Rehabilitation—Between management and knowledge practices: An historical overview of public action in Norwegian welfare reforms

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Policy and Society 31 (2012) 119–129 www.elsevier.com/locate/polsoc

Rehabilitation—Between management and knowledge practices: An historical overview of public action in Norwegian welfare reforms Marte Feiring Norwegian Institute for Urban and Regional Research & Oslo and Akershus University College of Applied Sciences, Norway

Abstract This article explores current Norwegian welfare reforms using the example of rehabilitation policy. One distinctive trend is the development of rehabilitation as part of a management system across administrative levels, sectors, as well as at the interface between public and private service provision. Another is the emergence of rehabilitation as a knowledge practice based on diverse disciplines, in addition to the experiences of both service providers and recipients. My research question is: in what ways do policy reforms redefine rehabilitation as a knowledge practice by using management tools? In terms of design, I briefly describe the history of rehabilitation services before addressing how today’s welfare reforms redefine the field. I use document analysis and conduct a critical examination of selected political documents. The article concludes that in current rehabilitation practices, professionals, managers and clients are more interwoven than in the past. # 2012 Policy and Society Associates (APSS). Elsevier Ltd. All rights reserved.

1. Introduction Rehabilitation is a complex and comprehensive task area that operates in the field of somatic and mental health, drug abuse, work-related rehabilitation and social life, and its practice is multi-professional and based on an ability to cooperate (Report No. 47 to the Storting, 2008–2009, section 6.4.3).1 Rehabilitation is the process of enabling someone to live well with impairment in the context of his or her environment, and as such, requires a complex individually tailored approach (Hammell, 2006, p. 8). The two citations represent the Norwegian authorities and an internationally known practitioner and researcher in the field of rehabilitation, respectively. The first quote refers to rehabilitation as part of a complex management system involving administrative, organisational and structural features that consist of institutions and actors who control, coordinate and organise services related to health, work and social life. Two of the institutions are the Norwegian Parliament (Stortinget) and the government, which in addition to law making and allocating money, draft and discuss white and green papers, conduct assessments, formulate plans and carry out strategies. The system also consists of ministries and directorates tasked with the administration and preparation of political actions, including making decisions

E-mail address: [email protected]. Retrieved on March 1, 2012 from http://www.regjeringen.no/pages/2206374/PDFS/STM200820090047000DDDPDFS.pdf and from http:// www.regjeringen.no/en/archive/Stoltenbergs-2nd-Government/ministry-of-health-and-care-services/tema-og-redaksjonelt-innhold/kampanjesider/ 2008/the-coordination-reform.html?id=524777. 1

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in different areas, as well as politicians and civil servants at the municipal and county levels who draft plans, make decisions and dispense money to local and regional causes. Finally, supranational arenas and actors may be added, such as the EU and WHO, that can be further broken down into multiple committees with administrative and professional experts, from which emanate documents, strategy plans and recommendations for their respective member states. The second definition deals with rehabilitation as a multiple knowledge practice, which refers to a composite of the activities, experiences, theories and reflections, as all the doers of knowledge practice are actors in the welfare system. For Hammell (2006) it is important to question the superiority of certain types of knowledge. This entails the everyday knowledge and experiences of all involved, including clients, professionals, scientists, and even politicians and civil servants, and also refers to academic knowledge produced by scholars and researchers at universities, colleges or applied research institutions, while further comprising professionals’ experiences of working directly or indirectly with clients. The aim of this article is to explore how Norwegian welfare reforms are redefining rehabilitation between management and knowledge practice. My primary aim is to analyse the complex interaction between administrative and professional, and between the logic of management and the logic of professional practices. Over the past few decades, many countries have taken major action to reform their welfare systems and services, which are aimed at promoting a better integration between administrative sectors and professional practices, between service providers and recipients, and between public and private actors. I will elaborate further on how others scholars have dealt with rehabilitation as a composite public action, or what Per Koren Solvang (2012) has characterised as a cross-field of academic, professional and administrative interests. Several scholars have portrayed the multiple challenges to rehabilitation policies. For Hanssen and Sandvin (2003), rehabilitation in Norway is challenged from four quarters: (1) political institutions that demand more services for less resources; (2) multiple professionals struggling for a share of tasks among the various stakeholders; (3) a growing and stronger disability movement, and (4) a modernism challenged by a new vision of disorderliness and diversity, which states that the multiple challenges comes from above, from within, from below and from without (Hanssen & Sandvin, 2003). Kendall and Clapton’s, ‘‘Time for a shift in Australian rehabilitation’’ (2006), highlights great tensions in the field from medical expertise, from economic rationalisation, from business models of privatisation, from quality controlling agencies, emancipation movements and the advocates of humanistic morals or values. They refer to the area as a clash in values, and the tensions and turbulences that may be characterised as a double-edged sword that hinders reforming and managing. Winance, Ville, and Ravaud (2007) outline three stages of disability policy in France since the middle of the 20th century: a category-based policy, a universalistic policy and a personalized policy, while referring in the conclusion to current tensions between the approaches. Søren Hagen (2008) describes the four main principles of today’s Danish rehabilitation policy as compensation, equal treatment, sector responsibility and solidarity. He understands rehabilitation as a comprehensive and specialised task area, in which coordination between the main institutions and actors presents a major challenge. For Hagen (2008) a new type of network governance is necessary to allow coordinate sectors and professionals to make individually tailored approaches. Last but not least, the Swedish scholar Morten So¨der (2009) underscores the many tensions in the field of disability studies between research and political action, impairment and disability, and theory and empirical research. He recommends that researchers deal with these strains in a constructive dialogue that promotes pluralism and creativity. In this text, I will attempt to follow this advice. 1.1. Analytical concepts This article argues that in today’s welfare reforms, the interaction between governing management and professional practices is undergoing major changes. The concept of welfare is used in a broad sense in comprehending education, health and social policies. In order to capture these changes, I will analyse several intermingling processes from government to governance, from direct to indirect management tools and from mono- to multiple-knowledge practices. According to Axelsson and Axelsson (2007), today’s Nordic rehabilitation policy is an example of a shift from government to governance, as well as from vertical coordination and horizontal collaborative relationships to more complex types of cooperation. This is the first processes to be dealt with in this article. In their words, coordination entails a large measure of vertical integration, collaboration refers to the integration of actors in horizontal relationships, while cooperation is a complex combination of horizontal and vertical integration. A related term is public action, and Bernard Delvaux (2008) states that public action has newly been introduced in French policy studies. The main reason for this was the need to make a break with the classical terminology of political science and to

