Challenges for Management in Implementing Reforms at the Ministry Level and in Health and Social Service Organizations in Finland

The Finnish health and social care sector is currently undergoing numerous reforms. These reforms involve novel demands regarding the role of steering, decision-making, and management in health and social services. This article sheds light on some of the critical factors encountered by decision-makers and managers when implementing reforms to change health and social services. The article investigates cooperation between the steering ministries and different dimensions of management in local health and social service organizations. Interview data from the ministries were studied through content analysis, and quantitative survey data were analyzed using mean values guided by the model of multidimensional management. The co-operation between different ministries has intensified while implementing different reforms, but functional and cultural boundaries between them persist. The management dimensions in changing health and social service organizations stress the role of managers as facilitators and enablers, highlighting the significance of caring for the human resource dimension as one of the managers’ core tasks. The successful implementation of change should never be automatic. What emerges prominently is the skill essential to achieve cooperation which transcends the borders of both multiprofessional and traditional professional and administrative work both in ministries and local health and social service organizations.


Introduction
The organizational and operative aspects of health and social care in Finland are undergoing numerous reforms. These involve novel demands with regard to the role of steering, decision-making, and management. More generally, several reforms in the Finnish public sector have been implemented starting from the mid-2010s, with some still underway. These reforms are going to change the operational models and management systems in the public government (as well as local health and social services) in state administration and the relations between different ministries (Joensuu and Niiranen 2018). However, the reforms are not new; as in many other countries in Europe, in the last 20-30 years many reforms in public administration have taken place.
The Finnish health and social service system is by international standards fairly decentralized. The services are typically delivered by relatively strong local governments and authorities, in other words by municipalities that may have very small populations, or larger federations of municipalities (Hulst and Montfort 2011;Couffinhal et al. 2016;Anttiroiko and Valkama 2017). The municipal self-government, state welfare objectives, and, more widely, European Union policy determination or international management trends are emphasized as the context of management. Responsibility for welfare, which even now is shared among the state and municipalities or federations of municipalities, highlights the fact that the service system is simultaneously a tool for the implementation of social and health policy and a target in the organizational context.
Thus, in research it is important also to bear in mind that the health and social services provided by the municipalities and federations of municipalities assume several roles in society, not merely as service providers but also as part of the functioning of a democratic society. The ever-increasing collaboration between the enterprises of the municipalities, the third sector, and health and social services fuels the growth of new enterprises. New forms of collaboration produces new work practices and new forms of networks. At the same time, they require of the experts a new kind of management and knowledge when working in distributed and multi-professional organizations.
The aim of this article is to shed light on some of the critical factors encountered by decision-makers and managers when implementing reforms to change health and social services. This is done by using theoretical and methodological triangulation that gives previously underexamined insights in the subject. The key questions are: (1) How does cooperation between ministries change as the reforms, either planned or implemented, proceed? (2) How are the dimensions of leadership emphasized in the everyday work during the implementation of many ongoing reforms in the work of managers in health and social service organizations?

Theoretical Background
Our theoretical means of approach, theoretical triangulation, combines aspects of implementation theory (Hill and Hupe 2014;Hupe and Hill 2016), and multidimensional management (Quinn 1988;Niiranen 1994).

