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Introduction: Health and social care systems are constantly undergoing major reforms to meet the rising demands of an increasing proportion of older patients, with many such reforms aiming to improve integration and coordination. The aim of this systematic review was to synthesize the evidence on inter-organizational coordination interventions between hospitals and outpatient (health- and social care) providers for older patients with complex needs during- and after hospital discharge.

Methods: A systematic search of four databases was performed to identify interventions of inter-organizational coordination at hospital discharge for older patients with complex needs. The retrieved literature was analyzed using a narrative synthesis.

Results: Twelve studies were included (seven randomized controlled trials and five non-randomized intervention studies). The most common intervention components were; needs assessments, dedicated care coordinators and multi-professional teams. Findings show that inter-organizational coordination could decrease- or even increase readmission rates, with similar findings for hospital length of stay and mortality. Furthermore, inter-organizational coordination seemed to have a positive impact on quality of life and activities of daily living.

Conclusion: Inter-organizational coordination could potentially reduce health-care utilization and improve quality of life for older patients with complex needs. However, the findings remain uncertain and further research is warranted.

Background: In Sweden, healthcare provision for the frail elderly entails coordination between municipalities and regions. Despite formal agreements, deficiencies persist in achieving practical coordination, leading to adverse effects on patients and increased costs. The Covid-19 pandemic further strained the health- and social care system, exposing shortcomings in eldercare coordination. This paper explores the impact of crises on inter-organizational coordination between long-term organizational collaborators, operationalized through medical care coordination in Swedish nursing homes during the Covid-19 pandemic.

Methods: The study examines coordination between regionally employed physicians and municipal nursing home nurses through a mixed methods approach. A survey was sent to regional physicians and municipal nurses working in eldercare, as well as managers at both nursing homes and healthcare centers. A total of 170 responded to the survey, and 20 participants took part in a subsequent follow-up interview.

Results: Findings indicate that medical care coordination was perceived to have functioned relatively well during the pandemic and even to have improved afterward. Key factors contributing to this outcome include the adoption of innovative solutions, such as digital technologies, to address both staff shortages and increased demand brought on by the crisis. Trust and shared cultural values among staff fostered collaboration, while personal engagement became crucial when compatibility was lacking. The respondents also highlighted improved communication channels and enhanced coordination as a means to combat uncertainties during the crisis.

Conclusions: The perception of well-functioning crisis coordination among the respondents contrasts with more critical views in general society. This discrepancy might be attributed to different expectations during crises; healthcare professionals adhere to specified standards, values, and beliefs within their specialized cultures. Healthcare professionals might therefore have a more nuanced perception of what they believe constitutes good medical care coordination. The contributions of this study include integrating the crisis management literature with inter-organizational coordination in healthcare. The approach provides new insights to clarify the impact of crises on medical care coordination and identify important factors regarding inter-organizational coordination during crises.

This article investigates the impact of NPM reforms on two prominent welfare state professions; medical doctors and teachers. The case study context is Sweden, where the impact of NPM led to a series of reforms in health care and education after 1990. The focus in the paper is on professional autonomy, which can be seen as a core trait in professional work. The findings in the article point to both medical doctors and teachers having lost professional autonomy as a result of NPM-reforms, particularly with regards to the dimensions of work organization and evaluation. Autonomy in individual decision-making seems to have been least affected, even if there are indications of this being infringed upon as well. Despite these broad similarities, the loss of autonomy is found to be more pronounced in the case of teachers. One reason behind this difference, which manifests itself in teachers having become subject to higher level of direct administrative control by school managers while at the same time experiencing a more distinct loss of autonomy to evaluate their work, appears to be that medical doctors have been more successful in establishing themselves as experts in relation to new public audit agencies.

Decommissioning programmes pose a substantial risk of failure compared to other change processes in healthcare. A better understanding of the challenges associated with change processes initiated by resource scarcity faced by healthcare managers is crucial. This study describes and compares department and unit managers' experiences during the implementation of a large-scale decommissioning programme in a Swedish region. A survey was developed and a cross-sectional study was performed, measuring 172 healthcare managers' experiences of (1) the region's leadership, (2) their own participation and (3) their own commitment and responsibility during the implementation of the decommissioning programme. Respondents were 50 department managers and 122 unit managers (93% and 58% response rate, respectively). There was a significant difference between department and unit managers in their experiences of the region's leadership and their own participation in the decommissioning programme. Unit managers were more dissatisfied with the way it developed compared to department managers. For example, unit managers reported a lower level of leadership support, incentives to participate, and that their knowledge and skills were not fully utilised. Involvement of unit managers in a more fruitful way might enhance the results of decommissioning programmes. This study highlights a key actor in this context: the unit manager.

Introduction

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

Aim

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

Methods

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape—our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

Results

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

Conclusions

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Purpose: A local healthcare organisation providing healthcare to 288,000 residents in Sweden struggled with a longstanding budget deficit. Several attempts to overcome the demanding financial situation have failed. A decommissioning programme was launched, and two years later, an evaluation indicated positive outcomes. The aim of this study was to explore factors politicians and public servants perceived as enablers to the successful implementation of the programme.

