RICERCA ITALIANA     

New Health Needs and Care Services: Governance, Organisations, Professions and Citizens in the Integration of Health and Social Care

Università degli Studi di Macerata

Abstract

Background:
The need to provide social and health services in an integrated manner (IHSC) is increasingly recognized in Western Europe, mainly as a result of two processes developing in the last thirty years: on the one hand there is an increase of people with chronic diseases, who often require more extensive than intensive care; on the other hand, health and social policies seek to move increasingly towards a de-institutionalization and de-hospitalization of interventions in order to maintain people in their community and home environments and also to contain costs. As this awareness grows, the practical translation of these principles faces difficulties in good part due to the fact that the social and health sectors are largely produced by different institutional, organizational and professional system and often competing with each other. The general objective of IHSC is to obtain unitary answers to health needs in order to enable citizens to reach the highest level of autonomy, personal expression, quality of life, involvement in social life. Robert K. Merton back in the'50s focused the attention on the concept of "patient as a total person", being the crucial issue of IHSC not the merging togheter two sectors (the social and health ones), but the making them to interact for a plan with at the center the person in her/his psycho-physical unity. The interconnection between social services and health services should take place at three levels: institutional (definition of health pacts between different actors), managerial (adoption of consistent organizational models) and professional (synergy between the skills of various social and health care professionals), providing an involvement of the users, families and community in order to improve the effectiveness.


Objectives:
The project aims to analyze, adopting a perspective of analysis on all three levels (institutional, managerial and professional), hoa are concretely built models of integrated intervention. The study on provides one side a deepening of the operation of interventions in each level, on the other an analysis of comparative nature among different Italian regions and between Italy and other Western countries that face similar problems. In addition, the goals of the project have both theoretical and applied nature with reference to the policies and system of actions in the field of social services. In particular we will analyze how to be build and transform relationships among various actors which, at different levels, are involved in the process of IHSC: public actors belonging to different institutions (Municipalities, Health care local authorities, the educational system, etc. .); private ones (managing services, both for profit and non-profit associations); the families of users and beneficiaries; the various types of professionals working in the field.

National and International Relevance
This research is important both nationally and internationally for several reasons. At the international level the literature on the Italian case that concerns the helath and social care welfare is relatively limited and therefore the present study could expand the knowledge in this regard.
Moreover much of the literature on the topic tends to be characterized either by a very narrow approach to the practices of IHSC but is less usefull in terms of theoretical remarks, or it develops theoretical approaches generally focused on single aspects (professions, organizational models, governance, etc.). Therefore, on one side, we want to integrate the literature on practices and policies with the more theoretical one. On the other we want to trengthen links between different fields of theoretical study, that tend often to be considered individually, in order to reach a better interpretation of the studied phenomena. Such an integrated approach, bringing together the analysis at micro-meso-macro levels with both theoretical and operational goals, and that it intends to operate in comparative terms for these three levels, it is not widespread in the national and international literature on both the issues of socio sanitary integration and over other issues relating to welfare systems.

Composition and Integration among the Research Units
The Project is based on different forms of integration and coordination among the different Research Units. Overall the project will be mainly run by sociologists with different but integrated skills and research interests (studies on policies, organisations, professions, methodological issues). Togheter with the sociologists the research group will also be made by statisticians and medicine scholars in order to strenghen and broaden the analysis. <<<

Principal Investigator

Emmanuele Pavolini Università degli Studi di MACERATA

Research Objectives

Final Objectives:

This project has three main goals. Each of these three main goals has more specific research questions. These goals have both a theoretical and applied nature in the field of IHSC. Finding answers to theoretical questions means to propose models of intervention more careful to the needs of IHSC and users. In particular we will analyze how the relationships among different actors involved at different levels in the process of IHSC are growing and transforming: public actors belonging to different institutions (Municipalities, Health, educational system, etc. .); private ones (those that run services, non-profit associations); the families of users and beneficiaries; the various types of professionals working in the field.
The three main goals of this project can be put into a framework of macro-meso-micro analysis:
- Macro - characteristics of governance models: given the economic importance and the centrality of health and social-sanitary services in local contexts, the social-sanitary integration is an ideal issue to analyze changes in various Italians contexts, with reference to relations between different public actors (in this case Regions, hospitals, local health companies and municipalities), private actors with roles in management services (for profit and nonprofit), associations for the protection of users and labor union, as the relationship between politics, bureaucracy and civil society; the importance of this phenomenon concerns not only the issue of territorial welfare, also important (about four-fifths of regional budgets are invested in health, 15 % -20% of municipal budgets is invested in the social), but more generally in relation to assets and models of local governance. Within this framework, the specific sub-objectives are:

