The Norwegian substance treatment reform

Transcription

1 Sverre Nesvaag & Terje Lie Research report The Norwegian substance treatment reform Between New Public Management and conditions for good practice Introduction In 2004, the responsibilities for all of the treatment and rehabilitation services for substance abusers in Norway covering health, psychosocial, and social educational aspects were transferred from the county level to the stateowned regional healthcare enterprises. These enterprises had been established 2 years previously as part of the much larger reform of hospitals, when all specialized healthcare services where transferred from the county level to the new enterprises (Lægreid et al. 2005). As part of the specialized healthcare system, the services for substance abusers were defined as multidisciplinary specialized services for substance abusers. This reform is known as the Rusreform (the Substance Treatment Reform). Both the reform of hospitals and the Substance Treatment Reform can be analyzed as examples of the health reforms that have occurred throughout Europe (Opedal 2006). Most countries share certain goals and prob- Submitted Initial review completed Final version accepted A B S T R A C T S. Nesvaag & T. Lie: The Norwegian substance treatment reform: Between New Public Management and conditions for good practice Background In 2004, the responsibilities for all substance abuse treatment and rehabilitation services in Norway were transferred from the county level to the state owned regional healthcare enterprises. Aim This reform, as many other European health reforms, was inspired by the same ideological and expert policy prescriptions for organizing public services. The aim of this paper is to analyze how these organizational principles influence the probability of services meeting the conditions of recognized prerequisites for a high quality of care. Data The paper builds on data from one national and two regional evaluations of the reform. Results The new organization principles have created a system of fragmented, linear transfer of responsibilities from one agency to the next, preventing the realization of fundamental preconditions for effective treatments of substance abuse. Initiatives of bottom-up organization are seen as attempts to counteract these consequences. NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

2 Conclusions There seems to be an inherent contradiction between the overall organization of healthcare and social services for substance abusers in Norway, and recognized preconditions for a high quality of care. Bottomup organization is, to some degree an effective counteract in alleviating the consequences of this contradiction. Top-down and bottom-up organizing seems to have been established as two parallel forms of organizational development in the Norwegian substance treatment system. Key words substance abuse, treatment systems, New Public Management lems that are clearly apparent in national healthcare sectors. Maximizing the health of their population, available and equitable health services, and cost containment represent important goals. Health policy within Norway and throughout Europe in general has become increasingly concerned with the growing costs of care. The aging of the population, higher levels of chronic disease, increased availability of new treatments and technologies, and rising public expectations have all exerted upward pressure on healthcare expenditures. The conflict between providing good healthcare and the fiscal imperative of cost control has been a driving force behind many of the healthcare reforms throughout Europe (Saltman 2008). The healthcare reforms of recent years constitute various attempts at solutions (or adaptations) to these changed conditions. This wave of reform has largely been inspired by similar ideological and expert policy prescriptions for organizing public services. One dominant policy prescription has been New Public Management (NPM). NPM has been characterized as a collective term for a wide range of organizational principles, all inspired by the private sector. These principles can be put in two broad categories (Klausen 2001). Firstly principles inspired by free market instruments, such as privatizing of services, the utilization of tenders, purchaser-provider systems, free users choice of services, legal user rights, profit centers and price-per-piece financing, and secondly principles inspired by private sector organization and management, such as strategic top-down management, increased decentralization of responsibility, but at the same time with increased demands on standardization of service delivery and production and on economic reporting, often designated as centralized decentralization (Aucoin 1990; Christensen & Lægreid 2007). Even if the development of the public sector in Norway by no means has happened in accordance with all these principles, both the Hospital Reform and the Substance Treatment Reform were clearly inspired by many of them. It is also quite clear that, as is seen in many other countries (Hood 1998), the implementations of the principles have taken many forms. In this paper we will especially focus on: 1) the implementation of the new patients rights, assessing and defining who has the right to specific necessary health services within certain time limits, and 2) the implementation of the 656 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