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mark sociology’s entry into the political arena by borrowing the word ‘‘action’’ from a battery of sociological concepts, which broadens perspectives in the study of politics while creating links to the wider sociological literature on social processes. The shift from government to governance or from political action to public action has several distinguishing features such as a participation of multiple and varied actors and an increasing interdependence of network relationships, in addition to hierarchical relationships. In order to comprise these changes, there needs to be a focus on interdependence and relationality between the actors, as well as between the fragmented and flexible nature of the policymaking processes (Delvaux, 2008). To comprise such processes, Nikolas Rose (2006, p. 148) applies the concept technologies of government, which he defines as: ‘‘the strategies, techniques and procedures through which different authorities seek to enact programmes of government in relation to the materials and forces to hand and the resistances and oppositions anticipated or encountered.’’ I use tools of public actions as a synonym to technologies of government (Salamon & Elliott, 2002, p. 19). I argue in this article that a major change took place in the use of governing technologies after 1945 – i.a. a change from direct to indirect management tools. This is the second process to be analysed in this article. Direct regulation tools means using formal education and law-making, while also using indirect tools, i.e. using guidelines and the standardising of practices, regulations, plans and strategies. Following this understanding, governmental technologies or tools of public actions have shifted from being a visible part of welfare policies to becoming a more invisible part of rehabilitation, in which politicians, civil servants, professions, private service providers, and even service recipients, may play a role in enacting policies and programmes. This brings me to the analytical term knowledge practice, which refers to a composite of activities, experiences, theories and reflections. For Harald Grimen (2008), all professional knowledge is multiple and poorly integrated from a theoretical perspective. He argues that professional knowledge consists of meaningful units created outside the field of theory that cannot be separated from the actors who possess it, and cannot be separated from the situation in which it is produced and applied. It is further tied to the individual person’s experiences in given situations – it is practical and based on personal experience. In the research literature, an analytical distinction is made between: (a) explicit or codified knowledge, which is transmittable in formal systematic language as expressed in symbols, words and numbers and (b) tacit knowledge, which is personal, contextual and rooted in actions and experience (Bartunek, Trullen, & Bonet, 2003). This article will explore shifts in knowledge practices from mono-professional to multi-agency working. Following Andrew Abbott (1988), research and politics rely on the prestige of academic knowledge, whereas in direct work with clients or other concrete tasks, the experiences and reflections of the practitioner is what counts (Molander & Terum, 2008). The primary aim of this article is to analyse the complex interaction between public actions, management tools and knowledge practices. I explore how traditional government, governance and horizontal networks exist side by side, how new management tools are launched to enable municipalities and how central authorities interact with voluntary organisations and private enterprise, thereby helping to realise cross-border coordination and multi-professional collaboration. The interaction between agents with different logics and distinct views on informal experiential and formal codified knowledge is a highly complex issue. 1.2. Empirical sources In order to examine the shifts from political to public action, from traditional to new tools of governing and from monoprofessional to multiple knowledge practices, I rely on earlier secondary and primary sources. The historical data is based on a thesis published in 2009 under the title, Sources of Social Reforms (1870–1970). This is an historical case study of narratives and events leading up to today’s rehabilitation policies and practices (Feiring, 2009), so in order to address the second empirical case, I shall analyse relevant political and professional documents, starting with the late 1990s rehabilitation white paper (Report No. 21 to the Storting, 1998–1999) and ending with the National Strategy for Habilitation and Rehabilitation (2008–2011). Policy processes related to the reform of the Norwegian Labour and Welfare Organisation (known as the NAV reform) and the Coordination Reform provide the contextual frame of reference (Report No. 9 to the Storting, 2006–2007; Report No. 47 to the Storting, 2008–2009). I see today’s reforms as a product of previous socio-historical processes, and according to this view, welfare systems and their corresponding knowledge practices are constructed by social actors. To help investigate these processes, I make use of text and document analysis, while simultaneously undertaking a critical analysis of selected historical and political documents (Prior, 2003; Scott, 1990). Public and professional documents represent a diversity of actors, including examples such as government, Parliament, ministries, directorates, departmental and expert committees, not to mention professional textbooks

