Governing Integrated Health and Social Care: An Analysis of Experiences in Three European Countries

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.


(7) Appendix
Table A.1 Principles of health and social care systems in Italy, the Netherlands and Scotland

Country
Overall governance of health and social care Provision and financing of health care and social care

Italy
Responsibility for health care governance is shared between the national government and the 20 regional governments.National government provides the legislative framework for health care; it sets the basic principles and objectives within which the National Health Service (SSN) operates, and monitoring the SSN.In collaboration with the regions, defines the national benefits package (Livelli Essenziali di Assistenza, LEA).
The national and regional levels of governance of the health care system are strategically aligned in Health Pacts, co-produced by national government and the regions every 3 years.
The regions are responsible for financing, organising and delivering health care, through local health authorities (ASLs).Regions are accountable to the electorate, and the national government for complying with the LEA standards.Where standards are not met or where regions, hospitals and ASLs financially underperform, they are sanctioned and can be subject to national government recovery plans.
ASLs are directly accountable to their regions.
Social care and social welfare services are overseen by municipalities (local authorities).Members of the municipality are elected.
Health care is provided through the National Health Service (SSN), with office-based GPs and paediatricians acting as gatekeepers to specialist care.The SSN is funded through national and regional taxation.Resource allocation to the regions is negotiated annually based on a capitation formula.
The SSN is regionally based.Within regions, health care delivery rests with geographically defined, local health authorities (ASL), which organise primary, secondary and tertiary health care by contracting with public and private hospitals and overseeing office-based GPs.The number of ASLs has declined, from 146 in 2010 to 99 in 2021, reflecting a broader trend towards centralisation of authorities at the regional level.
Social care: Municipalities have responsibility for supporting non-self-sufficient individuals on a means-tested basis, covering home help (housework and personal care) and nursing homes.
Health services that are delivered in nursing homes and in the community setting more broadly, such as home nursing services, home hospitalisation and programmed home care assistance by GPs, are funded by the SSN and provided by ASLs.In some Italian regions, municipalities have also delegated part of their social care duties to ASLs.

Netherlands
The health care system is based on regulated competition.Health care system governance is shared between the national government and the corporatist (self-governing) health sector.
The role of national government is largely restricted to overseeing and defining the rules for the health care system, including quality, accessibility, and affordability of health care.The national government defines the essential package of care that all health insurers must provide.
The health insurance market is overseen by the Dutch Health Care Authority (Nza), is responsible for compliance of insurers with the Health Insurance Act (Zvw) and sets payment rates.
Health insurers are regulated as commercial enterprises.
Governance of social care and preventive care that falls under the Long-term care Act (Wlz), are decentralised to local government (municipalities).2022: contracts with 4 hospitals, 2 mental health care organisations and 1 pharmacy chain.

Regional
Serves a population of ~170,000.
All GPs in region are affiliated with ZIO ≈ 84 GPs working in 54 practices.

Regional
Serves a population of ~150,000.

Regional
Serves a population of ~120,000.

Regional
Serves a population of ~320,000.

Accountability
AZ is accountable to regional government, and its functions are specified by regional legislation.
As a public body all decisions must be made publicly available; published on website.
Public and private secondary care providers accountable to AZ.
ATS are accountable to the regional government.
Managing bodies are accountable to ATS for providing services as set out in care plans (PAI), and to patients.

Monitoring & reporting Evaluation
AZ legally required to establish an independent evaluation body to monitor its performances.
From 2020 required to publish a yearly report.

Table A 2
Key characteristics of the ten study sites in Italy, the Netherlands and Scotland

AZ), Veneto Chronic care (Presa in carico del paziente cronico, PiC), Lombardy Houses of health (Casa della salute, CdS), Emilia-Romagna
Meeting minutes, audits, papers, and financial accounts published on website.Annual performance report, documenting progress on nine national health and social care wellbeing outcomes (East Ayrshire additionally reports on national outcomes for children and justice (3 indicators in each) published on website.Independently contracted services audited by the Care Inspectorate.Annual audits of IJB & Highland Council published by Audit Scotland.