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Background: Demographic changes in all industrialized countries have led to a keen interest in extending working lives for older workers. To achieve this goal, it is essential to understand the patterns of retirement and specifically what characterizes individuals who continue to work beyond retirement age. Thus, the aim of this paper was to contribute to the international body of empirical knowledge about individuals who continue in the workforce after retirement age. We present evidence from Denmark and examine what characterizes individuals who continue in the workforce after retirement age and investigate the likelihood of continued work after retirement age while controlling for a set of socio-economic and lifestyle factors. Methods: The study population consisted of 5,474 respondents to the Copenhagen Aging and Midlife Biobank (CAMB) 2021 survey, divided into two groups. The first group included subjects (n = 1,293) who stayed longer in the workforce even though they had the possibility to retire. The second group consisted of subjects who had retired full-time at the time of the survey (n = 4,181). Survey data was linked to register data to provide a broader dataset. In order to investigate the heterogeneity between the two groups in terms of important socio-economic, work-related and health-related variables, t-test, Mann-Whitney U (Wilcoxon Rank) test, and chi-square tests were employed. Further, to examine the probability of an individual working after retirement age a logit model with step-wise inclusion was utilized. Results: Overall, individuals who continue to work even though they could retire tend to be wealthier, healthier, and males compared to individuals who are retired full-time. Further, there are more older workers who have partners and are co-habitants than retirees. The likelihood of continuing in the workforce past retirement age is affected by several work-related factors as well as life-style factors. The likelihood of working past retirement age decreases by years spent in the workforce (marginal effect of -0.003), if you have a partner (-0.080) and if your partner is outside of the workforce (marginal effect of -0.106). The likelihood increases by health (marginal effect of -0.044 of moving from excellent/very good health to good health or to fair/poor health, physical working capability (marginal effect of -0.083 of moving from no/some problems to severe problems or cannot work at all) and income (marginal effect of 0.083 from moving from the lowest income-quantile to higher quantiles). Conclusion: These results are in line with the previous literature and suggest the importance of designing retirement policies that tailor the transition toward retirement according to specific characteristics of both the individual and the segment of occupation. [ABSTRACT FROM AUTHOR]

Background: Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality. Methods: A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined. Results: Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65–74 age group (22%) and the highest percentage mortality in all age groups (27–62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67–1.97) and showed interactions with both age and fall history. Conclusion: In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall. [ABSTRACT FROM AUTHOR]

Health systems internationally face demands to deliver care that is better coordinated and integrated. The health system financing and delivery model may go some, but not all the way in explaining health system fragmentation. In this paper, we consider the road to care integration in two countries with Beveridge style health systems, England and Denmark, that are both ranked as highly Integrated systems in Toth's health integration index. We use the SELFIE framework to compare the policies and reforms that have affected care integration over the past 30 years in the two countries. The countries both started their reform path by reforming to introduce choice and competition, but did so in different ways that set them on different pathways. Nevertheless, after two decades, the countries ended the period with largely similar structures that emphasised the creation of a cross-sectoral governance structure. In the relatively centralised England, by introducing decentralised Integrated Care Systems, and in the relatively decentralised Denmark with a centralising element in the form of new Health Clusters. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic necessitated wide-ranging adaptations to the organisation of health systems, and primary care is no exception. This article aims to collate insights on the role of primary care during the pandemic. The gained knowledge helps to increase pandemic preparedness and resilience. Methods: The role of primary care during the pandemic in five European countries (Austria, Denmark, France, Hungary, Italy) was investigated using a qualitative approach, namely case study, based on document analysis and semi-structured interviews. In total, 31 interviews were conducted with primary care providers between June and August 2022. The five country case studies were subjected to an overarching analysis focusing on successful strategies as well as gaps and failures regarding pandemic management in primary care. Results: Primary care providers identified disruptions to service delivery as a major challenge emerging from the pandemic which led to a widespread adoption of telehealth. Despite the rapid increase in telehealth usage and efforts of primary care providers to organise face-to-face care delivery in a safe way, some patient groups were particularly affected by disruptions in service delivery. Moreover, primary care providers perceived a substantial propagation of misinformation about COVID-19 and vaccines among the population, which also threatened patient-physician relationships. At the same time, primary care providers faced an increased workload, had to work with insufficient personal protective equipment and were provided incongruous guidelines from public authorities. There was a consensus among primary care providers that they were mostly sidelined by public health policy in the context of pandemic management. Primary care providers tackled these problems through a diverse set of measures including home visits, implementing infection control measures, refurbishing used masks, holding internal meetings and relying on their own experiences as well as information shared by colleagues. Conclusion: Primary care providers were neither well prepared nor the focus of initial policy making. However, they implemented creative solutions to the problems they faced and applying the learnings from the pandemic could help in increasing the resilience of primary care. Attributes of an integrated health system with a strong primary care component proved beneficial in addressing immediate effects of the pandemic. [ABSTRACT FROM AUTHOR]