3 purchaser-provider model both within the specialized healthcare system (from department, via regional health authorities to hospitals and private services) and between primary healthcare and specialized healthcare (trough the referral system). The aim of this paper is to investigate how the implementation of these principles has affected what is widely recognized as fundamental preconditions for effective treatment of substance abuse (see below for a description of these preconditions). We also want to investigate how initiatives of bottom-up organization can be understood as reactions and adaptations to the top-down implementation of these NPM inspired principles. Research questions, methods and data This paper is mainly based on data from one large and two smaller evaluation projects directly related to the Substance Treatment Reform. The large nationwide evaluation was funded by the Government through the Norwegian Directorate of Health (Lie & Nesvaag 2006). The two smaller evaluations were funded by the Municipality of Oslo (Lie 2006) and the Regional Health Authority of Mid-Norway (Karlsen et al. 2007). The Substance Treatment Reform evaluation projects were all conducted in 2005 and 2006 (i.e., 2 to 3 years after the start of the implementation process in 2004). All three evaluations were contract research projects based on terms of reference formulated by the funders. This paper is, however, based on an independent analysis of data from the evaluations, asking research questions that were not formulated as part of the original evaluation terms of reference. As with many large reforms in the public sector, the list of aims of the Substance Treatment Reform was rather long. The main aim was, however, rather simple: to integrate the treatment services for substance abusers in the already established legal, economic and organizational structures of the specialized healthcare services in Norway. Most of the other aims formulated by the Government and the Parliament had to be understood as preconceptions about how a new treatment system would function and as good intentions for prioritizing treatment services. To grasp these different kinds of aims, the conceptual framework for the evaluations was based on a notion of a possible split between structural changes and functional consequences of the reform. Structural changes refer to elements of the reform, such as changes in formal ownership of services (from county municipalities to state-owned health enterprises), new agreements between the state-owned regional health enterprises and privately owned service providers, new management and budgeting principles and reporting systems, new patients rights, and new principles and procedures for organizing and managing clinical pathways. The first main question of the evaluation projects was: to what degree had these structural elements been successfully implemented 3 years after the start of the reform? The evaluation of the functional consequences of the reform was related to the aims the Government and the Parliament had formulated in addition to the main aim of integrating the treatment services for substance abusers in the already established specialized healthcare system. The second main question of the evalu- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 ation projects was therefore: to what degree had the reform led to an increase in capacity and competence in the services? Related questions were as follows: to what degree had the implementation of the reform been followed by an increase in capacity in treatment institutions and in the number of personnel in both residential and outpatient treatments? To what degree had the integration of the services into the specialized healthcare system been followed by an increase in personnel with a formal healthcare competence? This part of the evaluations involved a large amount of formal documentation of laws, white papers, national-strategy documents, purchase documents from owners, accounting information, information related to capacity and formal personnel competence, information on waiting lists and on surveys and mappings of changes in the specialized services and the primary social and healthcare services for substance abusers, and on qualitative interviews with governmental representatives, service organization authorities, and managers at all levels. The third main question of the evaluation projects was: had the reform led to a better quality of care in the treatment system? When designing the evaluations there was no attempt to directly measure the quality of care in terms of treatment outcomes. Instead, the evaluations were designed to examine those indicators of good treatment quality that were formulated in the governmental reform act proposition (Ot.prp nr , 20 21). These indicators were:1) easier access to services owing to the reform, 2) more individualized treatment, and 3) a better continuity of care. In treatment research these three preconditions are, in addition to the quality of the individual treatment relation and the self-change capacity of the patient, often referred to as common factors, explaining a major fraction of variance in the outcome of treatment. Such common factors are seldom mentioned in traditional treatment reviews (such as the Norwegian NOU 2003:4), but they are often some of the most important points in popular science guidelines presented to managers and practitioners (Sellmann 2010; NIDA 2000). This part of the evaluations employed several methods. We compared a mapping of all patients in residential or outpatient care in a large, representative sample of treatment facilities during a 2-week period in 2006 (2201 patients) with the same kind of mapping performed during a 2-week period in In addition, we surveyed 218 social service offices at the municipal level, focusing on their experiences of change in treatment service chains and of cooperation related to clinical pathways. In the three evaluation projects we also conducted qualitative interviews with 76 service managers and providers at different levels, 15 representatives of user organizations, and 14 substance