The European Journal of Public Health Advance Access originally published online on March 28, 2007
The European Journal of Public Health 2007 17(5):532-536; doi:10.1093/eurpub/ckm001
Miscellaneous |
Co-operation as a strategy for provision of welfare services—a study of a rehabilitation project in Sweden
Christina Norman and Runo AxelssonNordic School of Public Health, P.O. Box 12133, SE-402 42 Göteborg, Sweden
Correspondence: Runo Axelsson, PhD, Professor of Management, tel.: +46 31 693924, e-mail: Runo{at}nhv.se
Received March 7, 2006, accepted January 2, 2007
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Abstract |
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Background: During the past 15 years, there have been many initiatives to improve the integration between different welfare agencies. This study is describing and analysing the co-operation between agencies involved in a rehabilitation project in Sweden, and discussing such inter-agency co-operation as a strategy for provision of complex welfare services. Methods: The study is based on a process evaluation, where the co-operation between the agencies was followed and documented during the time of the project. Different kinds of data were collected through interviews, focus groups and diaries. The contents of these data were analysed in order to evaluate the process of co-operation. In addition, there was also an evaluation of the effects of the co-operation, based on official documents, statistics, etc. Results: The evaluation shows that it was possible to co-operate across the organizational boundaries of the different agencies, but there were obstacles related to organizational and cultural differences of the agencies, divided loyalties of the officials and limited resources available to deal with the complex needs of the clients. At the same time, the commitment and the relations between the officials were facilitating the co-operation. Discussion: Based on the evaluation of this project, it seems that co-operation could be an effective strategy to deal with clients who need services from different welfare agencies. At the same time, however, it is clear that inter-agency co-operation requires a lot of time and energy and should therefore be used with caution.
Keywords: co-operation, integration, rehabilitation, welfare services
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Introduction |
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In 2003, the number of early retirements in Sweden was for the first time more than half a million in a population of about nine million.1 This was regarded as a failure of employment policy, social policy and vocational rehabilitation. It was also blamed on a lack of co-operation between the different welfare agencies involved: the employment service, the social insurance administration and the health and social services. In the Swedish welfare system, state agencies are responsible for social insurance and employment service, while regional authorities are responsible for health services and local authorities for social service.2
This lack of co-operation between different agencies is not unique for the Swedish welfare system. Most welfare systems were established during the post-war period, but they have been criticized in later years for not being adapted to the needs of the post-industrial society.3 Moreover, the welfare agencies have become increasingly specialized, and they have been criticized for delivering more and more ‘fragmented’ services.4,5 According to many critics, it is necessary to improve the integration of the welfare system in order to deal with the complex needs of the modern society and deliver more ‘holistic’ services.6–8 Co-operation between welfare agencies is one strategy to improve the integration of the system.9,10
During the past 15 years, there have been many initiatives to integrate the services of different welfare agencies, for example in care of the elderly, open psychiatric care and other forms of community care.11–13 In Sweden, there have been a number of experiments to improve the co-operation between welfare agencies involved in vocational rehabilitation.14–17 One of these experiments was a project called ReSam.
This project took place in a well-defined area of Gothenburg, the second biggest town in Sweden, between 2002 and 2004. The project was dealing with individuals who were unemployed due to physical, mental or social problems and needed services from different welfare agencies. The ultimate goal was to help these individuals to an employment, but the purpose of the project was to improve the integration between the agencies involved, in order to have a joint assessment, an early and co-ordinated rehabilitation and appropriate financial support for those who could not be employed. The name of the project, ReSam, is an acronym for co-operation in rehabilitation.
There were five different agencies involved in the project: the local branch of the employment service, the local social insurance administration, the primary health care and the psychiatric care of the regional health authority, and the social service in two districts of the local community. A group of officials from these agencies met for 2 h every other week to deal with clients that they had in common. There were different professions represented in this group: a physician, an occupational therapist, a social worker and administrators from the employment service and the social insurance. In addition to the regular meetings, members of the group worked together in teams to deal with individual clients. The rest of the time they worked in their ‘home’ agencies as usual.
The project had a steering committee consisting of managers from all the agencies involved, but the different members of the group reported to the managers of their home agencies. The social insurance was the formal ‘owner’ of the project, but the financial responsibility was shared by all the agencies involved. The time that the officials spent on project activities was regarded as normal working time and additional costs for training, supervision and evaluation were divided between the agencies. Medical assessment and psychological support to individual clients were paid by the agencies that were initiating the referrals.
