Governance and finance of long-term care - University of Birmingham

Allen et al., 2011 Governance and Financing of LTC | European Overview
2.2 Governance in emerging long-­‐term care systems
In public welfare policies and in the context of ‘new public management’ approaches we have seen a
general trend towards increasingly market-­‐oriented governance mechanisms accompanied by
decentralisation and the multiplication of actors (Nies et al., 2010; Kazepov, 2010). In most countries
this has involved the substitution of public providers by private service provision or at least a stricter
purchaser-­‐provider split within public authorities and the emergence of new types of providers (for-­‐
profit or non-­‐profit) to complement public provision. In theory, the enhanced division of roles between
public and private actors should enhance the problem solving capacity of the supply system and
improve quality by means of competition between providers. However, this expectation has only shown
scarce evidence over the past 20 years (Börzel, 2010: 10; Leichsenring et al., 2011).
With a view to the governance of emerging LTC systems and their link to health systems it has been
argued that market-­‐mechanisms might exacerbate or even endanger networking, coordination or
integration of service provision as an integral characteristic of LTC quality (Nies et al., 2010; Billings and
Leichsenring, 2005; Leutz, 1999; Kodner, 2002). Models to improve the provision of LTC according to the
principle of integration are still being developed and cover a broad range of integration aspects, such as
shared information among professionals from different sectors, standardised communication formats,
single access points or defined multi-­‐disciplinary pathways of care. Similar aims have been defined
within health care systems, where so-­‐called ‘managed care models’ are addressing existing gaps
between financial aspects and inefficient delivery of services. Being derived from a management
approach, they aim for the application of principles and techniques including risk sharing between the
providers and financers of primary and secondary care, selective contracting with service providers and
increased beneficiary cost sharing. Their overall aim is to efficiently steer the costs of providing health
benefits and improve the quality of health care (Amelung et al., 2009: 5). However, while Health
Maintenance Organisations (HMO) in the US or similar approaches in Canada (Fleury, 2002, Tourigny et
al., 2002) are offering a complete continuum of services with a health maintenance approach, in Europe
the impact of managed care on LTC has hitherto been very limited.
Models of integrated LTC thus seek to close the traditional division between health and social care and
focus on stated goals of public policy, i.e. by aiming at sustaining and promoting the autonomy of the
older persons in order to delay, or avoid nursing home placement (Egger, 2007: 10). Different forms of
integration are often described as steps on a continuum going through linkage, coordination,
networking and cooperation from a full segregation to a full integration (Leutz, 1999; Nies, 2004).
Such pathways towards complex, dynamic integrated models are demanding solutions by and
involvement of all actors involved, be it from the public or private sphere. Therefore different models of
steering supply and demand can also be found side by side in LTC provision; depending on the
circumstances, one party may take the lead in a specific case and leave it to another under different
conditions (Kooiman, 2005: 162), thus creating different ‘governance mixes’ (Schuppert, 2008) when it
comes to the coordination of health and social care services.
The empirical findings from differences in country-­‐specific governance models, actors and mechanisms
will be illustrated in detail in the following chapters, with a specific focus on the governance of
networking, coordination and integration between loosely coupled LTC and health systems.
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