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Gepubliceerd in: TSG - Tijdschrift voor gezondheidswetenschappen 2/2024

Open Access 24-04-2024 | Wetenschappelijk artikel

Who, what, where? The influence of the Integral Care Agreement (IZA) on established regional networks in Dutch healthcare

Auteurs: Robin Peeters, Daan Westra, Rachel Gifford, Dirk Ruwaard

Gepubliceerd in: TSG - Tijdschrift voor gezondheidswetenschappen | Uitgave 2/2024

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Abstract

Health and welfare organizations are encouraged to collaborate in regional, cross-domain networks. Although the literature has shown that policy changes can influence the effectiveness of existing networks, the impact of the Dutch Integral Care Agreement (Integraal ZorgAkkoord, IZA) is not yet known. We investigated this in a longitudinal qualitative case study of a network that has been in existence for a long time. The results show that after implementation of the IZA, a new overarching network at the healthcare administrative regional level was established. This led to uncertainty regarding the objective, composition, and sustainability of the existing network. A division emerged in the existing network between members who participated in the new network and those who did not. Organizations that participated in the new network questioned their participation in the existing network, to reduce administrative pressure. Organizations that only participated in the existing network doubted their participation because they lost sight of the network’s purpose and experienced a lack of transparency regarding decisions made in the new network. The Dutch national government and policymakers would do well to seek close alignment with practice when further developing the IZA.

Introduction

For over a decade, government initiatives have encouraged organizations in healthcare and welfare to collaborate in cross-domain networks. In the Netherlands, nine experimental regions were designated in 2013 to monitor the development of such collaborative efforts [1], and in 2018, the movement ‘The Right Care at the Right Place’ (De Juiste Zorg op de Juiste Plek) was introduced, emphasizing collaboration as a prerequisite for quality care [2]. These networks involve various organizations such as health insurance companies, healthcare and welfare organizations, municipalities, and patient advocacy groups. They are often perceived as solutions to grand challenges, such as long waiting lists and high healthcare costs, to keep healthcare systems sustainable [35]. Recently, the Integral Care Agreement (Integraal ZorgAkkoord, IZA) 2022 has emphasized such collaborative efforts in healthcare administrative regions [6]. While many networks predated the IZA, they often operated on a smaller scale than that of the healthcare administrative region, and questions regarding the existence of a definitive region to address these challenges have been raised previously [7]. Therefore, it is crucial to investigate the influence of the IZA, particularly the designation of collaboration in the healthcare administrative region, on existing regional networks.
The scientific literature has shown that numerous determinants are able to influence the effectiveness of networks [8]. Changes in the internal environment of networks can impact a network’s functioning, such as alterations in network composition or diminished commitment of network participants [9, 10]. Additionally, research has indicated that disparities in the catchment areas of network organizations can pose challenges for defining network boundaries and goals [11]. Furthermore, various differences between network organizations, such as the level of trust [12], perceived differences in influence within the network [13], and the degree of openness and transparency in decision-making [14], can affect network effectiveness. Changes in the external environment, such as policy changes (e.g., implementation of the IZA), can either facilitate or impede network goals, depending on how well they align with existing roles and responsibilities in practice [15]. However, the specific impact of the IZA as a policy change on existing networks and the dynamics between their members remains uncertain.
Therefore, the research question of this study is: ‘What influence does the IZA have on existing regional networks?’ Answering this question is important for several reasons. First, it can assist networks and participating organizations in coping with the changes brought about by the IZA. Conversely, it can contribute to preparing government policies, and specifically, ensuring that any further developments of the IZA align well with practical needs and support existing and developing networks in practice. Finally, it can help fill gaps in our knowledge regarding network effectiveness and the role of policy in creating effective networks, thereby stimulating targeted future research.

