Le services à l’enfance et à la famille à l’ère numérique De nouvelles opportunités pour la collaboration multi-professionnelle et l’autonomisation des usagers
- Type de publication : Article de revue
- Revue : European Review of Service Economics and Management Revue européenne d’économie et management des services
2017 – 2, n° 4. varia - Auteurs : Leväsluoto (Johanna), Hyytinen (Kirsi), Toivonen (Marja)
- Pages : 17 à 47
- Revue : Revue Européenne d’Économie et Management des Services
Child and family services
in the digital era
New opportunities for multi-professional collaboration
and the empowerment of users
Johanna Leväsluoto1,
Kirsi Hyytinen2
and Marja Toivonen3
Introduction
Securing the welfare of population is one of today’s grand challenges, a characteristic of which are increasing service needs and diminishing financial resources. In Western countries, the service needs have grown due to the ageing of population (Bloom et al., 2015) and to the persistence of many social problems: unemployment, economic inequality, alcohol and drug abuse, etc. (Mossakowski, 2008). To some extent, the problems have become more ‘wicked’ (Blackman et al., 2006), and accumulate among certain individuals and households that need several different services simultaneously (Korpi et al., 2007). Both governmental authorities and local policy makers aim to develop intervention strategies and reconstruct their responses to these problems to maintain the basis of the welfare state (Harrisson et al., 2010).
18In the intervention strategies, the improvement of access and continuity of services is an important goal. Integration across sectoral and organizational borders and collaboration between the service providers and users have been central means to achieve this goal (Winters et al., 2016). Empowerment of citizens to do their best in promoting the conditions of their welfare is another new focus and part of the efforts to prevent problems in advance. It has changed the view of the service user as a passive recipient and highlights the co-creation of service value (Alves, 2013; McColl-Kennedy et al., 2012). Integration and collaboration have also been suggested to promote efficiency and effectiveness, which are pursued as an answer to the problem of scarce resources and have favored the adoption of evidence-based approaches to the development of welfare services (Sanderson, 2002).
In the welfare sector, new practices have been examined and implemented first and foremost in healthcare. Here, the integrated care models have been developed systematically to include patient support, structured follow-up and case management, multi-professional teams and clinical pathways, and the education of professionals (Ouwens et al., 2005). Also the combination of health and social care has become common in both research and practice (Cameron et al., 2014). However, this discussion has been at a general level and has not concerned the integration of subsectors of social care (Fisher and Elnitsky, 2012). Reasons are probably country-specific variations in the field as well as its dispersed nature. Social care includes extensive service wholes promoting and maintaining the functional capacity, social wellbeing, safety, and inclusion of individuals, families and communities (Jensen, 2008).
Thus, we have identified a research gap concerning the integration of different services linked to social care. In the present article, we aim to narrow this gap by examining first the central theoretical issues that influence the opportunities, benefits and challenges of the integration of social care. Thereafter, we describe results from an empirical study that we have carried out in Finland in a sub-area of these services: social care for children and families. This area is especially important from the viewpoint of problem prevention: early support helps to avoid the development of ‘problem career’ and the ‘inheriting’ of problems to the next generation (Korpi et al., 2007). Child and family services are also an illustrative example of the dispersion of social care: there are 19multiple services requiring different expertise and professional practice, and part of these services are tightly linked to healthcare and schools.
The integration of child and family services was already highlighted twenty years ago when publicly supported programs in this area started to develop actively (Knitzer, 1997). Initiatives of cross-system collaboration and early intervention spread in different sub-domains of these services. The transformation was aimed to concern responses to the needs of children and families, professional practices, and the ways in which services were organized. However, the actual changes have not been as notable as was desired. The lack of coordinated multi-agency working in children’s services has been highlighted in many studies (Percy-Smith, 2006; Sloper, 2004; Watson et al., 2006). It is also unclear to which extent these services have adopted the new practices of user involvement and empowerment – actively applied in healthcare. As regards the most recent development, very little is known about the utilization of digital tools as a supporting device or platform in the integration of social care and in the collaborative practices in this area.
We pose the following two research questions to guide our study: 1) What are central issues in the integration of child and family services across sub-sectors and professions and how could digital tools promote this integration? 2) What kind of practices of user involvement and empowerment can be found in child and family services and how could digital tools promote these practices?
Our theoretical analysis is structured to provide basis for the empirical examination of these research questions. It reviews literature on professions that have traditionally been strong in welfare services and built on a specific discipline and expertise (Currie et al., 2012). It also summarizes research concerning the participation of users in the provision of services aimed at helping them. We mainly apply the concept of ‘user’ as we consider it to describe best the active and long-lasting role of the service ’recipient’. However, in some contexts describing the collective nature of welfare services, the concept of ‘citizen’ is more natural. We also use the concept of ‘customer’: in the reviews of studies with this focus and in the direct quotes of our interviewees.
The perspectives applied in the research of welfare integration and the respective cross-sectoral collaboration have usually been divided into macro, meso and micro levels. Here, the macro perspective has 20represented the viewpoint of the society, the meso perspective the organizational and professional levels, and the micro perspective the everyday practice (Fisher and Elnitsky, 2012; Winters et al., 2016). Our study is mainly positioned at the meso and micro levels. However, in the theoretical part, we also briefly touch the macro level: we start our literature analysis from the paradigmatic development of service views in the welfare context. This is because we consider it important to realize that the practices to be discussed mean profound changes and it is not surprising if the novelties do not gain ground very rapidly.
