Interinstitutional Networks and Democratization of Services in Social Intervention with Older People in Portugal

The data are part of a large corpus collected in the course of interdisciplinary research: “Aging, poverty and social exclusion: an interdisciplinary study o n innovative support services” 1 . The documentation of good practices in intervention with older people at risk of exclusion were the aim of the research project. The data collected incudes: interviews, observation and recordings of inter-institutional meetings. The study discusses the ethnographic account in relation to relevant policy documents. Describing the main aspects of the intervention strategies with the older population, the article documents the value of these experiences and the approach in policies for the democratization of services and the inclusion of citizens participating in decision making about delivery of services and the promotion of inclusive societies. What are in fact the objectives of this group? Primarily, by bringing everyone together and keeping an updated report of the main problems of older people. This is informally produced because we do not have enough means. It is mainly an empirical report, i sn’t it? It is based on the work experiences of partner agencies. The objectives also are to develop joint projects, to maximize the use of resources, to create services in partnership and to also try to change, over the years, the way people view old age. (…) To try and make people understand that social cohesion can be achieved by everyone coming together and also through getting older people more involved in the life of the community and not by their segregation. We identified the lines of strength among those that were raised. There were three lines of strength. One was related to the issue of accessibility and autonomy. The other was related to active ageing and the third one, (…) to family relations. (...) Therefore in this forum we organized three workshops. People would register in the one they preferred and so they were discussing these issues, these big topics on the basis of what had already been identified. it way

state and by the citizens, restrained in the expression of their citizenship. Nevertheless, in this period, situations of social vulnerability were alleviated formally through institutions of the Catholic Church, Misericordias, and other private institutions of social solidarity (using a charity approach), and informally through familiar and communitarian solidarity. There were initiatives carried out by citizens belonging to Christian associations such as Juventude Operária Católica (Catholic Workers Youth), Juventude Agrária e Rural Católica (Catholic Agrarian and Rural Youth), etc. Moreover, cultural associations, at the level of the borough or of the neighbourhood (local communities), political organizations, unions and/or cooperative organizations all had the objective of raising the awareness and inclusion of citizens in small social development projects for local communities. It was hidden work that after the Portuguese revolution of 25th April 1974 facilitated the creation of production cooperatives of housing and socio-cultural associations and NGOs. In various municipalities, methodologies of cultural intervention and education were developed.
In the period between the 1960s and 1980s, various experiences of local participation arose for the promotion of community development, involving people in rural and urban communities. The adhesion of Portugal to the European Union (1 January 1986) was an important turning point. It was a political stimulus for the building of joint work, in the area of social intervention and employment which was reinforced by the creation of the PELCP II (1986)(1987)(1988)(1989). On the basis of this policy orientation, 91 actionresearch projects were created in relation to vulnerable groups. The transnational activities and the learning derived by these experiences were fundamental. Some statistical studies were also conducted with the objective of measuring and operationalizing the notion of the definition of poverty. PELCP III (1989III ( -1994 followed. This policy document had a different orientation with respect to the previous plan. It included 42 local projects, and it promoted participation and networking. With this program the concept of social exclusion became more used. This program had a great influence in the creation of the model for the Programa Nacional de Luta Contra a Pobreza (National Poverty Alleviation Programme -PNLCP) in 1990.
Halfway through 1990, the Government recognized the importance of these informal networks, and promoted a set of policies promoting active citizen participation. Francisco Branco (2009, p.82) describes the policies relating to the "Rede Social" (interinstitutional network) as "active social policies, oriented by a principle of active solidarity replacing the logic of passive solidarity mechanically developed by the Welfare State." The institutionalization of "Rede Social" (Interinstitutional Network) In this context, which was favourable to participation, experimentation and innovation, the formalization process of the "Rede Social" (Interinstitutional Network) program started as a result of the RCM no. 197/97, of 18 November 1997. The Program was defined as follows: The "rede social" (interinstitutional network) is defined as a set of different types of mutual assistance, between the set of non-profit private institutions and public bodies that work within the context of social intervention and which organize between themselves and the Government actions targeted at the eradication or attenuation of poverty and social exclusion and for the promotion of social development. (p. 6253) The key objectives of the programme were focused on the promotion of this integrated social development, through the implementation of a set of means and institutional agencies that could provide a response to the social problems identified at a local level. In one of the explicative documents accompanying the programme, the specific objectives were summarized as follows: To stimulate the identification of problems and participatory planning, to promote the coordination of the interventions at a municipal and borough level, to look for solutions for families and for people in poverty and at risk of social exclusion, to train and improve professionals involved in the process of local development within the context of the "rede social" (interinstitutional network), to promote an adequate coverage of services and equipment, and, lastly, to improve the dissemination of knowledge on local realities. (IDS, 2001) In this context, it was important to promote a participatory methodology of intervention respecting the principles of integration, connection and subsidiarity.