Implementing Reforms
At the state level, in the ministries there are many different aspects to be considered when implementing large national reforms and steering new functions and assignments. The implementation of some reforms likewise entails different stages. In the health and social service organizations both staff and managers continue to carry out their everyday tasks while local organizational reforms are taking place, simultaneously developing their professional knowledge, very often in the context of larger national or international changes. Implementing (new) organizational reforms in the context of public administration frequently entails adopting new steering models, new types of decisions, and new procedures at the national level. For example, it may be possible to develop new modes of cooperation between the steering ministries and between the ministries and local health and social service organizations. Implementation is always connected to actual, specific policies in order to respond to specific reforms or in order to solve some problems in society. In the 2010s there has been an interesting combination of traditional bureaucratic modes of operation in public management and the reform and development of implementation processes. It is important to recognize what kind of reforms are planned or decided, what organizations are responsible for steering the reforms, and what interactions re called for between large national authorities, e.g., ministries. Implementation is a process, not only the result of the reform (Hill and Hupe 2014, pp. 5, 33-34;Hupe and Hill 2016). It is important that, when planning reforms, the managers are aware of the whole strategic planning process from the beginning, and design the process to formulate, implement, evaluate, and further develop the new action (Joyce 2015, pp. 128-31).
Taken as a whole, the reforms in the Finnish municipalities (especially those in the health and social sector) are not at all new. There have been many big reforms, e.g., the Free Commune Experiment (1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996) and the Project to Restructure Local Government and Services (PARAS 2005(PARAS -2012, as well as many other nationally organized reforms in social and health services in the 2010s. Many reforms (notably those in social and health care) and changes in public finance that took place at the beginning of the 2010s are also apparent in administration, management, and in new calls for reforms (Niiranen et al. 2013).
The farther-reaching plans to restructure social and health services in Finland were scheduled to be implemented in the period 2015-2019, but they were subsequently cancelled, and a new reform is planned for implementation at the beginning of the next decade. The main purpose of the reforms in this century has been to transfer social and health services from municipal responsibility to larger regional organizations. Even if the reforms at the national level have not succeeded as planned, they have increased municipal collaboration when municipalities have voluntarily created several federations of municipalities for delivering the health and social services in their region. The smaller municipalities especially have sought economies of scale through service production with cooperation (Hulst and Montfort 2011;Couffinhal et al. 2016;Anttiroiko and Valkama 2017).
Hence, our study is not narrowly focused on the reform of health and social care as presently planned at the national level; in the organizations studied here reforms have long been ongoing, with one of them implemented nine years ago (2010). In one organization a reform was implemented in 2017 and yet another organization implemented its reform at the beginning of 2019. These new challenges are apparent and will make themselves felt in the work of managers in both central and local government as well at the health and social service organizations.

Starting Points of Multidimensional Management
A leader is confronted with many different values and objectives, some of them contradictory and concurrent (Quinn 1988, p. 66). The competing values of an organization are reflected in leadership and create situations where the leader must solve problems containing contradictory elements. The competing values of different organizations are visible in the requirements set for their operation both in the internal relations among staff, human resources, efficiency, and cooperation, and in the demands for reworking the professional knowledge. Identifying the contradictions and tensions inherent in the manager's work will help to understand the tasks in the field of management and in problematic situations. It will also help to find functional solutions from the point of view of the work community. The multidimensional management model (Niiranen 1994;Niiranen 2006) is based on the notion that in the management of health and social care, and in everyday operations, many external factors and processes inside the organization exert influence simultaneously. An organization's own expectations are determined by the environment and external parties, by service users as well as separate groups of workers and decision-makers. A manager witnesses clashes between national and international changes, wider reforms in society, and changes in the economy. He also has to respond to meet the expectations of various service user groups and deal with the tensions between different and multi-professional groups of workers all at the same time. He cannot act only on one dimension; he must be able to both make decisions and take the whole into consideration. The starting point of the multi-dimensional management model is the model of competing values of an organization presented by Robert Quinn (1988), which has been edited and supplemented in such a way as to identify the social function of actions and the content of professional work, especially in the Finnish social and health services.
The several external factors of an operating environment and the internal processes of an organization simultaneously affecting health and social service management and everyday operations can be grouped into five dimensions, which, because of their simultaneity, can serve as preconditions for each other. They are the humane, open, rational, bureaucratic, and professional dimensions (Niiranen 1994). Each one of these is indispensable up to a point, but when overly emphasized can upset the balance of the organization and its management. The bureaucratic dimension describes the norms that monitor action and social regulation and the internal processes and power norms of an organization. The social functions of public services extend further than the actual service event.
The action policy and processes, qualifications of workers, clientship, and service users' legal protection are regulated by legislation.
The open dimension concerns the demands for action, responsivity, flexibility, and the capacity of municipal services to respond to the various and often very conflicting needs and expectations of the operating environment. Financiers, political decision-makers at the local and national level, international agreements, and, especially, the development of the economy impose their own limitations in marginal terms. At the same time, change in society, people's changing needs for services and conceptions of municipal services and the workers working in them direct, or ought to direct, the content of action and strategic management.
The humane dimension emphasizes the dimension of human relations in the organization. It comprises workers' ability to work and engage in joint processes, learning and innovativeness, and encouraging and making possible a leadership that appreciates workers. It is also an absolute precondition for reaching qualitative and quantitative goals in the rational dimension and for meeting the demands of profitability. In the long run only skilful and capable workers, convinced that their know-how is appreciated and that they can influence their own work, have the stamina to be productive. The fifth of these dimensions is the professional dimension, which reflects the social function of operations and regulates its value goals, visions, and substantive know-how (Quinn 1988, pp. 79-89;Niiranen 1994, pp. 102-9).
The model of multidimensional management is a conceptual frame based on management theories and their combination-an instrument which helps to understand the simultaneity of the various dimensions in municipal service operation. As a conceptual model, it helps to make visible, for example, tensions related to reforming the processes of municipal services and conflicting expectations such as demands for continuity and reliability of operation, and, on the other hand, expectations for reform and responsivity. If the existence of an organization is threatened, there is emphasis on the manager's tasks to exert influence on the operating environment, towards an open dimension, and also towards a rational dimension, since a manager must often prove, for example to the financiers, that the organizational operation is profitable (Quinn et al. 2003;Niiranen 2006).