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and articles. To identify the agents behind the documents is to situate, place or contextualise the document in a setting in relation to other texts and other non-textual circumstances. There are several limitations associated with the interpretation of political documents and professional texts (Prior, 2003; Skocpol, 1992), as these text are not neutral outlines of events; to the contrary, they are shaped by the political, administrative, professional and ideological assumptions of the authors. An important undertaking in this study has been to understand the different views that these documents represent since political records are quite ‘‘polished’’ versions of what has actually taken place. One important limitation is the fact that they mainly deal with goals and ideas, and not practical realities, while another weakness is that the committees often only represent the views of the accepted or approved experts (Feiring, 2009). The next two sections, outline the historical processes, with a focus towards inter-sectoral and multi-professional work. I first examine the management system and how it operates across institutional sectors and administrative levels, and thereafter analyse the knowledge practices. I follow this with a critical review of the traditional political programme using direct and visible tools and continue with an analysis of more indirect tools, starting with the White Paper on Rehabilitation (1998–1999) and ending with the National Strategy for Habilitation and Rehabilitation (2008– 2011). In conclusion, I discuss how the new less visible regulatory tools have led to an increasing interweaving of management systems and knowledge practices in the field of rehabilitation. 2. Sectoral and inter-sectoral policies Understood as the activity of enabling clients, rehabilitation has its roots in at least three sectors of society: education, including special needs teaching; social work and the previous social insurance and employment offices; and health services with somatic and mental health care at the level of the specialist and generalist. The three sectors have different origins, and have been regulated by different laws. General education was enacted into law in the 18th century, and the first special needs school law was adopted in the 1880s. The roots of social work lie in the poor laws of the 19th century, with the first modern law on social welfare being adopted in the mid-1960s, while together with state insurance schemes, the laws on unemployment and insurance can be traced back to the 1890s. Until 1960, many employment and social insurance offices shared the same premises in most small municipalities, and a mental health act regulated the health services, separating the treatment of patients with mental disorders from the care of the poor. When the (Somatic) Hospital Act was passed in 1969, we already had one law for the mentally ill – the Mental Health Act was renewed in 1961, and in accordance with this, separate health services for somatic and mental health problems as well (Feiring, 2009). In Norway, various levels of government administrations are responsible for welfare services. The local authorities are in charge of primary education and social welfare, the county council has been responsible for secondary education and hospital services (until the hospital reform of 2002), while the state has traditionally been in charge of special needs schools and specialist hospitals. Today, the state is responsible for all higher education and all hospitals organised into four regional health authorities (see Table 1, in the appendix for an overview). It is possible to view all public welfare services as a contract between the state and its citizens, and this contract includes access to a group of professions hired to perform different services. The educational field involved general teachers, special teachers and educational–psychological services. The welfare field consisted of social workers and officers in the social insurance and employment services, whereas the health field consisted of public, mental and somatic health professions at specialist and generalist level. In contrast to this, the state rehabilitation centre, which was established in 1946, is an example of doctors, psychologists, nurses and social workers working together within the same institution. It is the exception that proves the rule, as the rehabilitation centre has worked with local authorities, employment services, social security services, technical colleges, businesses, sheltered workshops, and so forth. It was reclassified early on as a vocational rehabilitation institution and a labour market service for the vocationally disabled that was answerable to the Ministry of Local Government and Labour. All of the ministries involved, including the Ministry of Education and Social Affairs, participated in coordinating and managing the tasks, which grew into a comprehensive task area, and is an example of a broad coordination and collaboration based primarily inside a state bureaucracy. In this section, I have described changes from processes of limited contact between public services representing different sectors to more complex processes of coordination and collaboration between institutions and professionals. During this period of time, the multi-professional and multi-sectoral rehabilitation centre is an exception. These