Methods

This study is part of a longitudinal qualitative case study focusing on a network in the Netherlands, spanning from April 2019 through September 2023. The region in which the network operates is characterized by a high degree of collaboration, and it was one of the nine national experimental regions in 2013 [16]. The network includes the major providers of primary and secondary healthcare, mental healthcare, support services, home care, youth care, and public health, as well as the dominant health insurance company, the largest municipality, and a patient advocacy group. The network is divided into four domains, each with its own focus area where numerous projects are implemented. The region in which the network operates is bound to several municipalities and is characterized by an aging population, high healthcare costs, low perceived health status, and low socioeconomic status [17, 18]. Figure 1 illustrates the intricate relationships between the organizations involved in the network’s initiatives. Data were collected during the project in which the four chairs of the four domains provided documents and were interviewed to obtain a comprehensive understanding of the network’s relationships. The data were then analyzed using UCINET.
Within the subregion, the network is seen as the overarching network in which the region’s direction is discussed and monitored. Given the network’s existence for over a decade and its active engagement in the region, this case is particularly suitable for studying the influence of the IZA because it allows us to compare the situation before and after its implementation. Moreover, the longitudinal research period allows us to observe the pre- and post-IZA situation instead of relying solely on retrospective assessments. In this study, ‘subregional’ refers to the region in which the existing network operates, including the four domains and initiatives. This subregion is one of two subregions within the healthcare administrative region. The study has been approved by the university’s ethics committee (anonymized).

Data collection

In this study, three types of data were collected (see Tab. 1), namely observations, documents, and interviews for data triangulation [19]. Quarterly network meetings were observed from April 2019 to July 2023 by at least one but usually two researchers. They took notes during these meetings and discussed their observations afterward. In total, 17 meetings were attended during this period. The observations provided insight into the dynamics between network participants. Additionally, documents from the network and the four domains were collected during the same period, including meeting minutes, internal documents, and publicly accessible materials (reports and media outlets), totaling 1622 pages from 226 documents. These documents also shed light on the network’s evolution over time and the influence of the IZA. Furthermore, 34 interviews were conducted, divided into three interview rounds. In all three rounds, network participants were interviewed, specifically the executives representing their organizations in the network. Data saturation was achieved in each round. Tab. 1 provides an overview of the topics covered in each interview round. The interviews lasted on average one hour and were conducted either on-site or online, depending on the prevailing Covid restrictions at the time. The interviews were recorded and transcribed verbatim.
Table 1
Overview of collected data
observations
number
hours
17
34
documents (number of documents (pages))
 
meeting minutes
internal documents
reports and media outlets
total
 
29 (95)
112 (987)
85 (540)
226 (1622)
interviews (34 in total)
 
round 1
round 2
round 3
period
April–June 2019
August 2020–February 2021
May–July 2023
number of participants
11
12
11
Five participants participated in all three interviews, nine participants were interviewed in both rounds 1 and 2, and six participants took part in both rounds 2 and 3. Changes occurred due to executive turnover in the respective organizations. Of the 11 respondents in round 3, six also participated in the newly established IZA network
subject
Why do you participate in networks and what is important for you to participate? How is the network organized? Who is responsible for what in the network?
When is a network effective or not effective? How do you assess whether a network is effective or not effective? Why do you participate in a network when you think it is not effective?
What is the influence of the IZA on this network and the larger region?

Data analysis

The first author analyzed the interviews inductively through thematic analysis using ATLAS.ti 9 [19]. Initially, we performed open coding on the interview data. Although interviews from rounds 1 and 2 had different foci, they provided relevant information about the network before the IZA was implemented. Therefore, relevant data regarding the organization and dynamics of the network and the region from interview rounds 1 and 2 were also included in the analysis. Interviews from round 3 were specifically used to gain insight into the influence of the IZA on the network. Subsequently, axial coding was performed by connecting different codes and identifying common themes. All findings were discussed with the entire research team to gain a comprehensive understanding of the results and their significance. Observations and documents were used to understand the network’s organization, composition, and dynamics and the way they changed over time.

Results

We present the results in two main categories related to the influence of the IZA on the regional network: changes in the role, purpose, and composition of the network; and changes in the dynamics between organizations in the network.

