sou · H0B333 · 2012-05-15 00:00:00 — The Danish administrative system has undergone a major structural reform in 2007 that shifted responsibilities and effected relation- ships between the national level, the county/regional level and the local level (et al., 2010). The reform reduced the number of regional units (from 14 counties to 5 regions) and local units (from 275 to 98) and transferred responsibilities for prevention, rehabilitation and social care from the regional to the local level. The reform created larger regions and municipalities but with a different distribution of responsibilities among them. In hospital and highly specialised care, this meant a more central form of administration, supervision and provision of care with fewer and larger hospitals and more centralized provision of highly specialised care. In addition, has been given more power to plan and provide guidelines for highly specialized services. In contrast, responsibility for prevention, rehabilitation and social care was shifted to a lower level of administration originally from counties to the municipalities. The new responsibility levels for administering and providing the different types of care means greater division of responsibility and accountability for over- all care provision. To enhance coordination between the different levels of care, the 2007 reform enforced mandatory regional health agreements between the regions and municipalities. Source: et al. The reform also included a change in redistributing funds: a new system of earmarked taxation was introduced at national level with approximately redistributed to regions though block grants and redistributed to municipalities to co-finance hospital services. The right for regions to levy tax income was removed. At the same time, central level influence of regions capital investments was increased: since 2007, the must approve capital investments of regions above a certain level. Policy priorities and tactics Priorities of the 2007 reform might be divided into official policy priorities and political priorities. An often stated policy objective of the concentrating element of the reform was to secure economics of scale in service provision according to the perception that larger catchment areas would guide more efficient specialisation and struc- tural adjustments. This was expected to eventually yield economic savings in specialised care and improve the quality of highly specia- lised services. In addition, more direct state control on hospital care provision was expected to enforce more uniform quality standards for hospital care, equalize waiting times, and improve the availability of technology and the provision of diagnostic and curative care across the country. Looking at the political motives, officials of the central government were keen to stop being held accountable for problems occurring at county level and which they effectively had no control over. In this way, the reform ended a power struggle between the counties and the central government. By empowering munici- palities and creating locally accountable planning structures for welfare, public health and health care services at the same time, the central government communicated the objective to improve co- ordination of care by eliminating duplications and insufficiently or poorly handled (grey zone) health care and welfare services (Ministry of the Interior and Health, 2004). Thereby the central government formed an effective coalition with the municipal level to ally against any potential opposition from the counties who might be seen as the main loser of the 2007 reform in terms of decision-making and planning power. There have also been commentators arguing that the 2007 re- forms paved the way towards more market oriented reforms by breaking the power of the regions and further encouraging out- sourcing and contracting out of services to the private sector. Out- sourcing has become more popular with the introduction of the waiting time guarantee in 2002, which allows patients waiting for treatment for more than one month to seek care by any provider. National frameworks and indicators have been important national level tools to coordinate policy and planning for health services. This applies not only to the 2007 reform but also to the whole of the last decade, albeit national guidance for services planning and for integrated care models was reemphasized with the 2007 reform. Obligatory health agreements are important contractual com- mitments conducted between each municipality and its respective region to secure health care provision in line with national guide- lines. Health agreements include arrangements regarding hospital discharges for weak and elderly patients, on the social service available for people with mental disorders, and on prevention and rehabilitation. They were introduced in 2007 to coherence between the different levels of care. became responsible to issues national indicators for patient path- ways and integrated models of care that were to be subscribed into health agreements. The development of a model to improve quality of care builds on regional initiatives but has progressively moved towards a natio- nally applied system. In 2002, national and regional authorities agreed to integrate a number of national and regional models into a com- prehensive national scheme comprising standards (process related standards for care; diagnosis related standards for care; and orga- nizational standards). A national quality database allows comparing quality in a number of clinical areas (including diabetes care, lung cancer, schizophrenia, heart failure, hip fracture, stroke and surgery for acute gastrointestinal bleeding) and national measures of patient satisfaction, all hospitals were included in the national quality scheme in 2007 and a national system for monitoring adverse incidents was introduced in 2004. The strong support of the central government and the