abusers (users of services) about their experiences of similar changes. Structural changes and functional consequences The evaluation projects of the Substance Treatment Reform focused on issues concerning nearly all aspects of the reform, while this paper concentrates on the question: what is the relationship between the implementation of the NPM inspired organization principles of the new treatment 658 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 system and the functional consequences of the reform regarding easier access to services, more-individualized treatment, and a better continuity of care as crucial preconditions for a high quality of care? As a preamble to investigating this question, we first provide a short summary of the results from investigating the main questions raised in the evaluation projects. Structural implementation of the reform The implementation of the Substance Treatment Reform represented a considerable challenge for all actors in the healthcare and social-service systems. For the regional health enterprises and many of the other specialized healthcare services, the treatment and rehabilitation system for substance abusers and the patient group itself constituted largely unknown parts of the healthcare and social-service systems, with their own peculiarities regarding organization, ideology, and treatment practices. Integrating treatment and rehabilitation services into the specialized healthcare system and the regional health enterprises represented new challenges regarding organization, procedures, documentation, ideology, and treatment practices. All of the actors have made considerable efforts to implement the associated laws and procedures and to regulate the specialized healthcare services in the treatment services for substance abusers. The discussions by the Norwegian Parliament about what parts of the services should be transferred to the regional health enterprises, restricted the time frame for planning this implementation. All of the actors showed an impressive ability both in finding regional and local solutions, and in rapidly implementing them. However, not only laws, regulations, and procedures had to be implemented; at the same time new cooperation relationships, with other specialized healthcare services and with the primary healthcare and social services, had to be developed. Many activities within and between these cooperating services have begun. In the first few years of the reform, attention was focused mainly on informing the different service providers about the new patients rights for the patient group described below, and on the new procedures for patient referral and assessment as required. Many general practitioners and the somatic specialized health services had little knowledge or experience in working with substance abusers, and had to be followed up both by educational activities and development projects. Capacity and competence On top of this, there was a clear expectation that provision of resources to increase the treatment capacity and expand the number of suitably competent treatment staff should rapidly follow the reform. This also occurred during the first 3 years after the reform: the regional health enterprises increased their budgets for substance abuse treatment by 40 percent. However, this was not sufficient to keep pace with the dramatic increase in patient referrals. The result has been longer waiting lists, although not as long as many had anticipated. This has put considerable pressure on both regional health enterprises and service providers. Considerable efforts have been made in trying to increase the capacity in all parts of the system. Now, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

6 in 2010, the lack of capacity and formal competence still seem to be the most-contentious issues. New patients rights New legal patients rights for substance abusers were seen as fundamental elements in the Substance Treatment Reform. The idea was for substance abusers to have the same rights and access to specialized healthcare services as other patient groups. However, assessing the right to services depends on two factors: the severity of the health problem and the evaluated costeffectiveness of the available treatment. Cost-effectiveness is used to decide which patients should have access to specialized services, what kind of services they should have access to, and for how long it is cost-effective to provide specialized services to each specific patient. In this way patients rights have become an important instrument for reducing the obligations of the health enterprises, and hence have also become an important instrument for controlling costs. The purchaser-provider system The above argument also applies to the purchaser provider system. The state (via the Department of Health) defines the obligations of the regional health enterprises to provide necessary services. The regional health enterprise authorities fulfill these obligations by delegating the responsibility to provide the services to their own hospitals in the form of award letters defining budgets and services to be delivered, or to privately owned services in the form of purchaser provider agreements. Within the purchaser-provider system we can also detect NPM inspired instruments such as new financing models and the use of tenders. The same reasoning is applied to the relationship between the primary care system at the municipal level and the specialized healthcare system. No patient can access specialized healthcare without a referral from the primary care system i.e. from a general practitioner or, in the case of referrals to the specialized treatment for substance abusers, from the social services. The primary care system behaves much like purchasers of specialized