o how they are addressed and solved (or not solved) the typical dilemmas of collective action among a multiplicity of actors, both public and private in an attempt to create models of social integration; if generally there is consensus in considering integration the most efficient and effectively way of addressing the problems emerging in the health and socio-sanitary, in reality a series of mechanisms makes more complex the feasibility of this goal;
o how it is thematized the subsidiary relationship and integration between communities and institutions; a specific phenomenon related to IHSC is the emergence, in recent decades, of associations of citizens users / patients / caregiver committed in the processes of Community Health governance; even if there is a broad literature, Italian and international, on the topic of forms and models of community governance, involving non-public actors, in other welfare areas the role and characteristics of associations of citizens, has been less studied, and especially the most vulnerable ones (chronically ill, disabled, etc.), in the health sphere.

- Meso-transformations of roles and organizational models in the field of social-sanitary actions: the public welfare area in fifteen years has undergone profound processes of privatization and managerialization (at least in the sense of expansion of private actors producing services for the public), as well as a new focus on territorial intervention (so called “distrettualizzazione” and diffusion of home services); these changes should be strongly modifying patterns of public intervention and open the way to organizational models of post-bureaucracy. They could have an impact on third sector organizations involved in supporting specific categories of users. Within this framework, the specific sub-objectives are:
o analysing if the public administration (in welfare field) is really adopting post-bureaucratic models, especially with reference to the leadership. The question is if management is really independent of the political power or if changes are just rethorical, with structures formally different from the past but working much more on the basis of traditional logics of Public Administration (bureaucratic);
o how voluntary associations in the protection of users are transforming themselves and fitting new opportunities compared to the public. It’s interesting understand if they are likely to end up caught in the logic of operation of the public or if they can actually promote a real citizen involvement.


- Micro- the transformations of professional profiles in health and socio-sanitary field and the role of customers and their families: organization of work in the health sector and social sector have been invested recently by a period of great change. The health sector has been for along time characterized from the decisive weight of professional logic, based on autonomy and auto-regulation by professionals, and the "medical dominance", ie control of the basic mechanisms of division of labour by medical profession. Both these features are now called into question. The most important processes are two: the growth of non-medical professions, the growing role of families and users in terms of empowerment and activation:
o how it is managed the composition of the staff / team in terms of professional features, in a context where new health needs and the organization of work (as in the case of inter-professional equips, now diffused in several social-sanitary processes) put in crisis disciplinary boundaries and roles consolidated by time and create remarkable tensions deriving from the encounter between "strong" health professions and "weak" social professions;
o what are the actual mechanisms by which the division of labour take place in the workplace; we intend to analyse how formal regulation of work is subordinate, in daily activities, to a process of negotiation, adaptation and appropriation heavily influenced by the strategies of actors involved;
o which role can be played by citizens / users / patients, families and their associations of auto-mutuum aid in order to become more empowered. The focus of the analysis is represented by the role of family relational capital and social network support at communitarian level.

The previous research questions will be developed in a comparative perspective as regarding several Italian local contexts and international ones, in order to better frame the Italian case and to learn important innovations eventually introduced elsewhere. We also intend deepening particular fields of participation in order to better comprise the patterns of these phenomena (for example the pediatric hospitalization). <<<

First Results

Altogether the predicted results of the project are twofold: theoretical and applied. In particular taking into consideration the three general goals of the research, the main expected theoretical results are:
1. Macro goal - characteristics of the models of governance:
• Individuation of the mechanisms and processes that explain the success of collective action among a variety of actors, private and public, in the attempt to create models of IHSC in one logic of governance; in particular it is expected to understand how much some of the more recurrent explanations in the social studies with respect to the dilemmas of collective action are satisfactory in order to interpret the analyzed phenomenon and, above all, if these explanations can be integrated with each other (political economy, network theory, approaches more oriented toward methodological individualism, with the focus on the role of the actors and their entrepreneurial abilities); following attempts that are increasingly being diffused in the social analysis it is expected to find proofs/hints on one side of the explicative ability of several models of interpretation, on the other of the possibility of a combined use of some of these different models (e.g. Mizruchi, 2007, is among those scholars who try to conjugate the political economy approach with network analysis).
• Forms taken by the horizontal subsidiarity and the interaction between community and institutions in the field of IHSC; in particular, taking into consideration the limited literature on the issue, greater information and insights will be provided regarding the role played from the citizens’ associations in the health sector, with a special focus on the forms taken by self-help groups, in the social promotion and the representation of the various social interests in the processes of governance; moreover a correlated result will consist in the appraisal of the effective impact that these associations exercise on health governance in relation to the agenda setting and the construction of the political strategies and their implementation at the local and national level; finally, from the analysis it is expected to find out the eventual existence of European networks among the different national associations and the ability of this network to exercise an effective action of lobbying at the regional, national and EU levels

