ORGANIZING CITIZEN-CENTRED
CARE AND SUPPORT NETWORKS
Master thesis, MSc Supply Chain Management
University of Groningen, Faculty of Economics and Business
January 28, 2019 T.S. Reindersma Student number: S2727277 e-mail: thomasreindersma@gmail.com Supervisor: H. Broekhuis Co-assessor: C.T.B. Ahaus
ORGANIZING CITIZEN-CENTRED
CARE AND SUPPORT NETWORKS
ABSTRACT
Individuals from disadvantaged neighbourhoods with low socioeconomic status have difficulties accessing curative and preventive forms of care and support. As such, delivery of services should be more citizen-centred, with a focus on ease of access, tailoring to needs and seamless delivery of services. Adopting an explorative multiple case approach, this research examines the organization of curative care and support for citizens for which the municipality is responsible. 13 interviews were conducted in 4 municipalities, complemented with document analysis. Drawing on service delivery network and coordination/integration literature, case evidence provides insight into the organization of the care and support networks. The study found that during different stages of the organization of a network, levels of integration influence citizen-centredness. This research contributes to management of public services, because up until now how public service characteristics influence service delivery has not been extensively studied.
Keywords: service delivery network, citizen-centredness, coordination, collaboration, integration, care and support
CONTENTS
1. INTRODUCTION ... 4
2. THEORETICAL BACKGROUND ... 6
2.1 Citizen-centredness ... 6
2.2 Service delivery networks ... 7
2.2.1 Actors ... 8
2.2.2 Ties ... 8
2.3 Network structure ... 9
2.3.1 Formal versus informal structures ... 10
2.3.2 Integration and collaboration ... 10
2.3.2.1 Integration by mutual adjustment ... 10
2.3.2.2 Integration by standardization ... 11 3. METHODOLOGY ... 12 3.1 Case setting ... 12 3.2 Case research ... 13 3.3 Case selection ... 13 3.4 Data collection ... 14
3.5 Data coding and analysis ... 16
4. FINDINGS ... 17
4.1 Curative and preventive care and support ... 17
4.2 Entrance to care and support ... 18
4.3 Exploration of needs and capabilities ... 20
4.4 Development of care and support network ... 25
5. DISCUSSION ... 28
6. CONCLUSION ... 30
6.1 Limitations and further research ... 30
REFERENCES ... 32
TERMINOLOGY ... 40
APPENDICES ... 41
Appendix A: Interview list ... 41
Appendix B: Informed consent form ... 43
Appendix C: Citizen profiles ... 44
Appendix D: Profile assessment survey ... 45
1. INTRODUCTION
Across the globe, health inequalities between and within socioeconomic groups are widening. Groups that are especially victimized by this phenomenon are those living in disadvantaged neighbourhoods with overall low socioeconomic status. Whilst most citizens in the European Union have universal access to affordable basic care and support, individuals from disadvantaged neighbourhoods with low socioeconomic status have difficulties accessing curative and preventive forms of (public) healthcare and social services (Kirby & Kaneda, 2005; Obrist et al., 2007; Robert, 1998). In pursuance of providing fair access, Obrist et al. (2007) propose a community or district-based approach that is needed “to better align services with poor people’s needs, expectations and resources” (p. 1584). Hence, delivery of (public) healthcare and social services should be citizen-centred: it should be organized from the perspective of the citizen and be responsive to a citizen’s holistic needs (Goodwin, 2014; Kernaghan, 2005).
Unfortunately, the current service delivery system remains fragmented and thus forms an important barrier to effective health improvement and well-being (La Placa, McNaught, & Knight, 2013; Stange, 2009). This fragmentation is caused by the multiplexity of well-intentioned yet loose initiatives which in turn hampers the development of “equitable, integrated, personalized and prioritized” forms of care and support (Stange, 2009, p. 102). Multi-problem citizens are, as recipients of multiple services (e.g., social work, financial help, reintegration), disadvantaged as a consequence of this fragmented and disorganized system (Carey, 2015). An estimation shows there are 42 actors in the Netherlands alone across different policy sectors that provide such services (Kruiter, Jong, Niel, & Hijzen, 2008). Those organizations act nationally, regionally and locally, which makes collaboration practically impossible (Kruiter et al., 2008). Storm, Den Hertog, Van Oers, & Schuit (2016) emphasize that collaboration between the (public) health sector and other policy sectors is crucial in order to reduce health inequalities.
(Loket Gezond Leven, 2018). Ideally, the network actors work together in such fashion that enhances citizen-centredness: services are easy to access, tailored to citizen’s needs and delivered to the citizen seamlessly (King & Meyer, 2006). The network perspective is necessary to emphasize the (in)direct and complex connectedness between the different actors in a public service network that is focused on providing services to citizens (Borgatti & Halgin, 2011; Braziotis, Bourlakis, Rogers, & Tannock, 2013). Hence, this paper addresses the following question: how do municipalities organize networks to enhance citizen-centredness? The exploratory and inductive nature of this research enabled to distinguish three stages that support structuring the findings and answering the research question: (1) Citizen’s entrance, (2) the exploration of citizen’s needs and capabilities and (3) the development of the actual care and support network. The stages represent the steps in which the network forms and evolves around the citizen.
