health Policy 48 (1999) 87–105

99

cooperational processes for integrated care development and delivery operate. Here then is the fourth remarkable feature of the Dutch health care system: a high level of reliance on networks with a considerable degree of discretion.

3.2. Principal de6elopments and barriers to integrated care in the Netherlands Service integration in the Netherlands has to be developed in a care system in which one of the principal difficulties is the unclear institutional arrangements. At the end the 1980s, under the influence of so-called ‘no-nonsense’ politics, a system was advocated to gradually transfer the regulation of supply and demand from the government to the health insurance companies and suppliers of care. An essential characteristic of this new system was ‘market targeting’ based on: (a) competition for clients between health insurance companies; and (b) competition between care-providers [36]. At present there is uncertainty about whether such reforms will eventually result in less state control. There is also growing concern about the ability of competition to contain costs. As a result, the political will to change the care system is radically disappearing and a huge gap exists between the rhetoric and reality of the Dutch reforms. Connected with the unclear institutional arrangements is the ambiguous role of government, advocating and stimulating both collaboration and competition at the same time. This promotes opportunistic behaviour amongst both providers and insurers. Another major difficulty arises from the fragmented power and financial structures in Dutch care for multi-problem patients. Although central government in the Netherlands has some strong steering instruments (juridical, economic and communicative) it is dependent on mainly private organisations to implement desired policy programs. Currently none of the relevant actors has enough power to force the other to cooperate. Moreover, care providers in the Netherlands are subject to different financial regimes (see Box 2). As in the UK, this is a significant barrier to cooperation between providers. There have been two dominant concerns in respect of Dutch care for multipleproblem patients: how to contain the cost of professional care; and how to make the system and institutions more responsive to the needs of this patient category— to make services needs-rather than service-led. In the Netherlands, much attention is given to ‘controlling the costs of care’ through the so-called ‘substitution’ policy: the partial replacement of institutional care by home and community care. The latter is assumed to be more efficient and better attuned to the preferences of (older) patients, so long as providers can deliver more flexible services and create a better task division and coordination of care, thereby improving the client’s pathway through the system, according to his or her needs. In respect of both policy aims—more efficient care and more responsiveness — the search for greater cohesion in the Dutch system of care is paramount. Although central government delegates to the regional players (care providers, insurers and local authorities) responsibility for achieving ‘cohesive care’, there is an explicit central government policy with regard to these themes. The government’s objective is to initiate or promote new developments by creating opportunities for experimen-

100

B. Hardy et al. / Health Policy 48 (1999) 87–105

tation and innovative projects. There have been grants for projects in the care for the elderly and for home-care projects, which aimed at creating more integrated care [38,39]. In addition, there have been several amendments to existing legislation and regulations, to help care-providers work more closely together. At the regional/local level, a number of impediments to integration can be identified. First, there is no single power centre in the networks for integrated and continuing care. The realisation of network aims and interests depends on the voluntary support of network members, especially when there is no external authority able to compel the members to collaborate [40,41]. In the case of the Netherlands, therefore, the authorities, insurers and other external parties are only able to encourage collaboration. Second, building support is a laborious and time-consuming job. The Dutch experience shows that several years are usually needed to get sufficient support for network objectives and activities. For this reason, the effectiveness of cooperation in the sense of creating integrated care becomes apparent only in the long term and greatly depends on how network managers cope with promoting and impeding factors. The extend to which they are able to manipulate these factors in such a way that they create optimal conditions for smooth network processes determines the network’s success in the realization of integrated and continuing care [2,37,42–45]. It is evident that coercion or a more technological approach of implementing new coordinative instruments does not work. Rather, successful management of networks in the Netherlands appears to depend of the managers’ willingness and ability to use communicative, negotiating and other ‘political’ strategies, for maximising opportunities and minimising the influence of barriers to integration. Third, there is a great difference in the insurers’ attitudes with respect to inter-agency collaboration. Some show a positive attitude and develop helpful initiatives but a larger number adopt a more cautious attitude and give no support to the providers’ activities in this field. This results in differences in the opportunities for proactive network management in different networks. Fourth, the quality of network management is generally modest. Project directors often have no experience or insufficient skills to manage these complicated network processes. Where network management is the responsibility of officials from the different providers, the individual interests of the participating (autonomous) organisations and professionals play a dominant role. Sometimes there is great confusion about who is responsible for the progress of network activities. Finally, local authorities could play an initiating and stimulating role here, but typically are not inclined to do so. In general, they have little experience of promoting integrated care and lack the financial resources or other instruments to play an effective coordinating role. Notwithstanding these problem areas, there are a number of positive developments which are promoting rather than inhibiting integration. For instance, although the development of integrated care is difficult and laborious, the number of collaborative relationships is steadily growing. The number of insurers with a positive attitude to cooperational activities is also growing and individual providers now recognise that they can no longer afford not to co-operate. It is also recognized that there is a need to develop cooperation on very concrete and limited tasks. The

