Johansson, I.-L., Noren, L. and Wikstrom, E. (2010), "Patient-centred care: the Nordic position", International Journal of Public Sector Management, Vol. 23 No. 4. https://doi.org/10.1108/ijpsm.2010.04223daa.001
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Patient-centred care: the Nordic position
Article Type: Guest editorial From: International Journal of Public Sector Management, Volume 23, Issue 4
About the Guest Editors
Inga-Lill JohanssonAssociate Professor in Business Administration at the School of Business, Economics and Law, University of Gothenburg. Her current research interest is ethnographic micro-studies of organizational practices and the role of trust in the communication of accounting information in health care organizations.
Lars NorénAssociate Professor in Business Administration at the School of Business, Economics and Law, University of Gothenburg, Sweden. His empirical work concerns New Public Management with a special emphasis of the use of markets to control the provision of public key services such as education, health care and social care in Sweden. His research about interpretative methodologies examines the different forms of such methodologies that are used in business administration research.
Ewa WikströmAssociate Professor in Business Administration at the School of Business, Economics and Law, University of Gothenburg. Her research interest includes the intersections of organizing and communication. She has published on collaboration in the health care organization and in the public sector, leadership in the health care organization and communication processes in project organizing.
Making the patient more demanding
The Nordic health care systems, in Denmark, Finland, Norway and Sweden, are often described as communitarian systems in which society has a strong interest in, and preference for, citizen equity (see Gustavsson and Jordahl, 2008; Money and Houston, 2008). Health care in the Nordic context is regulated and supervised by the national governments, while its operations are normally funded and performed locally at the level of county councils or similar institutions. Another characteristic of the Nordic health care systems is that citizens are covered by mandatory public health insurance. However, these communitarian systems were challenged at the beginning of the 1990s. Inspired by, among others, neo-liberal political ideas, Nordic politicians, as politicians in many other European countries, began to reform health care using techniques adapted from theories of new public management (Osborne and Gaebler, 1992; Ferlie et al., 1996; Christensen and Lagreid, 2001; Burau and Vrangbæk, 2008; Byrkjeflot and Neby, 2008; Vikkelsø and Kjær, 2008). The political argument was that health care providers must be more efficient and better adapted to the requirements of citizens. However, the evidence on the success of European health care reforms “indicates that attempts to indirectly affect providers’ behavior by generating financial pressure through individual patient-based demand or competing privately accountable payers does not work well, either financially or socially” (Saltman and Figueras, 1998: 101). This outcome, disappointing for the policymakers, may have various explanations. One is professionals’ resistance to change because of their experience of increasing working complexity and threats to autonomy (e.g. Dent and Radcliffe, 2003).
The policy instruments employed differ among the Nordic countries, and so does the enforcement behind them. Table I gives an overview of initiatives taken in order to strengthen the patient’s position in the countries included in studies in this special issue.
Table I. Initiatives taken to strengthen the patient’s position in Denmark, Finland, Norway and Sweden
Strengthening the patient’s position and making the patient more demanding is assumed to make care providers and professionals more inclined to improve their activities and the care delivered. The government (statuary or negotiated) regulates, e.g. the maximum waiting-time guarantees for care, and citizens are expected to choose providers with the best performance. Rose (1993) argues that such governance is affected by citizen choice, and to become successful it is dependent on new identities and practices of patients. This development, labeled consumerism (Potter, 1988; Needham, 2003) has been exposed to criticism, although we do not yet know much about the effects of patient empowerment (Clark, 2007; Greener, 2007). According to Needham (2003), there are two main arguments in the general criticism of consumerism in key public services. One stating that consumerism does not achieve what it sets out to achieve, for example, the empowerment of the individual and the improvement of public services. As the argument goes, patients might not necessarily want the freedom of choice, and care providers may tend to be selective in their choice of patients. The other is stating that a consumerized citizenry is ineffective because citizenship is only meaningful where it is political and discursive rather than transactional and self-interested. This argument emphasises that consumerism may lead to favouring the self-interest of citizens, thereby suppressing society’s democratic values.
This general criticism of consumerism is certainly relevant in the Nordic countries. Nordic research on consumerism is, however, pragmatic, and the research focus is mainly on how consumerism is transformed into practical arrangements. The issue for Nordic researchers is how consumerism is organized rather than if it is desirable or achievable. However, in this special issue, we would like both to draw attention to the ways consumerism appears in the Nordic countries but as well problematize the phenomena by relating it to the notion of patient centred care (PCC). By presenting a selection of recent Nordic studies on the management and organization of health care our purpose is to contribute to a better understanding of what is needed to develop a true patient-centred care.
The concept of PCC has a long history that is described by Mead and Bower (2000) and Hobbs (2009). According to Hobbs, the concept has been used in the nursing literature for more than half a century. In the 1950s, PCC meant, “individualized care based on patient-specific information” (Hobbs, 2009, p. 53). Although the meaning of PCC has changed over the years, the term usually identifies a deviation from existing practice, which means that whatever the existing practice might be, it is not patient-centred. In his article on patient-centred care, Hobbs (2009) refers to Mead and Bower’s (2000) literature review, which is one of the earliest and most cited literature reviews on PCC. Mead and Bower identify a number of dimensions as the key elements in the doctor-patient relationship that are crucial to the quality of the care. In both the Hobbs and the Mead and Bower articles, PCC is viewed as a complex series of interactions, whether it is the nurse or the doctor who meets the patient. Consequently, PCC is mainly focused on the personnel – patient relationship in health care. Some of the articles of this special issue fit in well in such a definition while other articles, focusing on the empowerment of the patients, do not emphasize the relation to personnel. Implicit in the latter type of articles is, however, the assumption that empowered patients get a stronger position in relation to personnel.
