The management of client inclusion in social and health services

What is client inclusion all about, why is it important? What does it require from management? What are some of the typical concerns that emerge among professionals in connection with client inclusion?

This page provides information about client inclusion primarily aimed to support the work of social welfare and health care supervisors and managers. Social welfare and health care specialists, professionals, experts by experience or peer developers can also find new perspectives from this page. 

1. Client inclusion is a new way of thinking
2. Promoting client inclusion concerns everyone
3. General concerns related to client inclusion 
4. Client inclusion as everyday activities
5. Measures to implement client inclusion in an organisations
6. Legislation supports to promote inclusion

1. Client inclusion is a new way of thinking

Client inclusion is about clients and client groups participating and influencing the planning, development, implementation or assessment of services.

Client inclusion can be related to: 
A) the service use of clients themselves or their loved ones, or
B) services and the service system in a wider sense.  

In this context, clients refer to both current service users and potential users, i.e. persons who are not yet covered by the services.

Client inclusion is about cooperation

• Equal encounters and cooperation between clients and professionals promote the service users’ self-determination and their opportunity to influence and take responsibility for services.
• Client inclusion empowers both clients and professionals. At best, the client’s commitment to the service will be strengthened, and professionals get to experience new kind of success in their work.
• Client inclusion can be used to improve understanding of clients throughout the working community and ensure that services are better aligned with service needs.
• Client inclusion advances the competence and knowledge base of everyone involved and the organisation. In the best-case scenario, shared understanding is increased. The client’s experience is verbalised and conceptualised, while professional concepts and practices become clearer to the clients.
• Client inclusion produces more effective services. Ideally, clients’ and professionals’ expertise, experiential knowledge, tacit knowledge and views will make services and working approaches more functional and effective.

From guardianship to partnership

A historic change is taking place in the relationship between the client and the professional. For a long time, social and health care services perceived clients or patients as an object with passive involvement. As a result of an improvement of the status of clients, a client-oriented and client-driven approach were introduced to service planning in the 1980s.

This led to a stronger understanding of clients’ active agency in their own lives. This enhanced the significance of experiential knowledge and expertise by experience in the services and related planning efforts. In the 2000s, the inclusion of clients in both their services and more widely in the service system emerged as a topic of discussion. 

The new concept of inclusion perceives clients with increasingly active agency in their lives working together with professionals.

Figure 1: Trend in client relationships and roles (adapted from Pohjola 2010, 2017).

The experience of inclusion

The experience of inclusion is related to inclusion in one’s own life, influencing various processes and the common good. The experience of inclusion extends beyond client inclusion.

Client inclusion in an organisation

From the perspective of an organisation, client inclusion is concerned with clients’ involvement in the services provided to them or their loved ones or more extensively the development of these services.

In the organisation’s activities, the clients’ involvement in their services lays the foundation for client inclusion. Other levels of client inclusion include:

• Clients give feedback on services
• Clients participate in a dialogue on services
• Clients and professionals develop services together
• Services are produced with a client representative

In addition to these, there is a need for a strategy and an action plan that creates a joint value basis and binds activities together.

Figure 2: Client inclusion in an organisation - the house of client inclusion (THL 2020)

Client inclusion as an organisational culture has been structured by the House of Client Inclusion. The structuring is based on previous ladder and staircase models of participation (see Arnstein 1969; Clark et al. 2008; Sihvo et al. 2018; THL 2018; Innokylä 2020), which have been iterated in the THL's client inclusion horizontal group in 2020.

From a societal perspective, inclusion can be examined as exerting influence in democratic processes in addition to the experience of the individual and the operating approaches of organisations.

Figure 3: Resident inclusion

2. Promoting client inclusion concerns everyone

The promotion of client inclusion concerns management, professionals and clients.  Collaborating and creating a common situational picture requires dialogue, joint events and time. Promoting client inclusion is a joint learning process in an organisation.

What does the promotion of client inclusion require from management and leadership?

The management must commit to and create preconditions for implementing client inclusion. This requires a positive attitude, appreciation of diverse expert knowledge and concrete forums for a shared dialogue, and the use of resources.

The commitment of the supervisors speeds up the spread of client inclusion in the organisation, while a lack of commitment significantly slows this down.