We have structured our paper as follows. In the first section, we present the theoretical background of our study. In the second section, we describe the context of our empirical study and the methods of data collection and analysis. The third section summarizes the results, and the last section includes the concluding discussion.
I. Theoretical background
This section provides the theoretical basis for the analysis of our research questions: it reviews central issues linked to cross-professional work and the involvement and empowerment of service users. In order to frame these questions, the section starts with a short analysis of the paradigmatic views concerning welfare services.
I.1 Three paradigmatic views on welfare services
The development of welfare services is tightly linked to the development of the public sector – in most countries, these services are at least partially public activities and publicly regulated. Thus, it is reasonable to suppose that the long term trends in welfare services are interlinked with the way in which the tasks of the public sector have been understood. Three paradigmatic views have been generally identified: traditional public administration, New Public Management (NPM), and network governance. Table 1 summarizes their central characteristics based on Hartley (2005). The original presentation has been slightly modified to highlight the topic of this article.
21
Traditional public administration |
New Public Management (NPM) |
Network governance |
|
Context |
Stable |
Competitive |
Continuously changing |
Governance practices |
Bureaucracy, centralization |
Market imitation, public-private partnerhips |
Networks, partnerships, empowered citizens |
Service needs |
Expert assessment |
Expertise and demand |
Context specificity |
Population |
Homogenous |
Atomized |
Diverse |
Service users |
State ‘subordinates’ |
Customers |
Co-creators, co-producers |
Technology as an enabler |
Discipline based |
Lean processes |
User-driven processes |
Key concept |
Public good |
Free choice |
Use value |
Tab. 1 – Three paradigmatic views on the public sector
(modified from Hartley, 2005).
These paradigms are based on particular assumptions about human needs and societal challenges and provide different approaches to the generation, adoption and implementation of welfare services. They include diverse understandings of the means to answer the needs and of the roles of various actors to tackle the challenges (Hartley, 2005; Lévesque, 2013; Moore and Hartley, 2008).
Traditionally, the public sector was understood in terms of authoritative and rule-based governance; a centralized, bureaucratic and hierarchic order was typical. The provision of necessary services was a central task of the public sector; services were seen as ‘public good’. The service needs were defined by professional experts, and the enabling technologies were discipline-based (e.g. medical technology). Citizens were given the role of ‘state subordinates’ and ‘service receivers’ (Torfing and Triantafillou, 2013). Services were often standardized as the basic needs were considered homogenous (Langergaard, 2011). This kind of paradigm worked quite well as long as the context was fairly stable. Along with the increasing pace of change and insecure developments 22in the society, the rigidity and inefficiency of the paradigm became evident and led to the introduction of ‘New Public Management (NPM)’, which started to gain foothold in the Western world more than twenty years ago.
The basic idea of NPM was to apply market mechanisms in the public context: business-type management and performance focus exemplify the aims (Langergaard, 2011). In an increasingly competitive environment, contracting out and partnerships with private companies were considered important. A core change was handling the citizens as customers who have the right to require high service quality. Free choice and customer satisfaction became central slogans. In addition to expert assessment, demand was emphasized as an indication of service needs, which were no more regarded as homogenous but individual (Hartley, 2005; di Meglio, 2013; Windrum, 2008). In addition to disciplinary-based technologies, the technologies of industrial management – lean processes – were adopted to pursue the efficiency goals (Pollitt, 1993; Tummers, 2013). The benefits of NPM are indisputable in terms of customer influence. On the other hand, the latest development has brought to the fore phenomena that have again revealed differences between the public and private sectors. As a result, a third paradigm ‘Network Governance’ has been emerging.
Network Governance broadens the perspective from the provider-customer dyad to multi-directional relationships and partnerships: to an open dialogue between various actors (Langergaard, 2011; Newman and Clarke, 2009). It argues that market imitation cannot solve the issues of increasing societal fragmentation, complexity and dynamism, but new forms of non-hierarchical, decentralized governance mechanisms are needed in the public sector (Moore and Hartley, 2008; Rhodes, 1997; Sørensen and Torfing, 2007; Voß et al., 2006). Co-creation of service value and co-production of concrete service processes are important phenomena that reveal the deeply contextual nature of human needs – the needs are diverse but not atomistic. Expertise is too narrow a means and demand is too general and temporary an indicator to assess these needs. A more suitable approach is interactive processes in which empowered citizens play a central role. Correspondingly, the discipline-based and lean technologies have to be supplemented with user-driven processes (Sørensen, 2002).
23Currently, Network Governance evolves in parallel with market imitation and the still surviving elements of bureaucracy (Newman and Clarke, 2009). In welfare services, there are increasingly horizontally organized service systems that cross professional and organizational borders and encourage bottom-up activity, but there are also sectorial ‘silos’ and centrally managed systems with a top-down order. One area in which the development shows contradictory features and has caused notable disputes is the nature of professional work. New Public Management has aimed to introduce a new settlement of relationships between the citizen and the state and between management, political control and professional responsibilities (Clarke and Newman, 1997). This new settlement has gained ground to some extent but both the older forms and new trends create tensions in its implementation. In the following, we analyze these tensions in more detail in order to understand the framework conditions for the cross-professional work in child and family services.