Background: The initial responses to the COVID-19 pandemic in Denmark and Sweden differed markedly. Balancing disparate concerns was crucial to generate trust in the COVID-19 restrictions. The aim was to investigate the extent to which there was trust in the handling of the pandemic by the Danish and Swedish governments and public health authorities in each country. A further aim was also to investigate the characteristics of those in Denmark and Sweden who expressed the lowest degree of trust. Methods: Cross-sectional surveys were conducted in 2021, using web panels that are nationally representative of the socio-demographic characteristics. The population consisted of 2619 individuals from Denmark and 2633 from Sweden, representative of the age, sex and region of residence of the populations aged ≥ 18 years. Trust in government and health authorities was captured in two separate trust questions on a 5-point Likert scale and dichotomized into low trusters and non-low trusters for analysis. Results: Approximately, 61% of the Danish respondents expressed moderately large or very large trust in the government's handling of the pandemic. The corresponding proportion for Sweden was 42%. The proportion of low trusters was 11% in Denmark and 34% in Sweden (p < 0.001). Moderately large or very large trust in the public health authority's handling was expressed by 83% of the Danish respondents and 74% of the Swedish respondents. The proportion of low trusters was 5% in Denmark and 17% in Sweden (p < 0.001). In both countries, trust was lower among men than among women. Age and education were associated with trust but differed between countries (p < = 0.011). Conclusions: In this study, differences in trust between Denmark and Sweden and both overall and within socio-demographic factors were observed. However, given the limitations and bias in the study, it is difficult to determine the cause and true size of these differences. With that in mind, we still believe specific populations and subgroups within those populations have the potential to affect trust in handling of the COVID-19 pandemic, and that these should be kept in mind when developing and communicating responses to pandemics. [ABSTRACT FROM AUTHOR]

This contribution examines the responses of five health systems in the first wave of the COVID-19 pandemic: Denmark, Germany, Israel, Spain and Sweden. The aim is to understand to what extent this crisis response of these countries was resilient. The study focuses on hospital care structures, considering both existing capacity before the pandemic and the management and expansion of capacity during the crisis. Evaluation criteria include flexibility in the use of existing resources and response planning, as well as the ability to create surge capacity. Data were collected from country experts using a structured questionnaire. Main findings are that not only the total number but also the availability of hospital beds is critical to resilience, as is the ability to mobilise (highly) qualified personnel. Indispensable for rapid capacity adjustment is the availability of data. Countries with more centralised hospital care structures, more sophisticated concepts for providing specialised services and stronger integration of the inpatient and outpatient sectors have clear structural advantages. A solid digital infrastructure is also conducive. Finally, a centralised governance structure is crucial for flexibility and adaptability. In decentralised systems, robust mechanisms to coordinate across levels are important to strengthen health care system resilience in pandemic situations and beyond. [ABSTRACT FROM AUTHOR]

Aims: The aim of the SCIENCE trial was to investigate whether a single treatment with direct intramyocardial injections of adipose tissue‐derived mesenchymal stromal cells (CSCC_ASCs) was safe and improved cardiac function in patients with chronic ischaemic heart failure with reduced ejection fraction (HFrEF). Methods and results: The study was a European multicentre, double‐blind, placebo‐controlled phase II trial using allogeneic CSCC_ASCs from healthy donors or placebo (2:1 randomization). Main inclusion criteria were New York Heart Association (NYHA) class II–III, left ventricular ejection fraction (LVEF) <45%, and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) levels >300 pg/ml. CSCC_ASCs or placebo (isotonic saline) were injected directly into viable myocardium. The primary endpoint was change in left ventricular end‐systolic volume (LVESV) at 6‐month follow‐up measured by echocardiography. A total of 133 symptomatic HFrEF patients were included. The treatment was safe without any drug‐related severe adverse events or difference in cardiac‐related adverse events during a 3‐year follow‐up period. There were no significant differences between groups during follow‐up in LVESV (0.3 ± 5.0 ml, p = 0.945), nor in secondary endpoints of left ventricular end‐diastolic volume (−2.0 ± 6.0 ml, p = 0.736) and LVEF (−1.6 ± 1.0%, p = 0.119). The NYHA class improved slightly within the first year in both groups without any difference between groups. There were no changes in 6‐min walk test, NT‐proBNP, C‐reactive protein or quality of life the first year in any groups. Conclusion: The SCIENCE trial demonstrated safety of intramyocardial allogeneic CSCC_ASC therapy in patients with chronic HFrEF. However, it was not possible to improve the pre‐defined endpoints and induce restoration of cardiac function or clinical symptoms. [ABSTRACT FROM AUTHOR]