In order to operationalize the relevant objectives, the very RCM no 197/97 instituted the organization of the "Conselhos Locais de Acção Social" (CLAS 2 ) (Local Council of Social Action), as a model of local governance. This larger network was coordinated by the president of the Council of the Municipality and of the Boroughs. The member organizations were expected to produce an internal procedural guideline: 1) carry out "Diagnósticos Sociais" (Needs Assessments), a mapping of the social problems and of the resources present in the territory 2) present "Planos de Desenvolvimento Social" (Social Development Plans) for three or five years. The plan had to define priorities and solutions for the problems that were identified; 3) produce the annual Action Plan; 4) create a system for the sharing of information among all the members of the network 5) make suggestions on a model of relationships among the various members of the network. In synthesis, the main idea of the programme was to rationalize and improve the means and services provided by the different member institutions of the network in their specific areas of intervention, creating planning procedures and having local development linked to the fight against poverty, among their main objectives.

The Development of the Rede Social (Interinstitutional Network) into an Institutional Planning Instrument
The implementation of the programme did not happen in all the municipalities at the same time, so there were different phases. In the first phase, between January 2000 and April 2001, the programme started to be experimentally implemented in 41 pilot municipalities, from the north to the south of the country. In this phase, various difficulties were raised and were discussed in the first National Meeting of the Interinstitutional Network. Among the main difficulties were: a lack of a tradition of planning social intervention in Portugal. Social intervention conformed to the logic of solving problems as they appeared in a sector-based modality, with no coordinated or complementary work objectives. There was also a lack of training of professionals in social intervention and the fact that in most of the Municipalities, with the exception of larger-sized urban municipalities, social intervention was limited to social housing.
In spite of the difficulties, the balance of the programme was positive, in particular for the cooperative efforts between public and private institutions to find joint objectives and set up coordinated intervention. At the end of this first meeting Jordi Estivil pointed out the importance of providing a greater visibility and stronger political support to such experiences that could be replicated in other European Countries. The Program of the Rede Social was presented in PNAI 2003-2005-Plano Nacional de Acção para a Inclusão (National Action Plan for Inclusion) as a good practice. The Programme supported interinstitutional intervention, by rationalizing it and trying models of integrated intervention models involving local partnership. Moreover, it introduced strategic planning processes into the areas, supporting the acquisition of deeper and more systematic knowledge of the local social realities and promoting the circulation of knowledge.
In the second phase of enlargement of the Programme, the funding provided to the Local authorities was determinant. Institutions were able to hire professionals who could ensure the implementation of the Programme and they were able to hire technicians. They could also carry out specific training activities. In this context DN No. 8/2002 created a specific implementation programme-Programa de Apoio à Implementação da Rede Social (Support Programme for the implementation of the Interinstitutional Network). A series of meetings were organized in order to reflect on both the implementation of the Programme and on planning and intervention practices: a 2nd National Meeting (2003), four Regional Meetings (2004), regular Inter-CLASS meetings and the first external evaluation of the Programme (2005) when interinstitutional networks had already been implemented in the whole territory 3 . These meetings were very important for reflecting, informing and exchanging experiences and disseminating good practices in the context of a program which was effectively capable of involving and mobilizing a great variety of agencies in relation to social issues. The second National Meeting involved around 600 Professionals and managers of local interinstitutional networks who met to reflect on and discuss issues such as: 1) The sustainability of the Rede Social (Interinstitutional Network) Programme; 2) Information System and marketing of the Rede Social; 3) promotion of effective and efficient networks and partnerships for local social development; 4) Joint efforts between the economy, the territory in social solidarity situations; 5) Contributions by the Rede Social for the improvement of the quality of life for citizens. (Castro et al., 2009, p.28). In 2006, through the decree: Decreto-Lei no. 115/2006, 14 June, the Rede Social (Interinstitutional Network) was transformed into a permanent structure, and was thus institutionalized, to involve the participation of all Municipalities. The participatory planning of local social development was still the main focus. There was an increasing preoccupation with coherence between this planning structure and the planning instruments at a national level, in particular the Plano Nacional de Acção para a Inclusão (PNAI) 4 (National Action Plan for Inclusion).