2. THEORETICAL BACKGROUND
As a result of service delivery fragmentation, networks are increasingly relied upon to deliver services (Tax et al., 2013). Literature has coined several terms for such applied networks, such as solution networks (e.g., Jaakkola & Hakanen, 2013), service supply networks (e.g., Harrington & Srai, 2016), service networks (e.g., Ekman, Raggio, & Thompson, 2016; Gebauer, Paiola, & Saccani, 2013), supply networks (e.g., Harland & Knight, 2001; Lamming, Johnsen, Zheng, & Harland, 2000), business networks (e.g., Hakanen & Jaakkola, 2012; Möller & Halinen, 1999) and service delivery networks (e.g., Graddy & Chen, 2006; Tax et al., 2013). For the sake of clarity, the latter will be used in this paper. First, the concepts of citizen-centredness (2.1) and service delivery networks, actors and ties (2.2) will be explained. Subsequently, network structure and how organizational theory enriches the description of ties between actors will be discussed (2.3). The conceptual model (see Figure 1) offers a simplified overview of how concepts are linked. An SDN consists of actors and ties, but solely actors and ties cannot describe a network. Therefore, literature is reviewed from formal and informal structures and integration and collaboration.
Figure 1. Conceptual model.
2.1 Citizen-centredness
Within literature, ‘-centred’ approaches are defined differently, depending on the context. In care settings these approaches are often referred to as ‘person-centred’, ‘client-centred’ or ‘patient-centred’, in business literature it is often termed ‘customer-centred’ (Shah, Rust, Parasuraman, Staelin, & Day, 2006). In this paragraph, insights from those ‘-centred’ approaches are presented. Furthermore, the overarching term ‘citizen-centred’ will be used (Kernaghan, 2005), because a citizen can be a patient, client and customer simultaneously.
product-centric approaches. In a customer product-centric approach, “all decisions start with the customer in mind” (Shah, Rust, Parasuraman, Staelin, & Day, 2006, p. 115) whilst product-centric approaches are merely about ‘just’ selling products. In line with this, Mead & Bower (2000) identify that sharing power and responsibility is an important dimension of patient-centredness. To continue patient-centred thinking, citizens should be regarded as experts in their own problems just like patients should be regarded as experts in their own illnesses (Tuckett, 1985). Hence, citizens should be included in the decision making process (Barry & Edgman-Levitan, 2012). In the most optimal form, citizens choose “what is delivered, the level or rate of the service, the identity of the gatekeeper or case manager, and the provider of the [care and support] service” (Eklund & Markström, 2015; Spall, McDonald, & Zetlin, 2005, p. 62). To conclude, citizen-centredness has three dimensions: services should be easy to access, services should be tailored to the citizen’s needs and services should be offered seamlessly (King & Meyer, 2006).
2.2 Service delivery networks
Figure 2. Fictional service delivery network.
2.2.1 Actors
The service delivery to multi-problem citizens through several providers makes up for a complex network. Kim, Choi, Yan, & Dooley (2011) add that if a network is complex, the network size is assumingly large. Considering the multitude of providers that are responsible for service delivery to citizens, it can be assumed that citizens with ample needs demand services from a vast network of providers. Graddy & Chen (2006) state that “bigger networks by definition create more [ties] among community-based organizations and thus increase the capacity […] to address community needs” (p. 534). Dependent upon the type of ties, a greater network size also gives the availability of switching partners (both provider-provider and customer-provider) more easily and it improves opportunities for knowledge sharing (Bouncken & Fredrich, 2016). Meanwhile, an increase of providers in the network can also cause rivalry as a consequence of overlapping competences (Hakanen & Jaakkola, 2012). Sharing of redundant information, due to overlapping competences, can however facilitate the transfer of tacit knowledge, which gives leeway to improved collaboration (Gummesson & Mele, 2010). Yet, as more providers contribute to the service delivery, “identifying the most valuable areas for improvement becomes more complex” (Tax et al., 2013, p. 463), such as how to improve citizen-centredness.
2.2.2 Ties
a specific function or task” (Brax & Jonsson, 2009, p. 541). In essence, this means that network actors need to be connected. In a network, ties denote those connections (Borgatti & Li, 2009). Lazzarini, Chaddad, & Cook (2001) distinguish between horizontal and vertical ties. Horizontal ties involve the connections between providers whilst vertical ties involve customer–provider connections. Windahl & Lakemond (2006) argue that an SDN with many actors involved in the provision of integrated services, necessitates strong horizontal ties to match the service offering of the providers with the needs of the customer. A seminal study by Granovetter (1973) defined tie strength as “a combination of the amount of time, the emotional intensity, the intimacy (mutual confiding), and the reciprocal services which characterize the tie” (p. 1361). Concerning the amount of time, Stanko, Bonner, & Calantone (2007) state that “partners in long-term relationships may develop efficient means to communicate as well as routines to coordinate activities” (p. 1097). Mutual confiding involves the frequent formal and informal exchange of (confidential) information between partners (Stanko et al., 2007). If reciprocal services are in place, this means that benefits, favours and feedback are equally exchanged between partners (Butt, Markle-Reid, & Browne, 2008; Gouldner, 1960). Since emotional intensity measures the strength of emotional bonds (Stanko et al., 2007), it is hard to operationalize and will be left out of scope.
Tie strength is assumed to be enhanced by proximity between actors. Small geographical distance facilitates face-to-face contact, which in turn enhances knowledge transfer (Knoben & Oerlemans, 2006). Another important dimension is social proximity, referred to as the social embeddedness of providers and customers, based on trust, friendship and personal experiences (Heringa, Horlings, Van Der Zouwen, Van Den Besselaar, & Van Vierssen, 2014). In R&D cooperatives, Autant-Bernard, Billand, Frachisse, & Massard (2007) found out that social proximity between network actors is more important than geographical proximity. Previously, Frankenberger et al. (2013) have stated that the number and strength of ties interact with the level of customer-centricity (i.e., citizen-centredness) in an ‘open business model’ network aimed at achieving high performance. How this mechanism works in a dynamic environment with changing needs of citizens, where the outcome is not firm performance but citizen-centredness and where providers constantly have to form new ties, is not clear.
2.3 Network structure
theory literature can enrich literature on networks by more precisely describing forms of collaboration and integration between network actors.