B. Hardy et al. / Health Policy 48 (1999) 87–105

101

time of attempting comprehensive co-ordination is over. Allied to this, the more experience the various parties have of collaborative activities the more confident they become about each other. In addition, all providers, home care organisations in particular, are increasingly confronted with financial problems, because of government measures such as steady budget cutting over the next few years. This could stimulate collaboration, because it is supposed to lead to greater cost effectiveness. On the other hand, developing inter-agency collaboration is itself costly, not least because of its time-consuming character.

4. A comparison of England and the Netherlands in respect of integrated care services When comparing England and the Netherlands at the most general level some clear similarities can be observed. In both countries the health care system is very complex, with a multiplicity of stakeholders and a pronounced structural split, which together impede the integration of services. The stakeholders do not exist in a vacuum: rather they operate in multi-level political and economic systems, within which those in the public sector (health authorities in England and insurers in the Netherlands) are held accountable by central government for the expenditure of the larger part of public funds. Central governments are the ultimate bodies which shape the environment in which the stakeholders’ interactions take place: they are responsible for the legal frameworks, the institutional structures and the patterns of incentives and sanctions in which stakeholders work. However, not all the actions of central government are necessarily supportive of service integration. For example, structural arrangements and resource allocation mechanisms may in practice encourage or reinforce the tendency for organisations to operate unilaterally in pursuit of their own goals. Another similarity between England and the Netherlands is that there is a common recognition that the starting point for the integration of care must be the needs of individual service users and their carer(s). Such integration is dependent upon the horizontal co-ordination of service delivery at the level of the individual care worker and service user. It is dependent upon the horizontal co-ordination of service planning at the level of the responsible organisations at local (and regional) level. Integration, is also, of course, dependent upon vertical integration between strategic planners/managers and operational providers. Notwithstanding the above similarities, when looking in more detail it appears that there are substantial differences between England and the Netherlands. First, the structural split is along different lines: between health and social care in England and between acute and long term care as well as between planning and financing in the Netherlands. And whilst the latter is only a financial split, the former (in the UK) is a financial, structural and political split. Another difference is that the English system is more hierarchical than the Dutch one. In England there are three systems of governance operating simultaneously: hierarchies, markets and networks. In the Netherlands the emphasis is on markets and, above all, on networks; although the latter is not completely absent hierarchies are much less