Changes in the role, purpose, and composition of the network

Following implementation of the IZA, a new regional network was established at the healthcare administrative regional level. This network includes representatives from the two subregions that the healthcare administrative region was previously divided into, each with their own networks. Consequently, the new regional network became a ‘network of networks’. This had three major consequences for the purpose and composition of the subregional network: The focus of meetings changed, participants questioned their involvement in the network, and the role and future viability of the network were questioned.
Before implementation of the IZA, the focus during network meetings primarily revolved around discussing project developments in the four domains. The network was perceived as effective by most participants and as important by all network participants. Documents reveal that numerous initiatives and projects had been implemented by the network, which were perceived as effective by the interviewed respondents. After implementation of the IZA and the establishment of the network at the healthcare administrative regional level, the focus of the subregional network shifted from discussing progress in initiatives to discussing regional developments and the regional execution of the IZA (i.e., regional visions and plans [6]). However, the purpose and role of the new network at the healthcare administrative regional level remained unclear, particularly in the long term. As a result, respondents indicated that the role of the subregional network at the time was also uncertain, depending on developments at the regional level. Documents also indicate that the agenda for meetings was heavily influenced by the IZA and the regional network.
‘But sometimes I find it difficult, like, okay, how will we proceed as [a network]? That is still very uncertain for me. […] The IZA has led to a significant transition, a whole new process actually, to which [the network] has to adapt to as well.’ (Interview round 3, respondent 0103)
Partly due to the shift in focus in the network and uncertainty about its role, many respondents questioned their participation in the network. On the one hand, respondents from organizations with a larger catchment area doubted their participation because the regional network better aligned with their catchment area. Prior to implementation of the IZA, some of these respondents already mentioned they also needed to participate in similar networks in other regions within the healthcare administrative region. This led to a high administrative burden, making it more efficient to participate solely in the regional network. For example, one organization with a larger catchment area considered participating solely in the regional network, which was seen as problematic by other participants of the subregional network as the organization in question was deemed crucial for the network.
On the other hand, organizations with a smaller catchment area questioned their participation in the subregional network, partly due to the changed focus. They felt that since the implementation of the IZA, healthcare-related challenges in the region were no longer adequately addressed and that the new regional network provided no added value for them as it did not align with their catchment area. Additionally, respondents indicated that due to changes in the role, purpose, and composition of the network, it remained uncertain whether the subregional network would continue to exist and if so, in what form. Due to the uncertainty surrounding the purpose, composition, and future of the subregional network, the legitimacy of the network decreased.
‘But currently, we will have to wait and see, like, to what extend the organizations sitting at the table right now will still be there after we have formalized and executed the IZA plans. Still, I find it very important to go for it as [a subregional network]. So, well, I hope so, but I do not know for sure. That is still too far in the future, and I just do not know what the consequences of this [IZA] will be.’ (Interview round 3, respondent 0601)