The organisation’s leadership provides preconditions and gives a face to work involving client inclusion, while first-line management solves issues related to practical management.

Management promotes client inclusion and allocates resources

The management must have an understanding of the objectives set for client inclusion and the activities promoting inclusion.

• The management should discuss the resources and expertise required from various agents.
  • What sorts of collaboration structures are needed?
  • For example, has the organisation considered how it will manage and coordinate the collaboration with non-governmental organisations and fourth sector operators and agreed on related responsibilities?
• The management decides what kind of resourcing is sufficient from the perspective of objectives.
• When the management participates in launching the activities, it shows its commitment.

First-line management understands the practices of client inclusion 

First-line managers must particularly form an understanding of what the promotion of client inclusion requires of professionals, and what this requires of the participating clients:

• For example, what does co-creation require of different parties?
• Who are you trying to get involved in the activities, and how will this decision affect the required facility and time?
• What role do the client participants play and how can this be supported?
• How will you convince the participants that the management stands firmly behind the issue?
• How will you organise orientation, fees, insurances and peer support for the client participants?

Clients’ service needs guide the planning process

The management outlines and decides whether to modify client paths in an organisational and systemic manner or based on clients’ service needs.

• Are clients and their needs or clients adapting to the terms of the service system at the core of the activities?
• Are clients and users already engaged in the service planning stage?
• Is it possible to use a client perspective to examine the job descriptions of various professionals, division of labour, and how the exchange of information works in multiprofessional cooperation?

Development has been considered in professionals’ job descriptions

The management rules and decides how results are assessed and what degree of freedom employees have.

• A strictly restricted and narrow performance-based working approach does not support the strengthening of client inclusion in the organisation.
• Involving employees and clients in joint reflection on the used operating methods motivates the parties.

The sensitivity of the management to outdated ideas

The management should aim to understand the concerns and fears that professionals face when the organisation is working to build a shared understanding of client inclusion.

• Client inclusion changes the work culture and the working approaches used in an organisation. It is a good idea to tackle these changes and create new approaches together. This also supports the organisation’s resilient activities.
• Individual differences also have an effect. Some people have an inherent ability to adapt to changes, while those who are slower to adapt must receive more support.

An experience of inclusion generates a good client experience

An excellent client experience cannot be created without an experience of inclusion.

•  An experience of inclusion or non-inclusion is largely shaped by service situations. People can learn from everyday encounters and process the resulting experiences.
• At best, the client is seen as an active agent; the service is based on positive encounters, joint agreement and shared decision-making, and mutual responsibility.

How does management perceive the role of professionals?

Managers perceive the role of professionals to strengthen inclusion, particularly when the professionals:

• activate clients to participate in their own care and decision-making as well as in independent activities based on the individual’s ability and willingness
• describe the services and provide realistic information and, if necessary, correct clients’ incorrect perceptions of the services
• develop new ways to encounter clients and listen to their needs
• listen to experiential and user knowledge, and reflect on their own expertise and operating approaches in relation to this
• develop their own work, work approach and working methods, and are active in relation to other professionals and build cooperation to ensure that clients get the services they need
• participate and enable co-creation together with clients:
  • co-creation is based on equality and dialogue, clients are perceived as partners
  • the aim of co-creation can be, for instance, increasing a shared understanding or developing a specific service
  • areas requiring critical agreement include objectives, recruitment of participants, lowering the threshold for participation and common operating methods
  • approaches and methods for co-creation are available, for example, on the Innokylä platform

What roles are clients considered to play?

Managers perceive the role of clients to strengthen inclusion, particularly when:

• client participants serve as an example of recovery and hope. At best, sharing an experience empowers both clients and professionals.
• the user perspective helps developing operations when client participants provide ideas about issues such as operating approaches, organisation practices or facility solutions
• client participants help professionals better justify their work practices and reflect on the operating approaches of the organisation or network of operators
• client participants provide social, emotional and informative support to other clients in a similar situation based on their own experience, for example by helping peers understand service processes, terms for accessing the service and other practical matters
• client participants build a bridge between professionals and client groups.

3. General concerns related to client inclusion

Professional expertise is undermined

Fear of losing one’s status as a professional can cause opposition. There is a common suspicion that professionals’ views and the weight of their competence are reduced as the client perspective gains more prominence. Sharing expertise with the client involves a new mindset. Client inclusion is a form of collaboration that does not involve taking something away from either party; instead, both gain new insight.