services, but instead of paying for the services, the access is regulated by patients rights. The responsibilities of the specialized healthcare system to provide services are then always limited. As one manager of a regional health enterprise has stated: Patients are temporarily discharged to specialized healthcare. Consequences for the quality of care The implementation of patients rights for substance abusers required a new system for evaluating the problem status of patients in relation to new patients rights. Considerable resources and effort had to be devoted to this evaluation and assessment system and to interpreting new guidelines defining the severity and costeffectiveness. This resulted in many related professional discussions, but with a much-reduced focus on the consequences on the quality of care. Firstly, it quickly became clear that the increase in referrals overwhelmed the increase in treatment capacity, which reduced rather than increased access to services. On the other hand an increased number of people with substance-abuse 660 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

7 problems now have access to specialized treatment services. Secondly, we discuss the more problematic results of the new system for assessing patients rights. The new system made it mandatory to implement special assessment units consisting of both healthcare and social-service professionals and to implement special procedures to obtain the information needed from the referring agency, and the criteria to be used in assessing if and within what deadlines the referred person should be given rights to a particular form of specialized treatment. One obvious result of this system was the transference of capacity often involving the most-experienced professionals in the system from treatment to assessment activities. Another result was a change in the aims of the assessment process. Before the reform, an assessment largely focused on the individual situation and treatment needs of the referred patients, whereas after the reform assessments have to be more oriented towards the single question of whether a patient has formal rights to treatment. Our impression is that many of those who are most qualified to perform assessments of individual treatment needs are now solely responsible for answering this question. The result is an unavoidable delay in developing an individualized treatment pathway. Our interviews with substance abusers revealed another, even more serious consequence of the new system. While other categories of respondents had focused mainly on the lack of capacity and on long waiting lists, most of the substance abusers did not mention waiting as a problem. Their main concerns were the breaches in treatment relationships (lack of continuity of care), illustrated by comments such as the following: As soon as I believe that things have started to happen, it stops again, and When I have been through a demanding treatment process and I am ready for the process of being integrated into society, there is nobody there to assist me. There are several possible reasons, unrelated to the implementation of NPM inspired principles and instruments, for why so many treatment processes for substance abusers represent a threat to the continuity of care. Firstly, the substance abuser s ambivalence about seeking help and staying in treatment is a fundamental aspect of the addiction itself, which makes reducing the drop-out-rate a crucial challenge to the treatment system (West 2006). Secondly, it is very difficult for any treatment system to provide instant targeted help upon the patient s decision to seek treatment. Thirdly, it is very difficult to correctly balance the provision of different services during treatment, for instance between services providing detoxification and those providing further residential treatment. Fourthly, it is difficult to maintain the treatment relationship in services where confrontation is seen as a fundamental and necessary treatment method (as e.g. in Therapeutic Communities). Finally, it is difficult to construct a treatment system that can deal with violence, continued substance abuse, or other violations of internal rules. Much has been done but continued efforts are needed in order to reduce the risks of breaches in the treatment relationships due to these causes. However, there is still a long way to go in develop- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

8 ing organizations and methodologies to reduce these risks. Our evaluations of the Substance Treatment Reform have revealed how the organizational principles inspired by the ideas from NPM have created new obstacles that hinder realizing a continuity of care as a fundamental precondition for high treatment quality. In this respect, the organizational principles implemented as part of the Substance Treatment Reform have not helped to improve treatment quality. Instead, it seems that these organizational principles reinforce the unwanted effects of the causes for breaches in the treatment service chain. There seems to be an inherent contradiction between these principles and preconditions for high treatment quality, which is also found in other areas of the healthcare system (Watts & Segal 2009). The continuity of care is often broken in each transfer of treatment and rehabilitation responsibility during treatment. The evaluation projects and subsequent work have shown that these structural obstacles to better treatment quality have not received much attention, with the focus instead being on the structural aspects of the services. New demands on economic reporting and activity reporting to authorities at all levels, new demands related to formal quality-assurance systems from regulatory authorities, and demands on implementing new