102

B. Hardy et al. / Health Policy 48 (1999) 87–105

significant. Each system of governance operates through a distinctive mechanism of integration: administrative orders in the case of hierarchies; contracts in respect of markets; and trust and co-operation in the case of networks. The problem with such mixed systems is not only their inherent complexity but also that they may themselves be sources of fragmentation and barriers to integration. Taking England as an example, there is a complex mix of hierarchical relationships on the vertical axis and, on the horizontal axis, there are networks between purchasers, market relationships between purchasers and providers, and networks between providers characterised by competition and collaboration. In addition, more or less formal networks also exist between purchasers and providers. Among the barriers to integration that arise in this situation are that, on the one hand, local actors are simultaneously being asked to collaborate and compete and, on the other hand, as Flynn et al. [46] have argued ‘‘quasi-market contracting may weaken the inherent network form and essential ‘high trust values’ embedded in community health services’’. Significantly the recent emphasis in the development of contracting in England has been on promoting long term, high-trust rather than tightly specified, arms-length contract management. In the Netherlands there is a clear emphasis on negotiating and bargaining within networks, which can eventually result into contracts. Not only is this very time-consuming but the benefits of network development are not immediately apparent. On the contrary, such processes often take many years before their first effects on patient care are evident. This bargaining is complicated by the governmental stimuli to simultaneously compete and coordinate.

5. Conclusion The institutional arrangements of the care systems in the Netherlands and England differ substantially but the factors affecting service integration—both facilitating and impeding — are similar in many important respects.5 Although we need to do further work to see whether similar factors are of similar weight or are similarly interdependent, this finding suggests that it may be possible to develop a 5 These factors are identified over the last 10 years as a result of our previous research. In the Netherlands we investigated a lot of collaborative processes which resulted in a model of promoting and inhibiting factors, namely legislation, finance and social context (network- external factors) and local context, commitment/trust and management of cooperation (network- internal factors). In England we have identified the range of barriers identified in Box 1 on the basis of extensive work in a range of localities and service contexts—not only the health and social care systems but elsewhere within the public sector and outside the public sector. We have also identified many examples of such persistent barriers to integration being overcome. These, we have suggested, acknowledge (though seldom explicitly) a set of what we have termed ‘Principles for Partnership’ (see for example, Ref. [27]). Most of these principles are reflected in the government’s most recent guidance to health and local authorities ‘Partnership in Action’ (London: Department of Health 1998) which spells out how the government expects local agencies to work together to secure integrated service planning and delivery for users and carers.

B. Hardy et al. / Health Policy 48 (1999) 87–105

103

framework which is non context specific; and one which contributes to a more generally applicable analysis of obstacles to integration and the means for overcoming them. Our current research in both countries suggests that the key variables are: (a) the recognition of interdependence and, therefore, of the need for integration of service systems; and (b) the willingness to pursue such integration and in so doing potentially surrender some degree of professional and organisational autonomy. As Alter and Hage [47] have noted: ‘‘if a willingness to collaborate does not exist, then the development of networks cannot occur. Thus, in some respects, it is the most important precondition’’. The extent to which interdependence is recognised and support for integration is given depends on various factors: • social, economic and political context; • legal/institutional context; • funding streams and mechanisms; • the local context, including the roles and characteristics of the local and/or health authorities, the insurers and the roles and characteristics of providers; • the broad structural and procedural arrangements on both the horizontal and vertical axes such as the definition and division of tasks, responsibilities, accountabilities and information flows; • the collaborative culture and tradition, which influences the extent of confidence and trust; • the broader co-ordinating/governance systems and integrating mechanisms. Despite the similarities between England and the Netherlands, however, there are also substantial differences in the nature, roles, tasks, interests and power of the complex constellations of stakeholders. We should not ignore the influence of this context on the extent to which integration is either sought or accomplished. Indeed, contextual variables such as organisational structures, power and resource flows are likely to be amongst the most significant determinants of successful integration at local level.

References [1] Kraan R, Baldock J. Care for the elderly; significant innovations in three European countries. Campus Verlag/Westview Press: Frankfurt am Main, 1991. [2] Mur-Veeman IM, Raak AJA, Maarse JAM. Dutch home care: towards a new organization? Health Policy 1994;27:141–56. [3] Health Advisory Service. Services for People who are Elderly: Addressing the Balance. The Multi-Disciplinary Assessment of Elderly People and the Delivery of High Quality Continuing Care. London: HMSO, 1997. [4] Thuiszorg en zorg thuis: kansen voor de toekomst. Ministerie vanVolksgezondheid, Welzijn en Sport.–Rijswijk, 1997. [5] Gillett AM. Future challenges of the social services in the building of the European Welfare Society. In: Jornades Internationals De Serveis Socials. Barcelona: Generalitat de Department de Catalunya Benestar Social, 1995. [6] Barnhoorn H, Walda R. De eerste lijn op Spitzen. Zorgvernieuwing in de praktijk. Van Gorcum: Assen, 1992.