2.3.1 Formal versus informal structures
In networks, formal and informal structures interact and are intertwined (Hartman & Johnson, 1990; Mintzberg, 1979). Formal structures are “the documented, official relationships” among network providers, whereas informal structures are the “unofficial relationships” within the network (Mintzberg, 1979, pp. 9–10). In formal structures, network actors may have documented their relationships through contracts or more fluid arrangements (Guercini & Tunisini, 2017; Øvretveit, 1996). Yet, even in more formal structures the degree of formalization ranges from “ad hoc temporary informal relationships” to a “full-fledge formal organization” (Waarden, 1992, p. 35). Informal structures can be compared to social networks (Barney, 1985). The informal structure is that part of the network which is not governed by formal structures (Zhou, Wu, & Luo, 2007).
2.3.2 Integration and collaboration
Because each service delivery provider has its own profession and corresponding tasks and roles, activities needs to be integrated through coordination mechanisms (Mitchell & Shortell, 2000). Integration means that collaboration is anchored within some sort of organizational framework (Boon, Mior, Barnsley, Ashbury, & Haig, 2009), such as a network meeting or multidisciplinary team (MDT). Coordination mechanisms for integration are mutual adjustment, standardization or direct supervision (Mintzberg, 1979). Because coordinating mechanisms are prevalent in both formal and informal structures (Mintzberg, 1979), the combination of coordinating mechanisms is ubiquitous. For example, Burgelman (1985) observed that real-time mutual adjustment and direct supervision are used simultaneously. In addition, Tranfield & Smith (2002) state that standardized coordination is mediated by mutual adjustment. Mutual adjustment and standardization will be discussed, since direct supervision is often absent in professional work (Goodale, Kuratko, & Hornsby, 2008).
2.3.2.1 Integration by mutual adjustment
tasks (i.e., citizen’s complex needs) (Glouberman & Mintzberg, 2001; Mintzberg, 1979). Mutual adjustment is characterized by horizontal information flows between partners and is shaped by voluntary group meetings of professionals or task forces to find solutions together (Glouberman & Mintzberg, 2001; Jones, Hesterly, & Borgatti, 1997; Molleman, 2000; Øvretveit, 1996). Partnerships based on mutual adjustment rely on trust, social control and reciprocity (Mitchell & Shortell, 2000). A downside to mutual adjustment is that each time a new actor enters the group meeting or task force, he or she must mutually adjust with other members, which takes away time and money from the actual task (Bushe & Chu, 2011). Furthermore, Molleman, Broekhuis, Stoffels, & Jaspers (2010) argue that mutual adjustment limits agency of actors, which might slow down the task-solving process. In a study on urban mental health networks, Wiktorowicz et al. (2010) found that relying on mutual adjustment without external supervision of a local authority lacks coordination, hinting that direct supervision is sometimes necessary. Ultimately, Cunliffe (2008) suggests that in environments where services are customized to individual needs, mutual adjustment is an appropriate coordination mechanism.
2.3.2.2 Integration by standardization
(Mandell, 1999). In more detail, professionals working in MDTs have policies for accessing each other’s information systems and agreed procedures allocation and referral of citizens (Øvretveit, 1996). Fleissig, Jenkins, Catt, & Fallowfield (2006) argue that regular MDT meetings contribute to efficiency of planning, avoiding double work and simplification of referrals between professionals. Referral may also be the task of a case manager (Nguyen, Chan, Makam, Stieglitz, & Amarasingham, 2015), selecting and coordinating professionals that integrate their activities (Jaakkola & Hakanen, 2013). As stated previously, organizational frameworks might consist of a hybrid of standardization or formalization efforts and mutual adjustment. Core teams, highly formalized itself, might be surrounded by other professionals which are loosely integrated to said core team (Øvretveit, 1996). As can be seen, configurations of such organizational frameworks are widely debated in literature.
3. METHODOLOGY
3.1 Case setting
Recent decentralization efforts by the Dutch government have forced municipalities to look for different ways of organizing their new tasks pertaining to care and support created by the decentralization. In this study, care and support includes social support, work and participation, youth care and social work. This is in line with the acts that have been decentralized. Responsibilities for executing the acts ‘Wet maatschappelijke ondersteuning 2015’ (social support), ‘Participatiewet’ (work and participation) and ‘Jeugdwet’ (youth care) have been
transferred to municipalities with the intention of focussing on own responsibility and strength of citizens, self-sufficiency, a shift from demand control to person-centred care, integrated approaches, more attention to collaboration and prevention and reduction of costs (Loket Gezond Leven, 2018). As of 2017, 83 percent of the municipalities delegate the execution of those responsibilities to district teams (Movisie, 2017), which consist of municipality employees and care professionals.
facilities are “the set of services, tools, home modifications and other measures tailored to the
needs, personal characteristics and possibilities of a person” (Wet maatschappelijke ondersteuning 2015). Additionally, some municipalities distinguish between individual tailored facilities (e.g., addiction care) and collective tailored facilities (e.g., day-time activities).
3.2 Case research
Due to the exploratory nature of the research question and the paper’s goal to map how the organization of a network impacts citizen-centredness (Handfield & Steven, 1998), case study research was chosen as the methodological approach of this paper (Yin, 2014). Case research is especially appropriate in novel topic areas (Eisenhardt, 1989). It allows to see how concepts discussed in the theoretical background manifest in real-life and how concepts relate. It enables researchers to investigate a case in-depth whilst maintaining a holistic and real-world view (Yin, 2014) and allows for using multiple sources of evidence.
The unit of analysis in this research is the organization of preventive and curative care and support for citizens for which the municipality is responsible. In order to guarantee robustness of findings and augment external validity (Karlsson, 2016), four cases have been selected (see Table 1). The resulting multiple case study allows for within-case data analysis and cross-case pattern searching (Eisenhardt, 1989).