clinical practice guidelines, keep service managers and providers busy fulfilling the structural aspects of their treatment organizations. Whilst these demands may be important in developing good treatment practices, they do not address the main obstacles to increasing treatment quality inherent in the fundamental structure of the service organization. Strategies for alleviating the consequences of the new treatment system It could be expected that these kinds of consequences regarding limited access to services, delayed individualization of treatment pathways and additional reasons for breaches in the continuity of care inherent in the system, could have very bad consequences for treatment outcomes. However, there are reliable indications that treatment outcomes are reasonably good in most parts of the system (Lie & Nesvåg 2006). Both the evaluation projects and other experiences indicate that managers and employees use several strategies to alleviate the worst consequences of the new treatment system. Most of these strategies are based on the direct personal relationships established by service providers through their own practice. These personal relationships are utilized in trying to develop clinical pathways with as few breaches in the continuity of care as possible. Depending on the complexity of patients problems, three alternative strategies to the normal organizing of services have been developed: 1. The first strategy is to develop effective logistics between service providers. One provider in the chain typically tries, in addition to the formal contact through referrals and discharge summaries, to contact the next provider directly. In this way they try to secure a quick assessment and evaluation of the patient s rights, and also attempt to check if the next provider has available capacity and is ready to treat the patient. This strategy is often used when a primary care provider or a specialized provider of treatment for substance abuse tries to re- 662 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

9 fer a patient to an additional service in the specialized somatic healthcare system or needs a brief intervention from another part of the healthcare system. 2. The second strategy is to develop effective coordination of simultaneous services provided by multiple organizations. Joint responsibility groups and plans have for a long time been used for this purpose. The Patients Rights Act makes it obligatory for all service providers in the primary care and specialized healthcare systems to offer patients a particular plan called the individual plan for coordinating purposes. Methods and models of care, such as case management, have also been important tools for improving service coordination. New coordinating roles have been developed, and the inclusion of a new kind of patient representative as part of patients rights has been suggested. However, it seems likely that personal relationships remain fundamental to the effective coordination of services. 3. If the patient has complex and strongly interwoven problems (typically combined substance abuse and severe psychiatric disorders), effective logistics or coordination between services are not sufficient to secure the necessary treatment. In such cases the patient must be offered what has become known as integrated treatment (Mueser et al. 2003), which is provided by a single service provider with the required competence in both problem areas. This has been a real challenge to the existing treatment system of specialized competence and services, but slowly both the traditional psychiatric services and the treatment service for substance abusers have become able to deliver more integrated treatment. The establishment of Assertive Community Treatment (ACT) teams could be seen as an extreme case of organizing integrated treatment outside or in addition to the ordinary services. This kind of strategy is important for increasing the quality of treatment for patients with complex problems, but is of no use when the goal is to overcome the problem of breaks in the continuity of care between the integrated service providers and the other parts of the treatment and rehabilitation system. All of the above three strategies may be called strategies for alleviating the negative treatment quality consequences of a system consisting of fragmented, linear transfer of responsibilities from one agency to the next. However, the fundamental problem of the treatment system is still there. One other kind of strategy that can be observed locally, and which tries in a more fundamental way to avoid this problem, is a bottom-up organizational strategy where local service managers, both in the specialized healthcare and primary care systems, develop new treatment delivery organizations that structurally cross the borders between these systems (Lie 2008ab). 1. These organizations tend to define their role in relation to other services and in relation to a description of wider clinical pathways, rather than in relation to an isolated description of their own services and methods. 2. These organizations are often financed as Dutch treats ( spleiselag ) between specialized healthcare providers and local municipalities. For this to be effec- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