104

B. Hardy et al. / Health Policy 48 (1999) 87–105

[7] Brown S, Flynn M, Wistow G. Back to the future: joint work for people with learning disabilities. Leeds: Nuffield Institute for Health, 1992. [8] Challis L, Fuller S, Henwood M, Plowden W, Webb AL, Whittingham P, Wistow G. Joint Approaches to Social Policy. Cambridge University Press: Cambridge, 1988. [9] Hardy B, Turrell A, Wistow G. Innovations in Community Care Management. Aldershot: Avebury, 1992. [10] Mur-Veeman IM, van Raak AJA. Interorganizational networks for care of the elderly in the Netherlands. Possibilities and limitations. Home Health Care Services Quart 1995;15:41 – 58. [11] Ovretveit J. Co-ordinating Community Care. Open University Press: Buckingham, 1993. [12] Wistow G, Whittingham P. Policy and research into practice. In: Stockford D, editor. Integrating Care Systems: Practical Perspectives. Longman: London, 1988. [13] Hunter D, Wistow G. Community Care in Britain: Variations on a Theme. King’s Fund: London, 1987. [14] Hatcher PR. The health system of the United Kingdom. In: Raffel MW, editor. Health Care and Reform in Industrialized Countries. The Pennsylvania State University Press: University Park Pennsylvania, 1997. [15] Secretaries of State for Health, Social Services, Wales and Scotland, Caring for People: Community Care in the Next Decade and Beyond, Cm. 849, London: HMSO, 1989. [16] Wistow G. Planning and collaboration in a mixed economy. In: Wolstenholme E, Wistow G, Gilroy D, editors. Community Care in a Mixed Economy: Meeting the Challenge. Leeds: Nuffield Institute for Health, 1989. [17] Department of Health. Implementing Caring for People, EL(92)13/C1(92)10. London: Department of Health, 1992. [18] Secretary of State, 1997. The New NHS. Modern. Dependable. London: Department of Health, 1997. [19] Hardy G, Turrell A, Webb AL, Wistow G. Collaboration and Cost Effectiveness, Final Report to Department of Health, 1989; and Hardy B, Turrell A, Wistow G. Innovations in community care management. Aldershot: Avebury, 1992. [20] Wistow G. Health and local authority collaboration: lessons and prospects. In: Wistow G, Brooks T, editors. Joint Planning and Joint Management. Royal Institute of Public Administration: London, 1988. [21] Wistow G, Knapp M, Hardy B, Forder J, Kendall J, Manning R. Social Care Markets: Progress and Prospects. Open University Press: Buckingham, 1996. [22] Henwood M, Wistow G. Hospital Discharge and Community Care: Early Days. London SSI/NHS Executive/Nuffield Institute for Health, 1993. [23] Henwood M, editor. Hospital Discharge Workbook: A Manual on Hospital Discharge Practice. Department of Health: London, 1994. [24] Wistow G, Henwood M, Hardy B, Hudson B. Hospital Discharge and Continuing Care: Update No. 1. Leeds: Nuffield Institute for Health, 1997. [25] Audit Commission. Making a Reality of Community Care. London: HMSO, 1986. [26] Griffiths R. Community Care: Agenda for Action. London: HMSO, 1988. [27] Hudson B, Hardy B, Henwood M, Wistow G. Inter-Agency Collaboration. Final Report to Department of Health. Leeds: Nuffield Institute for Health, 1998. [28] Wistow G, Hardy B. Balancing the Collaborative and Competitive Imperatives. Paper presented to EHMA Conference. Lisbon, June 1996. Leeds: Nuffield Institute for Health, 1996. [29] Department of Health. Practical Guidance on Joint Commissioning for Project Leaders. Department of Health: London, 1995. [30] Secretary of State. The New NHS. Modern. Dependable. London: Department of Health, 1997. [31] Rhodes RAW. The National World of Local Government. Allen and Unwin: London, 1986. [32] Rhodes RAW. Understanding Governance: Policy Networks, Governance, Reflexivity and Accountability. Open University Press: Buckingham, 1997. [33] Maarse JAM, et al. The health system of the Netherlands. In: Kickert WJM, van Vught FA, editors. Public Policy and Administration in the Netherlands. Prentice Hall: New York, 1995.

