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IN SEARCH OF AN ORGANISATIONAL STRUCTURE FOR INTEGRATED CARE. The Swedish experience. Runo Axelsson Professor of Health Management. Outline. The Swedish welfare system. Organisational trends in health and welfare services. Implications for integrated care.

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IN SEARCH OF AN ORGANISATIONAL STRUCTURE FOR INTEGRATED CARE

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In search of an organisational structure for integrated care

IN SEARCH OF ANORGANISATIONAL STRUCTURE FOR INTEGRATED CARE

The Swedish experience

Runo Axelsson

Professor of Health Management


In search of an organisational structure for integrated care

Outline

  • The Swedish welfare system.

  • Organisational trends in health and welfare services.

  • Implications for integrated care.

  • Organisational models of integration and collaboration.

  • Financial co-ordination as a model for integration of welfare services.


In search of an organisational structure for integrated care

The Swedish welfare system

  • Financing and provision of health and social services is decentralised to regions and municipalities.

  • Responsibilities are further decentralised to specialised local agencies.

  • Limited role and influence of the national government.

  • Employment service and social insurance are responsibilities of national agencies, but decentralised to local branches.


In search of an organisational structure for integrated care

Development of the system

  • 1930s: Development and consolidation of the Swedish welfare state; child benefits, health and social insurance, pensions.

  • 1950s: Economic growth and expansion of health care and social welfare. Large-scale hospitals built in most regions.

  • 1960s: All branches of health care concentrated to the county councils: an integrated health care system on the regional level.

  • 1990s: Care of the elderly and disabled from the county councils to the municipalities.


In search of an organisational structure for integrated care

Organisational developments

  • 1930s: Traditional public welfare administration; application of laws, rules and regulations.

  • 1960s: Centralisation and bureaucratisation; strategic planning and control; industrial ideals.

  • 1980s: Decentralisation, de-bureaucratisation and service orientation; “small is beautiful”.

  • 1990s: New Public Management; privatisation, market orientation and commercial ideals.

  • 2000s: Process orientation, mergers and re-centralisation; “economies of scale”.


In search of an organisational structure for integrated care

Implications for integration

  • 1930s: Integration of welfare services through a comprehensive legal framework.

  • 1960s: Integration through the hierarchy and management control of public bureaucracies.

  • 1980s: Integration through communication and management by objectives.

  • 1990s: Integration through the real or artificial markets of New Public Management.

  • 2000s: Integration of processes through development of integration and collaboration.


In search of an organisational structure for integrated care

Continuum of integration

(Andersson et al, 2011)

Case Management

Liaison functions

Partnerships

Formal

agreements

Autonomy

Mergers

Consultation

Information

exchange

Multidisciplinary meetings, teams or working groups

Co-location

Financial

co-ordination


In search of an organisational structure for integrated care

Between autonomy and mergers

  • Autonomous organisations are providing specialised welfare services.

  • Specialisation may lead to fragmentation, duplications and waste.

  • Mergers create large scale organisations.

  • Increasing size of organisations leads to increasing bureaucracy!

  • Bureaucratic organisations are divided into specialised departments, who tend to become more and more autonomous.


In search of an organisational structure for integrated care

Spectrum of integration

Multidisciplinary meetings, teams and working groups

Case management

Liaison

functions

Partnerships

Formal agreements

Co-location

Financial

co-ordination

Consultation

Information

exchange

Autonomy

Mergers


In search of an organisational structure for integrated care

Associations for integration

  • A number of experiments in the 1990s to im-prove integration in occupational rehabilitation.

  • Different models were developed for collabora-tion between health care, social service, social insurance and employment service.

  • The main obstacle was the different budgets; territorial problems of transferring costs etc.

  • Legislation in 2004 made it possible to create Associations for Financial Coordination.

  • More than 80 associations have been formed since the legislation was enacted.


In search of an organisational structure for integrated care

Association for Financial Coordination

Collaborating organisations

Board

Manager

Groups

Meetings

Activities


In search of an organisational structure for integrated care

The Swedish experience

  • The associations for financial coordination are useful organisational structures for integration of different welfare services.

  • The associations are arenas for collaboration between different welfare organisations.

  • The financial coordination is eliminating the most difficult obstacle to collaboration.

  • The associations are flexible organisations for integration with a minimum of bureaucracy.

  • The associations can be used for integration of other services than occupational rehabilitation.


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