Case Population Support and care policy Scope and level Descriptives
A 40,000 Positive health Municipality Church community, rural, amalgamated municipality
B 200,000 Healthy ageing District Urban
C 70,000 Positive psychology District pilots Urban, poor neighbourhoods
D 30,000 Positive health Area Rural, thinly populated, outstretched
Table 1. Case selection. Note. Population figures are from November 2018 and have been
rounded to thousands. Source: CBS Statline.
3.3 Case selection
each case has similar results or it has differing results, but for anticipatable reasons (Yin, 2014). A sample of diverse cases is suitable for exploratory research (Seawright & Gerring, 2008). In Table 1, the selected cases and corresponding size, policy, scope and characteristics are shown. The scope is dependent upon how the municipalities organize their care and support. Municipality A is not (yet) divided into areas or districts where teams are deployed, therefore it is studied at the municipality level. For municipality B, the study focuses on the teams that are organized on the district level. For municipality C, the scope is limited to the pilots that are run in districts. Municipality D uses area teams.
3.4 Data collection
To enhance triangulation, multiple sources and methods were used in data collection (Eisenhardt, 1989). First, several municipalities were asked to participate in the study. Municipalities that agreed were asked to provide relevant policy documents. The second step was conducting semi-structured interviews (see Appendix A). Semi-structured interviews allow for answers to be compared between cases and improve reliability (Yin, 2014) and allow for obtaining “both retrospective and real-time accounts by those people experiencing the phenomenon” (Gioia, Corley, & Hamilton, 2013, p. 19). Interview questions are related to the constructs discussed in the theoretical background (see Table 2). In order to refine data collection plans (e.g., how to structure interviews), a pilot case study was carried out at the non-participating municipality X. The main selection criteria for choosing the pilot case were accessibility and convenience (Yin, 2014). After the pilot, sequence of interview questions was changed, and a few questions were added. After each interview, questions about emerging topics were added to the common set of questions after having discussed with supervisors (Cardador & Pratt, 2018).
Construct Example question
Citizen-centredness “How are the citizen’s needs determined? Does this happen in consultation or does the professional determine this on its own?” Actors “Which organizations are involved with this citizen?”
Ties “Could you draw the mutual connections between the organizations?” Formal and informal
structures “To what extent does this coordination also take place informally?”
Integration/collaboration “Do structural partnerships/meetings exist?”
Among the participants were project managers, case managers and process managers (see Table 3). Confidentiality was ensured and participants were informed about the purpose of the study (Huber & Power, 1985). Participants were asked to sign an informed consent form (see Appendix B). Most interviews were carried out by two researchers, as so to cultivate different perspectives and strengthen grounding (Eisenhardt, 1989) Some interviews were carried out by one researcher. Interviews took place in the period November 2018 – January 2019.
Two citizen profiles were introduced to participants (see Appendix C). The profiles are based on self-sufficiency-matrix (SSM) customer profiles, drawn from a report by the public health service of Amsterdam (GGD Amsterdam, 2015). These so-called vignettes “act as a stimulus to extended discussion of the scenario in question” (Bloor & Wood, 2006, p. 183). The profiles range in complexity as so to operationalize the variable complexity of needs. Due to time constraints, not all domains described by the SSM are reflected in profiles. To check whether complexity was successfully conveyed to participants, they were asked to assess interrelatedness and ambiguity of profiles on a five-point Likert scale (see Appendix D). When participants gave the same score to the two profiles, they were asked which profile they found most complex. After the pilot case, it became apparent that the profiles had to be tweaked to better display differences in complexity.
Case Interview ID Position of participant Duration (minutes)
A P1 Process manager 64
P2 Policy advisor 66
P3 Case manager 65
B P4 Policy advisor 34
P5 Development manager 46
P6 District team manager 44
C P7 Project manager 58
P8 District team coordinator 48
P9 Senior advisor 40
D P10 Behavioural scientist / process manager 40
P11 Social worker / case manager 38
P12 Youth consultant / case manager 34
X Policy advisor 42
By interviewing employees with backgrounds in policy-making or practice (see Table 3), it was ensured that a multilevel view on the municipality’s role in the network was elicited. Questions have been formulated that were parsimoniously focused, without participants being led to giving specific answers. The interviews lasted 48 minutes on average, were recorded using a smartphone and transcribed verbatim. Recordings were deleted after processing the results. Since participants’ native language is Dutch, interviews were carried out and transcribed in Dutch. As such, instruments that were used during interviews were also translated to Dutch. Quotes that are illustrated to support findings will be carefully translated from Dutch to English. After reduction of the interview data (Miles & Huberman, 1994), the transcribed interviews were coded in ATLAS.ti version 8.3.0 (Friese, 2018) according to the grounded theory approach of Corbin & Strauss (1990). Another method employed is document analysis (Bowen, 2009). When deemed appropriate, municipal policy documents and other documents related to the topic were investigated to further improve understanding of the topic and to enhance triangulation and construct validity (Eisenhardt, 1989; Yin, 2014). Those secondary data were retrieved from open sources (e.g., websites) and after requests to share such documents. Documents are possibly “incomplete, fragmentary, and selective” (Bowen, 2009, p. 35). Therefore, it is important they be studied prior to interviews so subjects that are unclear can be treated during interviews. As with interview transcripts, documents were coded (Bowen, 2009).