B. Hardy et al. / Health Policy 48 (1999) 87–105

105

[34] van Raak AJA, Mur-Veeman I. Home care policy in the Netherlands: reforming legislation to facilitate the provision of multidisciplinary home care. Health Policy 1996;36(1):37 – 51. [35] Scheerder RLJM. The financing of the Dutch health care system. In: Schrijvers AJP, editor. Health and Health Care in the Netherlands, A Critical Self-assessment by Dutch Experts in the Medical and Health Sciences, Chapter 15. De Tijdstroom: Utrecht, 1997:163 – 70. [36] Commissie Dekker. Bereidheid tot verandering. The Dekker Committee, Willingness to change. Staatsuitgeverij:’s-Gravenhage, 1987. [37] Mur-Veeman I, van Raak AJA, Jongerius-de Gier G. Samen gaan om sterk te staan. Een onderzoek naar samenwerking in de zorg voor verstandelijk gehandicapten. University Press: Maastricht, 1995. [38] Instituut voor Toegepaste Sociale Wetenschappen (ITS). Demonstratieprojecten in de Ouderenzorg. Evaluatie van zes projecten in het kader van het substitutiebeleid, Onderzoekers Demonstratieprojecten Ouderenzorg. Nijmegen, 1991. [39] van Raak AJA, Jongerius-de Gier G, Massop J, Mur-Veeman I. Brug tussen Gisteren en Morgen. Zorgvernieuwing als veranderingsstrategie voor een betere zorg in de toekomst. Evaluatie Programma Zorgvernieuwingsprojecten Thuiszorg van WVC. Eindrapportage Vakgroep BEOZ, Universiteit Maastricht, 1993. [40] Hall RH. Organizations, Processes and Outcomes. Prentice Hall Inc: Englewood Cliffs, NJ, 1987. [41] Mijs AA. Ontstaan en Levensvatbaarheid van Interorganisationele Verbanden. In: Sociologische Gids, 1989, nr. 1, 48–61. [42] Mur-Veeman IM, van Raak AJA. Interorganisationele samenwerking in de thuiszorg. In: M&O, tijdschrift voor Management en Organisatie 3, 1996, 181 – 199. [43] van Raak AJA, Mur-Veeman I. Behoedzaam door de bocht. Evaluatie Project Wijkzorg voor Ouderen en Gehandicapten in Maastricht. Eerste voortgangsrapport. University Press: Maastricht, 1994. [44] van Raak AJA, Mur-Veeman I. Schakelen en Bijsturen. Evaluatie Project Wijkzorg voor Ouderen en Gehandicapten in Maastricht. Tweede voortgangsrapport. University Press: Maastricht, 1995. [45] van Raak AJA, Mur-Veeman I. Ingevoegd en op Weg. Evaluatie Project Wijkzorg voor Ouderen en Gehandicapten in Maastricht. Eindrapport. University Press: Maastricht, 1997. [46] Flynn R, Williams G, Pickard S. Markets and Networks: Contracting in Community Health Services. Open University Press: Buckingham, 1996. [47] Alter C, Hage J. Organisations Working Together. California: Sage, 1993.

. .