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transformations have been animated by an increasing bureaucratisation and government commitment to the building of schools, health institutions and other facilities and services for public use. 3. Specialised and comprehensive knowledge If we turn our attention from sectors and management structures to the content of the knowledge practices, we obtain a more comprehensive picture. The interaction between the three service sectors is more complex than I have described above, as in addition to the school sector, educational work is also a component of the basic training programmes in other task areas. Teachers have worked in child welfare services, in ‘‘health care for persons with impairments’’ and in health services and schools. In addition to working in the mental and somatic health services, medically qualified people have a long tradition of working in school health services, social insurance medicine, vocational medicine and social medicine. Social work has been carried out in hospitals and schools for many years, although the traditional social worker has tended to work in the social services, employment services and voluntary sectors, which may result in redefinitions of a particular task, or even in a shift of authority within the system of professions (Abbott, 1988). This section analyses professional knowledge as a collection of practice-syntheses (Grimen, 2008). Moreover, I will examine the relationship between academic and practical knowledge and between specialised or generalised knowledge in relation to rehabilitation practices. If we approach the rehabilitation task area as an historical process, it is obvious that it has been formed in conjunction with a dialogue with academia. One early example of a knowledge practice in this field is social medicine as it emerged in the eighteenth and nineteenth centuries (Feiring, 2009). In the early 1950s, a chair of social medicine was set up at the University of Oslo (Schiøtz, 2001), and academic social medicine emerged with the founding of sociological studies at the University Oslo and the establishment of a programme in social work at the college level. The first Professor of Social Medicine, Axel Strøm, defined the task area like this: Social medicine reaches across sciences other than medicine. Theoretical social medicine forms a grey area between medicine and social science (. . .) and applied social medicine stands at the crossroads where practical medicine meets social work in society. (Strøm, 1956, p. 31) In this quote, Strøm has an interesting distinction between theoretical and applied social medicine, and in rehabilitation practice it is the applied social medicine that is at stake. Throughout the 1950s and 1960s, applied social medicine became an umbrella term encompassing medical work, physiotherapy, occupational therapy, social work and nursing, psychological testing, vocational training and counselling, which entailed medical, psychological and occupational assessments and tests, as well as various types of training, therapy and education. Until the 1970s, professional practitioners in the field of vocational rehabilitation spoke of applied social medicine as a multi-disciplinary synthesis of a set of different practices. In contrast to the increasing specialisation of welfare professions, applied social medicine was both a multi-disciplinary system and local knowledge practice (Feiring, 2009). During the twentieth century, many new welfare professions were established in Norway. They were regulated by separate authorization laws, separate professional education and training and a protected title. Additionally, the government authorities offered courses for work in the social security- and employment offices. Several of these professionals were the very same groups as those covered by the term applied social medical from the 1950s. The professional identities and prestige of the new and traditional knowledge groups differed, so due to this, we can see an increasing tension regarding the division of work and specialisation from the late 1960s onward. It is possible to argue that vocational rehabilitation practices after 1945 were dominated by a social medicine and that the leading positions in the field were primarily exercised by doctors (Feiring, 2012). In all knowledge practices, actors possess various degrees of autonomy, distinctive power and possibilities for political and administrative authorities, which are factors that affect both management and collaboration. It is the prestige of academic knowledge that influences the authority to formulate policies and take part in administrative decision making and multi-professional team work (Abbott, 1988), as there has always been a hierarchy among rehabilitation professionals. Indeed, prestige in vocational rehabilitation was determined by the social medical profession’s stock of academic knowledge, and together with the authority and legitimacy, it was the social medical practitioners that had the mandate to command in the public eye (Hughes, 1984 (1973)).

