Purpose The purpose of this study is to identify what is practiced during collaboration exercises and possible facilitators for inter-organisational collaboration.

Design/methodology/approach Interviews with 23 participants from four exercises in Sweden were carried out during autumn 2011. Interview data were subjected to qualitative content analysis.

Findings Findings indicate that the exercises tend to focus on intra-organisational routines and skills, rather than developing collaboration capacities. What the participants practiced depended on roles and order of arrival at the exercise. Exercises contributed to practicing leadership roles, which was considered essential since crises are unpredictable and require inter-organisational decision-making.

Originality/value The results of this study indicate that the ability to identify boundary objects, such as injured/patients, was found to be important in order for collaboration to occur. Furthermore, lessons learned from exercises could benefit from inter-organisational evaluation. By introducing and reinforcing certain elements and distinct aims of the exercise, the proactive function of collaboration exercises can be clarified.

Context: With the increasing specialisation of services, integration has become important for health and other welfare organisations in order to address the complex problems of their patients or clients. This is particularly in care of the elderly, psychiatric care and vocational rehabilitation. The following presentation reports a review of literature on integration in vocational rehabilitation, focusing on models of integration as well as barriers and facilitators.

Methods: The review was based on a search in scientific journals from 1995 to 2010. It generated 13132 articles, which were reduced to 1005 after an initial overview. The abstracts were read by members of the research group. Each abstract was read by two members independently. If they agreed the article was included or excluded, but if not the whole group discussed the abstract. This procedure reduced the number of articles to 205, which were read in full text. Finally, 62 articles were included for thematic content analysis.

Results: Most of the studies came from Sweden, while others came from Canada, Australia, UK, Netherlands, Norway and Denmark. In these studies different models of integration were identified. They were classified as structural or process oriented. The structural models included case management, partnerships, co-location and financial coordination, while the process oriented models included informal contacts, interorganisational meetings and multidisciplinary teams. There were also a number of barriers as well as facilitators of integration. The barriers included structural and cultural differences, while communication, trust and continuity were important facilitators.

Discussion: There are different models of integration, but also many combinations. Case management is often combined with interorganisational meetings or multidisciplinary teams. There are also informal contacts in all models. There is a clear mirror effect between the different barriers and facilitators. Leadership may be either a barrier or a facilitator. In the same way, differences between organisations may be both barriers and facilitators. These results seem to be valid also for other fields of integration, for example care of the elderly, psychiatric care, and other forms of community care.

Today the concept of efficiency is a guiding light in public management. Increased efficiency is thought to control spending and provide better services. Two approaches to achieve this are through assessments such as evaluation and audits; and collaboration between different actors. Collaboration can imply e.g. networks or partnerships and vary in intensity and formality. Regardless of form, collaborative efforts are generally thought to achieve services better adapted to address complex social problems, and diminishing overlaps and unclear responsibilities caused by fragmentation. Assessments are used to determine whether or not a program or a service is efficient, but the act of assessment itself is also intended to increase efficiency. Thus, the act of assessment influences the practice it is assessing. Furthermore, in order to be assessed, a program or a service has to be “evaluable”, which may also influence practice. Collaboration is often a solution to previous sector failure, and at the same time it is perceived as difficult to both achieve and sustain. Assessments are used as a tool to determine whether or not collaborative advantage is achieved and if the investments in collaboration should be pursued.

Assessments of collaboration are a challenge since it confronts the regular vertical forms of organizing and thereby the focus of assessment. The challenge can be boiled down to the question of what collaborative arrangements can, and should, be held accountable for.

