From Hierarchical Steering to Dialogic Governance? 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.

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.

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.

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.

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.

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

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

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

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?...

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)

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?

Comparing four health reforms

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