Zorgen voor zorgketens: Integratie en fragmentatie in de ontwikkeling van zorgketens

For years, health care organisations have invested in the differentiation and specialisation of their services. This has led to a supply-oriented approach, fragmentation, problems in the coherence, control and efficiency of health care delivery. One strategy to eliminate these problems is the development of Integrated Delivery Systems (IDS). An IDS is a form of institutionalised partnership between institutions and health care professionals, aimed at facilitating cooperation at the level of management, support services and primary processes in order to achieve greater control, efficiency and an integrated care package for categories of clients. Developing IDSs is a recognised strategy, but also a complex one. This study seeks to shed light on the complexity, centring on the question “How do IDSs develop?” An aspect-centred approach was used to establish what IDS structures have been developed, what the interests, social relationships and cultures of actors are, how these change, and how they influence the development of structures. Quantitative research was used to collect data on mergers. Three case studies looked at the way in which developments occur at the level of management, support services and primary processes. Two integrated pathways (elderly and stroke) were selected to obtain insights into developments at primary process level. Chapters 2, 3 and 4 describe the theoretical and methodological choices. Chapter 5 examines the motives for creating IDSs and the merger processes underlying their creation. Chapters 6 and 7 look at structures and structuring processes. Chapters 8, 9 and 10 examine the impact of interests, social relationships and cultures. Chapter 11 concludes that interaction between structures, interests, social relationships and cultures causes IDS formation to display four processes of integration and fragmentation: processes of structural, social and cultural integration and fragmentation and processes of integration and fragmentation of objectives, interests, power and resources. Actors start to prioritise the interests of an IDS and develop new structures, cultures and social relationships to ensure that its objectives are achieved, but at the same time never lose sight of their own interests, social relationships and cultural traditions. As for the structures it is concluded that there is no blueprint for IDSs. There are four typical approaches as regards configuration: they can be control oriented, system oriented, institution oriented and market oriented. The configurations vary in the extent to which they are directed to achieving control and responsiveness, and the extent to which interests, positions and cultural traditions are preserved or abandoned. Each structure has its own advantages and disadvantages. It is recommended that the results of various IDS configurations, development strategies and the added value of such systems compared to others be investigated. This will help to ensure that the correct paths are taken in the following stages of IDS formation.

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