Based on the evaluation of the ReSam project, the purpose of this article is to describe and analyse the co-operation between the different agencies involved in the project, and to discuss such inter-agency co-operation as a strategy for provision of complex welfare services like vocational rehabilitation. There is growing research on integration of welfare agencies, but it has produced very little evidence on the effectiveness of such integration.18 Instead, much attention is focused on different obstacles to inter-agency integration.8,12 The following presentation will focus both on the process and results of the ReSam project, and on the problems and possibilities involved in this kind of co-operation.
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Theoretical background |
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There are many different definitions of integration and co-operation, and related concepts like co-ordination and collaboration.7,9 In general, integration means that different activities or services are brought together. This can be achieved either through a vertical (top-down) co-ordination within a management hierarchy or through a horizontal collaboration between more or less independent organizational units.19,20
Co-operation is a third strategy, which can be defined as a combination of co-ordination and collaboration.10 This may be the case when officials from different welfare agencies are collaborating in a group or a team, but at the same time they are also co-ordinated by managers from the agencies involved. In the management literature, such a combination of vertical and horizontal integration is called a matrix organization.21
Collaboration between welfare agencies is often organized in the form of multidisciplinary teams. Such a team can be defined as a small group of people, usually from different professions, who are working together across formal organizational boundaries to provide services to a specific group of clients.11
Studies have shown that such teams may be an effective way to integrate welfare services, but at the same time a lot of time and energy is required to make them work.22 The process of building a multidisciplinary team goes through several stages of development. According to a classic theory, there are stages of ‘forming’, ‘storming’ and ‘norming’ before a team can be ‘performing’ and accomplish its goals.23 During these stages, conflicts have to be resolved and mutual trust established between the members of the team.24
Team building is a difficult process, but the building of a multidisciplinary team is particularly difficult. What makes this process so difficult is the existence of different professional cultures in the agencies involved.25 The members of a multidisciplinary team may have difficulties in understanding each other, due to different educational backgrounds and professional languages, and they may also be defending their professional territories.26
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Methods |
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In order to benefit from the experiences of the ReSam project, the agencies involved decided that the project should be evaluated by an independent researcher. The evaluation was made in the form of a process evaluation, where the co-operation between the agencies was closely followed and documented during the time of the project. This process evaluation was also combined with an evaluation of the effects of the project.
Different kinds of data were collected in order to get a picture as rich as possible of the process and the effects of the project. These data were collected by different methods and at different intervals during the time of the project:
- Individual interviews were made with officials, clients and managers during all the 3 years of the project. There were a total of 18 personal interviews and 10 telephone interviews. Nine officials, 10 clients and nine managers were interviewed. All the interviews were made with an interview guide focusing on obstacles and facilitating factors at different stages of the project. The interviews were recorded, transcribed and coded thematically in accordance with qualitative content analysis.27,28
- After each individual interview, the transcriptions and the interpretations of the data were sent to the interview persons for comments. This process generated a lot of additional data and clarifications. At the same time, it also provided an inter-subjective validation of the content analysis.29
- Focus group interviews with the officials involved were conducted three times, twice during the first year of the project and once during the second year. The groups were gathered to discuss issues brought up during the individual interviews that seemed to be important for the project at these stages. The discussions generated a range of views on different obstacles, but also a lot of ideas that the officials could use in the further development of the project.30,31
- Official information was continuously collected from the different agencies in the form of decisions, minutes, records, statistics, etc. This information provided data on the health status and employment situation of the clients, and the different forms of financial support and rehabilitation activities.
- The officials in the project were writing individual diaries about their experiences during the project and the individual cases they had been involved in. These diaries were collected three times during the project, and the information was used to supplement the official data from the agencies.
There was a continuous analysis of the different data during the time of the project, in order to evaluate the process of the co-operation and its effects. The process evaluation was also continuously discussed with the officials and managers involved. These discussions influenced the analysis, but they may also have influenced the development of the project. Similarly, the focus group discussions generated a lot of ideas that may have influenced the project. In this way, the evaluation of the project can also be regarded as a kind of action research.32
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Results |
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The development of the project
During the first months of the project, the most important issue was to establish a mutual trust among the officials in the project group. They tried to show each other respect and started to work together on clients. Very soon, however, the climate of collaboration deteriorated and there were destructive discussions, for example about the use of diagnoses and the status of different professions. Therefore, an external facilitator was brought in to help the group through this difficult period. By the end of the first year, the officials still had their disagreements, but they were now focusing more on their clients.
