integrated services: myths and realities

INTEGRATED SERVICES: MYTHS AND REALITIESAuthor(s): Brian WharfSource: Canadian Journal of Social Work Education / Revue canadienne d'éducation en servicesocial, Vol. 3, No. 3 (December/décembre 1977), pp. 24-31Published by: Canadian Association for Social Work Education (CASWE)Stable URL: http://www.jstor.org/stable/41668881 .

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INTEGRATED SERVICES: MYTHS AND REALITIES

Brian Wharf School of Social .Work University of Victoria Victoria, B.C.

ABREGE L'auteur prétend que l'intégration des services

comporte des coûts aussi bien que des bénéfices. Et pourtant, au milieu de l'enthousiasme actuel envers l'intégration et ses possibilités soi-disant illimitées en vue de l'amélioration de la prestation des services, on s'arrête rarement aux coûts. L'article en relève un bon nombre: le danger que la préoccupation de réorganiser les services sociaux personnels amène à négliger la suffisance des dis- positions fondamentales à prendre en ce qui a trait à l'emploi, au revenu, à l'habitation; et le fait que l'intégration des services aboutit à une expansion de la bureaucratisation, à la centralisation de l'autorité et à la diminution des chances de participation chez le personnel et les consommateurs. Enfin, il n'existe que peu ou pas de preuves que l'intégration assurera des services plus efficaces.

In an article published some forty years ago, the distinguished American sociologist Robert Merton wrote about the unintended consequences of purposive social action.1 In this article he argued that those charged with the responsibility of social planning must concern themselves with the unintended consequences of their acts. As we are now aware, well intentioned slum clear- ance schemes had results other than those intended by the planners; other examples of negative outcomes of plan- ned social change are not difficult to identify.

In some instances unintended consequences cannot be predicted in

1 Merton, Robert, "The Unintended Conse- quences of Purposive Social Action**. American Sociological Review , I, 1936.

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advance. In other plans some possible negatives are known but kept hidden. However, it is suggested here that we know some consequences of social service integration. While the primary goal of those favouring integration is not bigness per se, this is a not unusual out- come. We need to be very clear then that a likely consequence of service integration is the creation of super agencies with all the attendant evils of centralization, impersonalization, inaccessibility, and dépendance on rules and regula- tions - in short, a system which stifles initiative and criticism. For example, the seemingly disorganized child welfare system in Ontario allowed the staff and board members of many of Ontario's fifty-one Childrens Aid Societies to picket Queen's Park to protest budget cuts. I am not aware of any such possibilities is a regionalized integrated child welfare system such as exists in British Columbia.

Social planning is very much an exercise in which one gains on the roundabout and loses on the swings. One can rarely have it both ways. It is suggested the integration issue is a classic case in point. Some benefits will accrue in terms of an apparently more organized, rational and comprehensive service system. But there will be costs and unpopular as the points presented in this paper may be, they need to be in- troduced into the debate and considered along with the expected benefits of service integration.

There is little doubt that the integration of social and health services has become one, if not the , fad of the day. The prestigious magazine Evaluation



devoted its entire recent issue to the topic and the Canadian Journal of Social Work Education focused its last issue on service reorganization in Canada. Integration has, in fact, re- placed the long-cherished notion of coordination as the panacea for all the ills of the social services. Thus, Joseph Ryant argues that "integration has conceptual merit in its own right and contains the real potentiality for solving a long list of persistent social service defects."2 And after an examination of three dominant trends in reorganizing services - integration, decentralization and community participation - Andrew Armitage contends that "of the three, integration of services appears to be the most significant in its total effect upon service patterns".3

These conclusions are consistent with the writings of leading theorists outside Canada and are in tune with the developments that have occurred in practice during recent years. No less than twenty-six states in the United States have established comprehensive human resource agencies in order to concert the services of a variety of human service departments. In Canada the most ambitious attempt at integration has occurred in Quebec but other provinces have made significant efforts in this direction.

Given this evidence of enthusiasm for integration it is not exactly a task for the timorous to even raise questions about the presumed benefits. It should be noted that the writer's philosophy and

2Ryant, Joseph. "The Integration of Services in Rural and Urban Communities". Canadian Journal of Social Work Education , Vol. 2, No. 3, Dec. 1976, p. 5.

3Armitage, Andrew, "An Analysis of Social Ser- vice Delivery Organization". Canadian Journal of Social Work Education, Vol. 2, No. 3, Dec. 1976, p. 6.

convictions have been based on the need for basic social services to be made available, under public auspices, in such a way as to make these services readily available and accessible to all citizens.