Client perspective does not seem acceptable

Clients’ inability to verbalise or understand what is best for them and their needs may be used as a reason for ignoring the client’s own views or for retaining decision-making power solely in the hands of professionals. Professionals may feel that they know more about their clients’ needs or that the clients are unable to broach or verbalise their needs. Although well-intentioned, a patronising attitude is particularly emphasised when dealing with individuals without legal capacity.

It is possible to examine a client's case together without making any presumptions.  Similarly, professionals can try and understand their clients’ perspective even when they cannot personally accept it.

Clients have unrealistic wishes

Professionals may perceive the clients’ expectations and wishes as excessive in relation to the resources and task of the sector or service provider. However, client inclusion does not mean that everything is possible. Clients usually understand the limitations of activities and what is possible when professionals explain and give reasons to these in an understandable manner.

Some may also presume that clients are generally not interested in developing services and participating in related discussions. Once they try a more inclusive approach, they may be positively surprised.

Client inclusion means freedom of choice

Client inclusion is sometimes perceived narrowly, as a matter solely concerned with the client’s freedom of choice or decision-making authority. In this case, professionals may try and shift professional responsibility onto the client. For example, responsibility for knowing the service network and making choices can be perceived as a matter solely related to the client’s personal choices. The collaboration required by client inclusion is realised through negotiations.

Client inclusion takes time away from actual work

Client inclusion can be perceived as extra work or as a separate task handled alongside other work assignments. It is key to understand that client inclusion concerns everyone. This is not a project that can be completed once and then forgotten about. Client inclusion involves a shift in perspective that affects operations at many levels and is part of everyone’s day-to-day work.

Only the voices of those most active are heard

Many end up believing that client inclusion will further strengthen the voices of those who are active, while at the same time suppressing those in most vulnerable positions. Those participating in client panels and surveys tend to be active citizens. However, client inclusion is realised through various means.

A work culture that strengthens inclusion, diverse opportunities for participation, and support for professional competence are necessary to ensure that the voices of as many people as possible are heard. 

Pseudo-inclusion and work performance

Professionals may suspect client inclusion as work performances and pseudo-work. Professionals may feel that clients are promised more than they can actually be offered.  Clients’ opportunities for influence and related limitations should be decided and clearly communicated. Client inclusion requires communication, commitment, resources and trust from the management.

An organisation-driven mindset is rare

A lack of options in the service system can be used as a reason why professionals feel that they cannot listen to the clients. Listening to clients’ needs is challenging if professionals’ possibilities are subject to too many restrictions.

Considering services through user needs can be difficult because services have traditionally been built and described in an organisation-driven manner. A mindset based on needs also requires cooperation and a comprehensive vision from the management.

4. Client inclusion as everyday activities 

The management of client inclusion is promoted by a political decision on including inclusion in strategic objectives.  The strategy should also state how related implementation is monitored and evaluated.

The service provider’s inclusion programme or implementation plan on inclusion makes the strategy more concrete. Achieving goals set out in the strategy may also be required from service providers in the competitive tendering process.

Establishing an inclusion programme as part of daily practice

Knowledge and acceptance of an inclusion programme or implementation plan is required in an organisation to ensure that this is incorporated into daily work. Constructing the plan from the scratch together with different parties will promote its acceptance and implementation.

People must be included in the work to translate the objectives into measures that are accepted and included in daily practice.

Joint forums for discussion and development 

Developing inclusion requires resources, i.e. working hours and designated responsible parties. Responsible persons, inclusion coordinators and agents as well as various networks and groups supporting inclusion are important in promoting inclusion. The best way to foster an experience of client inclusion involves building joint forums for discussion and development. 

Joint participation platforms uniting management, professionals working with clients and those in need of services are important.

Inclusion in knowledge lays a foundation for client inclusion

For service users, inclusion is based on correct and real-time information about services. The used language and terms matter. Client inclusion is promoted by understandable language and clear communications, and plain language, interpretation or special aids as necessary.

Mutual cooperation is also strengthened by raising professionals’ awareness of available services, locally agreed service chains and the service ecosystem.