Contexts of the Study
This study is part of the Finnish research project entitled Competent Workforce for the Future (COPE). The project explores the transition in health and social services and its impact on competence needs and competence development. The project is divided into five subprojects and this study is part of the subproject focusing on administration and management issues. The COPE project is funded by the Academy of Finland and coordinated by Finnish institute for health and welfare and is set to run from 2016 to 2019. (Stncope.fi 2018). This is a case study of four different local organizations offering health and social services, and four ministries which are steering the reforms and the content of services in Finland. The local organizations were selected for the COPE project because they integrate municipal health and social services into large regional organizations. One of the organizations has been operational for almost 10 years, one started a few years ago, and two of the organizations started their regional integration just recently. The ministries involved are the Ministry of Finance, the Ministry of Employment and the Economy, the Ministry of Social Affairs and Health, and the Ministry of Education and Culture. These ministries bear most of the responsibility for planning and steering the reforms and they are also the most important parties determining the content of municipal services-including the health and social services.

Research Methods and Empirical Data
The study uses both interview and survey data collected on the COPE project during 2017. The ministerial interviewees (n = 14) were individuals working closely with the planned major reforms. Two of the interviewees were cabinet ministers and the rest were civil servants from the four ministries listed in Section 3.1. The thematic interviews were conducted by one of the authors and the questions concerned, for example, the planned reforms and their impact on competences needed in the ministries. The interviews lasted from 20 to 50 min and were transcribed verbatim by one of the authors. Almost 89 pages of transcribed interview data were analyzed by content analysis guided by implementation theory.
The COPE survey data for this study was collected with a cross-sectional research design in the spring of 2017 from the four local organizations offering health and social services. The purpose of the survey was to collect information about different topics concerning the development of the competent workforce needed in the changing health and social services. The questionnaire in Finnish covered several topics. There were, for example, questions about work and management changes, management in general, professional decision-making, and competence. The whole data set consisted 1943 responses from employees, supervisors, and senior management. This article uses the responses to one of the questions by strategic and middle management (n = 65). The data were analyzed using mean values guided by the model of multidimensional management.

Changes in Interministerial Co-Operation as the Reforms Progress
At the level of central administration, especially in the steering of reforms in health and social services, the respective ministries identified a need for novel forms of cooperation, but these were not easy to implement. These forms include, for example, new information and communication technology (ICT)-systems making information sharing between ministries and information management more efficient, different kinds of horizontal projects, and regular meetings between ministry personnel and more horizontal networking between ministry personnel. The reforms also afford opportunities for the career paths of the personnel between different ministries, but different organizations and steering roles between ministries and municipalities make these paths sometimes difficult to implement.
In the first decade of this century in Finland, numerous projects have been implemented aiming at reducing steering by norms, but paradoxically in the process of reform steering by norms has increased, as the theory of irrational organization (Brunsson 1985) has shown. The results of the interviews show that on the one hand the steering of service production and of the planned reforms in health and social services will-if indeed realized-produce stronger steering models and practices than before from central to local government and will serve to achieve a closer grip on steering in guidance from central to local government. Steering focused on the municipalities by the national government frequently tightens in connection with the reforms. Underlying this is an effort to strengthen the implementation of extensive national reforms and to ensure that citizens enjoy regionally equal opportunities for the use of and access to services (Niiranen et al. 2013, pp. 43-44).
Then again, in connection with the reforms a need may arise to transfer expertise between ministries, which may in turn necessitate novel professional paths, for example, between the Ministry of Finance and the Ministry of Social Affairs and Health, new careers for personnel, and new opportunities for cooperation between ministries. This need became apparent in the interviews. The civil servants interviewed noted that the Ministry of Social Affairs and Health in particular needs more information about the national economy, and the Ministry of Finance needs to know more about health and social services. The interviewees explained this by the need for more coherent steering; they did not want different ministries to speak with "different voices". This is an interesting result, because so far the relationships and interfaces between ministries have been quite strong-or at least apparently so. Yet the interviewees noted that cooperation between ministries has become more common as they tried to implement the reforms planned by recent governments. Cooperation in particular between the Ministry of Finance and the Ministry of Social and Affairs and Health has intensified. The interviewees still wished that the barriers between different ministries and inside the ministries between different departments were much lower. This is why the interviewees hoped for structural reforms in ministerial cooperation and these have been planned in the recent central administration reforms. Nevertheless, the interviewees noted that the reforms concerning administration structures and culture proceed slowly by small steps and will take several years.
The cabinet ministers interviewed talked more about the intentions and benefits of the planned reforms and not so much about the concrete issues about implementing them. This may reflect the ministers' roles as strategic direction setters in ministerial work, where concrete implementation issues are the purview of the top officials and civil servants. However, the ministers interviewed were concerned about the high barriers between the different ministries (emphasizing silos), and wanted new kinds of cooperation between them. For example, the ministers mentioned how they noted some conflicts between the Ministry of Finance and the Ministry of Social and Affairs and Health. This is why they decided to recruit few top officials from outside the ministries to plan reforms, thereby advancing the cooperation between the two ministries. Other ways of increasing the cooperation are new digital solutions, but the ministers did not specify what these would be.