I.2 Changing forms of professionalism
and social services as professions
In welfare services, the role of professions has traditionally been strong; the status of professionals has been legitimized by scientific knowledge (Tummers, 2013). The privileged expertise going with this status has maintained a social distance between professionals and service users and made their collaboration difficult (Parker and Joel, 2013). The basis of expertise has, however, been a target of lively discussion during the last decades. A key dichotomy has been between ‘organizational professionalism’ and ‘occupational professionalism’ (Evetts, 2003). The former is the traditional form of professionalism, emphasizing the self-regulation of work by professional groups, whose expertise places them in a position to act best in the interests of service users. The latter is the managerialist version of professionalism, being associated with the principles of New Public Management (Hood, 1991).
Managerial professionalism posits new requirements to professionals: besides the mastering of the disciplinary contents, they are expected to be entrepreneurial, creative, and efficient lifelong learners and team workers (Dent and Whitehead, 2002). They are expected to implement various policy programs whose practical content may be difficult to 24identify (Tummers et al., 2009). Both resistance and acceptance have been perceived as a reaction. A natural reason for resistance is the concern that the new practices threaten the autonomy of professionals. A commonly expressed fear is also the weakening of the basic values linked to professionalism (Evetts, 2011). On the other hand, it has been found that professionals may advance their own interests by capturing the reforms. Capitalizing on the opportunities afforded by NPM has been particularly visible in healthcare (Waring and Bishop, 2013).
It seems that neither of the two ideal forms of professionalism works as such in the reality, but they are combined into various hybrid forms (Skelcher and Smith, 2015). In recent research, the focus is moving to the identification of the ways in which professionalism is acted upon, and evolves over time (Tonkens et al., 2013). The embeddedness of organizing capability as a part of professional work has been highlighted in this context (Noordegraaf, 2015). Working together across professional groups is one area which represents an evolutionary adaptation of traditional professionalism and includes the acceptance of inter- and multi-professional approaches (Parker and Joel, 2013). As new services are increasingly co-created, there is a multiplicity of possible outcomes, i.e. hybrid forms between the extremes of professionalism (Fischer and Ferlie, 2013). The question is of the willingness of professionals to share their knowledge and of the ability to interpret it in different domains.
As mentioned above, social services do not form a homogenous entity. Here, the role of professionalism has been more ambivalent than in the sectors with a unifying disciplinary basis (e.g. healthcare). The complexities of social work practice and the diverse meanings associated with it are acknowledged in literature (Hutchings and Taylor, 2007). The lack of a distinctive knowledge base has been used to question whether social work is a profession. Social workers have never had the autonomy to define ‘private and public ills’ in the same way as the medical profession has defined diseases. Thus, the sector has adopted a looser approach to professionalism, even though a trajectory towards professional status and professional power has been recognizable to some extent (Parker and Joel, 2013).
Some researchers have argued that social work challenges both the traditional and managerial professionalism. It moves away from an exclusive, elitist and self-creating profession to one which focuses 25on core values and working together with those who use its services (Parker and Joel, 2013). While the first part of the argumentation may be justified, the conclusion sounds idealistic and resembles the views of traditional professionals – just from a different angle. It bypasses the internal diversity of the sector: the sub-professions and specializations. Within these sub-professions, different cultures exist and include their own values, beliefs, attitudes, customs and behaviors (Hall, 2005). In order to fulfil their basic purpose, some professions must use authority for the best of their customers (e.g. child protection) while others can rely on a much more dialogical approach (e.g. preventive family counselling).
I.3 Participation and empowerment
of the service users
The co-production relationship has been highlighted as a fundamental characteristic of services (Sundbo and Gallouj, 2000). The user of a service is an active party in the service encounter as the provider of the necessary background information, and usually also as the carrier of some tasks. Correspondingly, the benefit of a service is not only based on the outcome, but the success of the process is crucial (Grönroos, 1990). The approach of service-dominant logic (S-D logic) has supplemented this view with the value co-creation perspective. The service provider cannot create value on behalf of the user because value is not inherent in a service. Before it can be realized, the service has to be used. The user integrates the input received from one provider with other resources received from other providers (Vargo and Lusch, 2004).
Managerial implications of co-production and value co-creation have been studied from different angles. Understanding the needs of users on the basis of systematic accumulation of feedback is an established approach. Both service improvement and expectation management have been implemented in order to increase customer satisfaction; the latter refers to aims at transforming fuzzy expectations more precise, implicit expectations more explicit, and unrealistic expectations more realistic (Ojasalo, 2001). In recent years, a deeper view has been pursued: service experience and social networks as the framework for this experience have been highlighted (Payne et al., 2008). The focus has been on the customer path both in the service encounter and outside it: in the customer’s own context (Bitner et al., 2008). Facilitation of the activities 26that customers take on this path is considered important. Awareness of the central role of the customer is visible in the abundancy of concepts used to describe this role: collaboration, involvement, engagement and participation.
The perspectives of co-production and value co-creation are gaining ground in welfare services, too. In the public sector, where a great part of these services are produced, the role of citizenship comes to the picture and complicates the situation. Citizens are not only individuals but responsible members of a collective, and they are not always sovereign actors but restrained by existing structures, e.g. power structures (Rosenthal and Peccei, 2007). The rights and responsibilities of citizens differ from those of customers, which implies that also user participation and collaboration with users have specific characteristics in this context. However, both NPM and Network Governance highlight that citizens should be active partners in planning, creating and shaping the delivery of public services (Moore and Hartley, 2008).