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4. Integrating policy and knowledge practices using traditional tools There are few examples of multi-sector services and multi-professional cooperation prior to the 1960s, with the State Rehabilitation Centre and social medical knowledge practices being exceptions to this rule. The historical examples presented above demonstrate various forms of interaction between administrative sectors and client-centred practices, and the three sectors of education, welfare and health were all governed by separate laws, while measures for people with impairments were enacted as segregated care. There were also separate laws and schools for general education and special needs schooling; social, employment and social security services had their own separate bodies of law, and a clear distinction was made between services for people with mental and somatic health problems. After World War II, the welfare state continued to have segregated services for special needs teaching, as well as different types of specialised care and means-tested services based on what Georges Midre` (1990) calls the mechanisms of demarcation. These policies changed in the mid-1960s, as from that point on, three major welfare policy reforms aimed to create more comprehensive services: a national insurance scheme (1967), a common secondary education law (1974) and a common health law at the municipal level (1982). These three laws led to a universal insurance system, a universal education system for all school children and a universal municipal health service that included mental and somatic health for all members of the community. These public actions coordinated and integrated services within an existing sector, with the comprehensive policy proposed in the 1970s educational reforms, the 2006–2010 reform of national insurance and the national employment and social assistance service administrations (the welfare administration reform also named the NAV reform), as well as the 2008–2012 coordination reform of the health services, all indicating that the sector-wise welfare policy is changing (Thommesen, 2010). See Table 1, in the appendix for an overview. In addition, a reform of the professional’s college training was launched in the 1970s that introduced a set of subjects to be taught to students in different professional training programmes, nursing, physiotherapy, occupational therapy and social work. The 1972 Bjørnsson Committee recommended a universal component in professional health and social work curricula, although the proposal met widespread resistance, and was not adopted (NOU, 1972: 73; Report No. 13 to the Storting, 1976–77). In my view, this committee increased the professional identity of the participating professions, and almost two decades later, several multi-professional training programmes were established at universities and regional university colleges in the 1990s. Early examples of this included milieu therapy for workers in the mental health sector, family therapy for workers in the child welfare services and family counselling services. Continuing education training and master’s programmes in rehabilitation, mental health and public health were established, while several professionals working in specialist institutions were also given the opportunity to acquire clinical specialist qualifications during the same period. The three laws on intra-sectoral integration and the corresponding professional training programmes are all examples of how policymakers attempted to create more comprehensive welfare services from the 1970s. Firstly, regardless of their ability to learn, all pupils were now sorted under the same educational system; secondly, all claimants for unemployment, social insurance and social assistance benefits now had one office; and finally, health services for all citizens were reorganised in the coordination reform – in which the local level was delegated more responsibility and better funding. The main management tools for these reforms were legal measures and formal education, which we may term direct or visible. From approximately 1990, the public action included new technologies or tools that were more diverse, flexible and based on citizens’ involvement, as there was a shift from direct to indirect regulation tools. 5. Integrating policy and knowledge practices using new tools Several scholars have characterised the 1990s as a turning point (Solvang, 2012). I will discuss this shift as three public actions represented by policy documents; firstly, the Norwegian Parliament adopted a white paper on rehabilitation in 1999; secondly, the Ministry of Health and Social Affairs created two regulations in 2001, a general one on habilitation and rehabilitation and one specifically on an individual planning scheme; lastly, the government forwarded the National Strategy on Habilitation and Rehabilitation, 2008–2011. See Table 2, in the appendix for an overview. The white paper on rehabilitation underscores three critical aspects of the task area: that user involvement is not sufficient, the professional practices lack quality, status and prestige and the management of the task area lacks overview, planning and continuity (Report No. 21 to the Storting, 1998–99; Sandvin, 2012). In order to address these shortcomings, the white paper recommended the following measures: (i) approach rehabilitation as an individually