Design/methodology/approach: A deductive content analysis approach using a framework of factors facilitating successful implementation of decommissioning decisions was applied to analyse interviews with 18 informants.FindingsImportant factors were: (1) a review report contributing to the clarity of evidence, which (2) made the clarity of the rationale for change undeniable and (3) strengthened the political support for change. Additional factors were: (4) the strength of executive leadership, (5) the strength of clinical leadership supported by (6) the quality of project management and (7) a cultural and behavioural change seen as an important outcome for the path forward. A way to maximise the potential for a successful implementation of a large-scale decommissioning programme is to build a shared vision and a collaboration grounded in convincing evidence. Include public servants with a clinical background in the executive leadership team to contribute with legitimacy, competence, and trust in the decommissioning programme's intention.

Originality/value: The paper addresses the limited knowledge of best practices in decommissioning processes and contributes empirical knowledge from a successful case.

Purpose: According to the Swedish Act concerning Support and Service for Persons with Certain Functional Impariments (The LSS Act), personal assistance (PA) aims to enhance good living conditions for people with disability. The Act is operationalised by a policy tool, an instruction developed and refined by the Swedish Social Insurance Agency (SSIA) to grant PA. The study explores how this instruction is aligned with the LSS Rationale and goals.

Material and method: Qualitative content analysis was applied on the material i.e., a government bill preceding the LSS Act and the policy tool, i.e., the SSIA instruction, versions 1994 and 2019.

Results: The result shows that the instruction has deviated from the LSS Act over time, by decreasing users' access to community life, a shift towards health and care activities, lack of support for the PA user, increased control and service-granting criteria. 

Conclusion: This paper emphasises that the selection of policy tools goes beyond mere pragmatism, as they are subject to refinement procedures that have significant impacts over time. The deviations observed in fulfilling the objectives of the LSS Act highlights the importance of ongoing adjustments to policy tools to align with the original policy goals in order to promote disability rights. 

Purpose

The build-up of large-scale COVID-19 testing required an unprecedented effort of coordination within decentralized healthcare systems around the world. The aim of the study was to elucidate the challenges of vertical policy coordination between non-political actors at the national and regional levels regarding this policy issue, using Sweden as our case.

Design/methodology/approach

Interviews with key actors at the national and regional levels were analyzed using an adapted version of a conceptualization by Adam et al. (2019), depicting barriers to vertical policy coordination.

Findings

Our results show that the main issues in the Swedish context were related to parallel sovereignty and a vagueness regarding responsibilities and mandates as well as complex governmental structures and that this was exacerbated by the unfamiliarity and uncertainty of the policy issue. We conclude that understanding the interaction between the comprehensiveness and complexity of the policy issue and the institutional context is crucial to achieving effective vertical policy coordination.

Originality/value

Many studies have focused on countries’ overall pandemic responses, but in order to improve the outcome of future pandemics, it is also important to learn from more specific response measures.

Healthcare systems may run into economic problems that may require 'active' decommissioning by policy-makers and managers. The aim of this study was to investigate, from a sustainability perspective, the implementation of an extensive decommissioning programme in one of the Swedish regions. Interviews were performed with 26 clinic managers 3 years after initial implementation. Those were analysed inductively, and then discussed based on a model of potential influences on sustainability. Although the programme was only 'partly sustained', the result point to a sustained attention to the health system's poor economy, visible in a great effort by the clinics to maintain their budgets. The most important influences were intervention fit and modifications made at the clinic level (i. innovation characteristics), clinic and health system leadership (ii. context), champions (iii. capacity) and shared decision-making and relationship building (iv. processes and interactions). When implementing decommissioning, it is particularly important to engage managers responsible for the care of patients and clinic budgets from an early stage and to allow them to design approaches based on the staff's and managers' detailed knowledge of the situation at their clinics and of the disease area, that is, to achieve fit at the clinics. In this way, the decommissioning approaches can more likely get the character of quality improvement efforts, which increases sustainability and may lead to positive quality outcomes. Despite being unpopular, the study suggests that decommissioning can have positive effects as well, such as creating opportunities to make difficult but necessary changes and fostering increased collegial support during the centralisation of services.

The COVID-19 pandemic has been an ultimate challenge for health systems as a whole rather than just single sectors (e.g. hospital care). Particularly, interface management between health system sectors and cooperation among stakeholders turned out to be crucial for an adequate crisis response. Dealing with such interfaces, it is argued in the literature, demands from health care systems to become resilient. One way to analyse this is to focus on the ways in which bottlenecks in health systems are dealt with during the pandemic. This paper investigates six bottlenecks, including overburdened public health agencies, neglected nursing homes and insufficient testing capacities that have been encountered in the health systems of Germany, Sweden and the Netherlands during the pandemic. Based on empirical findings we identify and critically discuss preliminary lessons in terms of health system resilience, an increasingly popular theoretical concept that frames crises as an opportunity for health system renewal. We argue that in practice health system resilience is hindered by path dependencies of national health systems and, owed to the crisis, interim policies that lack ambition for broader reforms.