‘Citizen empowerment’ has been a key concept in the analysis of participatory practices in the welfare context. WHO (1997) defines empowerment as a process through which citizens get greater control over the decision and actions affecting their health and wellbeing. In the background of this definition, there is a view that people are subjects and actors who have sufficient skills, understanding and self-efficacy to take the responsibility of their own health and wellbeing (Mäkinen, 2006). Citizen empowerment gives users the role of partners – a view that can be regarded as ‘revolutionary’ compared to the traditional paradigm of public services. Locating citizens in the middle of service-related decision-making improves democracy and encourages politicians and professionals to find new ways to interact with citizens (Bovaird, 2007).
The advancement of information technology and the creation of new digital applications have provided citizens with new capabilities and ways to participate and express themselves in the networked society. Thus, citizen empowerment through digital platforms has become a topical discourse (Mäkinen, 2006; Papastergiou et al., 2009; Samoocha et al., 2010; Webb et al., 2010). Research and development (R&D) in this area has been especially active in health care (Honka et al., 2011). The aim is not only to promote the use of technical facilities, but to 27create a multi-stage process for better networking, communication and cooperation opportunities, and to increase the competence of citizens as influential participants in the society (Mäkinen, 2006).
Several studies indicate that digital empowerment is not only a goal but the empowerment of citizens can be accelerated with digital devices and applications (Papastergiou et al., 2009; Samoocha et al., 2010; Webb et al., 2010). Digital empowerment has helped in ‘setting citizens on the drivers’ seat’ so that they can manage their own wellbeing (Honka et al., 2011). The ways in which new digital services enrich participation include diversifying the information flows, increasing horizontal communication and opening new bridges to marginal or remote areas and people (Mäkinen, 2006).
On the other hand, researchers argue that the potential of service co-production is deficiently understood in the public context (Bovaird, 2007). A weak point is especially the collaborative process through digital platforms (Honka et al., 2011; Moore and Hartley, 2008). Digital tools and practices to support citizen participation are not developed and utilized sufficiently (Mäkinen, 2006). The reasons behind these problems are only partially known: their linkages to inefficient policies, to the service culture, and to the attitudes of professionals and users need more detailed studies. It is also unclear what are the concrete changes in the practical activities that would support in the best possible way both the actual partnership with citizens and the utilization of communication and interaction channels between citizens and professionals.
I. Empirical context and methodology
Our empirical study analyzes an ‘experiment’ in which a middle-sized Finnish city (with 67 000 inhabitants) developed ‘an integrated model of wellbeing’ for child and family services. The development was part of a nation-wide project that aimed at promoting local experiments as an alternative to centralized planning in the renewal of public services. Based on a decision of the Finnish Parliament, cities and municipalities were given the possibility to experiment a selected new service practice 28for two years (2015-2016). The goal was to accelerate innovation in the public context and in this way to answer better the needs of citizens and empower them, enhance multi-actor collaboration, and reduce costs. This section presents the research context in more detail and describes the collection and analysis of the empirical data.
II.1 Context of the study
In Finland, the development of social services is based on the model of ‘Nordic welfare state’ in which a broad social security and a strong role of the public sector are central characteristics (Kettunen, 2001). Cities and municipalities are the core actors in the delivery of social services. They are also responsible for the majority of health services, children’s daycare and primary schools. Based on the procurer-provider model, private companies can deliver some services but here, too, the public organizations define the nature, costs and quality of services (Kivisaari et al., 2013).
The ‘integrated model of wellbeing’ in our case was a life-cycle based total offering whose objective was to support multi-professional work and reinforce the citizens’ ability to take responsibility of their own wellbeing. The integration focused on the sector of social care (child protection and family counselling) but it also included the preventive and therapeutic services for this population in the neighboring sectors: daycare, primary schools and health care including child health care. In the core of the model was the use of a digital platform as a mutual information and communication channel between citizens and different professionals. Another important cornerstone was a ‘service plan’ to which both the citizens and the service providers commit themselves. It also aimed at empowering citizens to participate in planning the services targeted to them.
The development of integrated social services was not a totally new idea in our case city. Rather, the nation-wide experiment provided a natural continuation to the work which had started in 2008 and included a renewal of the organizational arrangement and customer processes in the services targeted to children and youth. The responsibility for the organization of these services was allocated to suburban level in the city; seven local suburbs were expected to promote service integration and user-based processes. This renewal included all services in daycare 29and primary schools (i.e. not only social support), and it also included leisure services for young people (Mäensivu et al., 2017). In addition, the city had experience of integrated health care: cross-professional work, selfcare and digitalization were in use in its primary health centers when the corresponding effort started in social services (Määttä et al., 2014).
In the new experiment, integrated services were especially targeted to citizens who have multiple needs for social care and who therefore are in contact with different professionals from different sectors. The focus was on preventive services that can diminish problems whose afterward relieving requires much more resources. Four key processes were identified: early discussion about the concerns of citizens, high quality multi-professional collaboration, support to the parenthood (from pregnancy to adolescence), and the development of social skills of both parents and children. These processes were concretized into life-cycle based and integrated service products. Local differences were taken into account by involving representatives of both the city center and the suburbs in the development work. A management team including professionals from different sectors was established in each region to take care of the implementation of the new types of services; the appreciation of the views of grassroots employees was also encouraged.