Changes in the dynamics between organizations in the network

Besides the changes in role, goals, and composition of the subregional network, there were also shifting dynamics between participants in this network. The subregional network gained legitimacy as it was perceived as a means to make a claim to ‘transformation funds’ that were made available by the IZA; organizations with a smaller catchment area that were not involved at the regional level felt a lack of transparency; and organizations that were involved at the regional level believed that other organizations should cede authority to maintain effectiveness in the new network.
While the legitimacy of the regional network was questioned regarding its role, goals, and composition, it also gained more legitimacy in other aspects. Respondents indicated that the network acquired a different significance as it was seen as a crucial mechanism for collectively accessing IZA transformation funds. Consequently, respondents felt that some organizations became more proactive in the network. Documents and observations from the months preceding the IZA release showed that some organizations occasionally sent a manager to attend meetings instead of the executive themselves. After implementation of the IZA, we observed that in organizations where a manager used to attend some of the meetings, the executive themselves were now present. This was the case for both organizations with a larger and smaller catchment area.
‘What you see now with the IZA, you see a different dynamic arising in this network because suddenly the network is also of material interest to organizations. […] Where they first had a very reactive role in the network, they are now suddenly fulfilling a proactive role. […] As soon as you know that there are millions to be distributed and that [the network] needs to, so to say, sign off in order for you to lay claim to these millions, then you will make sure you are sitting at the table.’ (Interview round 3, respondent 0901)
Respondents from organizations with a smaller catchment area frequently expressed that the IZA created many uncertainties for them because they were less included in, for instance, drafting a regional plan, which primarily took place in the regional network. They viewed it as the responsibility of the organizations involved in the regional network to provide transparent feedback on these matters in the subregional network, to ensure everyone is informed and other organizations are also well represented. Due to the lack of perceived transparency, organizations expressed concerns about whether their interests were adequately represented and sometimes found it challenging to maintain trust in the other organizations. During observations, we also noticed that organizations not involved in the regional network frequently asked questions about the developments and indicated that they thought these were unclear.
While a regional network is desirable for organizations with a larger catchment area, respondents also expressed that networks should have fewer members to gain efficiency. They were concerned that a regional network with too many participants would become chaotic and therefore less effective. One respondent provided an example of a previous network in which many organizations were involved and that covered the entire healthcare administrative region. This network was eventually divided into subregions because it was not feasible to effectively collaborate in the network at this level. As a solution, this respondent suggested that organizations with a smaller catchment area should give up a certain degree of control. Only then would a regional network not have too many members. Another respondent indicated this required reducing the number of organizations in the region, making it easier to set a specific course and cede control.
‘Look, on the one hand, reducing the number of organizations. If you see that some municipalities have agreements with 300–400 care providers, you can never set a direction with all of them. So imagine that you can reduce that to about ten per region, with some smaller organizations that can still be there, then it becomes easier to give up some of that control. […] So for me, it begins with reducing the number of organizations and then creating trust among those that are left.’ (Interview round 3, respondent 0302)

Discussion

The development of a new network introduced after the IZA at the healthcare administrative regional level adds an additional layer of governance. The literature indicates that networks are more challenging to be governed than other organizational forms. They typically involve multiple layers of governance [5], rely more on their members (i.e., organizations), and are less able to resolve conflicts [20]. Moreover, there needs to be a balance between broad representation of participants while simultaneously maintaining a network that is small and agile enough to be effective [21, 22]. There is limited understanding of how to govern such an additional network layer, often referred to as a ‘network of networks’ [20], but one can anticipate that these governance challenges would be exacerbated. This raises questions about the manageability of a network of networks in practice, both from the perspective of the network itself (e.g., what is the right balance between representation and effectiveness?) and that of organizations in the region (e.g., how do organizations manage their participation in these networks, both when operating in a single subregion and when operating across multiple healthcare administrative regions?). Since there is still limited literature on governing such networks of networks [5], it is important to continue monitoring and researching these developments. Policy should align more closely with existing network structures and initiatives in practice, especially considering a potential IZA 2.0 [23], to facilitate collaboration and avoid hindering further development [24].
Our finding that primarily organizations with a larger catchment area and/or higher market power are made central to the development of regional IZA plans may have implications for the way the IZA is implemented in practice. The literature suggests that larger organizations are often less innovative than smaller ones [25], while smaller organizations are often better at implementing change [26]. Consequently, given IZA’s focus on innovation and transformation [6], it appears to be crucial to also involve organizations with a smaller catchment area more prominently in the regional execution of the IZA. Additionally, the idea behind collaboration in networks suggests there must be a collectively recognized problem in a specific context and that participants must feel they need each other to solve it [3]. The healthcare administrative region is relatively large, and the catchment area of many organizations is much smaller. Therefore, it is uncertain to what extent they will perceive a shared problem in their daily practice with organizations that serve a completely different region and possibly a different population. Moreover, regional plans developed in relation to the IZA appear to vary little between healthcare administrative regions [27]. The bigger differences only become noticeable within healthcare administrative regions, for example, in neighborhoods [28]. This raises the question of whether the healthcare region is the appropriate level at which collaboration should be organized and what form it should take [7]. Networks at the healthcare administrative regional level should explore the appropriate scale for implementing IZA plans. Existing networks at the subregional level can be particularly valuable in this regard. The healthcare administrative region can play a crucial role in facilitating cross-pollination and the exchange of best practices between subregional networks and simultaneously be open to input from less involved organizations. The value of such a ‘meta-network’ has also been argued in research studies in other sectors [29]. It is important for the government and health insurance companies to encourage input from a wider range of organizations to drive this transformation. Additionally, it is crucial to monitor these transformations, to assess whether the desired transformation is being implemented correctly and whether scarce resources are not being utilized in these networks without achieving the intended results [30]. This will require collaboration between practitioners, policymakers, and researchers.
Finally, the results indicate that organizations with a smaller catchment area are not only less involved in a network at the healthcare administrative regional level but also have a need for transparency from organizations that are involved. The lack of transparency leads to feelings of uncertainty. Since the literature has demonstrated joint decision-making and transparency are crucial for the effectiveness of networks and participant commitment [14] and network members should not experience power imbalances [13], it is essential to ensure that the regional IZA network does not adversely affect these dynamics. This could result in existing networks in subregions losing participants or even their effectiveness or legitimacy, despite often having implemented successful initiatives. Government and policymakers should play an active role in ensuring diversity in regional network participation to ensure all interests in the region are represented. Additionally, dominant health insurance companies often participate in both healthcare administrative region networks and subregional networks. The literature has shown that organizations in such networks are highly susceptible to normative and coercive institutional pressures and expectations, particularly when health insurance companies are involved. For example, an organization may fear the consequences for negotiations with the health insurance company if they do not comply with the network [30]. Government and health insurance companies must ensure that organizations with less involvement and potential transparency issues do not suffer adverse consequences in future negotiations.