During the second year of the project, the officials started to work together in teams, or they consulted each other in individual cases. These were the two main methods of co-operation used in the project. The teams consisted of two or more officials from different agencies, but sometimes the whole group also worked together as a team to deal with individual clients. The co-operation was focusing mainly on different forms of financial support and different activities of rehabilitation.
During the second year, the group was struggling with concepts like assessment, diagnosis and training. Each agency had its own definitions and there were also different interpretations among the officials. As the project continued, however, the officials learnt more and more about each other, and also about the rules and regulations of the agencies involved. As one of the officials put it, ‘you learn to know about things that are going on in the other agencies. I didn’t think that there were so big differences’.
In the beginning of the third year, the project work was described in very positive terms. According to the officials, there was now a good climate of collaboration and an open dialogue between the members of the group. They were listening to each other and trying to take advantage of the different competences in the group. They were also trying to find solutions instead of problems, and they thought they had good methods of co-operation that could be developed further.
Obstacles to co-operation
When the officials described the problems of co-operation during the first year of the project, the main obstacles were related to personal characteristics and relations between the members of the group. There was unwillingness to work together and a tendency to talk at cross-purposes. They felt that members of the group were questioning and attacking each other in a way that was seldom justified.
In the second year of the project, however, the description of obstacles changed. Instead of focusing on the relations within the group, the officials were now identifying obstacles outside the group. One major obstacle was the lack of support from colleagues in the home agencies. As one of the officials pointed out, ‘I have had to fight for this project and I have to defend myself against my colleagues in the agency. It is a consolation that my superiors are positive’.
Other obstacles described by the officials were the limited resources and the limited time allowed for the project. In their opinion, more resources were needed for project activities and more time was needed for meetings and coordination of the work. The clients confirmed the need for more time and resources. They would have liked to have more contacts with the officials and the teams dealing with them.
A particular obstacle, mentioned by all the officials, was that two of the agencies required a medical diagnosis on the clients. One of the officials described this obstacle as follows: ‘We are not coding our clients according to diagnoses, but others are asking for diagnoses in order to decide what services the clients can have access to. It is offensive for some people to be put into a certain category like that’.
Another obstacle was that when the group reached a decision, based on the assessments of the officials from the different agencies, it could still be overruled by one of the agencies. For example, the group could decide that a client should get sickness benefits and then, in the final stages, this decision was not accepted by the social insurance administration. When these things happened, the officials came into awkward positions in relation to both the project group and their home agencies.
Facilitating factors
There were a number of factors contributing to the positive development during the second and third years of the project. The most important factor was that the officials learnt more about each other and the agencies involved. They also learnt to know each other personally, which facilitated communication and exchange of information and experience in the group.
As the climate of collaboration improved, there was also an increasing level of activity and efficiency in the group. With this development, the initial difficulties could be seen in another light by the end of the project. According to one of the officials, ‘the collaboration is working very well today thanks to the process we went through in the beginning of the project, when the group was established’.
Beside the group process, another facilitating factor was the personal motivation of the officials. There was a lot of time and energy spent on group discussions during the first year of the project, but there was also a lot of personal commitment. The members of the group wanted to do something good and creative, and they had a willingness to try new ways of dealing with the clients. As one of the officials described it, ‘the individuals are very important for the ReSam group. It is partly a question of their courage, since the rules are very loose and everything can be discussed’.
There were also other facilitating factors mentioned by the members of the group, for example joint seminars and training sessions that brought new knowledge and helped to bridge the language difficulties in the group. The external facilitator, who continued to supervise the group after the initial phase, was also important for the development of the group. In addition, the co-operation was strengthened through informal contacts and meetings that the officials had outside the group. Many of the officials pointed out that co-operation is very much a question of getting to know the people involved.
The effects of the project
The project group was dealing with a total of 66 clients during the 3 years of the project. Most of these clients were financially supported by social assistance when the project started, but many of them were also supported by sickness benefits and unemployment benefits. After the end of the project, three of the clients had become fully employed, while one of them was employed 50% and another was employed 25%. As a consequence, the number of clients supported by social assistance and unemployment benefits was reduced.