A common service plan, which was a core idea in the experiment, aimed at collecting together the various plans that were made for the customer, each of them answering a specific need. In order to secure that the new holistic plan takes into account all these needs, a close collaboration was built between the different professionals and the customer. One professional within the multi-professional group was responsible for the compilation and the later updating of the integrated plan. He or she invited all other relevant professionals to this activity and to the respective implementation of the plan. An important element in the experiment was a digital platform which was established to facilitate the distribution of information: the professionals and the customer had access to common information. They could also update and complement the service plan that was made in the electronic form and located on the platform.
30II.2 Data collection and analysis
We applied semi-structured interviews as our main source of data: the topics were decided beforehand but within them, the respondents were given a great deal of freedom (Bryman and Bell, 2011). The main topics of the interviews were: 1) the background of the multi-professional collaboration and its current stage in the child and family services, 2) the role of customers in the multi-professional service interaction, 3) the main elements of the new integrated model of wellbeing, 4) the aims of the new model, concerning the digital service plan in particular, and 5) the managerial challenges linked to the new service practice and to the change pursued.
We interviewed both city managers and the professionals involved in the development of the new model. We applied snowball sampling in the search for the interviewees: we interviewed first the manager of child and family services in our case city. Based on her suggestion, we thereafter invited other interviewees: 4 other managers and 18 professionals. The group consisted of two managers of educational services, the manager responsible for the development of the digital platform, and the manager responsible for the procurement of child and family services.
The interviews of the four managers were conducted individually. The professionals were interviewed in three groups, which included five to seven participants. The first group consisted of five professionals from child protection, family counselling, and prenatal and child health. In the second group, seven professionals represented specialist day care, pre-primary education and therapeutic services (speech and activity therapies). While these two groups were specifically compiled for the interviews, the third group collaborated on a more permanent basis: this group with six professionals was responsible for the evaluation of customers’ service needs. They represented family counselling, health services in primary education, day care, and team leaders of child and family services. As there were several representatives of the same profession in the group interviews, the citations of different respondents belonging to the same profession have been marked with A, B, C, etc. The interviews were carried out between October 2015 and February 2016.
We also used supplementary material in our study. The first source of this material were official documents. They included strategy documents 31on the nation-wide initiative for local experiments, and descriptions and implementation plans provided by the city. The second source of supplementary material were our own studies that we had carried out earlier on the development of social services in the city suburbs (Mäensivu et al., 2017) and on the implementation of integrated primary care in the city’s health centers (Määttä et al., 2014). These studies, in which the second and third authors of this article had participated, provided us with important background material based on long-term observations and interviews.
The analysis and interpretation of the data was conducted in a dialog between theory and empirical findings. We did not use any computer-assisted coding tool, but several rounds of analysis were carried out to derive meanings from data and to reduce the amount of data (Huberman and Miles, 1994). While reading the interviews and the documentary material, we uncovered the most common and typical themes, and classified and structured them. Our aim was to create a holistic understanding of the research topic via systematic and thorough analysis of the interview responses. The quotations in the results sections illustrate the level at which extracts were picked from the material. The empirical observations were linked to the theoretical views of the article: the nature of welfare services, multi-professional collaboration, and the participation of users in service delivery. Finally, the analysis results were presented to the city representatives who participated in the study; for this purpose, a workshop was organized to validate the results and to acquire supplementary information.
I. Research results
This section presents the main results of our empirical study. It focuses first on the issues of integration in child and family services – issues that are tightly linked to the cross-sectoral and multi-professional collaboration. We start with the description of the general views on the collaborative culture in our case organization and analyze thereafter more specific views on the integrated service plan, on its technological 32aspects (the digital platform), and on its implementation. Second, we present the results that are linked to the participation of service users. This analysis is divided to the issues of customer expectations, potential benefits, and the ways to empower citizens; here again, we also pay attention to the role of the digital platform.
III.1 Integrating child and family services
and supporting them with a digital platform
The results revealed that the professionals participating in the change process had positive experiences about working with other professionals and they welcomed new possibilities in multi-professional practices. They wanted to break down organizational silos and to lower barriers between professionals and service users. However, the broad scope of the new model was seen challenging because there is an inherent difference between the ‘missions’ of social services and educational services. The latter (including primary and pre-primary education) are focused on teaching contents whereas the former (including daycare) focus on customers’ welfare in a holistic way. These differences make it difficult to set common goals despite a genuine will.
There were also doubts concerning the collaboration between social services and specialist health care due to the traditional division of labor and the power distribution between social and health sectors. These doubts were visible, for instance, in the prejudice that doctors in specialist care would not be willing to cooperate with social service professionals and participate in the use of the common service plan. However, the citation below shows that the situation was not that straightforward:
Two health care professionals in specialist care have been very excited. It has been a total surprise. [Representatives of] child protection and the hospital district have, for example, been very eager to initiate collaboration. However, the current legislation limits collaboration. Anyhow, the multi-professional collaboration has been seen as a good start also from the viewpoint of the professionals in specialist care. (Team leader of child and family services)
The interviewees considered that an important positive effect resulting from the new model and the related digital platform is the possibility to see information produced by the professionals of other sectors in common customer cases. An inadequate share of information had 33caused difficulties, for example, when a child gets special support in daycare and also needs therapeutic or child protection services. The lack of common information ground had hampered the creation of an overall picture of children’s situations and reduced possibilities to offer the best possible services. Without a common platform, the only ones who can combine information from various sources are service users, but they do not usually know which pieces of this information are available to each professional. Moreover, it may hinder dialogue between professionals and professional and customers in the information delivery is only on customers’ shoulders. The citation below confirms these problems:
I think that the parents assume or believe that we know all the customer information. They do not realize that in every sector we have different information systems and we do not have rights to use the information systems of other sectors. Therefore, currently it is customers’ task to inform professionals in other sub-sectors. If the customers do not pass their information, professionals should request them to do it. (Representative A of specialist daycare)
Another problem that the new model relieves is the change of the individual professional providing the service to the customer; the fact that the professional does not stay the same during the process causes breaks in the information transfer. According to the interviewees, the common service plan would help to manage situations in which a new professional enters the multi-professional team. He or she can see in the common plan, which issues have been discussed and which goals have been set earlier by other professionals and the customer.
