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Institutionally Shaped Response to the Introduction of National Guidelines: Case Studies in the Swedish Regional Health Policy Arena
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
2018 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians.

As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers.

The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting.

Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena.

To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , p. 48
Series
Linköping Studies in Health Sciences. Thesis, ISSN 1100-6013 ; 134
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-152648DOI: 10.3384/lic.diva-152648ISBN: 9789176852255 (print)OAI: oai:DiVA.org:liu-152648DiVA, id: diva2:1262074
Presentation
2018-11-09, Salix, hus 511-001, ingång 78/76, plan 11, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-11-09 Created: 2018-11-09 Last updated: 2018-11-14Bibliographically approved
List of papers
1. Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
Open this publication in new window or tab >>Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
2015 (English)In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 49, no 7, p. 911-927Article in journal (Refereed) Published
Abstract [en]

In the last ten years, the concept of management by knowledge has gained growing attention inSwedish healthcare, as well as internationally. In Sweden, the most prominent example ofmanagement by knowledge is the National Guidelines, aimed at influencing both clinical andpolitical decision-making in the health sector. The objective of this article is to explore the response among four Swedish county councils to the National Guidelines for Cardiac Care (NGCC). Empirical material was collected through 155 expert interviews with the target groups of the NGCC, politicians, administrators and clinical managers. Analysis of the responses to this multifaceted policy instrument was addressed by drawing on implementation theory (Matland 1995) and institutional theory (Oliver 1991). The NGCC are primarily based on the voluntary diffusion of norms. The county councils are a long way from having adapted all the means suggested by the National Board of Health and Welfare (NBHW): explicit prioritization, healthcare programmes and dialogue between the various actor groups. The high degree of ambiguity in the content of the NGCC, the inherent conflict and the multiplicity and uncertainty in the context of the county councils, have often resulted in avoidance and compromise. The strategic responses we observe can be viewed as an attempt to balance multiple constituents and achieve the various internal organizational goals. The ambiguity and conflict inherent in the policy of the NGCC influence the strategic responses made by the organization. The question remains how far management by knowledge can be applied in a political context.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keywords
Policy implementation; Institutional pressure; Strategic responses; Swedish National Guidelines
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-113304 (URN)10.1111/spol.12102 (DOI)000368267400006 ()
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2018-11-09Bibliographically approved
2. The dilemma of knowledge use in political decision-making: National Guidelines in a Swedish priority-setting context
Open this publication in new window or tab >>The dilemma of knowledge use in political decision-making: National Guidelines in a Swedish priority-setting context
2018 (English)In: Health Economics, Policy and Law, ISSN 1744-1331, E-ISSN 1744-134XArticle in journal (Refereed) Epub ahead of print
Abstract [en]

There is a growing recognition of the importance of evidence to support allocative policy decisions in health care. This study is based on interviews with politicians in four regional health authorities in Sweden. Drawing on theories of strategic use of knowledge, the article analyses how politicians perceive and make use of expert knowledge represented by the National Guidelines, embracing both a scientific and a political rationale. As health care is an organisation with a dual basis for legitimacy – at the same time a political and an action organisation – it affects knowledge use. We investigate how the context of health care priority setting influences the conditions for knowledge use among regional politicians. Our findings illustrate the dilemma of political decision-makers and how they prefer to use expert knowledge. The politicians use this policy instrument in a legitimising fashion, as it will fit into the current political debate on more equal care. As an instrument for resource allocation the politicians noted that ‘facts’ per se could not provide them with a sufficient basis for legitimising their governing of health care. The dualistic organisational context makes knowledge important as a political weapon in negotiations with the medical profession.

Place, publisher, year, edition, pages
Cambridge University Press, 2018
Keywords
Expert knowledge, Policy making, Health policy, knowledge utilization
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-149919 (URN)10.1017/S1744133118000233 (DOI)29986792 (PubMedID)2-s2.0-85049867288 (Scopus ID)
Available from: 2018-08-06 Created: 2018-08-06 Last updated: 2018-11-09Bibliographically approved

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