Based on an ethnographic study and two years of field work, this question is critically analyzed with an example from Sweden. The financial coordination of rehabilitation measures act came into effect in 2004, and regulates the construction of coordination associations. The foundation of an association is a pooled budget to which all members, four different public authorities in the field of vocational rehabilitation, contribute. An important condition behind the law was the notion that public services were not adapted to, and therefore had trouble handling, some groups with complex problems needing support from two or more organizations at the same time. The overall, and ultimate, aim with financial coordination is to improve the working ability in the target population. Though the objective of the associations is, according to the law, to support collaboration, finance efforts within the collected area of responsibility and evaluate these efforts. The financed efforts may be both operative and strategic, and should in some way complement the operations of the member organizations or aim at development of new knowledge or methods. The associations have no power to make decisions of authority in relation to the target population, which remains with the professionals in the member organizations. Following this, it may be argued that the first target group of the associations is the regular organizations and next, as a secondary target group; the individuals in the target population. This means also that the target population is not the associations’ own but the regular organizations’ target groups. The aim with the associations is thus to contribute to the regular organizations working better in relation to this group. The associations have no tools at their disposal to contribute to the overall goal but the pooled budget. Their responsibility is to construct the budget, distribute the resources and follow up.

However, as the findings presented and discussed in this paper show, the associations are generally held accountable to more than that in the frequent assessments being performed on both the associations and the efforts they finance. First, the associations are generally seen by others as being the efforts they finance. This makes the view of them almost like a new organization or authority, even though the efforts actually are organizationally owned and performed by regular organizations. Second, they are held accountable to the aim of improved working ability of the target group, i.e. the overall policy goal. Their objective to support collaboration and the notion that the law was introduced in order to ensure that, through collaboration, those individuals in the intersection of different organizations get the needed help is thus overlooked and focus is turned to effects on individuals.

This paper argues that the assessments have highly influenced practice in the associations, and has shifted focus from organizational outcomes such as increased equity and quality of services due to decreased fragmentation, to individual outcomes such as employment and dependency of benefits. These latter outcomes are easier to account for and are also in line with conventional more hierarchical assessments. Since many associations perceive themselves to be questioned due to lacking efficiency, they may start seek legitimacy and thereby behave in line with the focus of assessments and start to “produce” improved working ability instead of supporting collaboration. Furthermore, the assessments and their focus on individuals tend to treat the associations not as a collaborative structure between four actors with a supportive aim, but as a regular organization with authoritative power. When the associations are held accountable for a group’s outcome, this group has been “passed on” from ordinary organizations on to the associations. Organizational outcome related to collaboration is greatly overlooked, in line with the “common wisdom” that collaboration is not an end in itself, and an end in public management collaboration must thus be measured as individual benefit. Increased quality and equity in services are thus outcomes that are not only not being assessed but might also be at risk of being lost with the current assessment focus. Last, there is an evident risk that the narrow and vertical assessment focus increases, instead of decreases, horizontal fragmentation within the welfare system due to its impact on coordination association practice.

Introduction: Collaboration between welfare organizations is an important strategy for integrating different health and welfare services. This article reports a review of the international literature on vocational rehabilitation, focusing on different organizational models of collaboration as well as different barriers and facilitating factors.

Methods: The review was based on an extensive search in scientific journals from 1995 to 2010, which generated more than 13,000 articles. The number of articles was reduced in different steps through a group procedure based on the abstracts. Finally, 205 articles were read in full text and 62 were included for content analysis.

Results: Seven basic models of collaboration were identified in the literature. They had different degrees of complexity, intensity and formalization. They could also be combined in different ways. Several barriers and facilitators of collaboration were also identified. Most of these were related to factors as communication, trust and commitment.

Conclusion: There is no optimal model of collaboration to be applied everywhere, but one model could be more appropriate than others in a certain context. More research is needed to compare different models and to see whether they are applicable also in other fields of collaboration inside or outside the welfare system.