Despite the voluminous literature on the subject of social and health service integration it is worthy of some note that few articles or monographs bother to come to grips with the definitional problems. Precisely what is meant by integration? Does it refer to the local level cooperation of area and district workers who concert their efforts and pyramid their energies by meeting on a regular basis to discuss common problems and to identify gaps in services? These efforts depend largely upon the initiative and determination of direct service workers who, despairing of the separate mandates of their respective agencies, attempt to bring more coherence to the social service pattern by meeting together on a regular basis. In effect, this represents an attempt to overcome at a practice level the limits imposed by departmental and agency boundaries. These developments have occurred in many parts of the country and, with very little expenditure of resources, produced some worthwhile results.

At the other extreme, does integration mean the amalgamation of agencies under one public authority such as occurred in Quebec and, to a limited extent, in British Columbia? Between these two poles lies a variety of possibilities including, for example, the comprehensive and ambitious Brittania Social Service Centre in Vancouver which brings together, under local citizen control, a wide variety of services in health, education and recreation. It is worthy of note, however, that Britannia excludes the statutory social services: a decision reached by the local citizen board.

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In this paper integration is defined as the provision of a number of the social and health services under a common authority. In some instances the development of integrated services requires the initiation of new services. In other instances integration involves the joining together of either departments or agencies which have existed on a separate basis for some time, and as we have been painfully aware in British Columbia, this is exceedingly difficult to bring about. Peter Marris develops the concept that reactions to enforced change from without can be viewed as grief. While most of us fully understand grief as a reaction to death and divorce, we only dimly comprehend that reactions to organization and community change can also be conceptualized as grief.4

Why Integrate Kathleen Heintz notes in an article in

Evaluation , "The trend toward the development of comprehensive human resource agencies is the result of two developments: growing interest in integrating the delivery of human services at the community level, and a desire to modernize and rationalize the adminis- tration of government at the policy- making, planning and budgeting level."5 There is little doubt that these two factors represent the essence of the argument for integration. In the first place, all the studies which have been conducted on service delivery patterns, the actual experience of consumers attempting to obtain services, the frustrations of the direct service worker,

4Marris, Peter. Loss and Change , N.Y. Anchor Press, 1975.

5Heintz, Kathleen, "State Organizations for Human Services", Evaluation. Vol. 3, Nos. 1-2, 1976, p. 106.

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and the impressionistic observations of volunteers and politicians all agree on one central point; that the network of services in many urban centres in North America seems chaotic and confusing. In the words of a Metro Toronto social planning report "To search for a cumulative coherence in all this public activity is to seek out a logic that was never intended in the beginning."6 In the second place, the existence of many and often competing departments within provincial and federal levels of government in the broad area of human services creates difficulties for those charged with setting priorities and allocating funds. Integration appears to have the potential of resolving many, if not all, of these dilemmas.

A series of case studies on social planning, describing attempts of local social planning efforts to reorganize services, utilized a framework which outlined a number of problems in the delivery of social services.7 Briefly, this framework suggested that: - where services are not adequate more

resources must be provided, - where services are not accesible, de-

centralization is required, - where services are not accountable

and responsive, then mechanisms such as avenues of appeal and redress and of consumer participation must be developed,

- where services are ineffective, then techniques of intervention must be improved,

- where services are not coherently organized, policies at senior levels and practice at the direct service level must be changed.

6Social Planning Council of Metro Toronto. In Search of a Framework , January 1976, p. 15. 7Wharf B., and Carter. Planning for the Social Services , Canadian Council on Social Develop- ment, Ottawa, 1972.



The argument holds that each of these separate problems requires a separate solution. Thus, to overcome the prob- lem of incoherence, a variety of integrative mechanisms are required at both the direct service level and at the policy level. However, focusing on integrative strategies will avail little if the most significant problems are those of adequacy and effectiveness. In fact, adding to the stock of services in order to overcome inadequate resources may exacerbate problems of incoherence.

This point requires some elabora- tion. Few, if any, integrative efforts have sought to include manpower, housing and all income security prog- grams. Indeed, it would be difficult to envisage how such integration could be achieved, since three levels of government are involved. These basic social provisions are, however, largely responsible for determining the quality of life. If these provisions are inadequate, life for many people will be characterized by poverty, unemployment and poor housing. This is the reality confronting many Canadians in 1977. Unemployment is at an all-time high and affecting most severely high- risk groups such as the unskilled and poorly educated; public housing provisions are inadequate and social assistance rates across the country maintain people below "accepted" poverty levels.

The responsibility for the basic social provisions in income, employment and housing rests with the provincial and particularly the federal governments. These provisions are largely determined by a combination of economic conditions and political philosphies. It is not suggested here that social workers and social agencies have had in the past, or should have in the future, the responsibility for these policies. It is suggested that a basic responsibility of social service

agencies, both those providing direct services and those engaged in social planning, is to monitor and assess the effect of economic conditions and political philosophies on the lives of the people being served. The establishment of a bureau of social statistics to perform this function was one of the principal recommendations of the Winnipeg Audit and of many other studies on social planning, but to date it has not been implemented in Winnipeg or any other major centre.

