With the increasing differentiation of organisations involved in the pursuit of public health, there is also a growing need for inter-organisational integration. Starting from the concepts of differentiation and integration, this article is attempting a theoretical reconstruction based on published research on inter-organisational integration in public health and related welfare services. Different forms of integration are defined and related to each other in a conceptual framework, which is in itself an integration of different theoretical perspectives. According to this framework, integration in the field of public health requires inter-organisational collaboration across different sectors of the society. Such intersectoral collaboration can be organised mainly in the form of multidisciplinary teams across the boundaries of different organisations and sectors. Such an organisation is fragile and volatile, however, which means that it needs a lot of management support in order to survive.

Integration and collaboration in public health—a conceptual framework

Interprofessional collaboration has become more and more necessary in health and social care, mainly because of the increasing specialization of services and the increasing professionalization of different occupational groups. Most interprofessional collaboration is at the same time also interorganizational and it is taking place within a complicated structure, where collaborative teamwork is combined with hierarchical co-ordination and control in a sort of matrix organization. Based on the literature on organization, leadership and collaboration, this paper discusses territorial behaviour among professional groups and agencies as a difficult barrier to interprofessional collaboration. In order to overcome that barrier, the concept of altruism is explored as an alternative to territoriality. Professional altruism as well as altruistic leadership is discussed as a condition and a possibility for interprofessional collaboration. The discussion is illustrated with empirical data from a case study of collaboration in vocational rehabilitation.

From territoriality to altruism in interprofessional collaboration and leadership

This article reports the results of a review of the research evidence related to joint working in the field of adult health and social care services in the UK. It explores whether recent reforms to joint working have met the objectives set by policy-makers. The review followed an established methodology: electronic databases were searched using predetermined terms, abstracts were screened against inclusion criteria, studies that met the criteria were read in full and assessed for inclusion and data were extracted systematically. The findings of the review suggest that there is some indication that recent developments, in particular the drive to greater integration of services, may have positive benefits for organisations as well as for users and carers of services. However, the evidence consistently reports a lack of understanding about the aims and objectives of integration, suggesting that more work needs to be done if the full potential of the renewed policy agenda on integration is to be realised. Additionally, while the review acknowledges that greater emphasis has been placed on evaluating the outcome of joint working, studies largely report small-scale evaluations of local initiatives and few are comparative in design and therefore differences between 'usual care' and integrated care are not assessed. This makes it difficult to draw firm conclusions about the effectiveness of UK-based integrated health and social care services.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/hsc.12057

Factors that promote and hinder joint and integrated working between health and social care services: a review of research literature

The causes and effects of marketization of public services have been analysed extensively in the literature, but there is relatively little research on how those policies impact on the development of new forms of governance, and the role of users in these new arrangements. This study reviews examples of competition, freedom of choice and personalized care in health and social services in England and Sweden, in order to examine the type of relationships emerging between the user/consumer vis-a-vis market driven providers and various agencies of the state under the marketized welfare. The article focuses on the possible roles users might assume in new hybrid arrangements between markets, collaborations and steering. A user typology: namely, that of a consumer, citizen, co-producer and responsibilized agent in various governance arrangements, is then suggested. The article concludes by arguing that pro-market policies instead of meeting the alleged needs of post-modern users for individualized public services are likely to promote a new type of highly volatile and fragile partnerships, and create a new subordinated user who has no choice but to ‘choose’ services they have little control over.

Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers in health and social care in England and Sweden.

Introduction In Denmark, the magnitude and impact of work disability on the individual worker and society has prompted the development of a new “coordinated and tailored work rehabilitation” (CTWR) approach. The aim of this study was to compare the effects of CTWR with conventional case management (CCM) on return-to-work of workers on sick leave due to musculoskeletal disorders (MSDs). Methods The study was a randomized controlled trial with economic evaluation undertaken with workers on sick leave for 4–12 weeks due to MSDs. CTWR consists of a work disability screening by an interdisciplinary team followed by the collaborative development of a RTW plan. The primary outcome variable was registered cumulative sickness absence hours during 12 months follow-up. Secondary outcomes were work status as well as pain intensity and functional disability, measured at baseline, 3 and 12 months follow-up. The economic evaluation (intervention costs, productivity loss, and health care utilization costs) was based on administrative data derived from national registries. Results For the time intervals 0–6 months, 6–12 months, and the entire follow-up period, the number of sickness absence hours was significantly lower in the CTWR group as compared to the control group. The total costs saved in CTWR participants compared to controls were estimated at US $ 1,366 per person at 6 months follow-up and US $ 10,666 per person at 12 months follow-up. Conclusions Workers on sick leave for 4–12 weeks due to MSD who underwent “CTWR” by an interdisciplinary team had fewer sickness absence hours than controls. The economic evaluation showed that—in terms of productivity loss—CTWR seems to be cost saving for the society.