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tailored process that involves user participation; (ii) improve the competence of the professional experts, and (iii) increase the management of the task area in relation to controlling, planning and coordination. First, over the past 10 years, we have seen a diverse array of political reforms in the field of rehabilitation. When it comes to user involvement, actions have been taken to encourage ideas and feedback that apply to administrative and service arenas. Local user knowledge is communicated through consultations and user panels, user surveys are conducted to communicate quality and satisfaction and citizens’ participation is increased by the development of Empowerment Centres (Lærings- og mestringssentre in Norwegian). There has been an emphasis on home care services and local helpers, with a greater amount of attention being paid to individual users and their families, along with the implementation of a new scheme in user-controlled, personal assistance. There is a new terminology for user experiences, user knowledge, user participation and user influence, all of which are new concepts that have appeared in the political strategy of empowering the citizen. Secondly, to improve professional quality and competence, and to also increase research, competence building and network building, the rehabilitation white paper suggested the establishment of the National Research and Development Centre for Rehabilitation known as SKUR (Statens kunnskaps- og utviklingssenter for helhetlig rehabilitering in Norwegian). SKUR was a pilot project assigned to a university college that lasted for six years, which was headed by a social scientist before its tasks were incorporated into the portfolio of the Health Directorate. SKUR was praised for its work in network building and the dissemination of knowledge, while being criticised for not promoting more research in the field (Grut, Kvam, Lippestad, & Tyrmi, 2007). Other initiatives were a diversity of national and regional competence centres all over the country, as well as several new master programmes in multiprofessional subjects, including rehabilitation. The regulations adopted in 2001 on rehabilitation and individual planning scheme introduced a set of new rules,2 which is my third point. The first directive demanded a new organisational body, coordinating units in both specialist health services and municipal services to help improve cooperation and collaboration among the actors. This was supported by an additional directive for an individual planning scheme that entitled users to a systematic plan when services were delivered by multiple providers. The right to an individual plan is authorised in several pieces of legislation, including Patient’s Rights, Municipal Health Services, Primary and Secondary Education, Social Services and the Labour and Welfare Administration. The last public action to be discussed in this context is the National Strategy for Habilitation and Rehabilitation, 2008– 2011 (Prop. No. 1 to the Storting, 2007–2008).3 As a forerunner of the national strategy, the aim was to formulate a national plan for rehabilitation. Three reference groups were appointed: a client group, a group of service providers and a group of researchers. Representatives of the municipalities, labour organisations and the Norwegian State Council on Disability were also all involved. Their mandate was criticised for being too narrow and it was said that its primary object was the health and care sector and not the overall field of rehabilitation announced in the white paper on rehabilitation (Report No. 21 to the Storting, 1998–1999). Consequently, the authorities eventually decided to abandon a specific plan for rehabilitation and replace it with a national plan for the health services and a national strategy for rehabilitation. The main actors in the field were not satisfied and started an action group to promote rehabilitation policies. This led to a three year ad hoc initiative and a historical alliance of institutions, user associations and professionals (named rehabiliteringsaksjonen in Norwegian). The protest movement claimed that rehabilitation policy had to be a new area of priority and they asked for an action plan for both habilitation and rehabilitation. The protest movement also asked the government and Parliament to put forth a plan for rehabilitation similar to the action plan on mental health, in addition to earmarked funds in order to bring people back to work after rehabilitation and more coordinated services at the regional and local level.4 When the work on the national strategy started, the protest movement monitored the work for some years. The work on the national strategy was headed by the Ministry of Health and Care Services and adopted by Parliament in December 2007, with a forum set up to oversee work on this strategy. Forum members came from user organisations, professionals and other involved bodies, and is headed today headed by the ministry, and its goals include encouraging a common perception of reality among people working in the field of rehabilitation (letter from the Ministry of Health and Care Services, January 16, 2008).

2

Retrieved on October 20, 2011 from http://www.lovdata.no/for/sf/ho/xo-20010628-0765.html; and from http://www.lovdata.no/cgi-wift/ ldles?doc=/sf/sf/sf-20041223-1837.html. 3 Retrieved on June 6, 2011 from http://www.regjeringen.no/upload/HOD/SHA/S%C3%A6rtrykk%20av%20St.prp.nr.1%20kapittel%209.pdf. 4 Retrieved on June 6, 2011 http://www.rehabiliteringsaksjonen.no/.