Leadership Tasks and Dimensions: The Need for Internal and External Orientation
The definitions of management have a bearing on the meaning of management and how matters are understood to take place. If the general phenomena of management, independent of situations and contexts, are sought, management will simultaneously be rescued from the grip of its social and organizational environment. To proclaim that management is "non-contextual" and "non-historical" would be to ignore the social, organizational, and individual factors that affect management and the control of action (Tsoukas 2000, p. 31). In the regional health and social service organizations participating in the research there has been, or is currently, a move more towards multi-professional entities and partly also to distributed organizations. Working in distributed organizations remote from each other requires that both workers and managers have novel interactive and virtual presence skills. For managers, distributed organizations also entail team building skills. Leading a multi-professional organization requires managers to be the new masterminds of managerial thinking and also of crossing professional silos (Niiranen 2016;MacKillop 2017).
The management profiles of managers were scrutinized using the model of multidimensional management. In the midst of reforms managers frequently find themselves beset by conflicting expectations; they are expected to promote innovations and to support the workers within the organization. At the same time, they are required to be active in interaction with various stakeholder groups and decision-makers in the operating environment.
In bigger organizations in particular, the local manager's tasks include a professional command of the work and familiarity with professional content. In some places, however, the managing director of the whole organization is required to be familiar with the content of the core assignments of the enterprise and have a professional education in that field. It is often expected that the manager be aware of the professional development of the organization. Depending on the size of the organization, the manager may indeed take a major part in the basic work of the organization and in developing new functions or forms of work. On the other hand, however, in the case of so-called know-how organizations, managers can achieve results by strengthening workers' know-how without necessarily acquiring the same knowledge.
In the figure below we present the results regarding the main dimensions of the respondents' leadership profiles in the multidimensional management framework (Figure 1). The results show that in the work of managers multidimensionality of management is most visible in improving public health and social services. In particular, the competing values of human resources, the performance of public services, and the demands for responsibility and quality pervade the everyday work of the manager 1 . 1 Respondents were asked to evaluate how often they acted in the way described in the questionnaire. The following response options were included in the scale of semantic differentials (Osgood 1957;ref. de Vaus 1986): 1 = never; 2 = very seldom; 3 = seldom; 4 = occasionally; 5 = frequently; 6 = very frequently; 7 = almost always or constantly. The means of each role are presented in Figure 1 following the procedure often used in the competing values model (Quinn 1988;Niiranen 1994  When thinking in terms of performance, the results and effectiveness of operations are emphasized. Here, too, neither human relations nor workers' interaction and learning (in other words the humane dimension) can be ignored. Good results are achieved only with the help of an informed, knowledgeable, and motivated workforce. Operations need to be anticipatory and continuous, and at the same time sensitive enough to comply with the changing demands and expectations of different service user groups, decision-makers, and financiers.
The study shows that when managing workers during ongoing reforms and between major changes, managers may have to divide their working time between management tasks outside and inside their own organizations. Both strategic and middle managers accomplish their tasks in different dimensions. They direct their efforts inside their own organizations towards managing professional work, supporting subordinates, and creating the preconditions for the completion of tasks. Outside their own organizations they dedicate themselves to interaction with the operating environment, to ensuring supply or resources, and to the strategic level of co-operation with decisionmakers and other co-operation partners. each role are presented in Figure 1 following the procedure often used in the competing values model (Quinn 1988;Niiranen 1994  When thinking in terms of performance, the results and effectiveness of operations are emphasized. Here, too, neither human relations nor workers' interaction and learning (in other words the humane dimension) can be ignored. Good results are achieved only with the help of an informed, knowledgeable, and motivated workforce. Operations need to be anticipatory and continuous, and at the same time sensitive enough to comply with the changing demands and expectations of different service user groups, decision-makers, and financiers.
The study shows that when managing workers during ongoing reforms and between major changes, managers may have to divide their working time between management tasks outside and inside their own organizations. Both strategic and middle managers accomplish their tasks in different dimensions. They direct their efforts inside their own organizations towards managing professional work, supporting subordinates, and creating the preconditions for the completion of tasks. Outside their own organizations they dedicate themselves to interaction with the operating environment, to ensuring supply or resources, and to the strategic level of co-operation with decision-makers and other co-operation partners.