Implications for the patient
We begin our presentation from the perspective of the empowerment of patients and the first four papers reflect on how various types of tools –, e.g. national health care portals, information infrastructures in general, care guarantees and lastly private health care insurances – contribute to create pressure for organizational and professional change. The first article, “Transforming patients to consumers: evaluating national healthcare portals”, is written by Agneta Ranerup. Her study of national health-care portals in three Scandinavian countries and UK shows how patients are transformed into intelligent consumers of health care. She concludes that Norway’s technological devices to some extent, and the UK and Danish devices to a greater extent, equip patients as consumers. Sweden’s technological devices are presently much more limited. The Danish and UK devices that have quality indicators are in the forefront of patient-centred care.
Not only web-portals, but information technology in general, is significant in supporting the patient. In the article, “Mobilizing information infrastructure, shaping patient-centred care”, Signe Vikkelsø analyses four types of information infrastructures used by Danish patients (i.e. care records, internet health sites, online data access and electronic consultations). She concludes that the development of information infrastructures for patient-centred care requires the adoption of technical, legal, clinical and ethical standards, as well as a change in entrenched organizational and professional boundaries. Furthermore, she argues that the mobilization of information infrastructures entails unexpected transformations of basic categories, such as patient and professional identities, records and consultations.
Just as information technology today is an important element of the development towards establishing a health care market, care guarantees also play an important role in this movement. Ulrika Winblad, Karsten Vrangbæk and Katarina Östergren raise the question “Do the waiting-time guarantees in the Scandinavian countries empower patients?” in their article. As accessibility in health care is a highly valued quality in all Nordic countries, patient waiting times have been a debated issue for over a decade. Although there are many similarities among Nordic countries in the policy instruments used, there are some important differences. For example, Norway and Denmark use a stronger policy instrument (regulatory) to enforce the waiting-time guarantees than Sweden, with a positive effect on the patients’ position in the health care system.
Although private health insurances (PHI) are not sanctioned by politicians, they are supposed to contribute to competitiveness and thereby help the health care reform project. Lars Norén examines in his article, “The private interests of consumers in the healthcare market”, how PHI in Sweden contributes to the development of customers’ private interests in health care. They do so by offering access to specialised care and access to personal consultation. His focus is on how insurance company managers encourage their customers to use PHI. He finds that PHI contributes to the development of two types of private economic interests. One is the employers’ interest in managing their total health costs and the promise of PHI to decrease these costs. The second is the employees’ and sports persons’ interest in managing economic risks connected to poor health and the promise of PHI to limit such risks. The article concludes by pointing to the value of short waiting times in public health care.
Complexities experienced by professionals
Turning from the patient perspective onto the perspective of the provider, the four remaining articles deal with what happens when the new governance systems and policy instruments meet reality and challenge the traditional provision of health care. First out, is the article “Lost in translation: a patient-centred experience of unintegrated care”, by Hannele Kerosuo. She takes on a patient-centred position in her exploration of the care of multiple and chronic illnesses in a Finnish case study. She concludes that the patient experiences the care organization as un-integrated when the patient has to take individual responsibility for his/her overall care and when the various medical professionals have only limited knowledge of other providers’ care. Despite their efforts to collaborate, professionals are lost in translation across health care boundaries, which have implications for the responsibilities of providers as well as for the responsibilities of patients.
The next article, “The role of disciplining/translating accounting practices in patient-centred-care” written by Ann-Christine Frandsen, brings up related problems faced by medical professionals at a hospital in Sweden. She argues that accounting is increasingly interlinked with medical practices today, with more and more people involved in translating action and thought into accounting-based terms and values at all levels of their work lives; as this happens, accounting “produces” a way of thinking and valuing that even modifies the identities of patients and professionals. When exposed to new accountabilities and new accounting models nurses produced two categories of patients, one that can be taken care of within ten minutes, and another where more time is needed. In this way the ten-minute nurse is produced.
Although efforts are made to handle the complexities created by boundaries of various kinds, the real care pathway is far from ideal. In her article, “Expanding care pathways: towards interplay of multiple care-objects”, Anu Kajamaa shows in her Finnish case study how the actual care pathway, far from being a clear – cut process, is fractured and unpredictable. Since doctors, nurses and patients have different conceptualizations of care, the care-objects are fragmented and clash in the practical work activity. Her main message to hospital management is that in order to expand care pathways, these multiple care-objects need to be placed in constructive interplay.
The last article, “Bringing about change in patient-centred preventive care”, by Loni Ledderer reports on the implementation of motivational interviewing, a health behavior concept part of a project launched by a public health authority in Denmark. The concept, which may be perceived as an important element of patient-centred care, focuses on mobilising patients’ motivations and their own interpretations of their health problems. Those ideas on health care translate into specific activities in organizations following pre-existing, general rules of medical practice. The article demonstrates how preventive care services are constructed in a tension between a biomedical and a behavioural understanding of patient-centredness, resulting in divergent organizational practices.
To conclude, all articles in this special issue show that health care policies in the Nordic countries are influenced by the rhetoric of consumerism, although in unique ways in the various countries. However, it is too early to draw any firm conclusions about the effects of this new trend on the practices of professionals and patients. Nevertheless, the articles in this special issue call attention to a number challenges to a true patient-centred care. The challenges identified in this special issue are common to most European countries however the experienced problems as well as the solutions to the problems may differ.
All the articles were presented at the 2nd Nordic workshop on “Health care management and organization” in Göteborg in December 2007. The theme of the workshop was “Patient centred-care”.
Inga-Lill Johansson, Lars Norén, Ewa WikströmGuest Editors
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