It is important to point out that the Rede Social (Interinstitutional Network) has become the main structure of participation in the field of social intervention in the Country due to the commitment of the professionals and member institutions that participate and work at the various territorial levels -local, regional and national.
Even if tensions and difficulties have cyclically arisen, both in the pilot phase and during the institutionalization of the Programme, there has been an evolution (in quality and quantity) in the participation of members of the network. Their participation has been driving the Rede Social (Interinstitutional Network) to a third consolidation phase, testing its actual ability to face current interinstitutional network challenges (Godinho & Henriques, 2012, p.9). Godinho and Henriques (2012, p.1), the authors responsible for the most recent evaluation, highlight the richness of the experiences found in the context of the Rede Social, "They [such experiences] are potentially transferable to other contexts, there is no space for their suitable dissemination." These issues have also been pointed out by the actual participants in the network. The difficulties of interinstitutional intervention and inter-professional cooperation were highlighted in the relevant literature, as it will be presented below.

Intervention with the Older Population: an Integrated Approach
Paradis and Reeves (2013), in their extensive literature review covering 40 years , argue that the field of interprofessional research is growing rapidly and it is increasingly acquiring legitimacy as an independent research domain. Interinstitutional social intervention is increasingly promoted at policy level (D' Amour & Oandasan, 2005;Hudson, 2002;Sousa & Costa, 2010;Xyrichis & Lowton, 2008). In various policy documents of the World Health Organisation the importance of team working is emphasized; in particular "Learning together to work together for health" (WHO, 1988) is a key document, highlighting the importance of multiprofessional education. Sousa & Costa (2010) point out that the multiprofessional approach is desired at governmental level, but it is difficult to achieve. They also highlight the scarcity of empirical works documenting actual professional practices: "the literature has paid little attention to the interaction and behaviours of front-line professionals (those who interact directly with service-users), and to how they put this way of working into action, integrating what is useful into day-to-day work flows while screening out less useful or more problematic demands." (Sousa & Costa 2010, 444) Studies documenting actual interactional practices (Arminen & Perälä, 2002;Carrier, 2012;Kvarnström & Cedersund, 2006;Nikander, 2003; are still scarce. Difficulties in interprofessional team working have been pointed out (Hudson, 2002;Lloyd et al., 2011;Rice et al., 2010;Xyrichis & Lowton, 2008). Xyrichis & Lowton (2008), in their review of the literature, describe what fosters or prevents interprofessional team working. They highlight some aspects which foster interprofessional cooperation in team structure, such as "team premises, team size and composition and the availability of organisational support" (Xyrichis & Lowton, 2008, p.141) and in team processes, such as "setting clear goals and objectives for the team, ensuring regular team meetings and audit" (Xyrichis & Lowton, 2008, p.141). Dowling et al (2004) problematize the way of conceptualizing a successful partnership, underlining the importance of measuring success in terms of improvement of delivery of services, and focussing less on process issues, that is, how well professionals can work together. A literature review (Miller & Cameron, 2011, p.41) describes the difficulties in the implementation of shared interagency assessment in the UK, for example, a tension between "standardisation of tools and facilitation of local flexibility in tool development" with consequences in information management. In fact, Miller and Cameron Point out that "There was also evidence that over-attention to the format and structure of tools could be counterproductive to good assessment practice". Hudson (2002) makes a distinction between partnerships among institutions and among professionals, pointing out that there is a gap between the two in the UK: "Partnership working is now a central plank of public policy in the UK, especially in the field of health and social care. However, much of the policy thrust has been at a level of interorganisational working rather than at a level of interprofessional partnerships" (Hudson, 2002). Hudson carried out an ethnographic study among health and social care practitioners working with frail older people across three localities in northern England. His study describes some of the difficulties involved in interprofessionality, but he also highlights positive outcomes. Hudson points out the need to explore what he calls 'optimistic hypotheses' (Hudson, 2002, p.16), with an example, among others being: "That socialisation to an immediate work group can override professional or hierarchical differences amongst staff" (Hudson, 2002, p.16). In this study, I aim to highlight the importance of the creation of an "interinstitutional working culture" for the successful joint working of professionals.
