Main issues facilitating or hindering multilevel collaboration in the study area are summarized in Table 1, in categories and sub-categories without respect to levels.
[Table 1: Categories and sub-categories influencing multilevel collaboration]
Communication
Many participants described the importance of having common terminology in order for health professionals to understand how their work contributes to outcomes. A respondent from the health unit of the Region of South Denmark said: “Then we should learn to speak the same language, and also have a deeper insight into each other’s work and working conditions… I think that could help lift something.” All participants mentioned the need for meetings and workshops where professionals from different sectors could meet to discuss and plan further collaboration and create an opportunity to interact and create relationships across disciplines. A municipality worker mentioned:
I really think that the more we know each other the more it will lead to good collaboration. For instance, one day we invited the general practice staff, doctors and nurses for a workshop. We met face to face and had conversations about what works and what doesn’t work. It really helped because now you know them personally and have seen their faces.
The same individual also said, "I think it’s really relevant that we keep meeting across cultures and educational backgrounds.”
Participants also stated the importance of establishing a data and information platform allowing for quick and complete exchange of information between professionals as well as providing an overview of the patient’s status, offers and needs. As a general practioner stated:
One of the clear problems is that we do not write in the same systems, i.e. that the information is found in several different systems. Where we do not necessarily have direct access to their systems, and they do not have access to ours.
Financial issues
The reimbursement system was seen as a barrier, as mentioned for instance by a hospital doctor as follows:
Most important thing is that the municipalities seek “pulje” [grant] money for all possible projects, but they never have an intention to introduce them as a fixed procedure… and we are so terribly tired of being involved in projects that do not lead to permanent changes… it does not contribute to the collaboration.
…An option could be that each sector put some funds into a shared pool, and then secure a common education concept across sectors so all professionals get trained in the same direction in working together, and this also provides the opportunity to get to know each other and make better relationships regarding collaboration.
Legislation as barrier for collaboration
Another factor that hinders collaboration is legislation on different areas: for instance, differences arose between social care and health law, as described by a respondent from the National Board of Health:
"There are also some restrictions in relation to legislation. The two, the service law and the health act, must interact.” The same respondent also said:
One of the elements in creating good coherent processes is that you have updated relevant knowledge about the citizen regardless of what sector. And there is legal discrepancy between the different sectors in relation to data sharing. Legislation is conservative to what the patients or citizens themselves are expecting. For instance, they may wonder that their own GP or health workers in the municipality do not know what you have talked about to your doctor in hospital. And that’s not because our system has let them down, but that’s because we are not allowed to talk about such things. It is obviously also a barrier. This is probably one of the most important issues concerning collaboration between the levels.
Lack of clarity concerning content of collaboration
The majority of the respondents support the idea of collaborating with other health professionals; however, there is no clarity concerning the content of collaboration. Disease management programs are a part of the health agreement (19) which describes the areas of responsibility for the GP, hospital and municipality; a hospital doctor said: "Clear collaboration agreements are needed. The municipal self-government allows all the municipalities to act differently and they have different ways to do things.” A municipality worker described: "We are all important parts in creating good collaboration; no part is more important than the other.”
Another important topic identified in the interviews was to what extent the disease management program for T2DM was implemented in the municipality, both by GPs and hospitals. A number of doctors had never heard of a disease management program, which is developed to improve coordination and collaboration regarding prevention, management and rehabilitation.
Municipal reform and Denmark’s Health Act were established in 2007, at which time it became mandatory for municipalities and regions to enter into binding agreements for collaboration (19). At the same time, municipalities were allowed significantly greater responsibility for health promotion, disease prevention and rehabilitation. Yet GPs and hospital doctors have a lack of trust or belief in municipalities’ competency to perform health activities; as a general practitioner stated: "But there are some municipalities that are not geared to do it; they did not obtain competencies to carry out the task. That is discussed a lot recently. How can they get the skills, should it be with help from us? Or how?”
Organizational issues
A major challenge identified by a great number of informants is organizational complexity. In order to apply the multilevel approach, respondents mentioned that organizations need to communicate and collaborate to offer rehabilitation to citizens. For instance, the need for a formalized approach as specified in the health agreement, where there is a definite structure of formal collaboration between the levels.
Another topic discussed during the interviews was the lack of common management and leadership for GPs. This makes collaboration even more problematic due to the fact that no one can represent the GPs; an interviewee from the Region of South Denmark said:
So, I think the biggest challenge in general practice as a sector is that it’s a lot of small private units. Hospitals and municipalities have management and leadership, and if you want something at the director level, you have at least a hierarchical system to get things done, with the challenges that are of course also internal to large systems. But with general practice, there are about 400 private units that do not have a common board of directors. They have a common association, but it’s just not the same. And that makes it unequal to implementing new initiatives, difficult to communicate, difficult to be in dialogue with them as a sector. And they are struggling to represent each other, also internally at the municipal level.
Structural limitations
The informants emphasized the need for a clear mandate from the top to enable the different levels in the health system to work together effectively. A respondent from the health unit of the Region of South Denmark stated:
It is not always the resource which is a limitation, we have to be honest to ourselves; in many cases it could be different traditions or sector limitation. You know the barriers with incentives or other things, which makes it really difficult. Sometimes it is limitations in the general structure that are decided on the highest level.
All participants mentioned the general incentive structure as challenging for collaboration. For example, a respondent from the health unit of the Region of South Denmark formulated it as follows:
Yes, that’s it. Incentive structures [are] so basic. So what do you get money for and to. The hospital is rewarded for activity and productivity and not so much for quality. General practice is paid by the service, so they do not necessarily get incentives to prevent or refer to community activities or to create coherence at all. That’s how it may be. In fact, it may be time-consuming to collaborate for doctors, if you look at it economically. And, of course, the municipalities also have their incentives, which is different. It is probably the biggest barrier…
Resources
The participants viewed having a diabetes nurse at the GP’s office as a facilitator for collaboration, as mentioned by a hospital doctor:
There is a big difference if [a] general [practitioner] has a practice nurse in his consultation. Sometimes it is the nurse who follows up on citizens/patients, meets them, asks questions about their knowledge about diabetes and complications.