3.5 Data coding and analysis
The first step in the coding process is open coding, in which parts of text are grouped together and given conceptual labels, those are first order concepts (Gioia et al., 2013). Subsequently, axial coding relates first order concepts to second order dimensions (Gioia et al., 2013). During axial coding, preliminary patterns and relationships in cases are discerned. Coding was done in both deductive and inductive ways. Deductive coding links definitions for second order dimensions to constructs from the theoretical framework, whereas inductive coding left open the opportunity for first order concepts to be identified that fell out of the scope of the literature background. This allows to see how constructs from the theoretical framework manifest in real-life and how they link, and whether there are other important constructs that were not included in the theoretical framework. Due to the exploratory nature, coding was mostly conducted in an inductive fashion.
case. This is necessary in order to subsequently generalize patterns across the different cases (Eisenhardt, 1989). During the second step – cross-case analysis – similarities and differences across cases were listed. This method of looking for subtle differences and similarities is useful to gain a more sophisticated understanding of patterns (Eisenhardt, 1989). During and after data analysis, findings were discussed with multiple researchers to improve reliability and overcome potential bias (Denzin, 1978).
4. FINDINGS
Before the findings will be discussed, a contextual distinction between curative and preventive care and support is given. Initially, this study focused on the complete spectrum of care and support, because one notion of the decentralizations was to enable municipalities to focus more on preventive care and support. However, during the empirical phase of the study, it became clear that most attention is focused on curative care and support. This will be discussed shortly in the first paragraph. Subsequently, three stages of organizing the care and support will be elaborated upon. The first stage is the entrance, succeeded by the exploration of needs and capabilities and the process is concluded by development of the actual care and support network. In each stage, the network around the citizen evolves.
4.1 Curative and preventive care and support
For the sake of this research, a dichotomous division between preventive and curative support and care is made. Although participants indicate that care and support teams have both a preventive and curative task, it becomes clear that they are confronted with high work load. Furthermore, data indicates that preventive care and support are not provided individually, but more collectively and in specific programs. A quote gives a good illustration of the relation between preventive tasks and curative tasks: “In the past, for example, we had not purchased
social skills courses, while many children turned out to be short of social skills and if you are unlucky, then they are all sent to the psychologist” (P9). In this event, social skills courses are
a form of collectively organized preventive care, whereas the psychologist is a form of individually organized curative care.
A participant from case D said the following concerning the proportion of curative and preventive tasks: “Prevention is one of our pillars, so we really have a task for ourselves to
municipality would want to work preventively, most attention is focused on curative care. A case manager adds to this that preventive work is surely not part of her tasks: “I explicitly do
not work in the context of prevention, so that must be really clear. […] they deploy me when there are already problems and not to prevent them [from happening]” (P3). A district team
manager from municipality B corroborates by stating that they still mainly have people in long-term care and support pathways with their providers. Hence, the remainder of this section will discuss how municipalities organize the curative care and support according to three stages.
4.2 Entrance to care and support
Entrance is defined as the point where the first contact is established with the citizen. In general, the citizen registers or is registered at a counter. The registration at the counter can be preceded by signalling or outreaching activities performed by the district or area team – since this is out of scope, it will not be explained in further detail. Entering the care and support process is organized differently across municipalities, regarding location (see Table 4) and the number of counters and, coherent with that, the integration of counters (see Figure 3).
Level Centralized vs. decentralized Case
Municipality (e.g., townhall) Centralized A
District (e.g., community centre) Decentralized B, C
Area (e.g., community centre) Decentralized D
Table 4. Location of counter.
Case A (municipality level) Case B (district level) Case C (district level) Case D (area level)
Figure 3. Simplified overview of counters. Note. Counters with dashed lines are a the
centralized (municipal) level.
counter automatically refers to tailored facilities. In the future, the municipality is planning on integrating both counters, as so to facilitate and ease the referral of citizens. As a case manager mentions: “[…] that we [will be] united in a front office where the question comes in, so that
we can make a well-considered referral. So not directly with a consultant, so that you go into indications, but that preceding facilities are used” (P3). The consideration to unite both
counters is also based on the fact that automatically referring to tailored facilities is very expensive relative to the referral to preceding facilities. Another goal is providing unity and clarity to citizens and that the counter transcends life areas, meaning that multi-problem citizens can go to one counter with all of their problems. A policy advisor named two prerequisites for successful integration of both counters: those who refer should trust and be aware of all general and basic facilities. Integrating both counters ultimately means that every citizen enters via one counter. This enables the municipality to make a deliberate choice about how to provide care and support to the citizen and to abstain from or postpone providing indications when this is not necessary. Notifications at counter B are automatically referred to the back office by an operator. Subsequently, a case manager is assigned to the citizen.
Municipality B still has centralized, dedicated counters at the municipal level (e.g., town hall). Yet, municipality B also has one counter in every district that is responsible for answering every question pertaining to care and support: “We actually have everything that has to do with a life
area in our support package” (P6). The district team is equipped with a volunteer whom
establishes first contact with the citizen. The volunteer welcomes the citizen and does a simple inquiry into the citizen’s problems or questions. The volunteer then determines whether or not to notify the back office. The difference with intakers at the centralized counters is that the latter have a limited view concerning the citizen’s problems. The following quote illustrates the limited view of centralized intakers: “As far as I know, emphasis is on the entitlement to benefits
and the prospects for work” (P4). For a multi-problem citizen, this implies that formerly the
citizen had to go to another counter to receive support and care for the remainder of their problems. Thus, having one clear entrance prevents citizens from being chased from (centralized) counter to counter.
Like municipality B, municipality C also has centralized counters at the municipal level. When a citizen has a question or problem that specifically pertains to one life area (e.g., work and participation), that is not a problem, but in the case of a multi-problem citizen it is more complicated: “[…] if you have different problems, then we chase you a bit from counter to
the employee of the other counter]” (P7). Yet, this study is focused on a pilot that is run in some
of the municipality’s districts. The municipality is shifting from the dedicated, centralized counters to one intake team that is located in every district. Similar to municipality B, the district team is responsible for answering questions pertaining to care and support. A member of the intake team welcomes the citizen and does a simple inquiry into the citizen’s problems or questions. When needed, it invites the citizen to a follow-up consultation, a so-called action meeting. This will be discussed in the next paragraph.