munici- palities have been important factors in the implementation of the reform, and this watered down the resistance of the counties to- wards giving up their remits. This in turn has affected the com- pliance of hospitals with the reform, as hospital managers of public hospitals are civil servants directly employed formerly by the coun- ties and now by the regions. This means that they traditionally often do not operate as independent policy actors and do not form a strong representative interest group. Overall most health pro- fessionals were indifferent with the reform, but some have also promoted the reforms as they saw professional merits in a higher degree of specialisation. The implementation of the reform was a complex process since it has drastically changed responsibilities for planning, managing and administrating health and welfare services across the different organizational tiers. The changes in administration through the mergers of counties into regions and the mergers of municipalities into larger units took place at relatively quick pace. Regional plans have helped to implement new provisions for capital investments in hospital infrastructure according to national guidelines. A number of smaller health care facilities have closed, as they no longer com- plied with national requirements for services infrastructures and for the required volumes of interventions. The closure might have influenced geographical access to acute care in some remote areas of but this has not been subject to major public concern so far. Recorded waiting times have reduced substantially due to the introduction of the maximum one month waiting time guaran- tee in 2002, but they have not yet substantially changed since the reform in 2007, suggesting that the reform is likely to have had measurable impact on waiting times to date. Implementation for the new prevention, rehabilitation and social services planning responsibilities at municipal level has been more varied, partly owing to the large differences in size and capacities of the municipalities. Many of the larger municipalities have been proactive in developing health agreements with pro- viders. For some of the smaller municipalities, it has been more difficult to deliver highly specialised rehabilitation and long term care services, for instance cater for patients with complex disabili- This has triggered a debate in the new government to revisit and potentially reduce the functional remits of the municipalities. The 2007 reform has shifted responsibilities for health services planning to the municipal level and has increased the role of the national government in setting out national frameworks for local and regional health services plans, speciality planning and the per- formance on quality and efficiency. Considering the large scale of the reform, opposition was not very fierce, partly owing to the highly integrated nature of the policy-making and provider institutions and implementation has been complex but considerably smooth. observations suggest that the more centralized form of planning clinical specialties has increased efficiency so far with- out fundamental compromises to access to care, as measured by waiting times. The results of the reform in planning and provision of long term, rehabilitation and social care are more heterogeneous due to the large differences in size, capacities and health and social structure of the different municipalities. Health care figured as one of the major election campaign themes in the preface of the national election in . The liberal-conservative coalition had launched plans to abolish the regional health administrations. The election however resulted in a return of the leftist government to power, which is less likely, compared to the previous government, to introduce fundamental changes in the division of responsibilities. The new government has just taken office (), and it is too early to determine how this will exactly influence the current health care governance arrangements. Overall, it is unlikely that the government will fundamentally change the current dele- gation of responsibilities. Some instant decisions have been taken along with the election manifesto, including the removal of regula- tion in favour of tax deductibility for private health insurance con- tributions that the previous government had introduced to en- the uptake of voluntary health insurance schemes. These plans already start to show an effect with substantial losses en- countered in the private health insurance sector. In contrast to private funding schemes, the new government is however not expected to dis-encourage private providers from offering services under the public waiting time guarantee scheme. It will likely con- tinue to encourage regions to embark on outsourcing agreements with private providers where there are shortages of public providers and where there are cost effective alternative private providers such as in the auxiliary services branches. Under consideration is the scope of municipal responsibilities and also environmental health regulation and to return this to either a regional or a national responsibility as some municipalities have found it difficult to regulate industrial behaviour of industries they rely on. Municipalities responsibilities for complex long-term care are also at stake. Governance model and recent changes has a centralised health system administered through the publicly funded (). The NHS is a pioneer in providing national guidance for clinical interventions through (), quality through the Care Quality Commission, or finan- cial sustainability through Monitor, which supervises Foundation Trusts. The NHS also has a long track of national clinical policy development inscribed into Frameworks, and targets that guide priorities and resource allocations at regional and local levels and have contributed to a substantial reduction of waiting times. were created in 2002 to manage the NHS at regional level and to make sure that local health service plans integrate national health priorities. The number of originally 28 strategic health authorities was reduced to 10 in 2006. Since 1989, has been on a quest to find the right balance between strong national level guidance and market approaches. The introduction of GP fundholding in 1991 was designed to stimulate entrepreneurial provider behaviour by giving GPs limited responsi- bility to manage budgets and purchase secondary care for their registered patients. In 1998, GP fundholding and purchasing system was replaced by a system of commissioning of primary, secondary and tertiary care services through managerial units called primary care trusts. Around 150 primary care trusts manage about of the budget of public hospitals and general practitioners. 