Limitations

This research has some limitations. First, we have only studied one case. This has the disadvantage that we cannot compare, for example, different regions or long-established and newly formed networks. However, ongoing research in other regions and with networks in the start-up phase shows similar dynamics. Therefore, we expect that our results will not only be applicable to this specific case. Additionally, we have only included a mainly executive network, which means we did not assess the effects of the IZA in networks closer to its implementation. However, networks closer to the implementation are often part of a larger executive network. It is important to investigate how these dynamics translate into the daily operation, especially in relation to the transformation that the IZA aims for.

Conclusion

Collaboration in cross-domain networks is regarded as one of the solutions to sustain the Dutch healthcare system, and the government has been strongly encouraging this for several years. While implementation of the IZA focuses on innovation and transformation through regional collaboration, it impacts existing subregional networks. After implementation of the IZA, collaboration needs to be organized at a higher level (the healthcare administrative region) than before, making it increasingly complex and putting pressure on the legitimacy of existing networks as they need to redefine their role, purpose, and composition. A split arises among network members who participate in the new regional network and those who do not. When organizations participate at the regional level, they question their involvement in the subregional network because, given their catchment area, it is more efficient to operate solely in the network at the healthcare administrative regional level. When they are not participating at the regional level, organizations question their involvement in the subregional network because they are unsure whether the purpose of the subregional network still aligns with their organization and they feel a lack of transparency from organizations that do participate at the regional level. Government and policymakers should better align future policies with practice to facilitate collaboration more effectively. Additionally, strong emphasis should be placed on monitoring transformations to ensure that scarce resources contribute to the intended outcomes.
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Metagegevens
Titel
Who, what, where? The influence of the Integral Care Agreement (IZA) on established regional networks in Dutch healthcare
Auteurs
Robin Peeters
Daan Westra
Rachel Gifford
Dirk Ruwaard
Publicatiedatum
24-04-2024
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
TSG - Tijdschrift voor gezondheidswetenschappen / Uitgave 2/2024
Print ISSN: 1388-7491
Elektronisch ISSN: 1876-8776
DOI
https://doi.org/10.1007/s12508-024-00433-1