The dynamics between policy and practice: A case study on the integration of municipal health and social care services for people with mental health and substance abuse challenges

Abstract

This doctoral project examines the integration of municipal health and social care services for people with concurrent mental health and substance abuse challenges. The main aim is to explore how professionals and managers adapt to and operationalize policies regarding the integration of municipal health and social care services. This aim is explored through four specific research questions, which are addressed across three research articles.

The Norwegian health and social care sector faces sustainability and quality challenges while providing services to people with concurrent mental health and substance abuse challenges. These issues stem from the increasing number of people who seek help from the public services, and from the fragmentation of the service system. In fragmented systems, service recipients can experience difficulties in accessing care, maintaining continuity of services, and having their needs adequately met. Consequently, researchers and decision-makers promote the integration of health and social care services as a means to improve access, quality, and continuity of services, while mitigating the negative consequences of fragmentation.

The doctoral project is designed as a qualitative single-case study with participants recruited from three Norwegian municipalities. Data is gathered through various sources including: observation of meetings; individual in-depth interviews with professionals and managers; focus group interviews with professionals, managers, service recipients, and family caregivers; and individual telephone interviews with service recipients and family caregivers. The result of this is a comprehensive data set which enables the analysis of how factors at system, organization, and practice level influence the integration of municipal health and social care services. The findings from these analyses are presented across the three embedded research articles.

The first article explores how the values within public management principles influence organizational and financial structures as well as professional practices in municipal health and social care services. As such, this article connects central public management values at the system, organizational, and practice levels. The second article consists of a competence framework required for the implementation of service integration, along with a discussion on the need for a collective approach to develop service integration competence. This article contributes to analyzing the impact of factors at the organizational and practice levels. The third article explores formal and informal integration. The article highlights how professionals’ relational work related to networks and networking skills are important for achieving service integration. Thus, the third article illustrates the impact of factors affecting integration at the practice level.

Findings from the articles are integrated in this dissertation to explore how public management values influence the ways in which professionals and managers adapt to and operationalize policies regarding service integration. The economic and frugal values within government documents, stimulate municipal managers to structure health and social care services in a way that makes financial management, accountability, and reporting feasible. It also stimulates municipal managers to promote frugal approaches in decision making rather than integrated approaches. The policies directing service integration do not entail strong incentives, but appeal more to the autonomy granted to Norwegian municipalities. Municipalities who choose to structure and approach services based on the integrative values of adaptivity, flexibility, robustness, and resilience, succeed to integrate services to a great extent.

The dissertation also discusses the trust-control nexus between the Norwegian government and the municipalities. On the one hand, the controlling elements within performance management policies, creates sanctions and anxiety for the municipalities. On the other hand, Norwegian municipalities are granted autonomy to adapt to and operationalize service integration policies according to their contextual needs. This may be understood as a high level of governmental trust in municipalities’ abilities and willingness to accommodate the aim of service integration.

Lastly, this dissertation points out that the trust-control nexus between the Norwegian government and the municipalities should be better balanced. This requires new tools for controlling and safeguarding qualitative policy objectives such as the integration of municipal health and social care services. In this regard, this dissertation proposes that in the development of municipal health and social care, national authorities can consider controlling qualitative policy objectives by enabling professionals and managers to provide resilient services. Investing in the capacity of practice level managers and professionals to respond to evolving changes and challenges, can prepare for the national authorities’ trust in Norwegian municipalities to provide safe and high-quality services for the wellbeing of citizens.