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Coordinated and Tailored Work Rehabilitation: A Randomized Controlled Trial with Economic Evaluation Undertaken with Workers on Sick Leave Due to Musculoskeletal Disorders

The lack of collaboration between health, social and other welfare services is believed to impair efficiency and reduce effectiveness in addressing the complex problems of patients. Differences in funding streams, political accountabilities, organisational structures and professional cultures are all alleged to contribute to barriers between services. Drawing on their respective evaluations, this paper describes experiments in England and Sweden that use pooled budgets between services to improve interagency and interprofessional collaboration and presents evidence on their impact. Despite differences in the funding and organisation of health and welfare services in each country, some similar conclusions are reached. Among senior managers and politicians, budget pooling broadened their awareness of interdependencies with other agencies and professionals in promoting patients’ welfare. However, these broadened perspectives were not immediately shared by professionals working at the front line, with whom patients had immediate contact. Moreover, neither experiment yielded unequivocal evidence of improved cost-effectiveness or of the benefits of budget pooling on the outcomes for service users. These experiments also raise questions about the equity and accountability of welfare services because in both countries only a limited range of services has been integrated under the umbrella of the pooled budgets.

Using pooled budgets to integrate health and welfare services: a comparison of experiments in England and Sweden.

Co-financing as a means to improve collaboration between primary health care, social insurance and social service in Sweden. A qualitative study of collaboration experiences among rehabilitation partners

Previous research shows there can be good results from co-financing between welfare sectors on the perceived quality of interprofessional collaboration. However, little is known about the impact on patient outcome of such schemes. This study aimed to assess whether co-financed teams with personnel from primary care, social insurance and social services have any effect on patients' health status. A comparative study of patients attending health care centres with and without a co-financed collaboration model was carried out. Although research has shown positive results from co-financed collaboration on staff and organization, we could not find that this new interdisciplinary team structure gave a better patient health outcome than conventional care.

Interdisciplinary collaboration between primary care, social insurance and social services in the rehabilitation of people with musculoskeletal disorder: effects on self-rated health and physical performance.

In this paper, we present an ongoing research project aimed to determine the impact of co-financing on collaboration around patients with musculoskeletal disorders. A trial legislation that allows the social insurance, social services and health care services to unite in co-financing under joint political steering has been tested in different areas in Sweden. In a series of studies, we compare collaboration processes and health outcome for patients with musculoskeletal disorders between health centres with co-financing projects and control health centres without co-financing projects. In this paper the studies are described and some preliminary results are discussed.

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Evaluation of the effect of co-financing on collaboration between health care, social services and social insurance in Sweden

Background: In 1994 Sweden introduced a trial legislation allowing co-financing between authorities. The legislation aimed to stimulate new ways of collaboration between health and social care providers. One of the specific objectives was to make management of patients with conditions requiring multidisciplinary care more efficient and reduce costs. This study aims to assess if there were any differences in management of patients with musculoskeletal disorders at health centres applying the trial legislation compared to health centre with conventional care with regards to health services utilisation, health care interventions received, and costs. Method: A comparative prospective study was conducted. Consecutive patients aged 16-64 with musculoskeletal disorders attending the health care centres with (n = 107) and without (n =3 1) co-financing model were interviewed at inclusion and after 6 and 12 months. Number of contacts with professionals and interventions received were registered. Results: Patients at the intervention centres had significantly more contact with physiotherapists and physicians than the controls. Contacts with other services such as social insurance office, social services office or hospitals did not differ significantly between the groups. Costs were higher for the interventions centres. Conclusion: The findings do not suggest that the trial legislation reduced health care utilisation or costs for patients with musculoskeletal disorders.

Effects of a co-financed interdisciplinary collaboration model in primary health care on service utilisation among patients with musculoskeletal disorders.

Eva-Lisa Hultberg

Papers

Using pooled budgets to integrate health and welfare services: a comparison of experiments in England and Sweden.

Co-financing as a means to improve collaboration between primary health care, social insurance and social service in Sweden. A qualitative study of collaboration experiences among rehabilitation partners

Interdisciplinary collaboration between primary care, social insurance and social services in the rehabilitation of people with musculoskeletal disorder: effects on self-rated health and physical performance.

Evaluation of the effect of co-financing on collaboration between health care, social services and social insurance in Sweden

Effects of a co-financed interdisciplinary collaboration model in primary health care on service utilisation among patients with musculoskeletal disorders.