Municipality D has counters that are located in areas instead of districts, assumed to be due to the vast and rural character of the municipality. Each designated area has a counter. Those counters are open to public on designated times during the week, or citizens can reach the counter by phone. The counter is open for all questions pertaining to social support, youth care and general social work. This means that therein the counter for work and participation is not integrated and acts as a separate counter. In the future, the municipality is planning on integrating the counters: “At the moment we are still quite separate pillars, but you would want
that at the moment that someone receives a benefit and you notice that there is more going on, that we are then being involved with the area team” (P10). The operator of the area counter
welcomes the citizen and does a simple inquiry into the citizen’s problems or questions. When needed, it notifies the area team.
Across all municipalities, differences occur on several occasions. The biggest difference between municipalities is how they organize their counters, which also reflects the level of integration: one counter for all forms of care and support (high integration), dedicated counters (low integration), or a mix in between (medium integration). Smaller, rural municipalities (A, D) do not work with district teams. This implies that the number of counters for those municipalities is also less. Bigger, urban municipalities (B, C) do have district teams. Both population size and spatial characteristics of the municipalities seem to exhibit links to the amount and location of counters.
4.3 Exploration of needs and capabilities
distinction between facilities is refined based on the analysis. Basic and general facilities are often placed under the all-purpose word preceding facilities: they precede tailored facilities. As a policy advisor states, the set of preceding facilities is described as “[…] everything that
precedes professional effort and that is accessible to everyone and that does not require an indication” (P2). This paragraph will conclude with an overview of the levels of integration
throughout the municipalities during the exploration stage. Instances involved with intake are shown in Figure 4. All instances involved in the exploration stage are shown in Figure 5.
Cases A, B & D Case C (intake team)
Figure 4. Actors involved with the needs and capabilities assessment.
Figure 5. Process steps and actors involved in exploration stage. Note. Follow-up consultation
is not necessarily applicable to case B and case C. First contact is first face-to-face contact in exploration stage.
providers, based on the contents of the support plan. For more complex cases, however, a case manager cannot provide indications but instead must turn to social support consultants, youth care consultants or work and income consultants. However recently, the case manager is tasked with referring as much as possible to preceding facilities: “Our assignment, especially for the
last time, is once again genuinely intensifying those contacts with social work and [name of support organization] so that it can also be solved in a different way than always using an indication” (P3). Intensifying ties with the preceding facilities seems to be an important factor
to refer more easily to those facilities. Hereby, the provision of indications can also be postponed.
In municipality B, the volunteer at the counter engages in a conversation with the citizen and makes a first assessment of the complexity of the problems. This explicitly means that no professionals are involved in the first conversation. Dependent upon the complexity of problems, the intaker informs the citizen about the available preceding facilities. When the intaker notices that something more is going on, he or she sends a notification to the back office. Subsequently, a back office makes an appointment with the citizen for an intake. During the intake, two T-shaped professionals – with backgrounds that match the problems that were initially noticed by the intaker – ask the citizen what they need in terms of support. T-shaped professionals ideally are trained to have a general look at the citizen’s problems, but they are still bound to their expertise. They assess whether preceding facilities or tailored facilities are needed. As with case A, the SSM is used. When an indication is needed, the professionals engage with a consultant. Regarding the facilities, an area support network (ASN) was established. The newly established ASN has two main tasks: matching citizens – that have been referred to the ASN by the district team – to suitable providers and realizing adequate preceding facilities. The first has a clear implication for the way a citizen is referred. In the old situation, after having extensively determined the needs of a citizen, the district team made a considerate referral to suitable partners. Now, the district team refers to ASN which in turn refers to a suitable provider. This step does not seem to add value. Realisation of the second task should impede district team professionals from providing indications, because the ASN should have realized suitable facilities that are based on what the citizen in the district needs.
At municipality C, the district team has an intaker that engages in a conversation with the citizen. For example, when a citizen applies for social welfare benefits the intaker’s job is to ask what else is going on in the life of the citizen: “The core competence of the intaker is to be
in mind: what are the different life areas and what [care and support] are we responsible for”
(P7). The intaker decides to either refer to preceding facilities – in this case the member of the intake team remains responsible for the citizen – or to arrange a so-called action meeting. This meeting is attended by the citizen and the intake team, consisting of the initial intaker and district coaches. The municipality has four types of district coaches: youth & family, participation & work, adult support and elderly support. The action meeting leads to an action plan, in which each actor has responsibilities and actions that are fed back to a case manager – one of the district coaches. Ideally, the action plan is attended by actors from inside the municipality (district coaches) and actors from outside the municipality, such as care providers:
“Suppose you know that someone is addicted, then it really makes sense to invite the addiction care provider to an action meeting” (P7). Having all actors involved around the table makes
for a broad exploration. Furthermore, it prevents duplication of activities and unburdens the citizen: “There are so many [parties] involved with the citizen. It is simply not convenient to
do that separate from each other. Moreover, the citizen must constantly tell his story again, we want to prevent that from happening” (P8). Similar to municipality B, partners of the
municipality are tasked with developing adequate preceding facilities. District coaches are tasked with abstaining from providing indications as much as possible, which prevents referring to expensive tailored facilities. Having realized adequate preceding facilities makes this possible: preceding facilities that are matched to citizen’s needs can be as suitable as tailored facilities.