The aim of this study was to explore the development of interprofessional collaboration aiming to improve secondary prevention of osteoporosis by studying this topic expansively from the perspectives of different stakeholders. The method used was a longitudinal single case study with both qualitative and quantitative data sources. The findings elucidate that the bottom-up structure used triggers a freedom to act for the professionals and a changed leadership. Such an approach seems to make managers aware of the need for a horizontal organizational focus that, in this case, was crucial for developing interprofessional collaboration. Furthermore, the study shows that continuous feedback was central to motivate professionals to collaborate. Constructive feedback was created by interprofessional and patient-centered interaction skills, facilitated by confirming leadership promoting ability to recognize the efficacy of joint collaboration. The interprofessional collaboration resulted in an improved chain of care with increased transparency and collective control with benefits for both patients and providers. Outcomes at the system level showed an appreciable increase in patients investigated for osteoporosis: 88% were followed up in primary care and nearly half had improved their health behavior. The implementation of a bottom-up structure where leaders and professionals are developing interdependency, measuring collective performance and using feedback loops generated, in this case, motivational forces for interprofessional collaboration. It is reasonable to assume that these findings could be transferable to similar healthcare settings.

Through a discourse analysis of the end-users’ statements on their choice of primary care, there is a focus on how they use certain discourses in society with regard to which discourses governs their choices of primary care. For this purpose, a group interview was administered in a location in the south of Sweden. It was strategically designed to on the whole include individuals with following characteristics: age between 20-45 years, and 65 year or older, and also living in a small community. The following main discourses have been identified in the discussion; freedom of choice; i.e. to say that one has actively chosen one’s health centre or doctor, to be able to reject and re-select care-givers, networking; i.e. ‘to say that friends’ and acquaintances’ experiences affect the choice of a new health centre and professional service, i.e. to say that doctors and other staff should give professional service. It seems like choice of care has improved the possibilities of the citizens to choose preferred care provider, or drop one due to dissatisfaction. When implementing reforms in health care it is valuable to take into account the voices of the users, as they are able to contribute to the development of health care.

Aim: Based on the concept of value creation the aim was to analyse a sample of patients’ unstructured responses, and to show what the patients perceived to be healthcare values.

Method: Using content analysis the patients’ responses to three questions underwent a categorization involving the identification, coding, and emerging of themes.

Results: This is good: fellow feeling, receptivity, proficiency, efforts matched to requirements, popular food, informed patients. The theme was professional care. This I would like to change: offer more conventional forms of accommodation, better quality food, better cleaning, more time to their patients, better information, and improved accessibility. The theme was patients want good service when in hospital. Other complaints were linked to care, resulting in; improve personal integrity, friendlier demeanour, more focusing on the individual. The theme was patients expect to be acknowledged and respected by nursing staff. However, the answers did not convey anything essentially new.

Conclusion: The patients expressed different values. It is debatable to use service management concepts in healthcare in a simplistic way. Practice implications: Patients’ unstructured answers are of interest in improving the attitudes of the co-workers.

Introduction: The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007-2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services.

Objective: To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat. Method: Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis.

Result: Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health.

Conclusions: The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes.

The need for collaboration in health and social welfare is well documented internationally. It is related to the improvement of services for the users, particularly target groups with multiple problems. However, there is still insufficient knowledge of the complex area of collaboration, and the interprofessional literature highlights the need to develop adequate research approaches for exploring collaboration between organizations, professionals and service users. This paper proposes a conceptual framework based on interorganizational and interprofessional research, with focus on the concepts of integration and collaboration. Furthermore, the paper suggests how two measurement instruments can be combined and adapted to the welfare context in order to explore collaboration between organizations, professionals and service users, thereby contributing to knowledge development and policy improvement. Issues concerning reliability, validity and design alternatives, as well as the importance of management, clinical implications and service user involvement in future research, are discussed.