2010, the NHS had three prevailing governance models in parallel (, 2011): one model consists of direct management by natio- nally defined targets delivered through local managerial arrange- ments; one is characterized by specialist regulation and guidance provided through national institutions; and one model is deter- mined by market mechanisms designed to stimulate competition and promote patient choice. In early 2011, the Conservative Liberal Democratic coalition government launched plans to fundamentally alter the arrange- ments for commissioning services. This came somewhat as a sur- prise as the health election campaign theme of the Conservatives had ruled out fundamental changes in the NHS. The current proposal is to introduce local , dominated by general practitioners but also including represen- tatives of specialist physicians and other health professional groups. Their role is to purchase hospital and specialist care for their regi- stered populations, negotiating with regulated autonomous hospi- tals. They will be free to purchase care from the public, private, and charitable sectors According to these plans, the territorial com- missioners – primary care trusts and strategic health authorities – would be abolished and the government would devolve responsi- bility for vertical performance management, which would pass to a new . would be responsible for regulating local commissioning groups, potentially through regional branches of and will play a leading role in defining standards for the quality of care, together with the National Insti- tute of Clinical Excellence. will moreover hold local commissioning groups responsible for their contributions to achieving a set of NHS outcomes. The NHS Outcome Framework published in 2011 confirms plans to move away from performance management by targets and replace them with local planning processes whereby locally expected results will be negotiated between the national actors (represen- tatives of ) and the local actors (local commissioning groups). The local plans are also expected to emphasize a more integrated approach to social and health care for adults, for example in the domain of long term care. The most consistent driving force for the changes in governance arrangements across the different governments in the past 3 decades is the to control costs without compromising on quality in a system that tries to provide access to care (, 2011). This priority has also driven the agenda of the current government. Officials in the current government maintain that this is a decen- tralizing agenda. By introducing the local commissioning groups, local clinicians will be empowered to take a leading role in deciding how care will be delivered whilst the role of the national com- missioning board is limited to overseeing and supervising their operations. Yet, there is an alternative view, namely that the commissioning board will increase central influence, and impose a rigid regulatory framework for the commissioning groups who would consequently become agents of the state. The coalition government has also officially argued for a need to produce more cost effective care by bringing services closer to patients homes. They furthermore stress the need to move away from reliance on a management driven commissioning agenda towards a clinical outcome agenda. One parallel objective of the reform plans are to cut expendi- tures in the NHS by about , mainly through substantially reducing management in the NHS. The abolition of the primary care trusts and the strategic health authorities is expected to release approximately 24.000 jobs – most of which will be NHS managers – and will effectively eliminate the regional and managerial tier of the current health services commissioning process, albeit replaced in part by A more hidden agenda is a reversion to a more contestable environment for health services provision because NHS and private health care providers are expected to compete for the contracts with . In essence, the current govern- ment is also keen to see their electorates benefit from increased choice of provider along with a higher variety of provider organi- zations. As mentioned before, the Health and Social Care 2010/2011 proposes an independent NHS commissioning board to allocate resources and provide commissioning guidance; proposes to make general practitioners responsible for commissioning services on behalf of their patients; strengthen the role of the Care Quality Commission; change the remit of Monitor; and abolish the primary care trusts and the strategic health authorities. will therefore be the most important tools for implementing the reforms at local level. Local commissioning groups will take control for about of the and the Monitor, will be the national regulatory and oversight bodies for the new commissioning and care arrangements. Monitor is a national agency that has so far been responsible for regulating NHS trusts. It is planned to become an independent economic and care regulator for access to care, integrated care and competition in the NHS. One new national institution – – will be formed, and the