The inclusion in knowledge of everyone involved is promoted by joint planning of operations, the transparency of preparation work, and openness. In public social welfare and health care services, administrative legislation also guides this.

Partnership between clients and professionals

Interpretations of the same issue may vary based on the perspective and experience of professionals and clients. Professionals representing the same field may also have different views. Professionals should remember that they can try and understand a client’s perspective even when they cannot accept it.

When working with clients, the key is to support the clients in reaching their personal goals. In development work, it is essential to equally listen to the views of all parties.

The opportunities of professionals to influence their own work and time use when working with clients and the development of their own competence significantly promote a partnership mindset.

Expertise appears in a new light

When client inclusion is achieved, expertise appears in a new light. It involves both the expertise of professionals and the expertise of clients. Client inclusion does not reduce professional expertise.

Combining expertise by experience with professional and theoretical knowledge creates new understanding for everyone involved. Client inclusion is about shared expertise and collaboration.

Assessment of client inclusion

Knowledge and assessment of client inclusion is necessary for providing sufficient resources for related activities and to make the benefits, costs and quality of the activities visible.

It is important to measure and assess goal achievement and implementation. However, an attempt to understand client inclusion as a whole and to verify its effectiveness is more essential than measuring individual participation performance.

For example, we may consider whether a comparison of personnel experience and client experience could produce useful information on the quality of services and whether this could be used to direct development work.  Could an increased inclusion of clients in their own service be reflected in matters such as a reduced number of appeals and complaints? Have the clients of the organisation felt heard? Have they felt that inclusion has affected how their cases have been progressed?

Supporting assessment

The TEAviisari tool for benchmarking the means to participate and exert influence in primary health care: Participation: Whole country 2018

5. Measures to implement client inclusion in an organisations

Client inclusion is something you must experience yourself – you will often understand something only after you have personally tried it.

6. Legislation supports to promote inclusion

According to sections 2 and 14 of the Constitution of Finland (731/1999), the individual has the right to participate in and influence the development of society and the living environment. The task of the public authorities is to promote individuals’ opportunities to participate in societal activities and influence the decision-making that concerns them.
Constitution of Finland (731/1999) 

Under Section 22 of the Local Government Act (410/2015), residents and service users have a right to participate in and influence the activities of their region. The local council must ensure versatile and effective opportunities for participation. The municipality may decide how to implement this obligation. Statutory councils such as an older people’s council, a disability council or a youth council may also be actively utilised in the work to promote inclusion. 
Local Government Act (410/2015)

The Act on the Status and Rights of Patients (758/1992) and the Act on the Status and Rights of Social Welfare Clients (812/2000) highlight the inclusion of service users in the services they receive. Clients must be given an opportunity to participate in and influence the planning and implementation of their services. Clients’ wishes and opinions must be taken into account and their right to self-determination must be respected. 
Act on the Status and Rights of Patients (758/1992) 
Act on the Status and Rights of Social Welfare Clients (812/2000) not available in English

The Health Care Act (1326/2010) and Social Welfare Act (1301/2014) emphasise a client-oriented approach. The Social Welfare Act requires structural social work. This means producing data based on working with social welfare clients regarding the needs of clients and related societal links as well as the impacts of social services and other social welfare measures provided to meet these needs.
Health Care Act (1326/2010) 
Social Welfare Act (1301/2014) not available in English

Under chapter 5 § 29, 32 of the Act on the Well-being Region (611/2021), the regional council must ensure varied and effective opportunities and methods for participation. A key element is the planning and development of services in cooperation with service users and the staff of the welfare region. The regional council must seek the views of service users before taking decisions. They should also be given opportunities to participate in the financial planning of the welfare region. In addition, representatives of service users should be elected to the institutions and the planning and preparation of issues should be supported by residents and organisations on their own initiative. The regional government should set up vaikuttamistoimielimet similar to those provided for in the Local Government Act.
Well-being Region Act (611/2021) not available in English.

The regional council decides on the regional strategy for well-being. It must take account of the opportunities for participation. The strategy should also define the evaluation and monitoring of its implementation. According to the model statutes, the welfare areas must have a separate participation programme, which sets out the methods of participation, their objectives and effectiveness, and a description of how participation is linked to decision-making in the welfare area.

Further information

Leini Sinervo
Development Manager, THL
tel. +358 29 524 7609
[email protected]