Chronic diseases are major causes of death and reduction in the quality of life worldwide, and their prevalence is expected to rise due to changing demographics. Disease management programmes (DMPs) have been presented as a policy response to challenges of care coordination for such chronic diseases. This paper investigates the implementation of DMPs in a National Health Care system in the Nordic region using type II diabetes as an example. DMPs are detailed descriptions of the sequence and responsibilities for diagnostic, treatment, rehabilitation and prevention procedures. The paper applies a systemic implementation perspective to provide detailed analysis of implementation progress, issues and concerns. The implementation analysis shows that the framework of DMP has facilitated the development of new practices and attention to the roles that each of the stakeholders are playing within the service delivery. Many new initiatives contribute to improved coordination and overall management of the Type 2 diabetes (T2DB) population. Yet, there are also several cross-cutting challenges that are affecting the implementation process. [ABSTRACT FROM AUTHOR]

Chronic diseases are highly important for the future level and distribution of health and well-being in western societies. Consequently, it seems pertinent to assess not only efficiency of chronic care but also its impact on health equity. However, operationalisation of health equity has proven a challenging task. Challenges include identifying a relevant and measurable evaluative space. Various schools of thought in health economics have identified different outcomes of interest for equity assessment, with capabilities as a proposed alternative to more conventional economic conceptualisations. The aim of this paper is to contribute to the conceptualisation of health equity evaluation in the context of chronic disease management. We do this by firstly introducing an equity enquiry framework incorporating the capabilities approach. Secondly, we demonstrate the application and relevance of this framework through a content analysis of equity-related principles and aims in national chronic disease management guidelines and the national diabetes action plan in Denmark. Finally, we discuss how conceptualisations of equity focused on capabilities may be used in evaluation by scoping relevant operationalisations. A promising way forward in the context of chronic care evaluation may emerge from a combination of concepts of capabilities developed in economics, health sciences and psychology. [ABSTRACT FROM AUTHOR]

Background: Gestational diabetes (GDM) impacts 8-18% of pregnancies and greatly increases both maternal and child risk of developing non-communicable diseases such as type 2 diabetes and obesity. Whilst lifestyle interventions in pregnancy and postpartum reduce this risk, a research translation gap remains around delivering implementable interventions with adequate population penetration and participation. Impact Diabetes Bump2Baby is an implementation project of an evidence-based system of care for the prevention of overweight and obesity. Bump2Baby and Me is the multicentre randomised controlled trial investigating the effectiveness of a mHealth coaching programme in pregnancy and postpartum for women at high risk of developing GDM.Methods: Eight hundred women will be recruited in early pregnancy from 4 clinical sites within Ireland, the UK, Spain, and Australia. Women will be screened for eligibility using the validated Monash GDM screening tool. Participants will be enrolled from 12 to 24 weeks' gestation and randomised on a 1:1 basis into the intervention or control arm. Alongside usual care, the intervention involves mHealth coaching via a smartphone application, which uses a combination of synchronous and asynchronous video and text messaging, and allows for personalised support and goal setting with a trained health coach. The control arm receives usual care. All women and their children will be followed from early pregnancy until 12 months postpartum. The primary outcome will be a difference in maternal body mass index (BMI) of 0.8 kg/m2 at 12 months postpartum. Secondary maternal and infant outcomes include the development of GDM, gestational weight gain, pregnancy outcomes, improvements in diet, physical activity, sleep, and neonatal weight and infant growth patterns. The 5-year project is funded by the EU Commission Horizon 2020 and the Australian National Health and Medical Research Council. Ethical approval has been received.Discussion: Previous interventions have not moved beyond tightly controlled efficacy trials into routine service delivery. This project aims to provide evidence-based, sustainable support that could be incorporated into usual care for women during pregnancy and postpartum. This study will contribute evidence to inform the early prevention of non-communicable diseases like obesity and diabetes in mothers and the next generation.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001240932 . Registered on 19 November 2020. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities. Methods: Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40–59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension. Results: Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity. Conclusions/interpretation: In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people. [ABSTRACT FROM AUTHOR]

Background: Physician turnover is a concern in many health care systems globally. A better understanding of physicians' reasons for leaving their job may inform organisational policies to retain key personnel. The aim of this study was to investigate hospital physicians' intention to leave their current job, and to investigate if such intentions are associated with how physicians assess their leaders and the organisational context.Methods: Data was derived from a survey of 971 physicians working in public hospitals in Norway in 2016. The data was analysed using descriptive statistics and multivariate analysis.Results: We found that 21.0% of all hospital physicians expressed an intention to leave their current job for another job. An additional 20.3% of physicians had not made up their mind whether to stay or leave. Physicians' perceptions of their leaders and the organisational context influence their intention to leave their hospital. Respondents who perceived their leaders as professional-supportive had a significantly lower probability of reporting an intention to leave their job. The analysis suggests that organisational context, such as department mergers, weigh in on physicians' considerations about leaving their current job. Social climate and commitment are important reasons why physician stay.Conclusions: A professional-supportive leadership style may have a positive influence on retention of physicians in public hospitals. Further research should investigate how retention of physicians is associated with performance related to organisational and leadership style. [ABSTRACT FROM AUTHOR]