Discussion
One interesting result, as the interviews at the ministerial level show, is that the steering of ministries will become tighter at the same time that the municipalities and larger federations of municipalities are expected to provide new, inventive, and customer-oriented services. This result, however, is not new, because very often when rapid and complex reforms or new public models are introduced, steering by the state will tighten (Brunsson 1985, pp. 17-18, 182-86). More strategic autonomy for the various branches and at the same time the developer role of the staff and ministries may well become stronger (Lumijärvi and Leponiemi 2014, pp. 52-55).
In addition, local government, especially in the Finnish context, is very close to the municipal resident as it is charged with the responsibility for organizing the majority of the social, health, and educational services. The political leaders and public administrators in local government face a dilemma in terms of how to respond to the external, national change and manage the internal reforms while still being reliable and responsible from the perspective of the municipal residents (Niiranen and Joensuu 2014). The importance of local government is characteristic of the Finnish health and social service system that still relies on municipalities and federations of municipalities.
The context of management is connected to identifying the objectives and tasks of an organization and to making them visible. The starting point is often that managers are expected to improve the performance of an organization by applying managerial methods. They are expected to promote reform and at the same time find solutions to economic problems. Furthermore, they are expected to engage in supporting workers' coping abilities. In the 2010s in Finland there have been many public reforms, some of them overlapping. These many reforms are of course visible and a part of everyday management in local health and social service organizations and in ministries alike. It means that workers and managers are constantly in the middle of different reforms. This situation is also apparent in our research findings.
At the time of data collection for this study (2017) a far-reaching reform of social and health care and of the organizational systems at regional level was in the making in Finland. Due to the fall of the national government in spring 2019, the reform envisaged was not brought to implementation; however, it is likely that many of the forms of cooperation originating there will continue to make themselves felt during the term of the next government. It can be assumed that the inter-ministerial cooperation emerging in the research data will nevertheless be intensified.
The role of managers as facilitators and enablers is stressed in the study, highlighting the significance of caring for the human resource dimension as one of the managers' core tasks. In addition, the contextual factors were emphasized in the empirical findings that highlight the significance of the professional dimension of management and the comprehension of professional health and social services. It underlines the reciprocal nature of leader-member relationships and working side-by-side for the good of the organization. There is also a need for the ability to lead decentralized and novel multi-professional work organizations. The importance of utilizing information on operations and reforms at all organizational levels, in decision-making, in their implementation, and in the new operations themselves is increasing.
The multi-dimensional model used in this research is based on systems emerging from research on Finnish social and healthcare organizations with regard to these organizations' operating systems. Professional management constitutes a legally significant element of the manager's work, especially with regard to the immediate and middle levels, but also more widely at the level of strategic management, which involves the responsibility for the implementation of the strategic objectives of the entire organization and also for ensuring that the direction of social and health care is consistent with the judicial line in social and health care. This renders impossible any comparison, for example, with the findings of international studies using competing values (Tong and Richard 2015;Prenestini et al. 2014).
Many international and national studies, the COPE project among them, have shown that the successful implementation of change can never be automatic. In the reforms of Finnish health and social services in particular, what emerges prominently is the skill essential to achieve cooperation which transcends the borders of both multi-professional and traditional professional and administrative work. This may also mean novel modes of cooperation in the steering of operations at the level of central government, and possibly also novel career paths for personnel among the various ministries.

Funding:
The article is part of a larger research project entitled COPE-Competent Workforce for the Future, including the subproject WP5-Developing management, leadership and decision-making. The COPE Project is funded by the Academy of Finland (www.stncope.fi).

Conflicts of Interest:
The authors declare no conflict of interest.