A preoccupation with the structural arrangements of the social services, which exclude employment, income and housing programs might be com- pared to rearranging the deck chairs on the Titanic. It is an exercise in frivolity. The priority item on the social service agenda must be developing the capacity to monitor and, in as vigorous and repetitive a fashion as possible, to draw attention to the effects of the inade- quacies in our basic social provisions on the lives of the families served by social service agencies. The biggest single indictment against social workers and social agencies is the consistent record of failure to perform this social indicator function.

The Myths of Integration There are a number of rarely

questioned assumptions and percep- tions surrounding the integration of the personal social services and stretching to fields such as health, correctional services and income programmes.

The first myth is that integration makes services more readily available. As a lady in Washington is reputed to have commented about the multi-service centre in her neighbourhood: "I used to have to go to ten different agencies to find out there was no help

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available, now I can go to one."8 Just as the basic social provisions are

often inadequate, so are the personal social services. There is much experience and some evidence to justify the claim that the resources available to provide sufficient day care, homemaker and counselling services are inadequate.

A second myth is that integration always results in more effective and efficient services. I doubt that those in the Canadian Armed Forces will agree that the merger of the Air Force, Army and Navy has produced a more effective or a more efficient service. In a useful review of the benefits of regional government, and industry in England, John Child concludes that there is simply no evidence that larger units are better or cheaper.9 In fact, there is no evidence that they are more expensive.

Integration of small units inevitably results in the creation of large organizations and we, do know that the bigger departments or agencies become, the more people have to be added to take care of interdepartmental communication. Robert Townsend comments that "each level of management lowers communication effectiveness within the organization by about 25%."10 We know too that difficulties in supervision, and issues of identity and alienation are exacerbated with increase in numbers. John Child makes the following acid commentary. "On social grounds bigness is on most counts a

8Kahn, Alfred. "Service Delivery at the Neighbourhood Level: Experience, Theory and Fad". Social Service Review , Vol. 50, No. 1, 1976, p. 35.

'Child, John. Participation, Organization and Social Cohesion, Human Relativeness , Vol. 29, No. 5, 1976. ,0Townsend, Robert. Up The Organization. Greenich: Fawcett Crest Book.

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disaster - it helps to generate poor morale and lack of commitment among employees; it makes sharing in decision making and responsiveness to community interest much more difficult because of the remoteness in human relationships which it inevitably creates and bureaucracy reinforces."11

With reference to the integration of services in Quebec David Woods worth has pointed out that,

regionalization of social services may look like decentralization but it may also have the reverse effect. Where there was the possibility of personal influence at the local level that has now been removed in favour of a more remote rational authority devoted to standardization and central control.12

Finally to quote again from John Child:

Growth tends to generate departmentalism and an accumulation of different jobs. Prob- lems of communication and coordination then arise. The response is then, set up rules, procedures and written instructions which requires the addition of personnel to make sure these rules are carried out.13

In fact, if informal places with a high degree of worker and consumer involve- ment are to be sought, then by defini- tion small decentralized units must be created with a high degree of autonomy.

A third myth is that integration is necessary because of the chaotic frag- mented interorganizational field. As noted earlier this is the core of the integration argument. Yet a couple of studies in the United States, conducted two decades apart, indicate that since there is a common view of problems and intervention strategies which prevails in

"Child, John. Op. Cit., p. 447.

12Woodsworth, David, Power Redistribution in Canada. Canadian We re, Vol. 52, No. 6, Jan. - Feb. 1977, p. 15.

I3Child, John. Op. Cit., p. 443.



experience in Victoria that integrating income, child welfare and family counselling services has resulted in priorities of staff time being given to income and child welfare crises. Of course, crises have always and legiti- mately required attention first, but when separate administrative structures existed some protection was afforded to the non-crisis, preventive services.

A fourth myth relates to effectiveness. If there is no solution to social problems, if there is a need for a variety of innovative approaches and experiments, then perhaps there may be advantages in developing, on a very conscious basis, different service strategies. And again we know that large and bureaucratized organizations constitute a very inhospitable environ- ment for innovation.

To sum up, integrated services have a real potential for increasing levels of bureaucratization, for centralizing authority, for decreasing opportunities for participation by staff and consumers, for reducing choice and increasing expense!

Realities of Integration The first and most important reality

is that the myths discussed above will not be punctured and that we will continue zealously to develop integrated services. After all, integration promises to deliver benefits without the painful examination of the fundamental issue of adequacy. Any distraction from this will be welcomed by politicians, policy framers, social service staff and most of all by elitists in the country who, as in British Columbia, prefer increased exemptions in death duties to increased expenditures in income and social services.