Aims: Ischaemic heart failure (IHF) patients have a poor prognosis even with current guideline-derived therapy. Intramyocardial injections of autologous or allogeneic mesenchymal stromal cells might improve cardiac function leading to better clinical outcome.Methods: The SCIENCE (Stem Cell therapy in IschEmic Non-treatable Cardiac diseasE) consortium has initiated a Horizon 2020 funded multicentre phase II study in six European countries. It is a double-blind, placebo-controlled trial testing the safety and efficacy of allogeneic Cardiology Stem Cell Centre Adipose-derived Stromal Cells (CSCC_ASC) from healthy donors or placebo in 138 symptomatic IHF patients. Main inclusion criteria are New York Heart Association class II-III, left ventricular ejection fraction < 45% and N-terminal pro-B-type natriuretic peptide levels > 300 pg/mL. Patients are randomized in a 2:1 pattern to receive intramyocardial injections of either CSCC_ASC or placebo. CSCC_ASC and placebo treatments are prepared centralized at Rigshospitalet in 5 mL vials as an off-the-shelf product. Vials are distributed to all clinical partners and stored in nitrogen vapour tanks ready to be used directly after thawing. A total of 100 × 106 CSCC_ASC or placebo are injected directly into viable myocardium in the infarct border zone using the NOGA XP system (BDS, Cordis, Johnson & Johnson, USA). Primary endpoint is a centralized core-laboratory assessed change in left ventricular end-systolic volume at 6-month follow-up measured by echocardiography. The trial started in January 2017, 58 patients were included and treated until July 2018.Conclusion: The SCIENCE trial will provide clinical data on efficacy and safety of intramyocardial cell therapy of allogeneic adipose-derived stromal cells from healthy donors in patients with IHF. [ABSTRACT FROM AUTHOR]

Civic society voluntary associations promote healthy ageing by increasing older adults' social and physical activity levels and through the co-production of services aimed at other senior citizens. Local governments are increasingly interested in collaborating with such associations as a policy response to an expanding ageing population. Co-production requires a flexible, network-based governance approach, which has not been examined from the voluntary associations' point of view. This study explores how voluntary associations perceive the relevance and usefulness of public policies aimed at promoting co-production of services for ageing citizens. The study is based on quantitative data collected through a survey sent to 1,060 voluntary associations (N = 571) in three Danish municipalities. We also studied municipalities' policies relevant to co-production of services aimed at senior citizens. We found that all of these policies included the explicit ambition of network governance of co-production of services targeted to address healthy ageing issues. However, our study indicates that the voluntary associations perceive the actual network governance to be somewhat fragmented and the corresponding scope of co-production was limited, which indicates the failure of municipalities to implement policy goals. Accordingly, municipal co-production in this area could probably benefit from the use of relevant key performance indicators that can enable political-administrative monitoring in order to secure deeper implementation and political accountability that promotes healthy ageing at the local level. [ABSTRACT FROM AUTHOR]

This article presents the results of a systematic review of international studies on economic and quality effects of contracting out published in the period from 2000 to 2014. We conducted a comprehensive search of the literature and identified 49 relevant studies. There are three main findings of the systematic review: (1) cost savings documented in international contracting out literature have been decreasing over time; (2) cost savings have been much greater in technical services than in social services; and (3) economic effects have been twice as large in Anglo-Saxon countries compared with other countries. With regard to measuring the effect of contracting out on service quality, which is a vital component of any service delivery arrangement, very few studies assess this issue in a comprehensive manner. There is also a significant lack of studies that include measures of transaction costs, thereby making it difficult to evaluate the impact of contracting out on overall cost-effectiveness of public service delivery. We conclude that generalization of effects from contracting out should be made with caution and are likely to depend, among other things, on the transaction costs characteristics of the service, the market situation and the institutional/regulatory setting. [ABSTRACT FROM AUTHOR]

How does compliance with Court of Justice of the European Union (CJEU) rulings on patient mobility in the new Member States compare with the old Member States? Studying new Member States' compliance practices would highlight the state of territoriality, the CJEU's effective influence and the European healthcare union's strength among the new Members. To provide a structured analysis and transferrable results, we compare Poland, the Czech Republic and Bulgaria with France and Germany. These countries are selected on the basis of commonalities in their systems' organization. For the results for the old Member States, we rely on Obermaier's 2009 'The End of Territoriality'. This study is qualitative in nature and relies mostly on qualitative semi-structured interviews with experts from ministries of health, health insurers and legal experts from all three countries. We distinguish between formal and informal compliance and based on this, we advance an analytical framework for a systematic study of CJEU compliance across the EU. Our findings produce a heterogeneous picture of these countries, with all three of them demonstrating different modes of compliance. This is because of distinct domestic conditions, ranging from insurance fund amenability and national court complaisance to state administration obstinacy. [ABSTRACT FROM AUTHOR]

The public sector in the Nordic countries has been subject to substantial reform in recent decades. The article explores the changing reform dynamic in Denmark and Norway, focusing on centralising and decentralising trends in two prominent sectors: higher education and health care. The main question is: How can the reform dynamics over the last decade explain changes surrounding decentralisation and/or re-centralisation? A new trend can be observed in both sectors, namely the rise of re-centralisation and the concomitant growth of state responsibility in matters pertaining to political and fiscal decision- making. Both hospitals and universities have been given increased (procedural) autonomy. At the same time there is stronger centralised planning and management of performance management, which means that (substantive) autonomy has been reduced. [ABSTRACT FROM AUTHOR]