When we make a service plan for the customer and new professionals come to the team, they can see all the information and the issues that have been discussed and agreed earlier. (Representative A of therapeutic services)
Despite the positive attitude towards the model, the interviewees described that the new digital tool came as a surprise to them. Preparation of the renewal and development of the new digital platform were in the hands of the city management. According to the interviews, the development of the new service plan did not follow the principles of co-creation; only a few professionals participated in the development process. Broader information was given only in three implementation sessions arranged by the city. Also the dates of these sessions were informed very 34late. Due to the tight timeline and professional priority on the customer work, only a few professionals were able to attend these sessions.
We got an invitation yesterday to meet next week’s Tuesday. We have arranged customer appointments two weeks ahead and it is very difficult to fix new times for the customers. You would need to call to customers and rearrange the meetings, which might have been cancelled and rearranged many times before. Sometimes I feel that there is another project, which forces me to abandon my primary work. (Representative A of prenatal and child health)
Also more generally, the professionals considered that the experiment had generated new tasks and responsibilities that challenged the ordinary work. According to them, ‘a never-ending flow of new tasks’ decreases the face to face time with customers. In the long run, the increase of the workflow may cause well-being problems.
The main problem is that there are always more and more responsibilities even though your workload is already full. New tasks are on the top of the former responsibilities. Nothing is taken away. The key question is, how long you can increase the workload of professionals. Do we think that they can cope with all these new tasks and responsibilities? (Representative B of specialist daycare)
The professionals were also concerned about the experimental nature of the new model. They felt that the new model was again one experiment which will be tested and piloted in the city but will not become a part of their daily practices. Thus, they had difficulties in motivating themselves to participate actively in the development process. Notably, this was not the only development project facing this challenge as the following quotation of an interviewee from the pre-primary education shows. She highlighted problems in identifying which development projects are genuinely impactful in practice and therefore worthy to participate:
There are many experiments starting; in the end, they do not affect any practices. Often these initiatives even stop before they have properly started… Initiatives come and go, come and go. And when you have lot of work, you can continue without realizing the effects of these experiments. It is very difficult to know in which experiments you should take part. Quite often when I have tried to participate and wanted to find out what is the idea in an initiative, the experiment has disappeared meanwhile. (Representative A of pre-primary education)
35Deficiencies of the technological platform were described as a particularly difficult issue in the development of the new model. The interviewees also highlighted that the introduction of new digital platforms as such is time-consuming: it requires learning and patience both from the service providers and from the users. This time is taken away from the face-to-face customer contacts which, anyhow, are the most important part of the service. In the present case, an additional problem emerged from the fact that the platform had been developed separately and hence it was not connected to the other ICT platforms that the professionals used. Representative (A) of pre-primary education summarized the feelings of many others by saying ‘separate and incompatible digital platforms lay extra burden to professionals’.
In the implementation of the new tool, there were also many minor technical problems which had negative impact on the reputation of the renewal according to the interviewees. For example, the use of the platform required identification and all professionals did not have necessary tools for it. The interviewees highlighted that for ensuring the commitment of practitioners, it is important that the digital tools work without problems right from the beginning. They also remarked that the developers of digital tools often forget that some workplaces may operate without required digital equipment. This is a typical situation in daycare homes, for example. It is not self-evident either that all service users (e.g. immigrants) have computers. Mistrust towards new technology can be a problem, too, including fears about the disappearance of information.
Our study revealed that the expectations concerning the integrated model of wellbeing were very different between the managers and the professionals. The managers assumed that the new model would improve customer-centricity in social services and the digital tool would make the work of professionals easier because it facilitates the access to information. However, it turned out that even the basics of the renewal were poorly known among the professionals. There were misunderstandings and the professionals did not know how the digital tool should be used in practise and what it meant for their daily work. The following two quotes illustrate the opposite views:
Multi-professional work is an established way of working in the city. A common service plan is a good tool to make this multi-professional work easier. (Manager responsible for the procurement of child and family services)
36I have a very distant relation to this project and I do not know anything about it. I was not able to participate in the first implementation session in which the model and platform were presented. I have had a lot of work and [I have worked] also overtime hours so I have not had the time to ask my superior about this. I only received this invitation to the meeting [study workshop] – otherwise, this project is a total mystery to me. (Representative B of prenatal and child health)
All the problems included in the implementation of the integrated model led to a situation that the recruitment of users was passive. The interviewed professionals told that they felt unsure and did not have all the necessary information to start recruiting citizens. This opinion is illustrated in the next citation:
We did not have enough information to completely understand the concept. And because I did not understand it myself, it was not possible to market it to customers as a positive and good tool. (Representative B of therapeutic services)
The objective of the common service plan was, with the help of the digital platform, to enhance information flow between professionals and professionals and citizens, and thus, to empower citizens. However, citizens were not involved in the development of the model and the digital platform. It was the professionals’ responsibility to interpret and integrate the customers’ needs in the renewal. Consequently, also our research results reflect the views of professionals. Originally, we had a plan to include citizen interviews, too, and this idea was accepted by the managers of the experiment. This plan was given up due to the difficulties in the recruitment of users. It is, however, interesting to map how the professionals tried to take into account the perspective of citizens and empower them. This is discussed next.