It is difficult to know if these employments were effects of the project, since there may have been many other factors involved, but it seems that the project activities at least contributed to the employments. The clients were encouraged to seek employment and they were also supported in their job-seeking efforts.
In addition to the employments, a number of clients previously supported by social assistance or unemployment benefits were granted sickness benefits or early retirement. Most of these changes in financial support were decided after discussions between the officials in the project group. Thus, the project may have contributed to a more appropriate distribution of different forms of financial support.
The most important effects, however, were probably the lessons that the officials learnt during the project. One of the lessons was the importance of listening to each other. They learnt to be open to contributions from the different competences and the different ways of working that were represented in the group, and to take advantage of these differences in dealing with their clients. Another lesson was the importance of making a quick overview of all the problems involved in a case, in order to see the responsibilities of the different agencies. The officials found that the project had made them think in new ways and to see possibilities outside the existing boundaries.
Finally, as an additional effect, it should be mentioned that the co-operation between the different agencies has continued after the end of the project. This means that the methods of co-operation may be further developed, which may have long-term effects on the unemployment in the area.
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Discussion |
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The analysis of the co-operation between different welfare agencies in the ReSam project has been focused on the collaboration between officials in the agencies involved. Most of the work to integrate the services of these agencies was going on in the multidisciplinary project group and the different teams emerging from this group. The steering committee was co-ordinating the project by imposing limitations in time and resources, but otherwise not interfering very much in this process.
The development of the ReSam group followed the classic pattern of team development.23 First there was a ‘forming’ period, when the members of the group started to work together. Very soon came a period of ‘storming’, when there were disagreements and conflicts between the different officials. After some time, the storming period was replaced by a period of ‘norming’, when the officials slowly began to trust each other and develop different methods of collaboration. This period led to a period of ‘performing’, when the group was accomplishing its tasks in an efficient way.
In the ‘storming’ period of the project, many of the disagreements and conflicts were related to differences in the organizational structures and professional cultures of the agencies involved.25 The organizational structures were manifested in the different rules and regulations of the agencies and their different ways of working with clients. The professional cultures were based on the different educational backgrounds of the officials and manifested in their different languages and attitudes towards the clients.
In contrast to other co-operation projects,12 there were very few conflicts over resources in the group. Instead, there seemed to be a general agreement among most of the officials that the resources of the project were not sufficient to deal with the complex needs of their clients.
In the ‘norming’ and ‘performing’ periods of the project, there was a process of trust building between the different members of the group. Slowly, as the project went on, the officials learnt to know and trust each other. This was a long and difficult process, particularly in view of the previous conflicts in the group. Trust building always involves an element of risk taking.24 According to many researchers in the field, however, trust is a fundamental condition for all forms of co-operation.21,33
The relationships between the members of the group and their home agencies were complicated. The officials felt they had very little support from their agencies, although their managers supported the project. Moreover, as the project went on, their loyalties became more and more divided between the group and their agencies. They were torn between the regulations and resources of their agencies and the ambitions of the group. Similar difficulties have also been described in other co-operation projects.13,25
The effects of the project are open to discussion. It is difficult to know what the project really achieved, but there are reasons to believe that the project activities have contributed to reduce unemployment and maybe also to a more appropriate distribution between different forms of financial support. The question is whether the co-operation between different welfare agencies was more important for the officials than for the clients, but the fact that the officials have learnt to work together across the boundaries of their agencies may have important long-term effects on the provision of welfare services.
Returning to the debate on the future of the welfare system, many critics have envisaged a more integrated system that can deliver more integrated services adapted to the complex needs of the post-industrial society. The question is whether co-operation between different agencies is a strategy for provision of such services, or if it is just a way to save the old system for the time being.
The study of the ReSam project does not give any clear indications. Maybe 3 years was too short a time to see any clear effects. Maybe the effects will be seen only after a longer period.15,17 What the project has shown, however, is that it is possible to co-operate across the organizational boundaries of five different welfare agencies. The project has also shown that such inter-agency co-operation takes a long time to establish and requires a lot of energy and commitment from the officials involved. They often found themselves in difficult situations, where their loyalties were divided between the project group and their home agencies.
The main conclusion that can be drawn from the evaluation of the project is that co-operation may be an effective strategy to deal with clients who need services from different welfare agencies, but this strategy requires a considerable investment in time and energy and should therefore be used with caution. In the words of two leading researchers in the field,8 ‘don’t do it unless you have to’!
Key points
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