The result of this study points to some circumstances that are important to take into account when implementing a new policy or model in health and social care. However, this study has limitations. The limited involvement of primary health care in the model is reflected in our research. The primary health care perspective is only reflected in the initial phase. Furthermore, the process of implementing a new model in a complex organisational setting is too wide-ranging to allow this study to capture all relevant aspects.
In the interviews, it became evident that the organisations involved had different traditions and a different understanding of project work. Consequently, the roles of the actors involved in designing and implementing the model have to be clearly defined, including who the senders and receivers are, as well as whether the process is to work top down or bottom up, or both [23
Understanding the general aims of the model, and the ability to connect these to the operative performance, emerged as important in the interviews with the operative staff involved. Grasping the general idea contributed to the understanding of the weight of one’s own work and positively affected the response to the model. However, not only the staff who are directly involved needed to be informed about the general aims of the model. In order for the model to have an impact, the staff in organisational units that are indirectly involved are just as important. In addition to earlier identified components of successful implementation [24
], it is important to elaborate a strategy for spreading and maintaining the information about both the aims of the model and how to work according to the model within the organisations.
When introducing a new model, the senders have to be aware of recent and parallel projects in the organisations, and how these fit in with the new one. Fundamental for the commitment of the actors involved in our study was that the new model corresponded to experienced problems and was perceived as having the capacity to respond to them.
Furthermore, all organisations and professions involved have to see a potential benefit of the model for their own organisation and/or profession. These findings are also supported by results from previous research [34
Different aspects of what operative staffs need to be able to put the model into practice emerged in the interviews. It emerged as important for the senders of a new model to have sufficient knowledge about the organisations and professional roles involved to secure adequate competence of the operative staff and anticipate possible problems. Furthermore, they have to obtain resources to make implementation of the model possible. This encompasses both basic material resources, and time for the operative staff to perform their work properly, as well as time and other resources to work out and overcome obstacles in the organisations. Consequently, realistic interventions that fit within the existing conditions have been showed to be more successful [34
The importance of involving all organisations concerned with the issue at hand have been pointed out in the literature [34
]. In our study the interviewees reported of occurring problems related to the non-involvement of primary care. Furthermore, an inter-organisational infra-structure has to be evolved at different organisational levels to promote trust and confidence among the actors [22
]. In the project, this was done through the steering group and the project group. Both these groups had participants from all organisations involved.1
In our study the model was revised and transformed several times during the course of the project. This points to the importance of enabling the operative staff to elaborate the detailed components during the implementation process and adapt the model to the specific circumstances at hand, i.e., to use their discretion [26
] guided by mutual aims. Complex interventions have been found to be difficult to implement without allowing some flexibility, but the quality of the implementation relies on the understanding of the underlying ideas and core components of the implemented model [24
]. However, staffs operate in a professional landscape of conflicting and competing interests regarding professional status, discretion and jurisdiction [37
]. As shown in other studies, our results reveal some conflicts and problems in the implementation process based on professional self-interest [8
The commitment of the participants is crucial to the impact of the model, and depends on the model’s potential to solve critical problems experienced by the actors involved, professional groups and organisational units as well as whole organisations [34
]. What the problems are, and how they are apprehended, is closely related to the demands of the organisation’s environment, and differs according to the organisational level [25
]. For the operative staff, the demands came mainly from the older people, their next of kin and the personnel carrying out their health/social care and rehabilitation, and concerned the ideology of care. For the managers, the demands came from both the top levels in their organisation and from the organisation’s environment, and concerned cost and work effectiveness to promote the legitimacy of the organisation [9
]. Towards the end of this project, however, new competing ideas and policies regarding user choice caught the municipal managers’ attention and the project was marginalised within the organisation.
The new model comprised changing the traditional working modes and professional and organisational roles, as well as power and status conditions. Organisations, which have been described as a continuously changing and negotiated order [28
], consist of segmented social units with contradictory interests and goals. Consequently, the new model imposed a threat to the negotiated order and was partially counteracted and fought by professional as well as organisational actors at different levels [8
As pointed out by others, the role of upper management in the organisations involved emerged as crucial to the possibility of introducing organisational change, according to the model [34
]. Their support for the model had both a symbolic and a factual meaning, and was therefore necessary, although it was affected by factors in the organisation’s environment, such as new, competing ideas and trends. However, to introduce a model top down is a hazardous project. Therefore, a new model that is being introduced has to be experienced as effectively dealing with real problems in the everyday practice of all the actors involved in the organisation, from the bottom to the top. Conflicting conceptions of the problems as well as prioritised goals may hinder the possibility of reaching consensus on the importance of introducing a certain model. Therefore, it is necessary to work out ways to support change among those involved [8