1. From Hierarchical Steering to Dialogic Governance?
Scotland 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 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) ( )
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 (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° co funded by the European Commission within the Sixth Framework Program, October 2010, The Coordination reform, English version: Evaluation of the Coordination Reform, The Norw. Research Council: