Integrated Care, Competition and Choice-Removing barriers to care coordination in the context of market-oriented governance in Germany and Sweden

Introduction: Many scholars have argued for already more than two decades that integration between health and social care services would be needed to enhance system efficiency, quality of care and users’ quality of life. This has been emphasised worldwide by the implementation and evaluation of countless models, initiatives and innovative practice examples across the health and social care continuum. As the advance of integrated care took place in the context of a pronounced shift towards market-oriented governance – also in health and social care – increasing fragmentation has often been identified as a major barrier to integrated care. While the latter calls for cooperation and partnership working, ‘New Public Management’ is promoting user-choice and competition. Our contribution will address this most puzzling dilemma: How compatible (if at all) is integrated health and long-term care delivery with increasingly fragmented provider markets stimulating user choice in a competitive environment?

Introduction: Many scholars have argued for already more than two decades that integration between health and social care services would be needed to enhance system efficiency, quality of care and users' quality of life.This has been emphasised worldwide by the implementation and evaluation of countless models, initiatives and innovative practice examples across the health and social care continuum.As the advance of integrated care took place in the context of a pronounced shift towards market-oriented governance -also in health and social careincreasing fragmentation has often been identified as a major barrier to integrated care.While the latter calls for cooperation and partnership working, 'New Public Management' is promoting user-choice and competition.Our contribution will address this most puzzling dilemma: How compatible (if at all) is integrated health and long-term care delivery with increasingly fragmented provider markets stimulating user choice in a competitive environment?
Theory and Methods: The contribution is based on a mixed-methods study commissioned by the Swedish Ministry of Health and Social Affairs.In 2014/15, a literature review and three case studies in Germany (Dortmund, Leipzig) and Sweden (Norrtälje, Stockholm County) were carried out, involving 19 key-stakeholders that were interviewed following a semi-structured questionnaire.
The two countries were chosen for comparison to contrast the most pronounced open market for care services in Europe (Germany) with Sweden, where the market share of private providers is growing and where the 'customer choice' model has only been introduced since 2008.
The innovative feature of this research consists in bringing together the two strands of theoretical discourse that are dealing with market-oriented governance and with integrated care, and to provide empirical evidence how integrated care initiatives are coping with the challenges of choice and competition.
Theoretical considerations range from reflections on introducing elements of user choice in integrated care to contributions that put trust in integration as a response to a competitive environment and/or competition as an incentive for integrated care, in particular if new types of integrated funding are implemented.
Results: Each of the three sites are 'special cases' within their respective national context.The municipality of Norrtälje (Stockholm County) had realised a defined model of integrated care, including joint health and social care budgets, before introducing a regulated extension of providers and 'user choice'.Regulation and strong leadership were thus used as keyinstruments to reconcile integrated care provision and user choice.Stakeholders in the German sites reacted to the open market by searching for strategies to promote coordination and networking.This implied developing mechanisms to re-create trust between public, non-profit and for-profit providers, e.g.'Round Tables', as well as instruments to empower users' choice in the neighbourhood (coordination and consultancy centres, case management).In some cases, thematic and/or provider networks were established to coordinate stakeholders and to moderate competition, e.g. by defining operational areas.
Discussion: The findings showed a nuanced picture related to the conciliation of integrated care, choice and competition.The majority of key-stakeholders underlined opportunities to achieve integrated, or at least coordinated care in a context of user choice and competition.Especially in Germany user choice has been internalised as a de facto right of users.Integrated care initiatives are therefore forced to cope with it, in some cases they even were a reaction to this framework condition.In Norrtälje, competition and user choice became a new challenge for an already established integrated care model, but regulatory interventions were partly able to mitigate uprising fragmentation.Interestingly, instruments to better support and empower users to make choices have not (yet) been on the agenda in Sweden, while financial integration of health and long-term care budgets remains foreign to German stakeholders.

Conclusion:
The study showed that it is possible to build common values and to enhance trust and joint working through quite dissimilar approaches to integrated care.Full integration such as in Norrtälje is not the only way to achieve (better) collaboration.While there is no 'onesize-fits-all' solution, sufficient time and space are necessary to find common grounds.In all sites it took several years to develop ways of cooperation and mutual understanding.Shortterm projects of integrated care can thus hardly be successful, though competition and customer choice may accelerate the search for solutions.Keywords: integrated care; choice; competition; governance; case studies