In municipality D, questions submitted at the counter are discussed in a meeting where every consultant from the area team is present. Based on the question of the citizen and its corresponding ‘box’, the case is assigned to a consultant. Each box has its own consultant: social support, youth care and ambulatory assistance. Because of the ‘box’ system, a specialized consultant is assigned to the citizen. The consultant will engage in a conversation with the citizen to map in which life area the citizen faces problems, but due to the specialized character of the consultant, the exploration is said to be narrow. Currently, the SSM is used during intake, but the municipality is planning on introducing an SSM strengths indicator to further clarify to what degree the citizen and its social network contribute and to what degree the professional support contributes. The main reason for this: “Suppose you are very self-sufficient with a lot
of very professional support and that support ceases, how self-sufficient are you still?” (P10).
postponed as much as possible, this is made possible by the case manager who is also a social worker or consultant, and thus can provide ambulatory assistance. An explicitly stated reason for having multiple conversations with the citizen comes from a social worker (who is simultaneously a case manager): “If you switch to a system of having one conversation [with
the citizen] and then providing an indication, then you get much further away from the citizens”
(P11). Engaging in multiple conversations postpones the provision of indications. When sufficient ambulatory assistance is provided during the consultation by the case manager, an indication might not be necessary at all.
Each case has varying levels of integration during the exploration stage. For case A, it seems that the case manager is an integrated function, because it engages in multiple conversations with the citizen and maintains a broad look at the problems, hereby supported by the SSM. For case B, two T-shaped professionals engage in a conversation with the citizen. It can be said that their broad look as T-shaped professionals is supported by the SSM, yet bound by their own expertise, thus the function seems to be medium integrated. For case C, exploration stage is highly integrated at team level. A meeting is arranged with the citizen during which every district coach can apply his expertise on the citizen’s problem. Case D has low integration at the function level, because the citizen is immediately assigned to a specialized consultant. Table 5 summarizes the levels of integration at the entrance (function of counter and number of counters) and exploration stages.
Case A B C D
Level of integration
Entrance Function High Low High Medium
Number Medium High High Medium
Exploration High Medium High Low
Table 5. Integration at entrance and exploration stages.
overview of how a network is formed based on the previously discussed. The findings illustrate that some municipalities choose to let partners realize suitable preceding facilities. This is often done by providing subsidies to those partners. For example, partners such as volunteer organizations and well-being organizations are classified as preceding facilities and are also tasked with organizing activities that support the social network (e.g., buddy project). This way, referral to more tailored facilities is deferred.
Figure 6. Simplified overview of a network divided into cores. Note. List of municipality actors
is illustrative and not exhaustive.
4.4 Development of the care and support network
During this stage, the network is extended to external partners (see Figure 6). First, per case, this paragraph will describe the multitude of meetings teams have at their disposal. Thereafter, the role of the case manager in the provision of care and support is discussed.
frequency of an MDT meeting can differ, depending on the complexity of the case: “If it has
been some while, you can also say: ‘We've done it a few times every three months. Then we do it again in six months and if it goes well then, I can also leave [the MDT] meeting or let someone else take charge’” (P3). This implies that horizontal and vertical ties are perpetuated in MDT
meetings. Outside MDT meetings, vertical ties are monitored by the case manager; the case manager establishes and secures the ties between actor and citizen. Horizontal ties are not actively monitored. However, the case manager usually asks to feedback what actors have reciprocally agreed upon. This seems to rely more on mutual adjustment than on agreements. Besides MDT meetings, there seem to be consultations between municipality colleagues that have a more spontaneous nature, characterized by mutual adjustment.
Data from municipality B indicated that district teams have three case-based types of consultation: the open mental health care network (OMHC) meeting, a case meeting and an MDT meeting. The OMHC meeting is attended and coordinated by (representatives from) the district team. Further attendants are the main addiction care provider and the mental health care provider. Other external partners are invited when it is necessary for the case. The meeting is especially focused on psychiatric clients. During OMHC meetings, case specifics are discussed such as: “How is the case doing, are you really the [suitable] provider for this or do we have
to design it differently?” (P6). During a case meeting, district team colleagues can ask each
other questions pertaining to support and care. For complex cases, external partners can be invited for a separate consultation: “So, if you say, during your regular case meeting: ‘actually,
the municipal doctor should take a look at this’, then an MDT meeting will be organized” (P6).
OMHC meetings and case meetings are at set times, whereas MDT meetings are organized when the case necessitates this. During consultations, horizontal and vertical ties are perpetuated. Outside consultations, vertical ties are monitored by a case manager. How and if horizontal ties are monitored outside consultations did not become clear from the findings. OMHC and case meetings seem to be more standardized: actors have agreed to meet every once in a while. MDT meetings seem to show a higher level of mutual adjustment: they are voluntary and focused on finding solutions together. Still, some level of supervision is present during MDT meetings.
the main function of the system is supportive, it should not replace face-to-face communication:
“Try to do that face-to-face. Find each other for a moment, just in the old-fashioned way. The system is of course useful for that, but you have to do it together” (P8). Whereas the case
meetings and the usage of the system are more standardized, it can be observed that the district team itself yet very much leans on mutual adjustment, facilitated by geographical proximity. That all coaches are present every working day might contribute to this: “We are here every
day, we are present here in this community centre. And these are all coaches, because we think that all expertise together means that we are a powerful entity” (P8).
Data from municipality D indicates the use of three types of case meetings. The first type of case meeting is focused on debt relief support and is attended by a consultant (i.e., case manager) from the area team, a budget coach and two representatives from work & participation. This case meeting takes place every six weeks. The second type of case meeting usually takes place once every year, and is attended by the consultant (i.e., case manager) and every actor involved with the case. When the case makes it necessary, this meeting can be arranged within a day. However, as for other municipalities, involving actors is obstructed by new privacy laws: “Well, yes, it's getting even more complex now because of that new privacy
law. So, if I want to involve other parties, then I need permission [from the citizen]” (P11). The
third type is colleagues of the area team meeting weekly to discuss cases, and every four weeks a meeting with the behavioural scientist takes place. As with the other municipalities, horizontal and vertical ties are perpetuated within the meetings. Outside case meetings, spontaneous meetings can be planned between case managers to discuss cases: “That is how we can continue
to work with the customer, that we of course involve other experts and ask for information”
(P12). Hence, most case meetings are standardized: they take place on set times and actors have agreed to attend. Mutual adjustment is confined to the consultants discussing cases between themselves, without the presence of other actors involved.
are held with colleagues of district or area teams seem to be more standardized (e.g., on set times). Most meetings that are held with external partners seem to be more ad hoc, they are arranged whenever the citizen’s situation makes it necessary. Those meetings are arranged by the case manager. Additionally, all municipalities independently indicated that the recently introduced privacy law (GDPR) hampers the exchange of information between actors and thus coordination. Although, municipality B indicated that they ask permission from the citizen up-front to share its personal data with actors involved.