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The national strategy recommended: stronger traditional government and more collaboration in the form of framework agreements involving the government, ministries, directorates, municipalities, user organisations and private service providers; improved standardisations of professional practices to ensure quality, efficiency and fair treatment, while demanding user participation and an active participation of all parties. User participation at all levels, and experience-based knowledge in both administrative and client-centred work, could lead to controversies in the field. How is it possible to fulfil all of these well-intended public actions? First, the strategy recommended both traditional government and governance, and put forward a set of tools to enhance political governing that included user organisations and private institutions in the policymaking processes. It proposed direct and indirect tools to improve coordination, collaboration and cooperation among different sectors, administrative levels and professional specialities. Ministries, directorates, health regions, municipalities, private service providers and user organisations were encouraged to create formal agreements as well as informal interaction to facilitate coordination and collaboration. The aim of the political strategy was to improve the integration of services across sectors and to enhance holistic practice. Second, the strategy recommended increasing the use of technologies to standardise rehabilitation practices, e.g. the use of evidence-based practices, clinical guidelines and pathways. According to Fossestøl (2009), the strategy advocates: (a) scientific knowledge through randomised control group trials (RCT) and diverse ways of applying this knowledge in client-centred work; (b) knowledge based on professionals’ experiences and clinical judgement; and (c) everyday knowledge for service recipients, i.e. user knowledge. The Norwegian Knowledge Centre for the Health Services (Kunnskapssenteret in Norwegian) was established in 2004 to carry out systematic reviews of research projects and articles, in addition to disseminating this knowledge to policymakers, professionals, users and others. The national strategy also requested more practical training and courses for the development of skills, and emphasises the use of tools for promoting holistic practices based on multi-professional cooperation. In this way, the national strategy promoted quite different types of knowledge production from RCT to user experiences. To improve the management system and knowledge practices, the national strategy stresses the role of the service receiver and the importance of the user’s view, voice and experiences in rehabilitation policy in general, as well as for individual rehabilitation processes in particular. In this context, user involvement and peer support are examples of regulation tools, and the experiences and view of the user are not only an individual right according to law, but are also seen as an instrument for improving quality and reducing costs. In an individual tailor-made rehabilitation process the user’s voice is important, and it is up to the user to decide how to participate. It is the users’ goals, values and decisions that will guide the process, and the task of service providers and helpers is to assist the user to help increase his or her functional abilities and social life. Peer support (likemannsarbeid in Norwegian), in which peers are trained to help each other, is highlighted as an instrument for empowerment. The national strategy echoes the importance of the user’s voice vis-a`-vis administrative bodies and professional practices at the same time that it promotes more political control and more evidence-based knowledge practices. In this way, the national strategy for rehabilitation enhances regulation tools and procedures for improving the management system and quality of the client practices, including an increasing use of evidence-based practices and more user-centred client services. A major problem area of the new public action is that it has too many stakeholders and wants to satisfy them all. Hence, the question is: is it possible to increase government logic of control and monitoring, while enhancing user involvement and empowerment at the same time? It is also difficult to both follow the advice of scientific evidence and the subjective opinions of the individual user. Todays’ rehabilitation policy is an interesting example of a shift from government to governance, as well as from vertical coordination and horizontal collaborative relationships to more complex types of cooperation. The white paper on rehabilitation, the subsequent regulations and the national strategy of rehabilitation are all examples of conflicting public actions that recommend tools to enable municipalities and central authorities to interact with voluntary organisations and private enterprise, thereby helping to realise cross-border coordination and multiprofessional collaboration (Axelsson & Bihari Axelsson, 2007). Cooperation between stakeholders with different logics and distinct views on experiential and standardised knowledge is a highly complex and controversial issue. Increasingly, the rehabilitation task area is transcending its borders towards political institutions, towards academia and other disciplines, and towards users and civil movements. Sandvin (2012) points to a shift from an emphasis on traditional measures and services to a concentration on cross-professional collaboration and cross-agency coordination. ‘‘No longer is rehabilitation something accomplished by specific actors in specific organisations, but, on the contrary, something that happens between different actors in specific organisations’’ (Sandvin, 2012, p. 41). Today,

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the small but comprehensive rehabilitation apparatus created for the vocationally disabled after 1945 has expanded to serve all citizens in all circumstances (Feiring, 2012). 6. Integrated management and knowledge practices The aim of this article has been to explore in what ways welfare policy reforms have redefined rehabilitation as a knowledge practice by using visible and invisible management tools. Firstly, concentrating on policymaking processes in general, in what ways has a possible shift from political to public action redefined rehabilitation. By political action I mean traditional policymaking, while by public action I mean achievement, in which multiple and varied actors participate in the making of rehabilitation. A shift from political to public action involves multiple actors, including professional and user groups who get a voice in the planning and creation of rehabilitation policies, as well as practices. However, the main actions do take place both inside and outside the state in hierarchical, vertical or horizontal relationships. This may make the policymaking process more flexible and representative, but also more composite and fragmented, which may also lead to more negotiations, more persuasion and less overall transparency. A second and related shift in policymaking today is defined as a turn from direct and visible to indirect and invisible government technologies, in addition to an increasing use of new regulations and tools. Examples of direct and visible tools are legislation and education, whereas indirect tools are settlements, strategies and procedures for standardising practices. In traditional public sector politics such as education, health or welfare services, the main areas are regulated by direct and visible means such as laws and educational training programmes. In the previous section (Section 5), I outlined a set of indirect and partly invisible technologies such as regulations, action plans and strategies. The main aim was to increase coordination between sectors and professional tasks. As a consequence of this, it is possible that governmental technologies have shifted from being part of welfare policies to becoming part of rehabilitation practices. In the making of rehabilitation practices today, politicians, civil servants, multiple professions, private service providers, and even service recipients, play a part. These changes have not only led to more complex policymaking processes, they have also moved towards a more composite rehabilitation practice. The knowledge practices of rehabilitation have become far more compound. They are multi-agency and include academic, standardised and experience-based knowledge; they also include everyday- and user knowledge, involve a shift towards a more individually tailored rehabilitation process; and they are amalgamated by management logic, including more negotiations and interaction, as well as more monitoring, planning and coordination from above. The national strategy for rehabilitation is a telling example that recommends more professional, public and user involvement and more political governing. Several scholars have identified the development of new contextual knowledge that points to a more interactive relationship between science and society (Beck, 1999; Latour, 1997; Nowotny, 2001). This leads to several dilemmas: One is related to the fact that it is problematic to both increase the government logic of control and to monitor and enhance user involvement and empowerment. Another is that it is difficult to follow the advice of objective scientific evidence, while simultaneously allowing the individual user to have the last word. How these issues will be met in practical, administrative and client work needs to be analysed in case studies of various knowledge practices. This article has explored the creation of a new relationship between management and knowledge practice by applying historical and contemporary sources. The rehabilitation policy encompasses a set of direct and indirect administrative tools. The key tools of public action between 1970 and the mid-1990s being legislation and formal education. They primarily dealt with one sector, discipline or service. Since the late 1990s, the main public actions promoted inter-sectoral service collaboration, whereas today’s rehabilitation politics comprise both a continuation of traditional direct regulations, such as law and education, and a wider use of new indirect technologies of government. Today’s rehabilitation politics have been characterised by governance, which implies multiple agencies and an increasing assemblage of technologies. This means that tasks and services are coordinated within sectors (following the guiding principle of sector responsibility) through the application of traditional tools such as legislation and formal educational programmes. At the same time, a set of new technologies of government is used to improve collaborations across sectors, administrative levels and the interests of public and private actors. The recommended governmental tools for developing rehabilitation as both a research area and clinical practice indicate a new knowledge practice that has become more diverse, complex and fragmented. According to Grimen’s understanding of professional practices, experts in client-centred work need to integrate scientific and practical