III.2 Empowering citizens through digital platforms
The idea of answering citizens’ needs and empowering them via the integrated model of wellbeing meant a remarkable change to the earlier practice. Based on this practice, services had been delivered in a unidirectional process: the user had been seen as a target, not as a co-producer or the co-creator of value. The following quotation illustrates the change:
37The common service plan (in line with the nation-wide program) affects the role of professionals. They are no more expected to be omniscient and problem bearing experts. Rather they are expected to be sparring partners to their customers. (Manager of child and family services)
However, as mentioned in the former sub-section, the construction of common service plans with citizens started slowly. The main difficulty was selecting those families who would benefit from the new practice: who had a multi-disciplinary service need, who were motivated, and whose problems were not too severe to be handled in this new way of working. The professionals also had difficulties in marketing the new service to the customer families, because they felt that they didn’t have enough information about the experiment. Thus, the information about the possibility to use the new tool did not reach all potential customers.
According to the interviewees, the reactions varied among those customers with whom the new service was discussed. Some of them welcomed the digital service plan. They considered that wellbeing services will improve when the citizens have the opportunity of accessing all information that concerns their situation and sharing the information with professionals. Collaboration and communication becomes more effective between all the relevant actors required for the delivery of services. Thus, the use of services is simpler and more manageable. However, not all contacted customers were satisfied with the renewal. Some of them did not want to share openly their personal information, and they did not want different professionals to know about all the services they were using. The professionals assumed that this worry was based on the fear of stigmatizing. When a problem is not known by many professionals, it might feel more manageable to the customer. These thoughts are illustrated in the quotations below:
We thought that it is the interest of the customer that all the related professionals share the same information. However, customers do not necessarily want that all professionals know their problems. They prefer to tell about a problem only to that professional who is directly responsible for it… Maybe it is the feeling that the problem is smaller when only one or few professionals know about it. (Manager A of educational services)
Usually customers want to show that they are a “normal” family. They do not want that many professionals know about their problems. In the meetings with our customers, we always ask if there are any problems in the day care, 38for example. If there are problems, we try to get suitable professionals to participate in the meetings with the family. The customers who use multiple services should tell whether they have any other problems. It may, however, require efforts to get the “right” professionals to participate. (Representative C of prenatal and child health)
The interviewed professionals emphasized that it is very important to let the citizens know that they are all there to help; they do not ‘spy’ or just give outside advice. Along with the increasing multi-professional group work, there are also sessions in which a customer meets several professionals simultaneously. Here, it is a matter of expertise and experience to create a situation in which the atmosphere is confidential and comfortable as was pointed by an interviewee:
It is a certain skill of professionals to manage the situation in the way that does not put the customer as an underdog. (Representative A of family counselling)
Sensitivity and appreciation is also needed to avoid presuming what the customer should want or aim at. Finding a balance between customer centricity and expert advice was considered challenging by the interviewees. Even though this balance is not a new issue, it is highlighted when several professionals see the compiled information in the common service plan and participate in creating it. It is typical that professionals tend to transmit to customers their vision about what is ‘good life’. This vision may be offered as the goal to the customer even though it is not in line with the customer’s own vision. The following quotation illustrates this problem:
Customers often represent a completely different social class compared to professionals. We have these mantras and beliefs about what is ‘good Finnish everyday life’. And we set that as a goal. The reality is that the customer would be happy with something less… We need to better listen customers’ real needs. We have to take customer needs as the starting point and support them in achieving their own goals. (Manager of child and family services)
The interviewees considered that, despite its problems, the experimented model is beneficial from the viewpoint of citizens. It encourages them to participate in the development of ‘the service palette’ in line with their needs, and in this way, strengthens their role as active customers. In the best case, the empowered citizens are motivated to take 39care of their wellbeing in a proactive way. These opinions are illustrated in the following quotations:
I believe that when the customer sees the text that has been written in digital platform, it helps to create a comprehensive picture of the situation and to encourage dialogue… It is a tool which helps the customer to cooperate with professionals. (Representative B of specialist daycare)
I think that the most important benefit is that the customer becomes an active partner in the care process. The customer’s issues and problems are also handled in a comprehensive way and not in a way in which professional A deals with one thing, professional B with another thing, and professional C with the third thing. (Manager responsible for the development of the digital platform)
Summarizing these views of the interviewees: with the integrated model of wellbeing, including a common service plan and the related digital tool, citizens have a better chance of setting the goal they consider suitable in their own life. Correspondingly, the professionals providing services have a better possibility to answer the needs of citizens and to be more customer centric.
Concluding discussion
This paper has examined the challenges of developing and implementing an integrated model of wellbeing in the context of child and family services. In the model, integration crosses the traditional organizational boundaries and fosters collaboration between social care, daycare, primary school and health care. The aim of the integrated model was to support multi-professional work and reinforce the citizens’ responsibility of their own wellbeing. In the core of the new model was ‘a service plan’ to which the user and the service providers commit themselves, and a digital platform which functions as their mutual information channel.
