Key to the understanding of policy success or failure. Why do policies work sometimes but sometimes not.

The concepts ESSENTIAL in order to understand policy outcomes.

The main policy principles and policy goals the new goverment is committed to are the following: To sustain a world class quality health care services via state-of-the-art governance of the system in which the taxpayers, the ultimate funders of the system, and the users will be ensured equal access (geographically and economically), equity, quality, safety, cost-efficiency and effectiveness of care. The government is committed to deliver a policy of increased patient choice of services through increased diversity of service provision, and to implement a system in which the money follow the patient. A variety of payment systems will be in use, developed and implemented over the coming months and years. High standard of clinical excellence and quality of care is being ensured by the National Directorate of Health which is a public inspection agency.

The main policy principles and policy goals the new goverment is committed to are the following: To sustain a world class quality health care services via state-of-the-art governance of the system in which the taxpayers, the ultimate funders of the system, and the users will be ensured equal access (geographically and economically), equity, quality, safety, cost-efficiency and effectiveness of care. The government is committed to deliver a policy of increased patient choice of services through increased diversity of service provision, and to implement a system in which the money follow the patient. A variety of payment systems will be in use, developed and implemented over the coming months and years. High standard of clinical excellence and quality of care is being ensured by the National Directorate of Health which is a public inspection agency.

PC: Rule-based – command and control; Good in a emergency situation – but very littke space for individual enterprise or innovative exercise. PD: Still rule-based; However, a bit more space for individual enterprise or innovative exercise. Results rely on good co-ordination and team-work, but “silos” are common. PrD: Rules of the market; Individual patient choice – high innovation – high pressure on the provider-side. But the system becomes patchy and continuity and co-ordination is missing. PrC: Rules of business – business secrets Innovation, but monopoly of information – rising cost and “take-it or leave-it”.

EPR = Electronic Patient Record ICE = Integrated Collaborative Environment for Health Care

How to manage the process of expanding the range of providers of health care services

The argument is: The Policy Outcome is as much determined by the Policy Process as the Policy Idea

Key words: Health Care Systems Policy Context Transferability and Policy learning Regulation Transparency

Health care systems Taxed financed systems, Pooling Risk and Resources across a population: Young - Old Healthy - Sick Rich - Poor Market failure - not just because of imperfect information, but also...... Dynamic – unintended consequences of political interventions – and people inside the system respond to financial incentives, Government failure – when government fails to intervene, A well functioning health care system - National Security.

MINISTER OF HEALTH The Ministry of Health USERS DEMAND for SERVICES TAXPAYERS & VOTERS PROVIDERS SUPPLY of SERVICES User charges Provision of services General national taxation Funds NATIONAL COMMISSIONING AGENCY PARLIAMENT Decides the Government health care budget by passing an annual Bill Payment systems

MINISTER OF HEALTH The Ministry of Health USERS DEMAND for SERVICES TAXPAYERS & VOTERS PROVIDERS SUPPLY of SERVICES User charges Provision of services General national taxation Funds NATIONAL COMMISSIONING AGENCY PARLIAMENT Decides the Government health care budget by passing an annual Bill Payment systems Access Equity Safety Quality Costs Effectiveness

The Limits of Cross-country Transferability Differences England (1991;1997) General Managers Low capacity (Medical Doctors) Low quality Years of under-funding NHS Monolith provider Plurality of purchasers Increase Expenditure Choice and Diversity via extra capacity imported from abroad Iceland (2007) Nurses in management Over-capacity (Medical Doctors) High quality Costly Mixed economy of care One purchaser Sustainability of funding Choice via collective choice and money following the patient

9. mars 2009 8 There is never the only one right way....

Regulation

The policy instrument: A new legislation that states clearly: Who are insured in Iceland, What type of services they are entitled to, Who ensures that services are being provided, How these services are agreed upon, and How, on the behalf of the Minister, access, equity, quality, safety and prices are negotiated and monitored.

Strategic instruments which consist of: One national strategic commissioning agency, Transparency via cost analysis and mutual agreements / contracts, Governing “a market” – selective contracting, Patient choice facilitated via collective choice, Quality standards and Clinical guidelines, Information technology - EPR and ICE, Inspection and Monitoring,