The interest in governance in health care was aroused by the author of the dissertation, Margareta Karlsson, in her job as a controller in the Norrbotten Region.
I noticed how the management of the various service functions within health care, such as material supply, cleaning and food supply, began to be perceived as something separate from the care of the patient, as activities that could be managed based on business economics principles.
New Public Management
During the 1980s and 90s, so-called New Public Management began to be introduced in healthcare, including the introduction of internal markets, statutory requirements for financial management between legal organizations and a decentralized responsibility for finances within the organization. At the same time, a market-based discourse was developed in speech and writing that led to a we-and-they-thinking between the service function and health care, according to Margareta Karlsson.
The dissertation explores collaboration between a service function and health care activities, collaboration between region and municipalities in a supply process, knowledge exchange in an improvement work and how a market-based concept as an "internal customer" can affect collaboration in a health care process. The empirical material consists of, among other things, interviews and analysis of various governing documents.
Trust and reciprocity
The dissertation's interview studies show examples of how governance in health care has been inspired by governing principles from the private business sector and an increased belief in governance through legislation, regulations and standards. At the same time, the studies show that the desired effects of increased value for the patient can be achieved by striving for sustainable organizational collaboration where all actors strive for the same goal and where trust and reciprocity characterize the relationships.
Contrary to what was intended, according to the dissertation, governing principles from New Public Management can be both mutually inconsistent and have negative consequences. The introduction of an internal market and a market-based discourse can impair trust, and thus the ability to collaborate, between organizations. Another of the dissertation's conclusions is that requirements for cost control can counteract the pursuit of system-wide cost-effectiveness and target efficiency.
When the boundaries between the organizations are emphasized, the seamless care chain that is sought is counteracted. To increase trust and reciprocity, organizations must share information and knowledge and work together to improve the process. This was evident in the collaboration around aids for the patient, such as a wheelchair. There was a common view of all decision-making levels, from the political level downwards. It was clear to all actors that the patient's needs must guide all activities.