Scotland 22 - 23. April 2013

1. Scotland 22 - 23. April 2013 Helge Ramsdal Østfold University College From Hierarchical Steering to Dialogic Governance? Collaboration in health and social care – the Norwegian context.

2. The Norwegian welfare state • Pop.: 5 mill. • A «municipal» welfare state: • 430 local authorities, «general» municipalities in charge of medical services, elderly care, mental health, social services incl. housing (and much more). • 19 counties: • Reduced role in health and social policies. Since 2002: public health issues • State: • In charge of specialised services/hospitals since 2002, co-funding local services, national guidelines etc.

3. Norway health and social policies - the context The steering problem no. 1: Vertical coordination – State and municipalities - state funding, local implementation. But: 400 to 400.000 pop. The steering problem no. 2: Horizontal integration - Coordination of sectors, services, agencies, professionals at local levels.

4. Never-ending reforms to obtain better integration and coordination: 1)NAV reform 2000: Labour, Insurance, Social services, integrating state and municipal social welfare services. «One door» to all welfare services. 2) The Mental Health reform: 1999 – 2009: «A failure in all services» - focus on coordination of hospital and municipal services. 3) The Hospital Reform 2002: Specialised health services/hospitals transfered from counties to state responsibility, regional and hospital authorities – the «NHS» NPM design.

5. 3) The Coordination Reform: «Proper treatment at the right place and right time» - 2009 – 2017 Problems: • More people are falling ill, • population is ageing, • more people need help for longer periods, • more diseases are treatable with new technology, and the queues are lengthening for specialist health care services. Challenges: • Patients’ needs for coordinated services are not being sufficiently met. • In the services there is too little initiative aimed at limiting and preventing disease. • Population development and the changing range of illnesses among the population.

6. Measures - Key steps for proper treatment Key step 1: A clearer role for the patient • Patient pathways to «permeate» all services • Contact point for the patient • Review of the statutory framework –patients’ rights Key step 2: New role for municipalities in future • Future municipal tasks • Binding system of agreements between municipalities and health authorities • Reinforcing preventative health work • Better medical services in the municipalities

7. Measures cont. Key step 3: Financial incentives • Municipal co-financing • Municipal responsibility for patients ready for discharge • Increased financial framework of the specialist health care services Key step 4: Enabling the specialist health care services to apply their specialised competence more • Administrative systems • Competence • Pilot hospitals Key step 5: Facilitating better-defined priorities • National Health Plan

8. 3) The Coordination Reform – steering instruments • Legal measures – «The idea of the new municipality» - e.g. abandoning the «professions’ protocol» and organization of local services – local «medical centres». • Formal agreements between hospitals and municipalities on coordination related to e.g. diagnosis groups – patient pathways. • Financial – municipal co-funding of hospital services

9. Four issues: • The Collaboration reform as a political steering innovation: - «new governance», or?... • «Patient pathways» - «scientific-bureaucratic medicine», or?... • Welfare technology (municipal care) – an «innovation journey», or?... • Preventive health care/public health - new methodologies for implementing well-known policies, or?...

10. 1. The Collaboration reform as a political steering innovation: - «new governance», or?... • The traditional reform design models of the Scandinavian welfare states (1945 – ca.1990) – mix of hierachic, detailed steering instruments • A transition period: centralization and de-centralization – «the new municipality» (mental health reform and the hospital reform) (1990- 2000) • The Collaboration reform – new governance/WOG? A «direction» reform – indirect steering instruments - dialogues • Empirical studies on reform design (mix of steering instruments)

11. Collaboration reform - a «new governance» reform ? Four research topics: 1) The Reform design – mix of steering instruments – will «new governance» approaches improve vertical coordination or will we see new schisms between municipal and hospital services? 2) The «process perspective» on coordination – what are the consequences of implementing patient pathways? 3) The introduction of welfare technologies in municipalties – will it reduce the need for care personell – more need for collaboration and coordination? 4) The strengthening of public health strategies - will new social engineering methodologies work?

13. Comparing four health reforms

14. References Ramsdal, Helge: From hierarchical steering to dialogic governance? An analysis of four welfare state reforms in Norway, in: Barroso, J. and L.M. Carvalho (eds.): Knowledge and Regulatory Processes in Health and Education Policies. EDUCA, Lisbon 2012. (Ch. 3, pp. 89 – 131). Ramsdal, Helge and Mona. J. Fineide: Les défis de la réforme de la santé mentale. L’expérience de la Norvège (The Challenge of Mental Health Reform – Experiences from Norway). Revue de Sociologie de la Sante nr. 34, 2011 Autumn Ramsdal, Helge, Mona J. Fineide: Clinical Pathways as regulatory tool in Mental Health Policies. Report on Regulations in Health Policies in Norway, KnowandPol,Project n° 0288848-2 co funded by the European Commission within the Sixth Framework Program, October 2010, www.knowandpol.eu The Coordination reform, English version: http://www.regjeringen.no/upload/HOD/Dokumenter%20INFO/Samhandling%20engelsk_PDFS.pdf Evaluation of the Coordination Reform, The Norw. Research Council: http://www.forskningsradet.no/prognett-evasam/The_evaluation/1253972204894