The empirical study has been carried out in a middle-sized Finnish city, which has been one of the pioneers in Finland to implement integrated services in health and wellbeing sectors. This integration is a general phenomenon in the Western world and reflects the paradigmatic 40changes concerning the development of welfare services. The current stage is dominated by the paradigm of New Public Management (NPM), but it also includes elements of earlier traditional public administration and the emerging Network Governance. Empowerment of citizens is an element which particularly clearly reflects a transfer from NPM to network-based practices.
Our empirical study reveals that the attitudes towards multi-professional work were positive among social service providers and there were no significant prejudices towards the digitalization of services. The results indicate that the integrated model of wellbeing – including a common and digitalized service plan – has a possibility to enhance collaboration across administrative and organizational silos such as social care and health care, or social care and primary school. A common service plan is a good and practical tool to support and accelerate collaboration and lower barriers between a variety of professionals. It makes ‘soft’ and tacit information more explicit, and the digitalized platform helps to share information between professionals.
In principle, this kind of a model also promotes information flows between professionals and citizens. It improves the possibilities to answer the needs of citizens and to support the creation of more customer centric services. It clarifies and structures the use of services and makes them more manageable. In the new model, citizens can participate actively in target setting for the services. On the other hand, in our case the practical launch of the new practice turned out to be challenging and the achievements were actually minor, leading not to any permanent changes.
The difficulties manifested reflect the challenges of experiment-based innovation which is today gaining ground in the public sector, too. Experiments have recently been suggested as a more successful innovation model than the traditional linear model. It has been argued that experimentation corresponds to the conditions of modern society whose characteristics are continuous and rapid changes. In the theories on innovation management, experiments have often been linked to open innovation (Sørensen et al., 2010), which is one of the cornerstones of the modern views on innovation. Adaptive trial and error, i.e. quickly realised small successes and failures, are a more realistic way to tackle the uncertainties of future developments than strong pre-planning and systematic steps from ideas to pilots and to the launch (Read et al., 2009).
41However, the success of experiments crucially depends on the way in which they are carried out. In our case, a weak point was the lack of a bottom-up perspective. The initiation of the experiment actually followed a top-down practice that traditionally has dominated the activities of public administration (Hartley, 2005). A consequence of this problem was that the staff felt development activities like an extra burden. The interviewed managers were very eager about the renewal but they had not acquired sufficient commitment from the grassroots level and had not organized a balanced process between broad participation and small-scale pilots.
Our case city has a long tradition of development activities and its organization culture supports the creation and implementation of new services. There was also a positive attitude towards collaboration with users. However, the practical ability to implement this collaboration turned out to be challenging; there was not a clear analysis of what the elements of common activities should be and how they should be manifested (cf. Sharma et al., 2014). Difficulties also derived from the nature of social services: user problems are delicate and privacy is extremely important. These specificities of social services imply, among others, that well-functioning practices of other sectors, such as health care, cannot be copied directly.
As regards digitalization, our results revealed that the use of new technological tools is not as straightforward in ordinary work as it appears from the management point of view. Technological readiness (technical equipment, network capacity and know how) to use digitalized platforms is not yet at the sufficient level to fully utilize the potential. Professionals need support from the management to understand and accept these platforms, which many times are unfinished when they are taken into use.
Further, citizens’ attitudes towards new integrated and digitalized services are not solely positive, but may cause doubts: sharing all the information with many professionals on a faceless platform may be frightening and limit collaboration. This issue highlights active efforts to relieve fears in the different phases of the implementation and use of the new tools. On the other hand, the social sector will need online services in the future. Personnel resources have to be focused on those customers who require ‘heavy’ care and attention. Systems supporting 42the privacy and the accessibility of information can be secured through data protection.
Further studies are needed to understand the citizens’ role and perspective in the renewal of wellbeing services. However, our study indicates that organizing citizen interviews is a demanding task if the issues discussed are sensitive. Therefore, multiple methods to approach and involve citizens – to collect the valuable information of their expectations and needs – would be beneficial.
Another interesting research issue concerns the role of experimental approaches in tackling the uncertainties of future developments. The experiments usually materialize at the local level, but are dependent on the national policies and politics. At the national level, experiments are often launched without an allocation of resources for the spread and broader application of the results. To accelerate an experiment-friendly culture and to ensure experiment-based learning and dissemination, a better understanding is required of the interlinkages between the goals of the national government and the strivings of local authorities.
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1 Johanna Leväsluoto, Researcher (corresponding author), VTT Technical Research Centre of Finland Ltd. Tekniikankatu 1, 33720 Tampere, Finland. Johanna.Levasluoto@vtt.fi
2 Kirsi Hyytinen, Senior Scientist, VTT Technical Research Centre of Finland Ltd. P.O.Box 1000, FI-02044 VTT, Finland. Kirsi.Hyytinen@vtt.fi
3 Marja Toivonen, Adjunct Professor, Aalto University, Department of Industrial Engineering and Management. marja.toivonen-noro@helsinki.fi
- Thème CLIL : 3306 -- SCIENCES ÉCONOMIQUES -- Économie de la mondialisation et du développement
- ISBN : 978-2-406-07406-9
- EAN : 9782406074069
- ISSN : 2555-0284
- DOI : 10.15122/isbn.978-2-406-07406-9.p.0017
- Éditeur : Classiques Garnier
- Mise en ligne : 13/11/2017
- Périodicité : Semestrielle
- Langue : Anglais
- Mots-clés : Travail multi-professionnel, participation de l’usager, services sociaux, services publics, plateforme numérique