The following presentation of ethnographic data aims to describe an experience of interinstitutional intervention with the older population in a town near Lisbon, relating it to relevant policy documents that have institutionalized interinstitutional networks in Portugal. The presentation of the network, through the ethnographic data, is used to illustrate the policy document, it exemplifies the kind of networking practices that were ratified through the policy document "Rede Social".
The study primarily aims to document the value of these experiences and the approach in policies for the democratization of services, that is, the inclusion of citizens participating in decision making about delivery of services, as Seckinger (1998, p.237) points out: "According to a common view, social services will become more democratic if those to whom social services are offered are allowed to participate in the decision-making".

The Study
The data presented in this article are part of a large corpus of data collected in the course of interdisciplinary research: "Aging, poverty and social exclusion: an interdisciplinary study on innovative support services." 5 Paoletti, 2014;Paoletti & Carvalho, 2012;Carvalho, Paoletti & Rego 2011). This project aims at describing good practices in service provision that reduce social exclusion, in the social intervention with older population. Initially interviews were conducted with local managers (social workers in coordinating positions, services managers; NGOs coordinators; presidents of older people associations), involved in the support of older people, in order to identify good practices. On the basis of the interviews, two settings were identified for ethnographic documentation, in order to describe in detail the professionals' practices and in particular the institutional and professional culture that sustained such successful interinstitutional intervention.
The data presented in this article refer to the ethnographic data collection carried out in a town near Lisbon. The data includes interviews with key informant, audiorecordings of the interinstitutional networks meeting and field notes. Permission to record the interviews and other interactional data was asked to the research participants and granted. The names of the participants have been changed in order to preserve anonymity (See Paoletti, 2014;Paoletti et al., 2013, for the complex issue of anonymizing transcripts). The presentation of the inter-institutional network benefits from the whole set of data and the participation in the meetings and other relevant events, but the transcripts reported in the article come from an interview with the coordinator of the network. The interview was fully transcribed from a native speaker of Portuguese.
The interinstitutional network, "Grupo Concelhio de Idosos" (Municipal Older People's Group), will be presented drawing on the ethnographic data and reporting transcripts from this interview. Transcripts are hard to read, their content is summarized in their presentation. We encourage readers to have the patience to examine them because they enrich greatly this account. Presenting the network, we want to highlight the importance of understanding the culture of this network, and the ethical motivations and forces which have insured its lasting success. The transcripts greatly help in giving an idea of these dimensions of the networking practices.

The analysis: The creation of the network "Grupo Concelhio de
Idosos" (Municipal Older People's Group) The "Grupo Concelhio de Idosos" (Municipal Older People's Group) was created in a town near Lisbon as an informal inter-institutional network in 1981 and has been running for more than 30 years at the time of data collection. It is still an informal network, it has not been institutionalized according to the relevant legislation (RCM no. 197/97, of 18 November 1997). It pulls together practically all the social and cultural services related to intervention with the older population, public and private institutions. Professionals from the municipality, social security, local public health services, NGOs providing services to older people (day care centers, home help services, older people homes, meal on wheels, laundry service, etc.) and members of local associations take part in the network meetings. Recently the local public health services withdrew from the network although they were involved in the recent past. The reason for the withdrawal may be due to lack of time for professionals to participate in the network meetings and other activities, given the recent financial restriction and consequent reduction of personel. Althogh, this doesn't seem to be the only reason, as the coordinator of the network seems to hint: I am a Town Council professional, I am a social worker, and it is the Town Council who coordinates this partnership: "Grupo Concelhio de Idosos" (older people's Municipal group). (…) It is an informal structure, there is no subscription procedure and no fee, therefore the agencies participate through their free will if they consider it to be advantageous. Don't they? Right, so this group that was created in 1981 -therefore, 30 years ago -along with the first institutions, the Town Council, Health and Social Security and the institutions that were present at the time which were three in total. At the moment, we are roughly 23 partners. Right, so who is involved today? The Town Council, Social Security and Health withdrew last year, because they said they did not have the means necessary to participate -Health, and this is my opinion, has been closing itself off for some time. Institutions also participate, i.e. private social solidarity institutions which work with older people and which are involved in traditional intervention in homes for older people, in day centres, in home support services, in community centres, etc. (Interview with a Professional, 1) The informal network is aimed at planning and developing services in partnership for the support of older people. There is also an awareness of the importance of creating an inclusive culture in relation to this population group, as a professional in the network points out in the interview: What are in fact the objectives of this group? Primarily, by bringing everyone together and keeping an updated report of the main problems of older people. This is informally produced because we do not have enough means. It is mainly an empirical report, isn't it? It is based on the work experiences of partner agencies. The objectives also are to develop joint projects, to maximize the use of resources, to create services in partnership and to also try to change, over the years, the way people view old age. (…) To try and make people understand that social cohesion can be achieved by everyone coming together and also through getting older people more involved in the life of the community and not by their segregation.