A second reality is that integrated services efforts at the direct service level do provide a measure of support for

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social service agencies, it matters little that services are available from several different sources. Thus Norton Long in a classic article written in 1958 observes that

much of what occurs seems just to happen with accidental trends becoming cumulative over time and producing results intended by no one. A great deal of the community's activity consists of undirected operations of particular social structures each seeking particular goals and in so doing, meshing with other.14

And in 1974 Roland Warren after an exhaustive study of the model cities' programmes in the United States involving fifty-four organizations in nine large cities, came to a similiar con- clusion. "What appears to be a rela- tively chaotic field of planning organizations going their own way turns out to be a highly structured field with much more coordination than is (initially) apparent."15 There is then some basis for the contention that what seems like fragmentation and duplica- tion may be so only to the casual observer.

Some consumers have argued that the existence of a number of organizations affords some protection to them, and particulary to those clients who are typically shunted from agency to agency mainly because no one knows how or has the resources to assist them. The completely integrated service would offer a variety of services but only through one agency and initially one gatekeeper. If the integrated intake worker has a bad day, consumers might not receive optimum service. Without any hard evidence to convincingly establish the point, there is some recent

14Long, Norton. "The Local Community as an Ecology of Games", American Journal of Sociology , November 1958. 15 Warren, Roland. The Structure of Urban Reform , Lexington, D.C. Heath, 1974, p. 159.



a staff member in the Vancouver General Hospital to be responsible for interagency referrals and relationships.

Finally the largest single compelling argument in favour of integration is that it is conducive to the development of the social indicator function noted above. Ironically while integration is often seen as resulting in decreased costs, it may through the establishment of a comprehensive data bank on needs and resources, make possible for the first time, some definitive statements on the state of the community on a longitu- dinal basis - which in turn would high- light the need for additional resources.

Concluding Comments If current trends continue, integra-

tion will continue to be used as an argument to justify increasing control of human services by federal and particularly provincial governments. To offset the emerging provincial monopolies we need the following: - organizations which can monitor the

performance of public departments on a continuing basis,

- increased opportunities for involve- ment by citizens, staff and consumers in planning and administering services; the admittedly brief experience in British Columbia indicated that the local resource boards were beginning to question the discrepancies in payments to those providing sub- stitute care for children and that provided to natural parents receiving social assistance. With the same financial assistance might not some natural parents be able to improve their capacity to care for these children? Experiments in the local control of

services are badly required in Canada and the reluctance of provincial governments to consider long term commit- ments to these experiments is but added

direct service staff such as social workers and public health nurses. The support accruing from sharing information and clients help staff to preserve their sanity and commitment in the face of their day-to-day frustrations. And these informal work situations provide a marked contrast to and relief from the highly regulated and regimented departments which direct service staff must contend with.

A third reality is that there are a lot of brownie points accruing to those who can reorganize governmental structures particularly if the reorganization results in a reduced number of departments. One of Jimmy Carter's main planks in the recent American election was that he could reorganize the federal government just as he had done in Georgia. Yet as noted above, in England under serious examination the expected benefits of reduced costs and improved efficiency of government reorganization has proven to be illusory.

Fourthly, I do not intend to get carried away by the persuasiveness of my own arguments. There is a need for some integration to take place. For example, on a functional basis it makes sense to argue for the integration of core services to families and children including counselling, day care, homemaker, and other preventive and protective services. It would make sense to integrate income programmes particularly through a guaranteed annual income delivered on a central- ized automated basis. It would make sense for all health services to be integrated to ensure continuity in care for patients. And there is also much to com- mend the establishment of linkages between these various service systems in order to prevent distortions in communication. These can often be accom- plished fairly easily: for example, the Vancouver Resource Board has placed

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which like super tankers should be avoided at all costs, but to develop integrated systems for collecting and distributing information; to initiate small scale service centres which can provide the mix of services required by the area being served and to enhance the growth of citizen and consumer responsibility for health and social services. If these developments are to occur it will be necessary for provincial departments to be changed, to provide budgets on a block grant basis and to encourage experimentation. In all areas of life we need to create humane arenas for work characterized by a low level of bureaucracy - arenas which will enhance rather than limit human potential.

evidence of the trend towards central- ized control. It should be emphasized that since no one model of integrated services can be shown on a conceptual level or through empirical evidences to be clearly superior to others, we should refrain from the development of any more provincial blueprints to be implemented regardless of local conditions and wishes. A far more productive approach would be a provincial policy encouraging local communities to develop their own models of integrated services with provincial assistance for planning and evaluation. Of particular importance in developing different models would be the use of non stigmatized locations such as libraries and recreational centres for delivery of social services.

The challenge then seems to be not so much the creation of super agencies,

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integrated services: myths and realities

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