Chains of Care are today an important counterbalance to the ever-increasing fragmentation of Swedish health care, and the ongoing development work has high priority. Improved quality of care is the most important reason for developing Chains of Care. Despite support in the form of goals and activity plans, seven out of ten county councils are uncertain whether they have been quite successful in the development work. Strong departmentalisation of responsibilities between different medical professions and departments, types of responsibilities and power still remaining in the vertical organisation structure, together with limited participation from the local authorities, are some of the most commonly mentioned reasons for the lack of success. Even though there is hesitation regarding the development work up to today, all county councils will continue developing Chains of Care. The main reason is, as was the case with Chain of Care development up to today, to improve quality of care. Although one of the main purposes is to make health care more patient-focused, patients in general seem to have limited impact on the development work. Therefore, the challenge is to design Chains of Care, which regards patients as partners instead of objects.

Despite of an insignificant track record of quasi-market models in Sweden, new models of this kind have recently been introduced in health care; commonly referred to as "choice of care". This time citizens act as purchasers; choosing the primary care centre or family physician they want to be treated by, which, in turn, generates a capitation payment to the chosen unit. Policy makers believe that such systems will be self-remedial, that is, as a result of competition the strong providers survive while unprofitable ones will be eliminated. Because of negative consequences of the fragmented health care delivery, policy makers at the same time also promote different forms of integrated health care arrangements. One example is "local health care", which could be described as an upgraded community-oriented primary care, supported by adaptable hospital services, fitting the needs of a local population. This article reviews if it is possible to combine this kind of integrated care system with a competition driven model of governance, or if they are incompatible. The findings indicate that some choice of care schemes could hamper the development of integration in local health care. However, geographical monopolies like local health care, enclosed in a noncompetitive context, lack the stimulus of competition that possibly improves performance. Thus, it could be argued that if choice of care and local health care should be combined, patients ought to choose between integrated health care arrangements and not among individual health professionals. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Context

Swedish health care, like many other health care systems, is in a constant development mode to meet never-ending demands for improved efficiency and quality. Competitive and integrative policies are for example concurrently introduced in Swedish primary care; citizens‘ choice of primary care is launched while primary care is expected to integrate its activities with other providers for the creation of =local health care‘. Competition has though a tendency fragment the provision of services. The aim of this study is therefore to explore whether or not these two strategies are compatible in practice.

Methods

Group interviews were conducted at four locations in Sweden. The groups included persons aged between 20 and 45 years, 46 and 64 years and 65 years or over. The interviewees were living either in a big town or in a small community. Altogether, 21 randomly selected individuals participated in the group interviews. A deductive approach was chosen: six question topics were formulated with guidance from a theoretical framework about choice of care. The group interviews were thus semistructured without any predetermined codes. Each group interview took between 1 and 1.5 h to complete. Moreover, the conversations were recorded and transcribed as verbatim reports. As a consequence of the deductive approach, directed content analysis was chosen for the analysis of the group conversations.

Results

Choice of care is executed from the perspectives of being a prospective or current patient, which, in practice, imply choices are performed passive and active respectively. If the later group perceive interpersonal continuity, accessibility and demeanour of health professionals as favourable, they remain faithful to their actively chosen provider. The only condition that seems to trigger this group of patients to reconsider their choices is if they been the subject of bad manners. Those executing passive choices are less faithful to their original choice. When these former prospective patients, often younger persons, are in need of primary care they often disregard their choice if waiting times are shorter at other providers. This group generally prefer accessible service and seldom consider where it is provided. The group of passive choices also include citizens accepting suggestions presented by the authorities, founded on the conviction that ―they know what is best for me.

Discussion

Many patients that have made active choices are thus faithful to their choices. This is rare in a consumer-market, which is characterized by high degree of exchangeability of providers; a condition which by and large corresponds with the attitude of those making passive choices. Nevertheless, a majority of patients stay with their choice of provider, often selected among a limited number of options. Moreover, health care providers and patients have long-term relationships, which is typical of a producer-market. In other words, if politicians strive for a competition-exposed primary care, the competition concept ought not to be founded on the theories of a consumer-market. The principles of a producer-market seem instead to be more applicable, which imply that providers will be competitive if they are able to build stable relations with their patients, which, in turn, facilitate for integrative arrangements among health care providers.