The paper contributes to the existing literature on reactions to economic shocks by adding a specific comparative focus on core welfare sectors within the Nordic region. Comparing crisis reactions across two countries using a framework of "cost saving", "reorganisation" and "programme" logic reveals patterns and constraints in different institutional settings. The paper concludes that Denmark and Norway initially tried to shelter the health care and higher education sectors, but they have moved on to more radical strategic responses as the crisis has persisted. Many similarities in the crisis reactions are apparent across the two countries and sectors, but important differences are also clear that may be ascribed to the specific institutional contexts. [ABSTRACT FROM AUTHOR]

The issue of integrated care and inter-sectoral collaboration is on the health policy agenda in many countries. Yet, there is limited knowledge about the effects of the different policy instruments used to achieve this. This paper studies co-location as a driver for cross-sectoral collaboration with general practitioners (GPs) acting as coordinators in a municipal health centre. The purpose of the health centre, which is staffed by health professionals from municipal, regional and private sectors, is to provide primary health services to the citizens of the municipality. Co-locating these professionals is supposed to benefit e.g., elder citizens and patients with chronic diseases who frequently require services from health professionals across administrative sectors. Methodologically, the analysis is based on qualitative data in the form of semi-structured interviews with the health professionals employed at the health centre and with administrative managers from municipal and regional government levels. The study finds that co-location does not function as a driver for cross-sectoral collaboration in a health centre when GPs act as coordinators. Cross-sectoral collaboration is hampered by the general practitioners' work routines and professional identity, by organisational factors and by a lack of clarity concerning the content of collaboration with regard to economic and professional incentives. [ABSTRACT FROM AUTHOR]

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless, the nature and intensity of the reforms required are largely determined by each country’s basic social security model. Most reforms in Beveridge-type systems have sought to increase choice and reduce waiting times while those in major Bismarck-type systems have focused on cost control by constraining the choice of providers. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of healthcare system, which underlie these differences? Have recent reforms been effective?Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms. Thus, while countries may share similar problems in terms of improving healthcare performance, adopting a ‘copy-and-paste’ approach to healthcare reform is likely to be ineffective. [ABSTRACT FROM PUBLISHER]

Performance management (PM) has been developed to a central part of health care reforms. However, ideas of performance are traditionally contested in the health care sector and split up between a professional and a bureaucratic understanding of effective service delivery. With the rise of New Public Management, an additional layer of PM instruments has been put on the already existing structures. As a result, different PM regimes can be distinguished, which vary in the way they define performance, blame underperformance and design accountability instruments to ensure appropriate behaviour. The paper investigates the institutional design of PM schemes of three different cases -- Denmark, Germany and England -- which are representative for different PM regimes. [ABSTRACT FROM AUTHOR]

Following the spirit of an earlier volume in the series focusing on 'Comparative Approaches to Organizational Research', the mandate of the current volume is to provide a comparative account of dynamics across two organizational fields -- health care and higher education -- and, subsequently, two specific types of organizational forms -- hospitals and universities. In so doing, we take a broader perspective encompassing various conceptual and theoretical points of departure emanating from, mostly, the institutional literature in the social sciences (and its various perspectives), but also from public policy and administration literatures -- of relevance to scholars and the communities of practice working within either field. In this introductory paper to the volume, we provide a brief overview of developments across the two organizational fields and illuminate on the most important scholarly traditions underpinning the study of both system dynamics as a whole as well as universities and hospitals as organizations and institutions. We conclude by reflecting on the implication of the volume's key findings in regards to comparative research within organizational studies. [ABSTRACT FROM AUTHOR]

New public management (NPM) reforms have weakened the direct steering capacity within state bureaucracy. This article looks into how supreme audit institutions in three countries (Norway, Denmark, and Germany) assess these types of reforms. The analysis shows that all three SAIs have taken on an evaluative role when judging NPM instruments. At the same time their emphasis on legality and compliance can be at odds with some of the operating principles in NPM. All in all the German SAI seems to be the most radical critic. This may be linked to the lack of openness of the German SAIs results that makes it more internally focused within a mindset of administrative accountability. [ABSTRACT FROM PUBLISHER]

New public management (NPM) reforms have weakened the direct steering capacity within state bureaucracy. This article looks into how supreme audit institutions in three countries (Norway, Denmark, and Germany) assess these types of reforms. The analysis shows that all three SAIs have taken on an evaluative role when judging NPM instruments. At the same time their emphasis on legality and compliance can be at odds with some of the operating principles in NPM. All in all the German SAI seems to be the most radical critic. This may be linked to the lack of openness of the German SAIs results that makes it more internally focused within a mindset of administrative accountability. [ABSTRACT FROM PUBLISHER]