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knowledge, as well as basing their work on communication with colleagues and service recipients, and need to ponder the relationship between various theories, reflections and personal experiences (Abbott, 1988; Grimen, 2008). 7. Conclusion This article has discussed how the dynamics between political-administrative and professional practices in the field of rehabilitation have become more complex. One trend is that public action today makes regulations and programmes across formerly distinct sectors and arenas. The administrative control is being strengthened at the same time that the voices of private and professional actors are increasing, thus empowering private actors and offering new ways of partnering public and private service delivery, which is an example of the amalgamation of administration and service delivery in new ways. Another trend in the development of rehabilitation is the coproduction of knowledge across diverse academic and professional traditions. Concurrent with standardisation, there is an emphasis on a practiceoriented ideal (Nowotny, 2001). In today’s rehabilitation policy and practices, government and experts, private interests and public solutions intermingle and create new hybrid forms, as there is both more hierarchy and traditional government, and more governance and horizontal networks. On the one hand, a complex administrative rationality based on organisational and administrative tools is introduced in the rehabilitation field, which Sandvin (2012) says are dominated by organisational and administrative tools. On the other hand, there is a new, complex rationality based on controversies between evidence-based and experience-based practice models, between academic scholarships and client practices and between service providers and recipients. This is why Solvang (2012) characterises rehabilitation as a cross-field of different actor’s interests. Hence, new knowledge is in the making between previously distinct areas of expertise: education, welfare and health, and between different actors such as politicians, managers, professionals and clients. Today, rehabilitation as a knowledge practice is a synthesis of management strategies, professional theories, experiences and reflections, and client experiences. Appendix A See Tables 1 and 2. Table 1 A selection of legal acts on welfare issues in Norway, 1945–2011, sorted after knowledge practice. Knowledge practices

First legal acts 1730s–1900s

Abolishment of special services and policies, 1940s–1990s

Sectorial integration, cross-sectorial coordination and anti-discrimination policies, 1990s–2010s

Education

1739, general education enacted 1881, special education enacted

Segregated school policy abolished in 1969 for primary and lower secondary education and in 1974 for upper secondary education

Educational reform (Education Act, 1998)

Welfare

1845 poor laws(1863,1900) 1894, Industrial Accident Act

Poor help abolished by acts regulation: employment in 1947, means tested social assistance in 1964 and universal social insurance schemes in 1967

NAV Reform (Employment and Welfare Administration Act, 2006; Social Help in Employment and Welfare Administration Act, 2009)

Health

1855, Mental Health Act 1860, Public Health Act 1900, Tuberculosis Act

Differenciated health service legislation on mental health (1961), on somatic hospitals (1969) and on municipal health services (1981)

Health reforms (Acts on mental health, health personnel, and hospital trust, 2001; Coordination reform (Acts on primary health care and public health, 2011) Action on anti-discrimination (including acts on Ombud in 2005 and on accessibility and disabling barriers in 2008; Patients’ Rights Act in 1999)

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Table 2 A selection of new tools of public action on rehabilitation in Norway, 1995–2011. Public actions: regulations, strategies

Tools: technologies, centre, units, and devices

White paper on rehabilitation, Report No 21 to the Storting (1998–99)

User involvement technologies Empowerment centre (1997–) Research and Development Center, SKUR (2000–2006)

Regulations on Habilitation and Rehabilitation (2001) Regulations on the Individual Planning Scheme (2001)

Coordinating units in municipal and special health services Individual planning as a coordinating device

National Strategy on Habilitation and Rehabilitation (2008–11)

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