In this section we give a detailed chronological description of the intersectoral process. This is structured to present 1) the participants’ intentions, 2) the example of the “pitch” template, and 3) the outcome in terms of the approved strategy. We use the example of the pitch to illustrate how the process reproduced abstract rhetoric rather than plans for action.
High hopes and strong beliefs
“Everyone talks about breaking down the silos, but we try to achieve it”.
Participants in Townville described that they were in a process of breaking down organizational silos. This was expressed in phrases like “
breaking down the silos”, “
breaking the columns” or as “
creating coherence and consistency”. Intersectoriality was a main priority of the process and great efforts were put into achieving this: The policy had been developed in an intersectoral process and was accompanied by intersectoral governance mechanisms such as Health Forum and the working groups, intersectoral political consultations and a public conference, a public hearing, dedicated funding to support new initiatives, as well as commitment and leadership from top-level management, and a political mandate for intersectoral collaboration. Overall the process enjoyed great support among participants, who generally showed great enthusiasm. For instance, after the launch of Health Forum, several participants came over to congratulate the public health manager and told how excited they were. Only on one occasion did a local manager question whether it was necessary to introduce a new strategy. He did not receive much support from his colleagues though. Instead they argued for the necessity of an intersectoral strategy to ensure coordinated efforts:
“You can’t save the world with an intervention in your department alone. It needs to be consistent with what is done in social services, in employment services etc. This is why we need to have a strategy.”
The belief in intersectoralism was paralleled by a belief in control by strategic planning. At numerous occasions participants expressed how it was essential that the policy, and particularly the strategy, would set priorities and give direction for action: “It must be a tool to make priorities. It must give a direction”. Generally, participants believed that introducing the intersectoral strategy developed through a thorough intersectoral process, would help control action across sectors, thereby creating coherence and consistency.
Structuring the strategy: The pitch template
“[The health policy] has been approved, but that in itself does not produce health. So now it must be brought to life […] We cannot bring the policy to life alone in our small office. It requires that everyone […] must be involved”.
With these words the public health manager introduced the working groups to their task. The quote sums up their main intentions for the process: to move from policy to practice and to engage the entire municipality in the policy implementation. Implementation came across as a shared ambition that was highly desired, but constituted great challenges. For instance the working group initially described one of their aims as: “
to do what we say we do” and “
Townville employees must live up to our own policies”. Another example was a discussion on local policies:
“The thing that’s so damned about all the policies we have, because we have a billion policies and strategies. […] we can’t say that it is not described. Everything is described. It is a matter of whether it is being done.”
There was a general frustration among many participants who wanted a closer connection between policies and action.
To ensure this connection and achieve implementation, the project group introduced the “
pitch template”. The “
pitch” was a table on one sheet of paper with fixed phrases to fill out in order to present interventions concisely. It was presented as an “
innovation tool”, as the template should help clarify and convey ideas without any “
woolly talk”, thus ‘pitching’ them to get clout:
“Academic and administrative language sneaks in too easily. All this must be stripped away. We must communicate clearly. If we can’t communicate our ideas clearly we can’t collaborate.”
The pitch was conceptualized as a tool to establish collaboration and moving interventions from idea to action. On this background it was introduced to structure the strategy.
However, working with the pitch was difficult for participants, who struggled to concretize their ideas. For instance, during the workshop participants kept changing the overall theme of the pitch as they struggled to fill in the blanks in the template. E.g. relating to the aim mental health, they discussed whether preventing suicide or promoting general wellbeing was the objective. They were not sure what constituted the greatest problems or best line of action. Moreover, whenever participants were forced by the templates to make ideas explicit, these were the rare occasions when the atmosphere changed and became tense or tired.
Another challenge the pitch highlighted was the sheer number of objectives in the policy. The health policy outlined three overall aims: “
healthy measures”, “
mental health”, and “
equality in health”. Each aim included numerous explicit objectives, as well as statements of intent. The coordinators produced a table to create an overview, which amounted to 53 objectives. This included the objective to meet basic recommendations from the national prevention guidelines, which alone consisted of 176 recommendations. As such, the policy did not provide the direction they attributed to it and prioritization remained a key challenge. This was highlighted by the pitch template’s tight structure. Participants struggled to suggest specific action while maintaining the purpose of the strategy as an overarching document:
“It’s a challenge now that the implementation strategy is still at a very strategic, general level. If we use pitch it will be at least 30 pitches for each target group, so we need to lump it together in associated themes”.
As a consequence, over a period of some weeks PHO decided to use the pitch template to describe more general areas of intervention, and thus moved away from the original intention to communicate plans for action.
The working group produced five pitches describing overall areas of intervention in Children and Youth Services: “
health integrated as part of core operations” which focused on professional competences; “
strengthening parenthood and mental health of young families”; “
local health strategies in all daycare centers, schools and special services”; “
promote health among the youth”; and “
implement the national prevention guidelines”. The pitches were distributed to the working group and members of Health Forum for final comments. Most feedback was positive but some did suggest a few changes, for instance:
A manager comments on “strengthening parenthood”. The pitch suggests (among other things) to add an extra visit by community nurses to mothers within the first year of birth. The manager questions whether the costs of adding an extra visit would correspond with an equivalent outcome of better health. The coordinator replies that this proposal is based on the decision to meet national recommendations, which endorse five visits within the first year. Townville only offers 4. She adds that she will change the wording of the pitch and concludes: “I will try to rephrase this part of the pitch in relation to strengthening the parenting role, but without making a specific proposal”.
The pitches were then adjusted to incorporate the last comments, thus rephrasing some details to make them less specific.
The draft of the strategy, including pitches from all three working groups, was then distributed among Health Forum and the Steering committee for approval. At this point, top-management in Children and Youth Services (where two of four top-managers were members of the steering committee) rejected the strategy. At a meeting between the top-management group of Children and Youth Services, the public health manager and working group coordinator, the pitches were rejected. DHH was not present at this meeting, but learned later that the pitches were still considered too explicit, despite the reworking. As a consequence it was finally decided to remove the pitch template completely from the implementation strategy. The strategy then consisted of general descriptions presenting the headlines and general aims of the 16 areas of intervention, but without explicating the action involved.
Approving the strategy
The strategy was then (verbally) presented to the City Council for discussion. Here some politicians reacted negatively to the long recitation of the now 16 suggested areas of intervention. The City Council did not express explicit opposition to the content, but advised that the number was cut down to create a better overview. PHO edited the strategy to make it more easily readable for the politicians. However, instead of removing suggestions they joined them together into six themes: “child obesity”; “child and adolescent mental health”; “intersectoral substance use prevention”; “better health for vulnerable populations”; “well-being among sick, debilitated and at risk populations”; and “increased intersectoral collaboration regarding old-age medical patients”. The suggested areas of intervention were listed in boxes underneath the themes as “examples”. As a result all suggested interventions were still potential future actions, although no action was prioritized and decided upon. Moreover, the suggestions remained highly abstract, only introduced by a heading. Therefore the final strategy did not provide the prioritization and direction for action, which was initially desired. The strategy was subsequently presented to the political committee with the mandate to approve health interventions, who adopted it without further changes.
In follow-up interviews, participants expressed general approval of the strategy and evaluated the process a success. For instance the director of Children and Youth Services concluded: “It’s a good plan”. He told that his employees had started referring to the health policy and talked a lot more about health than they used to. He believed this would contribute positively to the future implementation.