It seems impossible to create a comprehensive evaluation model which fully takes into account the multi-dimensional context of integrated health and social care. Clinical integration, as a prerequisite for efficient outcomes of integration, must nonetheless get special attention. For more extensive evaluations, a quality chain matrix, including co-operating acts by different providers, has proven to be useful. Examples of evaluated services in Sweden are given, and the management benefits of the use of evaluation data are highlighted.

The differentiation of roles, tasks and responsibilities in health care has gradually increased because of efforts to decentralize, specialize and professionalize our health-care systems. These development approaches can on the one hand be regarded as successful, although there is also a negative flipside. Increased differentiation has concurrently fragmented the delivery of health care, which, in turn, can be divided into structural, clinical and cultural fragmentation. Patients are lost as a result of these conditions of fragmentation. This phenomenon can metaphorically be described as a ‘Patient Bermuda Triangle’. Actions to dissolve the Patient Bermuda Triangles are commonly termed ‘Integrated health care’, a global buzzword that includes integrated care pathway as well as other integrated health-care strategies. Moreover, integrated care is a means to an end: improved patient outcome. To achieve this, it is crucial to have necessary prerequisites in place: both functional and interactional conditions. This procedure seems to be an organic process where the stakeholders go through gradual changes until the optimum level of integration, as well as mutualistic interactions, is established. If these conditions are concealed or impossible to achieve, developmental work should be ended to avoid the evolvement of antagonistic relations between the stakeholders concerned. This state will likely establish a Patient Bermuda Triangle or reinforce an existing one.

In Sweden it is a public sector duty to finance and facilitate the provision of health care. It is thus a “Beveridge” health care system. All residents have accordingly the right to obtain the publicly financed health care. The system is decentralized and includes 21 county councils and 290 municipalities. Furthermore, it rests on a democratic platform: each of these authorities is governed by a parliament, with its representatives elected for a four-year period at every general election.

Objectives: Swedish hospital mergers seem to stem from a conviction among policy makers that bigger hospitals lead to lower average costs and improved clinical outcomes. The effects of mergers in the form of multisited hospitals have not been systematically evaluated. The purpose of this article is to contribute to this area of knowledge by exploring responses to the merger of Blekinge Hospital.

Methods: The evaluation was guided by the philosophy of triangulation. A questionnaire was sent to 597 randomly selected employees, that is 24% of the health care staff. Four hundred ninety-eight employees answered the questionnaire, giving a response rate of 83%. Furthermore, interviews of different groups of stakeholders were conducted.

Results: A moderate increase of quality was assessed, which, a low proportion of the employees perceived had decisively or largely to do with the merger. The majority perceives economical incentives as the drivers of change, but, at the same time, only 10% of this group believes this target was reached completely or to a large extent.

Conclusions: The employees believe the merger has neither generated economy of scale advantages nor substantial quality improvement. Instead, it seems more rewarding to promote cross-functional collaboration together with clinical specialisation. Needs for both integration and differentiation could thereby be fulfilled. (c) 2008 Elsevier Ireland Ltd. All rights reserved.

PURPOSE: The purpose of this paper is to explore the concepts of Swedish integrated health care, their state of development and interdependence, and, furthermore, evaluate whether the theoretical framework used improves the comprehension of why integrated health care arrangements endure or cease.

DESIGN/METHODOLOGY/APPROACH: The study is founded on descriptive data gathered from a literature search on integrated health care in Sweden. With inspiration from ecology theory, these data were analysed guided by a theoretical model based on a continuum of symbiotic effects, from antagonism to mutualism.

