We may ask what this means for the most vulnerable patients whose need for continuity of care is considerable (27). Our study suggests the existence of a management paradox (28) in that the local authorities are more concerned with the continuity of day-to-day operations than with the patients’ need for continuity of care.
Quality and safety at risk
Earlier research suggests that there are different interpretations of the concept of ‘quality’ among front-line staff and decision-makers (29). Our study shows that decision-makers have a broad understanding of what quality and patient safety entail within the context of the community nursing service. They highlight the importance of involving as few members of staff as possible with the care for any single individual (4) as well as the need to employ qualified personnel (6), focus on quality of life (30) and encourage service user involvement (8).
According to the Norwegian government it may seem as if the municipal freedom of choice does not work as intended because the chosen organisational model sometimes fails to meet the legal requirements pertaining to good practice and quality of care (1). In terms of assessing the current organisation of services, the statements made by the local councillors may give the impression that quality and safety are at risk.
We may ask to what extent the legal requirements for sound professional practice can be fulfilled within an organisational structure described as complex and fragmented, where there is a wide gap between decision-makers and patients, and where patients, according to all data sources, are forced to relate to too many staff.
The study has several limitations. Data were collected from only two municipalities, and neither staff nor patients were included in the sample. The first author has been working in the community nursing service since 2003. Both authors contributed to the analysis in order to strengthen its merit and credibility, and to avoid bias.
It was the case in both municipalities that the administration’s formal recommendations had significantly impacted on the way that the community nursing service was organised, while evidence-based knowledge and public health promotion were of limited importance. It seems that the role played by local councillors is marginalised in that they appear on the scene only at the decision-making stage, and the gap between decision-makers and patients is wide.
We identified several differences between the two municipalities. In municipality 1, the purchaser–provider model, reporting and regulatory requirements, and particularly finances, had a significant impact on the way that the community nursing service was organised. These factors were of limited importance in the smaller municipality.
Despite a reasonably broad understanding among decision-makers of the importance of quality and patient safety, these factors were in practice only considered to be of moderate importance in the smaller municipality and of little importance in the larger municipality.
One common denominator was that both municipalities expected the merger of community nursing teams and enterprise units to be beneficial. The fact that they advocated mergers, appears paradoxical since all informants highlighted that patients need to relate to as few members of staff as possible.
In line with more recent White Papers (1, 5), we therefore recommend that municipal decision-makers:
- focus on the quality of services and health promotion in the local community from the citizens’ perspective,
- map the community’s (healthcare) needs, networks and resources, and
- use the two points above as a basis for their organisation and funding of the community nursing service, and the municipality’s organisational structure.
Research suggests that this approach and organisational model may not only improve the health of the local community, but can also generate better satisfaction rates among patients, citizens and staff, in addition to financial savings.
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