remit of Monitor that has so far overseen Foundation Trusts existing will be increased towards becoming the main economic regulator in the NHS that would promote and regulate competition based on quality and pricing and promote coordinated integrated care approaches. The new NHS commissioning board will be established to set guidelines, regulate and oversee the commissioning process possibly with regional branches. Monitor is a national agency currently responsible for regulating NHS trusts. It is planned to become an independent economic regulator for access to care, integrated care, and compe- tition in the NHS. NHS hospitals will continue to be allowed to take on treatment of private patients (who are either privately insured, or who will pay their treatment out of pocket). Caps on NHS trusts on the income generated through private patients that was introduced under the administration will be removed. Impact, opposition and outlook The discussions about potential reforms are on going and can thus not yet been assessed with respect to their likely impact. But early signs of the reform is that trust and health administration staff are already leaving, and that more than 150 commissioning groups have been formed to date (October 2011). The draft bill created a lot of controversy and was thus with- drawn from the House of Commons (Lower Parliament) after its second reading in January 2011 as it risked failing to pass through the House of Lords (Upper Parliament) due to strong opposition from the Liberal Democrats who had fundamental concerns about the provisions on competition and the promotion of private sector services. In the first half of 2011, the underwent a series of con- sultations and listening exercises. These resulted in a number of amendments to the . One of the most important amendments is the revision of the duties of the Monitor towards promoting inte- grated care and not just promoting competition. This pays tribute to concerns over allowing competition to produce radical change to the look of the health service. In the past months, proposals have faced and still face significant opposition from a range of actors, including the representative bodies of the professionals, hospital boards, and trade unions. It is feared that the contestable environment for hospitals and a zero nominal budget growth up to the year 2015 will lead some hospitals into bankruptcy or forcing them to reduce services and that the market orientation will eventually erode the principal values in the NHS such as universalism, equal access and public account- ability. There are also concerns that provisions of the change the responsibility of the Secretary of Health and may essentially reduce accountability of central government to provide a comprehensive and universally accessible NHS. Opposition from the trade unions is fierce and focused on the reduction of labour. There are also fears that the reform plans, the speed and scale of the changes will bind considerable staff and capital resources and will thereby destabilize health services, making it impossible to maintain the level of care. Some commentators have expressed concerns about the possible fragmentation and duplication of services through the emergence of parallel public, private and charitable providers, and consequently inflationary volumes of health services and expenditures. Even amongst General who have called for more clinical orientation of the commissioning process within the NHS, there is widespread concern that they might not be qualified for the financial and administrative responsibilities of commissioning ser- vices and some fear to losing popularity amongst their patients by having to take on NHS management roles. In the second hearing in the House of Lords on 12 October 2011, some of the criticism of the focused on the lack of atten- tion provided in the on ensuring proper public participation means and democratic legitimation of the new structures such as the , . Others argued that the was mainly con- cerned with tackling costs – a comparatively well performing do- main of the English NHS – whereas the did not propose mea- sures designed to improve variations in health outcomes. It seems that there are two main scenarios that may lie ahead for the commissioning reforms – should they go ahead. One would lead to a more heavy-handed governance set-up through a strong regulatory and its potential regional branches. A second scenario is that local commissioning groups would take up an entrepreneurial and leadership role, and in some ways reverting back to the GP fundholding attempts to engage clinicians in helping to manage the services. Governance model and recent changes The central role of the Finnish government is that of a legislating and guiding role and providing block grants to municipalities. Decision-making related to the organization, provision and funding of health and social care is delegated to the 336 municipalities, which have a strong tradition of local democracy. The competencies of the municipalities progressively increased whilst the role of the central government has shifted from a steering role towards a guiding role: In 1993, municipalities were given the authority to decide upon the provision and financing of services whilst the central government was responsible for defining the general conditions such as for contracting out and cost sharing by patients. Funding was changed from a system of earmarked state funding for health towards a system whereby municipalities receive block funds from the state to cover health and social care and raise additional funding. Since then, has a multichannel financing system mainly by municipalities through a combination of municipal taxes, state subsidies and user charges; and a rapidly growing occupational health care system that provides additional coverage for the popu- lation under employment who enjoy easier access to primary care and outpatient specialist services.