Development of integrated care in England and the Netherlands: Managing across public–private boundaries
Introduction
In several European countries, over the last decade, the concept of integrated care has acquired a strong political emphasis. Politicians, but also care providers, argue that integrated care as a process of coordination of the current fragmented services, is necessary in order to improve efficiency and to better meet the changing demands of an increasing number of older people and people with chronic illnesses or handicaps. The care for these people is complex. It has to meet a variety of needs, with changing combinations of medical treatment, nursing and social care, as a continuous set of services. This requires cooperation of the providers’ care activities in a coherent and comprehensive way, as we discussed in a previous article in this journal [1].
In practice, the implementation of integrated care does not only mean the development of inter-institutional arrangements and new organisational instruments and methods, such as inter-disciplinary teams, ICT-facilities, protocols or special financial arrangements. It also implies a change of attitudes, willingness to invest time, and for service professionals to seek domain consensus and agreements over tasks and autonomy. With professional division of labour at stake, this involves changes in, for example, professional power and culture. Often professionals will be involved in a personal struggle between self-interests and their core values, such as service, commitment and calling [2].
Another problem is the difficulty for care providers to develop and deliver integrated care within the framework of existing national legislation and regulation. In many European countries, it appears that the health care system (including legislative structures, finance and policy processes) impedes integrated care development and delivery. Moreover, it often appears difficult for governments to change the national health care system in ways that promote integrated care. Legislation is inflexible, the different actors are often reluctant to change because they are afraid of loosing their status, power and position and new policies are difficult to implement. Thus, historically based structures, policies, legislation and regulations provide an inappropriate environment for integrated care, which requires flexible regulations and structures in order to realise the coordination and integration of care providers and care activities beyond the boundaries of institutions, cultures and finance.
In this paper we focus on the development and delivery of integrated care in the context of managing relationships across and between public and private sectors. We examine the impediments and opportunities, resulting from the national public–private mix. In this context we discuss, from a historical perspective mainly concerning the last three decades of the 20th century, the impact of the public–private mix on the development and delivery of integrated care. We identify not only patterns of funding and regulatory frameworks, but also attitudes and cultures. To broaden our insights we go beyond national structures, which allows us to look at different environments of integrated care. We compare England and the Netherlands as part of a broader study on steering of integrated care, which is based on the co-operation of the Department of Health Organisation Policy and Economics, University of Maastricht and the Nuffield Institute for Health, University of Leeds. We begin with an analysis of the Dutch case, followed by an analysis of the situation in England. We discuss the main features of the systems and describe their effects on integrated care. The concluding section, based on a comparison of England and The Netherlands is followed by some lessons for policy makers and those involved in integrated care development and delivery.
Section snippets
The Netherlands
Although traditionally a high value has been placed in the Netherlands upon private initiative in the health and social care system, the role of the government is prominent. This does not mean, however, that state intervention is equally intensive across all areas of health and social care or is characterised by top-down measures. Policy making and implementation take place as a continuing, negotiated process within an institutional framework which forms a complicated system with elements of
England
Partnership, policy co-ordination and integration have been leitmotifs running throughout the policy pronouncements of the two Blair governments in the UK since 1997. This has applied across all policy areas but particularly so in the case of the health and social care sectors, between which a so-called ‘Berlin Wall’ has developed. This fragmentation was exacerbated by the competitive pressures inherent in the quasi-markets introduced in the 1990s. In its 1997 White Paper, The New NHS Modern
Conclusions
Comparing the Dutch and English public–private relationships and their impact on the possibilities of integrated care development it seems clear that the English situation is, at least formally, more complex. In the Netherlands, with its Bismarck (privatised) system, the mix is about networks comprising public–private relationships, including between long-term and short-term provisions, i.e. the care and the cure sector. In England, within a tax-funded Beveridge system, these networks comprise
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