5. DISCUSSION
As shown in the previous section, the care and support to the citizen can be divided into three stages. Integration differs per stage and per municipality. In the entrance stage, some municipalities have integrated their counter. Furthermore, integration of counters has the attention of all municipalities. It provides clarity and unity to the citizen and questions for support are centralized. However, the person with whom the citizen established first contact does not always seem to have an integrated function. For example, the functionality of a volunteer as the first person with which contact is established can be questioned. As such, the value of the integration of counters is diminished.
Another interesting finding is the postponement of providing indications. In order to access tailored facilities, indications need to be provided for the citizen. Referring to tailored facilities is expensive for municipalities, so there is an incentive to postpone the provision or to not provide an indication at all. This can be done by the provision of ambulatory assistance during multiple consultations. As an additional measure, most municipalities order their external partners to realize suitable and adequate preceding facilities that should be as effective as tailored facilities.
other hand (cases A, B, see Figure 5) might thus prevent the citizen from receiving the care and support it needs. Also, a consultant is specifically trained for providing indications pertaining to one of the legal areas (youth care, social support and work & participation), which also is a cause for the functions in the exploration stage being separated. As a consequence, this can inhibit the integration of functions in the exploration stage.
Throughout the forming and evolving of the network, several remarks about dimensions of citizen-centredness can be made. The first dimension of citizen-centredness is the ease of access to care and support. This is reflected in the findings by the integration and location of counters, which are integrated to a great extent. The second dimension of citizen-centredness is tailoring services to the needs of the citizen. Literature states that in the most optimal form the citizens choose “the identity of the gatekeeper or case manager, and the provider of the [care and support] service” (Eklund & Markström, 2015; Spall et al., 2005, p. 62). Concerning the first two stages, citizen choice is very limited. The citizen cannot choose the identity of the gatekeeper (person with which first contact is established or intaker), and it cannot choose the case manager. The case manager is assigned based on the problems and needs of the citizen and not on the citizen’s wishes per se. However, during the third stage, citizen choice increases: the providers are assigned based on the needs, wishes and identity of the citizen. Together with that, municipalities have an extensive offering of providers. Literature states that the extensiveness of the offering, increases the coordination (costs) (Nordin, Kindström, Kowalkowski, & Rehme, 2011; Salonen, Rajala, & Virtanen, 2017). The observation can be made that due to an increase in citizen choice, the need for coordination increases.
The first two stages are focused on determining the needs, whereas the third stage actually involves organizing care and support that is tailored to the needs of the citizen. Of the provision of care and support to the citizen, it cannot be said that services are delivered seamlessly. A network of actors exists around the citizen, each providing their own services. The close geographical proximity between actors within the municipality (see Figure 6), such as being located in the same building, seems to enhance mutual adjustment and sharing information. This might offer opportunities, especially because in one case locating the district team in the same building as the general practioner facilitated the knowledge transfer between both parties, which is in line with findings of Knoben & Oerlemans (2006).
meetings and a case manager that monitors the provider-citizen tie, but there is no integration during this stage. According to Lillrank (2012), “[t]he essential difference between integration and coordination is that integration implies a fusion of components into something new, while
coordination is the arrangement of roles and tasks into an organized whole” (p. 8). We can
observe that coordination is attained: roles and tasks are assigned to actors in the network by the case manager and through meetings. However, integration is not attained. There is no combination of ‘components’ (i.e., services from separate parties) into something new, rather they still remain their own separate services. This is where opportunities lie for service modularity. By establishing groups of citizens with similar needs, modularity becomes attainable. By composing service packages or service bundles, municipalities together with external partners, can reduce the amount of service variations (De Blok, Luijkx, Meijboom, & Schols, 2010). The authors indicate that this can lead to effective customization, hence tailoring of services to citizen’s needs.
6. CONCLUSION
The exploratory nature of this study enabled to distinguish the process of delivering care and support to the citizen in three stages: the entrance, exploration and network development stage. The observation is that during the first two stages municipalities accomplish a certain level of citizen-centredness by the integration of counters, functions or teams. This way, the first dimension, or objective, of citizen-centredness (ease of access) is met to a certain extent. The third stage, the actual development of the care and support network is characterized by high need for coordination and low integration. As a result, the remaining dimensions of centredness, seamless and tailored delivery of services, are not fully met. To conclude, citizen-centredness currently seems to be limited to the ease of access. Thereby, this research emphasizes that being citizen-centred in one stage does not necessarily mean that this automatically skips on to different stages.
6.1 Limitations and future research
a constrained look of the process or organisation of care and support. This could for example mean that the mentioned set of meetings are not exhaustive. However, the profiles did provide for an adequate conversation starter, as was also intended in the methodology section. Second, the scope of the study in terms of time was too short to thoroughly investigate multiple municipalities. This resulted in the fact that only six municipalities were visited, of which the data of four municipalities were found suitable to be used in the data analysis. Furthermore, this limits the value of the assessment of citizen-centredness, because it was only investigated from the viewpoint of the municipality. And although insight was gained from multiple points of view within a municipality, it proved tough to interview a set of people with the same job title for every municipality.
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