Setting goals and targets for performance standards within the Swedish health care system

The development of any health care system towards setting goals and targets and intended outcomes--with national guidelines, a legislative framework, limited resources, consumer influence and competitive forces--makes great demands on the control mechanisms required. The Swedish health care system has no tradition of goal formulation of this type. Hence, the purpose of this article is to clarify the goal-setting process of performance standards, and to examine whether goal setting is a relevant method within the organization of a Swedish county council. Goal setting can be seen partly as a control method and partly as an administrative process. The approach used is a combination of qualitative and quantitative methods. Data have been collected from interviews, observations, notes taken in the field and available performance statistics. The analysis shows that working towards a goal is made easier through a common and simple concept. It 'stands and falls' with the management of the work and its manager. Good communications and information are important prerequisites if goal formulation, through dialogue, is to succeed. This process takes time and can be described as an iterative process, in which a common behaviour pattern develops a 'we-feeling' which spreads among the staff. It is important that the goal is relevant and directly related to the basic objects of the work. It is also crucial that the goal is realistic and reflects a priority. Goal formulation relating to performance standards can be a contributing factor to staff's experience of job satisfaction through increased engagement and motivation, and to the satisfaction of patients/relatives with the care given. It is difficult to formulate performance standards; there are many problems and obstacles. If goal formulation as a control method within the health care system in Sweden is to work, clearer manifestations of political will are necessary and also better measuring methods in order to guage achievement.

New Zealand's health providers in an emerging market

Services have almost completely replaced hospitals as the organisational units in the reformed New Zealand health care system. Within the secondary service provider sector service management, the decentralisation of general management to budget-holding clinical groupings has been an important factor in achieving a population focus, cost containment, accountability and integration. It is being further developed within the 23 newly formed Crown health enterprises (CHEs), the main providers of secondary, hospital and related services. The CHEs are evolving roles beyond a narrow definition of 'providers', taking initiatives to collaborate with other providers, or rejecting those elements of competition that might interfere with effective local co-ordination of services. Service management is also being extended to the demand-driven, fee-for-service primary care sector, where inflation-adjusted expenditure over the last decade has grown at more than 6%, compared with zero growth in the capitation-financed secondary sector. This is being achieved in both general practice and community budget-holder groupings through what might be called managed primary health care. The current health reform process has also created four regional health authorities (RHAs), responsible, within capped and capitated budgets, for the fully integrated purchasing of services from both primary and secondary providers. The success of these innovative arrangements, which could be of international significance, will depend upon the quality of the developing relationships between providers and their purchasing RHAs.

Strategic information systems

Successful transformation to a regional health care delivery system, rather than independent group practices and hospitals, will depend on the strategic use of information technology. Frank T. Sample, president and CEO of Phamis Inc., writes that information systems will be essential for achieving business and care objectives.

Contracts and supply assurance in the UK health care market

We present a formal model of the relationship between a health care purchaser and a provider drawing on the recent experience of explicit contracting in the UK health sector. Specifically we model the contractual relationships emerging between District Health Authorities, who are presently the dominant health care purchasers, and the providers of hospital care. The comparative static analysis implies that the transaction cost of using non-local hospitals, the expected patient demand, the extent of excess capacity in local hospitals, and the proportion of that excess capacity expected to be lost to competitive purchasers, are all important determinants of the choice of contract.

Core services and priority-setting: the New Zealand experience

Like people in other countries, New Zealanders have been struggling with the issue of how to decide which health services should be delivered and to whom. The government has established a Core Services Committee to advise on core services, that is, those health care and disability support services to be made available on affordable terms and without unreasonable waiting time. Such a core has a similar role to a standard package of benefits within a managed competition framework. Services not in the core would be left to individuals' own responsibility. Specific objectives for a core are to promote accountability of purchasers, to make explicit the services that are core and those that are not, to promote an efficient and equitable allocation of resources, to limit government expenditure on health care and to involve the public in decision-making. A number of different options for defining a core are identified, and the work undertaken so far is discussed. The original concept of a core has not been implemented in New Zealand. The Core Services Committee has established broad priorities and facilitated a series of consensus development conferences to provide advice on the effectiveness of services. Some of the committee's recommendations have been incorporated into policy guidelines, which set out what the government expects of purchasers. These guidelines include priority areas for health gains, service obligations and principles for purchasing. Service obligations are not sufficiently detailed to meet the specific objectives of a core and do not meet equity objectives, as they allow in effect each of the four purchasers to develop their own core of services. The key issue for the government now is to decide whether to allow RHAs flexibility in determining their own priorities or whether a national approach to efficiency and equity is to be preferred.

Sweeping changes for Welsh Health Authorities

Despite the fact that Welsh Secretary John Redwood has stated he would like to see Welsh health authorities (HAs) administration cut by around 50% he has provided no indication as to whether or not his local government reforms will alter the HA's geographical or structural basis. This may mean that not only is there the possibility of moves towards 'commissioning authorities' and increases in the number of HAs and FHSAs merging, in addition Wales will have to contend with the unknown effect of local authority boundary changes. This is a concept which England and Scotland will also have to deal with. Russell Deacon and Tracey Deacon explore.

Scattered-site crisis beds: an alternative to hospitalization for children and adolescents

This paper describes the rationale, development, and implementation of a countywide scattered-site crisis bed program for seriously emotional disturbed youngsters. The program was developed by an interagency coalition consisting of representatives of the county's mental health, social service, and juvenile justice systems and was implemented with no new funding using available beds in facilities administered by the participating agencies. Referrals are screened by an interagency crisis consultation team responsible for the program's operation. A computerized registry significantly reduces the amount of time needed to make placements and helps agencies meet the goal of placing youngsters on the day of referral. Evaluation of the first 100 placements indicated that the program is a cost-effective alternative to more restrictive, longer-term placements and has resulted in positive clinical outcomes.