Purpose – The purpose of this paper is to investigate different types of patient involvement in Denmark, and to discuss the potential implications of pursuing several strategies for patient involvement simultaneously. Design/methodology/approach – The paper presents a preliminary framework for analysis of patient involvement in health care. This framework is used to analyze key governance features of patient involvement in Denmark based on previous research papers and reports describing patient involvement in Danish health care. Findings – Patient involvement is important in Denmark at the rhetorical level, and many policies and initiatives have been introduced. All three governance forms (voice, choice and co-production) are used. However, there are important barriers and limitations in translating the rhetoric into practice, and potential synergy and negative synergy effects can be identified when pursuing the strategies at the same time. Research limitations/implications – Because of the chosen research approach, the research results may lack generalizability. Therefore, researchers are encouraged to test the proposed framework further. Practical implications – The paper includes implications for the development of patient involvement in health care. Originality/value – This paper fulfills a need to study different types of patient involvement and to develop a theoretical framework for characterizing and analyzing such involvement strategies. [ABSTRACT FROM AUTHOR]

The commentary discusses key issues for assessment of performance management within health care. It supports the ambition to develop more realistic understandings of performance management based on insights from behavioral economics as suggested by Adam Oliver. However, it also points to several pitfalls and potential risks to consider when doing so. The commentary concludes that this is a promising field, but further research is needed to support the development of policy instruments. [ABSTRACT FROM AUTHOR]

The commentary discusses key issues for assessment of performance management within health care. It supports the ambition to develop more realistic understandings of performance management based on insights from behavioral economics as suggested by Adam Oliver. However, it also points to several pitfalls and potential risks to consider when doing so. The commentary concludes that this is a promising field, but further research is needed to support the development of policy instruments. [ABSTRACT FROM PUBLISHER]

The past decades have witnessed an upsurge in governments’ use of contracting out as a means of reforming and privatizing public service delivery. This development has to a large extent been driven by efficiency and cost-effectiveness concerns, but may also result in important changes in the working conditions and work environment for the personnel in public organizations. In this article, we present the findings from a systematic review of studies documenting the consequences of contracting out for employees. The review is based on 26 empirical studies published between 2000 and 2012. We find both positive and negative effects for employees documented in the literature, although with a predominance of negative effects, including reductions in the workforce and other changes in the workforce composition such as the replacement of experienced employees with younger workers, poorer working conditions, lower salaries, fewer benefits, and reduced job satisfaction. We conclude that poorer conditions for the public service personnel are well documented as a short-term consequence of contracting out, while more studies covering a longer time-span are needed to assess whether the predominantly negative effects are transitory or will persist over time. [ABSTRACT FROM PUBLISHER]

The Cross-Border Patients’ Rights Directive represents an attempt to resolve the unclear situation that had developed due to ‘negative integration’ within the field of healthcare. While the adoption of the directive ends the EU-level decision process, it represents the start of the implementation process, where national institutional structures and interests play a key role. This article investigates the role of resources as a key factor shaping transposition within the member states, with a focus on Poland and Bulgaria. The article shows that a multidimensional perspective of resources is important for understanding transposition of EU directives in member states. While previous research has tended to consider resources at the aggregate, national level, the present study shows that specific concerns about the ‘adjustment costs’ at the sector system level are of key importance. [ABSTRACT FROM PUBLISHER]

Aims: To provide a preliminary answer to the question of whether the economic incentives introduced by the municipal co-financing of hospital services work as intended in the reform. Methods: This study is based on 30 statistical cross-section linear regressions, OLS, using data from Statistics Denmark (Statistikbanken) and the Municipal Financial Accounts. Supplemented by data from a survey study from municipal health managers in all municipalities of the country. Results: Despite the favourable conditions presented by the design of our analysis, it is not possible to demonstrate a clear link between local efforts and number of admissions from the municipalities. Conclusions: The study does not support one of the fundamental theoretical assumptions behind the municipal co-financing introduced in the 2007 structural reform in Denmark. While the study failed to establish systematic links between municipal public health efforts and hospitalisation levels, it appears from other studies that municipalities are in fact increasing their activities in public health. This presents a theoretical puzzle and we present several possible explanations for further empirical work. [ABSTRACT FROM PUBLISHER]

Accountability can be conceptualized as institutionalized mechanisms obliging actors to explain their conduct to different forums, which can pose questions and impose sanctions. This article analyses different ‘crises’ in immigration policies in Norway, Denmark and Germany along a descriptive framework of five different accountability types: political, administrative, legal, professional and social accountability. The exchanges of information, debate and their consequences between an actor and a forum are crucial to understanding how political-administrative action is carried out in critical situations. First, accountability dynamics emphasize conventional norms and values regarding policy change and, second, formal political responsibility does not necessarily lead to political consequences such as minister resignations in cases of misbehaviour. Consequences strongly depend on how accountability dynamics take place.Points for practitionersPolitical and administrative leaders as well as civil servants are faced with several demands from the wider public and from internal or external peers. There is a relationship between actors and forums that is important in understanding how public administration works. This relationship can be described as accountability dynamics. In cases of crises, these dynamics can overcome or sustain daily administrative practices and routines. Our accountability framework offers a systematic scheme to recognize five accountability relations which should be considered during reorganization processes or policy changing initiatives. [ABSTRACT FROM PUBLISHER]

