Thinking and acting outside the box: The co-existence of formal bureaucratic integration and informal street-level integration in municipal health and social care services

Abstract

Integration of health and social care services is the recommended approach for people with concurrent mental health and substance abuse problems. Integrated service approaches can, however, be difficult to achieve due to organizational and financial barriers. This is a study of practice-level service integration in municipal health and social care organizations that provide services to people with mental health and substance abuse problems. More precisely, we study the co-existence of formal and informal integration in a service field which is threatened by cost-savings and cuts in resource use. The study is designed as a qualitative single-case study, with three Norwegian municipalities as case organizations. The empirical data consists of a combination of in-depth individual interviews, focus group interviews and observations of decision meetings. This material is analysed with a deductive thematic analysis approach based on theories concerning formal integration and street-level diplomacy. The findings reveal that commitment to the goal of service integration can be both symmetrical and asymmetrical between managers and professionals. Co-existence between formal bureaucratic integration and informal street-level integration is possible if the commitment is symmetrical, and if professionals are granted increased autonomy and less formal control