10 tive the agreements must rely on trust between the financing parties, and they must not be focused on counting who pays the most and who pays for what. 3. These organizations are built on a mindset with permanent service arenas and mobile service providers. Typically the service arenas try to provide easy access to service, often defining the user s own home as service arenas, while services can be flexibly obtained from different service providing organizations. These organization principles illustrate the development of what could be called overarching communities of practice whose members are different service providers, offering different service levels. How these overarching communities of practice may develop remains to be seen, but it surely is an interesting phenomenon from the perspectives of both service organizations and from a sociological perspective. From the viewpoint of this paper, the most-interesting aspects of these organizations is how they (at least until now) may be seen as a bottom-up strategy for alleviating the bad consequences of the topdown organization of health services. By placing themselves at the border between existing services at different organizational levels, they try to fill the gaps between services and thereby also prevent breaches in the treatment and rehabilitation processes. While strategies for better logistics, coordination, or integration may be used to alleviate the consequences of the dominant service organization, the strategy of overarching communities of practice has involved the development of alternative organizations existing parallel with the dominant organization. Conclusions From the evaluations of the Substance Treatment Reform and information from other projects and experiences of the treatment system for substance abusers, we conclude that there is an inherent contradiction between the implemented organization principles, based on the ideas from NPM, and preconditions for good treatment outcomes. Increased treatment capacities have not been able to keep pace with the increased referrals for treatment. Along with more bureaucratic procedures for deciding whether a person has legal rights to treatment, this has not improved access to services and has delayed the process of developing more individualized treatment pathways. However, the contradiction between the implemented organizing principles and the recognized preconditions for a high quality of care is best demonstrated by the system of fragmented, linear transfer of treatment responsibilities. This system produces breaches in the treatment processes and continuity of care, in addition to the breaches produced by factors unrelated to the new organizing principles. The result is a high rate of dropping out of treatments, which hinders good treatment outcomes. Fortunately, service managers and providers have over the years developed different strategies for alleviating some of the bad consequences originating in the well-known reasons for patient dropout and the one created by the new top-down organizing principles. Three of these strategies better logistics, coordination, and integrated treatment are effective alleviating strategies, but they rely heavily on good personal relationships between 664 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

11 service providers and do not challenge the weaknesses of the normal service organization. However, in recent years a strategy has been used to develop new kinds of border organizations based on joint financing, new service arenas focusing on providing good access, and mobile service providers from different service organizations. These form a new overarching community of treatment and rehabilitation practices. This involves local service managers in both primary care and specialized healthcare. This alternative service organization exists in parallel with the normal organization. It remains to be seen if this kind of alternative organizations will develop and grow and, if so, what the long term consequences will be for the normal organization. In the Interaction Reform, newly adopted by the Norwegian Parliament, one could imagine that re-organizing for better cooperation between service providers and stronger continuity of care, would be an important issue. Instead the reform first and foremost concentrates on how to strengthen the primary care system, how to change the division of work tasks and obligations between the service levels, and how to reduce the overuse of expensive specialized healthcare services. It seems that innovative local service managers need to first develop alternative service organizations and then challenge the dominant organization in order to provide an effective organizational framework for ensuring high treatment quality. In the meantime it seems that top-down organizing through reforms and other kind of governmental initiatives, and bottom-up innovative organizational developments, will continue to represent two parallel forms of organizational developments in the Norwegian substance treatment system. Sverre Nesvaag, researcher Alcohol and Drug Research Western Norway, Stavanger University Hospital Norwegian Centre for Addiction Research, University of Oslo, Norway ness@sus.no Terje Lie, researcher International Research Institute of Stavanger Norway terje.lie@iris.no REFERENCES Aucoin, P. (1990): Administrative reform in public management: paradigms, principles, paradoxes and pendulums. Governance 3 (2): Christensen, T. & Lægreid, P. (eds.)(2007): Transcending new public management: the transformation of public sector reforms. Hampshire: Ashgate Hood, C. (1998): The art of the state: culture, rhetoric and public management. New York: Oxford University Press Karlsen, J.E. & Nesvaag, S. & Hansen, I. (2007): Rusbehandling i Midt-Norge. Fra bakgård til utstillingsvindu? (Substance treatment in central Norway). IRIS Report 2007 Klausen, K. (2001): New Public Management en fortolkningsramme for reformer (New Public Management as the framework for reforms). In: Busch, T. & Johnsen, E. & Klausen, K. & Vanebo, J.E. (red): (2001): Modernisering av offentlig sektor. New Public Management i praksis. Oslo: Universitetsforlaget NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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