2. Meso goal- the transformations of the organizational models in the field of health and social care systems:
• Indications of the effective degree of managerialisation inside Public Administration (in the field of welfare) and of adoption of post-bureaucratic models, above all starting from the top management; indication also of effective autonomy of managers in front of the political power; it is expected to understand how much the neo-istituzionalist theories (March and Olsen, 1989; Meyer and Rowan, 1977), based on concepts such as "organizational rhetoric of change" and "myths", are able to explain the effective processes of managerialisation in territorial welfare; equally indications on the usefulness of the concept of "soft-bureaucracy" in the specific study of local the public administrations are expected (Courpasson, 2000).
• Ability to adaptation and maintenance of the mission from health voluntary associations working with users regarding the relationship with the public institutions; it is expected to collect information on the ability for such organizations to develop strategies of interaction with Public Administration that on one side favour nonprofit influence on the P.A. choices, on the other avoid the risk for them to be ‘captured’ inside of logic of operation of the P.A.

3. Micro goal- the transformations of the professional profiles in health and social care and the role of the users and their families:
• Description and explanation of the models of workers and labour governance of IHSC systems, with particular reference to the forms of management of problems deriving from the conflicts among different social and sanitary professions.
• Description and explanation of the main forms of division of labour in the IHSC field, with particular reference to the conflicts and the mechanisms of conflicts solution in inter-professional teams.
• Description and explanation of the role of not paid work in the IHSC field, with particular reference to the role of coproduction carried out from the citizens/customers/patients, from the families and their associations in an empowerment perspective; information with respect to the role of relational and social capital at the communitarian level are expected.

Given these expected results at the theoretical level, the research will provide more knowledge contributions, for all the three dimensions (macro-meso-micro), on two other aspects: the comparative analysis and the generalization of results.

Comparative analysis
A contribution is expected also in terms of a comparison among different Italian situations and settings and then between the Italian and other European situations. The comparison will help offering information on the role played by the following variable in explaining the phenomena studied in this research:
• The more general role and way of functioning of the welfare system (degree of universalism, models of provision, etc.);
• Role of politics and of the ideological orientation regarding welfare;
• Role of the social-cultural dimensions (social capital, political, organizational and professional sub-cultures, etc.);
• Role of the economic system and its degree of development.

Generalization of results
It is expected that the research results, specifically addressed to study IHSC, will also be relevant the inside the more general scientific debate, at the national and international level, regarding the following topics:
• Models of governance (in welfare).
• Characteristics of health federalism, decentralisation and subsidiary interaction Center-Periphery.
• Transformations in public bureaucracies and processes of managerialisation.
• Relationship between politics and policies.
• Role and transformations of the civil society and its interaction with public institutions.
• Processes of communitarian integration.
• Processes of help and caring inside of the families.
• Processes of transformation in health and social professions.

Concerning the applicative potentialities of the project, the following aspects can be underlined:
• Sharing with the scientific / political / professional community related to IHSC of different legal instruments developed in different areas of Italy and in other European countries in connection with the regulation of IHSC.
• Sharing with the scientific / political / professional community related to IHSC of strengths and weaknesses of different models of IHSC (at the institutional, managerial and operating-professional level), showing also the different trade-offs each model offers (in terms of quality of performances, level of coverage, users’ involvement, etc.).
• Agreements with different (institutional, managerial and operating-professional) actors interested to the elaboration and experimentation of innovate models of IHSC, with the goal of continuing collaborations also after the end of the present project.
• Planning and experimentation of innovative forms of IHSC.

In particular specific applicative expected results are the followings:
• the expected outcome from the research-action on the "Family Learning" consists in a series of indications on the feasibility of a similar way of intervention with users and their relatives who complete the training experience;
• the expected outcome from the research-action on the Serious Acquired Brain problems consists in explicating of the problems met by the families with this serious illness, differentiating these families also on the base of familiar and relational resources used;
• constitution of an Observatory on health citizenship at the regional level in the Calabria region in collaboration with various actors;
• production and proposal of models, relatively more effective than others, in the concrete work of Inter-disciplinary teams in IHSC;
• production and proposal of models for a better working of the IHSC in the case of hospitalised children.