FINDINGS: The era of Swedish integrated health care started in the 1990s, when a kind of clinical network called chains of care was launched. At the beginning the chain of care development was predominantly surrounded by non-integrative conditions, which had a restraining effect on these efforts. Even so, it seems that chains of care are here to stay. This faith in chains of care can to some extent be explained by the crucial role they have as connectors in the emerging local health care systems. Thus, these systems need chains of care to evolve and chains of care seem to require the integrative framework of local health care to progress and endure. Integrated health care performance could be troublesome, unless such mutualistic conditions are in place. States of commensalism may also be promoted, but the advantages are unilateral and therefore there is a risk of disloyalty by the unaffected part, which, in turn, can create a breeding-ground for an antagonistic liaison.

ORIGINALITY/VALUE: A theoretical approach founded on what may be called "Health Care System Ecology" appears to enhance the understanding of the complex logic of integrated health care.

Purpose: Despite of an insignificant track record of quasi market models in Sweden, new models of this kind have recently been introduced in health care; commonly referred to as ‘choice of care’. This time citizens act as purchasers; choosing the primary care centre or family physician they want to be treated by, which, in turn, generates a capitation payment to the chosen unit. Policy makers believe that such systems will be self-remedial, that is, as a result of competition the strong providers survive while unprofitable ones will be eliminated. Because of negative consequences of the fragmented health care delivery, policy makers at the same time also promote different forms of integrated health care arrangements. One example is ‘local health care’, which could be described as an upgraded community-oriented primary care, supported by adaptable hospital services, fitting the needs of a local population. This paper reviews if it is possible to combine this kind of integrated care system with a competition driven model of governance, or if they are incompatible.

Theory: Inter-organisational and interprofessional collaboration, accessibility of services, and provider continuity.

Method: Literature-based review.

Results and conclusions: The findings indicate that some choice of care schemes could hamper the development of integration in local health care. However, geographical monopolies like local health care, enclosed in a non-competitive context, lack the stimulus of competition that possibly improves performance. Thus, it could be argued that if choice of care and local health care should be combined, patients ought to choose between integrated health care arrangements and not among individual health professionals.

Integration of care is high on public health agendas all around the world. The development and implementation of integrative arrangements has been promoted for more or less two decades. Despite this every so often extensive history, there are recognised needs to take research into areas yet poorly explored, which include measures and outcomes of integrated care. On the other hand, existing evidence and knowledge can probably become more ennobled and thereby contribute to a deeper understanding of the compound art of integrating of health care services. Accordingly, the aim of this article is to re-evaluate and synthesise some revisited theories for the facilitation of sustainable integrated care solutions.

This exploration shows it is important to have crucial prerequisites for integration in place: both functional and interactional conditions. This appears to be an organic process where the stakeholders go through gradual changes until the optimum level of integration as well as mutualistic interactions are established.

It could be argued that refined knowledge could be excerpted from existing research. Then again, this strategy does not exclude actions for new research in poorly explored areas. Both approaches are important for the development of sustainable integrated care.

Introduction

There is a growing interest in compensating for the fragmented delivery of care by promoting integrated care. This movement is a feature of national and local policy, and it is being supported and encouraged amongst care providers.

Aims

Discuss the concepts of Swedish integrated care and their impact on care delivery systems.

Results

The chain of care concept is commonly regarded as a means to make a care delivery system better adapted to the needs of patients. In many county councils, this transformation is supported by policies focusing on quality and comprehensiveness. Despite several years of experience, a vast majority of the county councils regard themselves as unsuccessful in developing chains of care.

In addition, many county councils have changed their delivery systems during recent years and implemented ‘Local Care’, an upgraded family- and community-oriented primary care supported by a flexible hospital system. It is unusual to find a high degree of organisational cohesiveness in the implementation of local care. Instead these solutions are in many cases supposed to be built on chains of care.

Conclusions

Chains of care are increasingly regarded as building stones of local care, which means that chains of care are embraced in a context and by conditions more favourable than former non-integrative care delivery systems. In this sense, chains of care may have a renaissance, after assuredly being high on the policy agendas but with several years of modest development results. Thus, local care needs chains of care to evolve and chains of care need the integrative framework of local care to sustain.