Achieving horizontal and vertical integration in local services – creating sustainable mechanisms?

Abstract

BackgroundThe coordination challenges for persons with concurrent drug dependence and mental health disorders (dual diagnosis) are constantly put to test in Norway as well as in other western countries. A key point of The Coordination Reform of 2011 was a transfer of responsibility from specialised hospitals to municipalities as self-governing authorities. Municipal organisation of the services is diverse, including the establishments of units for mental health services, units for drug abuse treatment (or a combination of these), rehabilitation, community care, nursing homes and social welfare offices. Some municipalities have established new units for FACT (Flexible Assertive Community Treatment teams) in cooperation with units at the hospital.In 2015, a risk assessment carried out by Office of the Auditor General of Norway found that the services in the municipalities has not been strengthened in line with the reduction of specialist health services; the municipalities have slightly increased their capacity and expertise after the introduction of the reform. Further, a countrywide supervision in 2017- 2018 held by the Board of Health Supervision found breaches of legislation and inadequacies in the services in two-thirds in all municipalities. These were related to the allocation of responsibility both within the services and between different services.MethodsThe study draws on an ongoing research in three municipalities in Norway. We seek an understanding of actors’ experiences of organisational and professional integration. We conducted interviews with service providers (professionals and managements) and service users (persons with dual diagnosis). We also studied relevant state-policy documents, reports from the Norwegian Board of Health Supervision and municipal reports to the government on how services are planned and structured. In the analysis, we draw on organisational theory, especially when it comes to structural and cultural dimensions. We found The Rainbow Model of Integrated Care (Valentijn et al., 2013) to be a fruitful conceptual framework in order to place the function of primary care within the dimension of integrated care and welfare services. Discussion The paper discuss how increased expectations of the role of local services are met andthe municipalities’ scope of achieving horizontal and vertical integration.Results and Lessons learnedBy exploring how the services are organised we illuminated mechanisms of horizontal and vertical integration within each municipality with special attention to why and how the services are organised in models considered to be sequential, parallel or integrated. Further results will be presented at the conference.Limitations and suggestions for future researchThis is an in-depth study, using a combination of descriptive and explorative design; consequently, it is not possible to derive generalization. However, the results can contribute to a better understanding of the organisational and professional complexity of integrated services.