The Swedish health and social care systems faced significant challenges during the COVID-19 pandemic, with nursing homes receiving particular criticism for high mortality rates, especially in the initial phase. One of the key reasons attributed to the rapid spread of the virus within nursing homes was the lack of collaboration between health and social care services. This issue is commonly observed in the care of elderly individuals with multiple health conditions in various countries, including Sweden.

The coordination challenge in Sweden arises from the fact that nursing homes are operated by municipalities, while regions are responsible for acute care health services. Since municipalities are not allowed to employ physicians, they must collaborate with the regions to address the medical needs of nursing home residents. The inadequate medical attention given by physicians to infected elderly individuals in nursing homes became a particularly critical issue during the pandemic. However, over the course of the COVID-19 pandemic, the situation seemed to improve as new forms of cooperation between regional medical actors and municipal nursing homes were established. This led to significantly lower mortality rates from COVID-19 during the second and third waves of the pandemic. The question that arises is whether these enhanced collaborative efforts, particularly in communication and information sharing, will be sustainable in the long term. During times of acute crisis, providers often spontaneously organize and implement improved practices of inter-organizational collaboration driven by a "sense of urgency" (Aldrich, 2019). However, the existing literature on the sustainability of healthcare policies, programs, and interventions suggests that while implementation during a crisis may be successful, such initiatives often fail to become ingrained in the routines of organizations in the long run (Wiltsey Stirman et al., 2012).

The aim of the proposed study is to investigate how regional providers of primary health care and municipal providers of elderly care developed their collaboration to meet the needs of the multi-morbid elderly during the COVID-19 pandemic, and whether these collaborative adaptations have been routinized in the organizations in a sustainable manner. Empirically, the study is based on 25 in-depth interviews with collaborating actors (GPs, nurses and clinical leaders) in three Swedish regions and 20 municipalities and a web survey administered to the same regions and municipalities. This is a very rich and unique material, allowing us to document what changes were implemented and what happened to them after the pandemic ended. Preliminary results show that the collaboration did increase markedly during the crisis, but that most of the changes enacted have not been sustained over time.

The contribution of the paper lies in providing in-depth knowledge regarding how providers within the health and social care can develop new patterns of collaboration during and after a crisis like the COVID-19 pandemic, thereby overcoming well-documented barriers to collaboration. The paper also investigates which of the organizational changes proved sustainable over time and why. In this regard, the paper also contributes to long-standing theoretical debates in the field regarding the conditions for coordinated care and sustainable policy change – particularly in the post-pandemic era.

The post-pandemic era demands more from social services professionals due to the growing needs of the population. Yet, the resources available to them are insufficient to meet these needs. As a result, collaboration - the well-known practice from the new-public management and post-new public management reforms - has become the modus operandi. Social services professionals need to combine abilities and resources with other stakeholders from diverse sectors to bring about solutions to these growing needs. Moreover, the involvement of citizens and their rights to participate in creating and implementing social services is also taking center stage.

These collaborations and the growing involvement of diverse stakeholders in policy design and implementation processes in social services raise the question of the changing power relationship between the diverse stakeholders in these collaborations and the place of professionals in the welfare state within them.

The paper focuses on the power dynamics between actors and organizations within collaboration arrangements identified in the literature as a crucial element that helps promote or undermine collaboration (e.g., Huxham and Beech 2003, Ansell and Gash 2008). In this paper, we build on the work of Margaret Stout and Roby Keast (2021), categorizing different kinds of power in a collaborative arrangement. The first is ‘power over’ – that focus on self-gain brings about the ability to control others and is more present in the consolidation and coordination version of collaboration arrangements. The second is ‘power for’ - which aims at an altruistic gain and taking care of others – and is more commonly associated with clientelism. The third is ‘power to’ - the ability to choose your way and refers to cooperation and competition when working together. The last category refers to ‘power with’ (or within) - the ability to empower others for mutual gain while maintaining autonomy as an actor or an agency within the collaborative effort. This category is closely associated with holistic and successful collaborative arrangements (collaboration).

Based on our data collected using in-depth semi-structured interviews with 20 SLBs in social services in Israel and Germany (different welfare regimes), we claim that to better understand the success and failure of collaborative efforts, one needs to bring about a more nuanced understanding of the place of power in the collaborative arrangements and the surrounding of the collaborative arrangements. Our preliminary observation on power reveals that successful collaborative efforts include not just the ‘power with (within)’ between partners in the collaborative arrangement but diverse ways of practicing power in the collaborative arrangement (e.g., sharing power – 'power within’ - regarding different skills and actions needed to be done while maintaining ‘power-over’ in the ‘governance’ of the collaborative arrangement) and utilizing power outside the collaborative arrangement (e.g., understanding the way to obtain political power – via timing and pressure on policymakers). More so, the need to practice power outside the collaborative arrangement was prominent in the diverse levels of collaboration, such as coordination and cooperation (e.g., creating political pressures using protests of the service users and long waiting lists). Thus, the paper contributes to the understanding of the place of diverse layers of power in the success and failure of collaborative governance among SLBs and sheds light on the changing role of professionals in the welfare state as facilitators of various kinds of power.

Policy coordination has become a central and challenging issue in modern welfare states. One area where the need for coordination is pressing is in the care of multi-morbid and frail elderly, who typically need both health and social care services and whose needs are complex and shifting. In Sweden, as in many other mature welfare states, coordinated care for multi-morbid elderly has long been on the political agenda and several reforms have been implemented over the past decades in order to promote this objective. Despite these efforts, evaluations suggest that care coordination around this group is still often poor, which results in stress for the patients, medical hazards and increased costs for society as a whole. One specific indicator of poorly coordinated care is unplanned re-dmissions of elderly patients to hospital, which indicates that outpatient medical and social care organizations have failed to provide the needed services. Achieving improved coordination for the multi-morbid elderly, which is a large and growing share of all patients, has therefore became one of the biggest challenges facing the Swedish health care system today.

It this paper we review the last thirty years of political reforms aimed at improving care coordination for the multi-morbid elderly in Sweden, asking why most of these attempts appears to have failed. Drawing on theoretical notions such as policy failure and “wicked problems” as well as the policy coordination literature at large, we discuss the main obstacles to care coordination for this group in Sweden. Particular attention is payed at the institutional division between care services, provided by local governments, or municipalities; and health care services, provided by the regions and the role that this has played in hindering care coordination. The same division, which has a long historical legacy in Sweden, also creates professional boundaries, as medical doctors are mainly employed by the regions. The empirical contribution of the paper is an in-dept analysis of the causes behind failed coordination in Swedish health care, a system which performs well in most other regards. The research methods used are mainly qualitative, such as policy analysis and evaluation. The theoretical contribution lies in the way the concept of wicked problems is applied to the area of multi-morbid elderly and the specific demands that this group places on coordination between different sectors in mature welfare states.