All these expected applicative results will be translated into the definition of concrete and specific proposals, in order to promote local / regional policies and possible specific care production processes in health and social services. <<<

Timescale

24 months

National and international background

The studies that in Italy and at the international level focus on different dimensions of the integration process of health and social services (institutional, organisational and professional) are relatively spread, but they often display one of the following two features.
On one hand, many of them are investigations based on a descriptive- prescriptive more than interpretative view. They aim to give a framework of the current situation of IHSC or to provide suggestions and advices for improving it. Moreover, the analyses based on a sociological perspective tend to study the integration process looking more at the Social Care actors (the municipality’s view); while the managerial / medical studies analyse it by the health care system perspective. Indeed, it is difficult to fine analyses integrating both social and health care dimensions.
Beside the individual contributions, there are reviews which sometimes publish articles on this topic by a sociological and political perspective or by a multidisciplinary one. Hence, there is lack in this literature of a wider theoretical interpretation on the current process. It makes often the proposed solutions too much technical and specific and not rooted / ‘embedded’ in the social-cultural-political context where they should take place. Quite a good part of the international comparative researches on the issue tend also to use the just illustrated above approach: these researches study and show the mechanisms of IHSC through international comparison, but they do not develop too much an interpretation.
On the other hand, next to this so called policy- and practice-oriented approach, there is another one more theoretically oriented (it includes also many sociological and political contributions), which generally focuses on the transformation of some of the main mechanisms of social integration of individuals (the family, the communities, the welfare state in its different branches). This approach often studies also the interactions among these mechanisms. Inside this literature, and in particular the Welfarist one, there have been developed more specific issues concerning IHSC or the transformations inside public welfare bureacracies. This literature concerns often different streams of research that, starting from general analysis of local welfare systems and decentralisation, then focus on more specifically on issues such as, for example, health and social care federalism processes, the relationship between state and regional/local governments, the changing public welfare bureaucracies, the relationship between managers and health professionals, the relationship between politics and administration, the sub-national dimension and the sub-cultures/ ideological orientations towards public policies.
In relation to the studies concerning the relationship between family and welfare the analyses have shown how the family, in a context such as the Italian one, represent a fundamental actor not only as a beneficiary of welfare policies, but also as a relevant provider of care. The focus on the family role plays a relevant role also in terms of IHSC, even if there are few studies on this issue: the more theoretical and applied research has concentrated on the relationship family-needs-welfare, regarding the issue more from a social care perspective then an integrated social and health one. Moreover such literature has little developed (regarding the topics considered) the dimension of the empowerment and the activation of individuals and their families in the processes of IHSC production.
Equally, beyond few and specific researches, they still do not exist relevant studies at the Italian and international level on the topic of IHSC and the role that the citizens and their associations can carry out in it. If the topic of the third sector research appears more developed in the personal social services field, the literature regarding the dimension of IHSC and of communitarian empowerment ` is somewhat limited.
Also in the field of the literature on professions and welfare a tradition of studies exists by now and it is quite consolidated, but it presents usually the two following characteristics: the literature has been focused mainly on the health care field and often on the main dominant professions (doctors), and fewer researches are available on those regarding social care, relatively less recognized and institutionalized; there is also less evidence and research on the tensions deriving from the working together between "strong" sanitary professions and "weak" social professions in situation where Inter-professional teams are more and more spread, creating tensions among consolidated disciplinary roles.
Finally regarding specifically the studies carry out on the topic of the paediatric hospitalisation, they regard nearly exclusively medical and pedagogical issues, even if the sociological analysis could give a strong contribution in studying the social and familiar background, the relations, the rolls definition changes, the integration between specific professional and non-professional agents (parents, brothers and sisters, other relatives, friends, volunteers…). Already starting in the 70’s a new sensibility in facing the health problem was developed thanks to important studies realized to create, who denounced the pathology generating and brutalizing effects of the big hospital systems, as well as the negative effects of technological impacts and the importance of prevention and attention to relational aspects.
Inside this framework, the research aims to mix together different approaches.
On one side the aim is to integrate both the theoretical and empirical/practice-oriented literature.
On the other side the aim is to strengthen and to merge different streams of literature, which are often taken into account one by one, such as: the classical approach on public policies and social-health services; the studies about the regulatory models and the multilevel governance; the organizational approach on the changing process of bureaucracies; the political-economic perspective on policy networks; the analyses on the changes inside the relationship between politics and administration by local and political sub-cultures; the studies on health and social professions; the research on the Third Sector e communitarian involvement; the studies on families’ and users’ role inside the care processes.
A similar integrated approach, that mixes together an analysis at micro-meso-macro levels, with theoretical and empirical/applicative goals and a comparative framework, is relatively not too common in literature related to IHSC and to welfare systems.

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