The article contributes to the literature on multi-level welfare governance and public accountability in the context of recent European hospital reforms. Focusing on the changing dynamics between regional and central governance of hospitals in Germany, Norway and Denmark, we raise concerns about the reshaping of traditional public accountability mechanisms. We argue that, triggered by growing financial pressures, corporatization and professionalization have increasingly removed decision-making power from regional political bodies in hospital funding and planning. National governments have tightened their control over the overall trajectory of their hospital systems, but have also shifted significant responsibility downwards to the hospital level. This has reshaped public accountability relationships towards more managerial or professional types embedded within multi-level forms of governance.Points for practitionersOur study may be taken to suggest that if reforms are responses to policy pressures, the accompanying changes in accountability relationships and arrangements in turn contribute to altering the pressures and constraints that form the context for administrative, managerial and professional work. As reforms in Norwegian, Danish and German healthcare contribute to corporatization, centralization and economization, there is reason to expect that what officials are held accountable for, and how, is also likely to change and to accentuate the span between policy aims and actual managerial and professional performance. [ABSTRACT FROM PUBLISHER]

The literatures on public values (PV) and public service motivation (PSM) both address whether public service delivery is driven by something more than self-interest. They have developed separately, although they can benefit from insights developed by the other, and this article discusses conceptual and empirical relationships between them. Based on a survey of 501 public managers, we find that PSM and PV are associated empirically, but not in a manner allowing total integration. The conceptual discussion reveals how the two concepts cannot be totally separated, as values can be motivating and motivation is often oriented toward something desirable (e.g., values). This suggests that neither total separation nor integration is a fruitful strategy. Given that the concepts are related, the literatures may benefit from more awareness of the conceptual overlaps and differences. [ABSTRACT FROM PUBLISHER]

Further integration of the public value literature with other strands of literature within Public Administration necessitates a more specific classification of public values. This article applies a typology linked to organizational design principles, because this is useful for empirical public administration studies. Based on an existing typology of modes of governance, we develop a classification and test it empirically, using survey data from a study of the values of 501 public managers. We distinguish among seven value dimensions (the public at large, rule abidance, balancing interests, budget keeping, efficient supply, professionalism, and user focus), and we find systematic differences between organizations at different levels and with different tasks, indicating that the classification is fruitful. Our goal is to enable more precise analyses of value conflicts and improve the integration between the public value literature and other parts of the Public Administration discipline. [ABSTRACT FROM AUTHOR]

The article presents a comparative analysis of the strategies applied by Danish and Norwegian patient organisations and organisations for disabled persons in order to promote the interests of their members. Three research questions are addressed: Are Danish and Norwegian patient organisations service organisations operating according to a 'logic of membership' or political pressure groups acting according to a 'logic of influence'? Do patient organisations apply 'insider' or 'outsider' strategies in their efforts to influence healthcare policies? What impact do different authority structures have on the patient organisations' influencing strategies? The latter question is related to recent reforms in the public healthcare systems of the two countries. The major responsibility for public hospitals now rests with regional authorities in Denmark and central government in Norway. The study is based on a survey among nationwide patient organisations in the two countries and shows that most patient groups are 'polyvalent''venue shoppers' combining a variety of influencing strategies. [ABSTRACT FROM AUTHOR]

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitt's suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice. [ABSTRACT FROM AUTHOR]

This paper presents a preliminary framework for analyzing how values in the public sector change over time. The specific dynamics are conceptualised as three types of change mechanisms: a teleological, a conflictual and a value-internal change mechanism. Choice of governance systems - hierarchy, clan, network or market - is an example of designing control systems to promote particular values. Another change mechanism is rooted in conflicts between values and the actors carrying these values leading to various organisational responses. Finally, influenced by basic properties of a value changes may follow several distinct patterns such as life cycles, pendulum dynamics, enlargement of scope, refinement and turbulence. The possible outcomes of value dynamic processes are basically changes in value configurations: crowding out, sedimentation, the core-periphery hypothesis, division of labour, and re-interpretation. The paper uses examples from a Danish context, but argues that the value dynamics identified have a more universal scope. [ABSTRACT FROM AUTHOR]

