From policy to practice : exploring the implementation of a national policy for improving health and social care

Sammanfattning: Introduction: Worldwide, health and social care systems struggle to develop processes that deliver coordinated, high quality care efficiently and at acceptable cost. For various reasons, many problems related to health and social care are extremely complex, including the fact that they involve many actors from different organizational levels. Such problems are sometimes described as “wicked” because of their complexity and the difficulties encountered when trying to solve them. One such problem is the increased demand on health and social care systems resulting from the ageing of populations. Given that health and social care systems are complex and adaptive, it is extremely challenging to make system-wide improvements. Large-scale change initiatives, such as comprehensive policies, have been proposed to address “wicked problems” in health and social care systems. However, such initiatives are difficult to implement because they require coordinated efforts over a long period of time. In recent years, Sweden has introduced several non-coercive, comprehensive policies aimed at managing fundamental concerns in health and social care. This thesis focuses on one such policy – the ”Agreement on Coordinated Care for the Most Ill Elderly People”. This policy derived from an agreement between the Swedish national government and the Swedish Association of Local Authorities and Regions (SALAR). The policy was implemented with national support in the years 2010 to 2014. Its aim was to help prepare the health and social care system to meet the demand for coordinated care for the increasing number of elderly people in Sweden. Aim: This thesis explores the implementation of a comprehensive policy that addresses a “wicked problem” in health and social care. Methods: This thesis takes a longitudinal case study approach. The four studies of the thesis focus on various actors’ perspectives on, and opinions of, the policy. The actors work with health and social care on national, regional, and local levels. Theoretical approaches from different fields of research inform the research. Qualitative data were collected using individual interviews and focus groups, observations, and documents. Quantitative data were collected from national quality registries. Qualitative content analysis and descriptive statistics were used to analyse the data. Study I is a holistic multiple-case study that compares the policy process of two national health policies aimed at improving care and preventing disease. The study takes a policymaker perspective. A conceptual model of the policy process, based on two existing frameworks, is used to identify and analyse similarities and differences between the two policies. Study II is a holistic, single-case study that examines the activities and strategies the program management team at SALAR used to coordinate the implementation of the policy on a national basis. Study III is an embedded single-case study that investigates key county-level actors’ perspectives on the implementation of the policy. The actors in the study are employed in three Swedish counties. Study IV is an embedded single-case study that investigates local actors’ perspectives on the development of quality improvement work in elderly care with the support of the national policy. The actors in the study are employed in three Swedish municipalities. Findings: Study I shows that the current policy, in comparison with another policy with similar scope and aim, reveals more pragmatic view of evidence, a stronger emphasis on contextualization of evidence, more active and adaptive national-level implementation support, and an adaptive formulation of the policy involving annual renegotiations based on progress evaluations. Study II shows that the national implementation support was dynamic and emergent, and that the policy and the implementation process matched known drivers of effective, large-scale change. Study III shows that local conditions have a great influence on policy perception and that a significant variation exists among the counties. However, the results also show that external pressures (e.g., performance bonuses) strongly influence the counties’ decision to participate in the policy implementation. Study IV shows that local conditions largely shape the municipal actors’ perception of the policy. The county-level improvement coaches, who were very important for the policy implementation at the municipal level, were also important in facilitating learning and networking among the municipalities. The results also show that leadership engagement and the municipalities’ ability to actively seek and use relevant external information are important factors in policy implementation. Conclusions: The policy was an ambitious attempt to implement a large-scale improvement initiative addressing a wicked problem in a complex adaptive system using a whole-systems approach. The findings suggest that when implementing such policies, policymakers should focus on involving relevant stakeholders and allow for the problem definition and the solutions to develop simultaneously because they are interdependent. Other issues to consider involve how the policy is communicated from national level and how a balance between steering and self-governance can be achieved. In addition, the results imply that networked support functions at the regional level can enhance the effect of national efforts to spread and implement comprehensive policies, and can also support the local capacity for knowledge development and quality improvement.