Dynamics of sustainable integration of health and social care: A 20-year case study

Abstract

Background: Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients i.e. people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy. Methods: A retrospective and qualitative case-study research design was used, and data from the model organisation’s steering-committee minutes covering 1995-2015 were gathered. Thematic analysis was used to handle the data and the results were mirrored to the key elements of the Dynamic Sustainability Framework DSF. At the outset, the analysis was explorative and inductive to map the steering committee’s actions. The results were intended to illustrate trends and changes in integration over time and to serve as a basis for the following analysis, which was the application of DSF on the findings. This two-step procedure resulted in a thorough data analysis that facilitated identification of the empirical themes from the narrative description. Results: Four empirical themes was identified, firstly, shared structure and ongoing refinement, secondly, continuous learning, thirdly, cooperation as a guiding principle for management and finally service user centeredness. Thus, the development of inter-sectorial cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and continuous quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic, sustainable health and social care. Conclusion: This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions in order to establish, develop and support integration of health and social care for people with complex mental health needs. We conclude that service user involvement and regular reviews of service users’ needs are essential in order to adapt to their current needs. Another major finding was the continuous adjustment of the content of intended change in relation to context. Therefore, we conclude that continuous refinement of the change content might be more important for sustainability than detailed designing of the change ahead of implementation. As this study primarily addresses the steering committee decisions and actions, future research could build on our findings by including perspectives on organisational champions and the meaning of organising networks for achieving sustainability. As the knowledge on champions and networks increases, we stress that organisations and services adjust accordingly.