Purpose - This paper aims to analyse waiting-time guarantees in the three Scandinavian countries (Denmark, Norway, and Sweden) and to assess whether their current policy designs have strengthened the role of patients in their healthcare systems. Design/methodology/approach - The paper compares official documents and legislation in the three countries. The main findings are that waiting-time guarantees have generally empowered patients in the Scandinavian health systems. This empowerment is stronger in Denmark and Norway, where formal waiting-time guarantee rules are applied, than in Sweden, where the guarantee is based on the "softer" regulatory instrument of agreements. While patients are formally empowered in all three countries, and care providers are gradually adjusting to this situation, it is also clear that the practical conditions for empowering patients are not fully in place. The issue of information dissemination is particularly important. Research limitations/implications - Assessments are based on current regulatory configurations in the three countries, where the process of adapting and implementing the policies is ongoing. These assessments are based on a comparative analysis of the institutional designs. There is no detailed information on how patients use the waiting-time guarantee. Practical implications - It is important to consider carefully the information that patients have available in exercising their right to choose healthcare as well as the incentives for providing such information to them. Originality/value - This is the first systematic comparison of waiting-time guarantees in the three countries. It is a starting-point for further research on the introduction of waiting-time guarantees in public health systems. [ABSTRACT FROM AUTHOR]

This paper investigates the policy process leading to the rapid and somewhat surprising introduction of a major structural reform in Denmark in 2007. The reform reduced the number of regional and local authorities and changed their responsibilities and financing. The research question is why a reform of this magnitude and scope was introduced in a Scandinavian country at this point in time in spite of previous failures and in spite of likely resistance from actors with vested interests in the existing structure? The article explains the initiation of the reform by a rare opening of a window of opportunity due to a number of contextual factors. Once the window was opened the process changed to one of opportunistic pursuit of institutional and personal interests. Skilful management of the reform process by central actors was important for getting the decision through possible resistance points. [ABSTRACT FROM AUTHOR]

The area of cancer care has received significant political attention in Denmark over the past decades. Colorectal cancer (CRC) has a relatively high burden of disease and high mortality. This paper describes the main initiatives to improve CRC treatment in Denmark. It highlights the introduction of national “cancer pathways” based on clinical guidelines. The pathways specify ideal patient pathways through the system and include standards for waiting times and care processes. The comprehensiveness and high quality of Danish patient registers will aid in the implementation. Yet a number of outstanding challenges are also identified. The most important include a shortage of nursing and medical specialists for cancer care, and issues of co-ordination between primary care, hospital care and follow-up services. [ABSTRACT FROM AUTHOR]

This paper analyses the introduction of a systemic standards based programme for governing medical performance in Denmark. The programme combines clinical, organisational, and patient related standards and measures, and contains both external evaluation and self-assessment based on standards. The substance of the programme is new compared to the previous decentralised or professionally driven state of affairs that was based on a largely voluntary introduction of clinical standards, combined with a case-by-case evaluation of malpractice incidents. The programme strengthens hierarchy-based forms of governance; these co-exist with salient components of network-based governance as well as some elements of market-based governance. Institutional and contextual factors are important in explaining why a systemic standards based programme emerged as a result of the policy negotiation processes. In particular, the programme reflects stronger governance ambitions from the government in response to claims of a relative decline in the quality of the regional health services. However, the actual design is mediated by institutionalised negotiation processes among the state, decentralised authorities, and health professionals. [ABSTRACT FROM PUBLISHER]

The issue of public sector values has been increasingly important in public sector reform debates in Europe in the past decade. While there is much debate over values and normative basis there is limited empirical evidence on value profiles and value changes. This article aims to address such limitations by presenting data from a major survey based study of value orientations at all levels in the Danish public sector. The article investigates the following questions: How do public managers perceive values in the public sector? Can we construct value profiles for the public sector or parts of it? Two related hypotheses are suggested. First that it is possible to identify a set of values that is regarded as important by almost all public managers and second that these value profiles are reflected in value orientations and perceptions regarding staff skills and motivation. [ABSTRACT FROM AUTHOR]

Introduction: Insights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, and discuss them in relation to interorganisational network theory. Policy practice: The policy initiatives to improve collaboration between primary and secondary healthcare in Denmark and Sweden include legislation and agreements aiming at clarifying areas of responsibility and defining requirements, creation of links across organisational boarders. In Denmark many initiatives have been centrally induced, while development of local solutions is more prominent in Sweden. Many Danish initiatives target the administrative level, while in Sweden initiatives are also directed at the operational level. In both countries economic incentives for collaboration are weak or lacking, and use of sanctions as a regulatory mean is limited. Discussion and conclusion: Despite a variety of policy initiatives, lacking or poorly developed structures to support implementation function as barriers for coordination. The two cases illustrate that even in two relatively coherent health systems, with regional management of both the hospital and general practice sector, there are issues to resolve in regard to administrative and operational coordination. The interorganisational network literature can provide useful tools and concepts for interpreting such issues. [ABSTRACT FROM AUTHOR]

What is the state of public service values in EU countries that have experienced similar yet far from identical administrative reforms? This article compares the findings of empirical studies on public sector values in three EU countries: the Netherlands, one of the founders of the EU and a member since 1951; Denmark, a member since 1973; and Estonia, a very new member that joined the EU in 2004 together with several other former Soviet countries. There are many similarities, as well as a number of interesting differences, among the three countries. In general, their public sector value orientations are in keeping with the values for public organizations in EU member states prescribed in the Sigma project, which supports prospective members. [ABSTRACT FROM AUTHOR]