Members of the network meet bimonthly to plan and evaluate the joint activities. They organize their activities into three working groups: 1) A socio-cultural Activities Group which promotes joint socio-cultural initiatives; 2) a Coordination Group, which mediates the relationship between the various institutions and social security, 3) a Group Systematizing Intervention, focussed on the creation of joint services and joint in-service training.
Given that we are a large structure, how do we operate? Usually, every year, we create working groups, and when we make our activities plan (…) there is one group which is more involved in promoting socio-cultural activities. The facilitators of socio-cultural activities of the institutions take part in this group. Some participate more at the beginning and then they occasionally involve others from the remaining institutions. (…) Then, they plan the joint sociocultural activities, because each institution organizes their own. (...) Each institution has their specific interventions, activities, etc. Right, so then there is another group, which is the group of the coordinator of the institutions. This is the group to which Social Security belongs. It gives guidelines and orientation regarding the protocols established with Social Security, the cooperation agreements in which the issues of a quality management system are discussed -(…) this has been a 30-year process. It already has a long history and has had many phases. (…) This is where we are now. -And then there is a third group which we call the group systematizing intervention because, after all, it is the group which makes decisions. Even if the Municipality coordinates the group, it only coordinates and does not make any decisions.
The professional in the interview points out the autonomy recognized at an institutional level to the network and consequently to the professionals and citizens participating in it. The network meetings represent an actual discussion space in which the direction to be taken by the intervention are negotiated among the different agents. Joint activities are planned and carried out, in particular, a series of joint services were put together through the activity of the interinstitutional network, as it will be described in the following paragraph.

The Creation of Joint Projects
Throughout the years, the network has been organizing joint services that are then used by users of all the different institutions. The home night service is one of them. It has been running for the past 15 years and it is offered by the "Santa Casa da Misericórdia" 6 . The institutions jointly established admission criteria for the services and the partners institutions signal cases to the Santa Casa da Misericórdia, as is pointed out by professional: We created the first home night service in the country (…) Each institution has a home help service. This service used to be for seven hours, now it is already for twelve hours. Social Security is making agreements of cooperation of twelve hours per day, when initially it was seven hours. And we created a night support for home help services, one service for all institutions. We defined the criteria of access to this service, (…). There is an institution promoting the service, that is, one which is responsible for the service. This is Misericórdia of A. and then the other partner institutions signal cases to the Misericórdia, either by fax or e-mail. They signal cases of people who, for example, need greater care, who need to take medication during the night and do not have anyone to give it to them. People who need to be helped to change positions, or anything like that. Therefore, there is a contact and a user referral made by the institution. The users belong to that institution, don't they? They do not belong to the Misericordia, but in some way Misericordia provides a service to that person through the institution. This service was created around 15 years ago.
Another joint service organized through the network is "the tool bank". It consists of a storage site where wheel chairs, articulated beds, sticks, etc. are acquired and stored. All the partner institutions can borrow the instruments whenever their service users need them. Private citizens are also invited to contribute to the bank with tools they no longer use: We also campaigned in churches, in parishes, among the population in general. So that people who might have these things, sometimes belonging to a relative who died, or if they broke leg and used some crutches and do not need them anymore, instead of throwing them out, they can donate them to the institution.
A group of retired school teachers run the University of the Third Age. They also created the project "Uma Palavra, Um Alento" (A Word, A Comfort) in cooperation with professionals from the interinstitutional network. The association promotes cultural activities with older people who are house bound. The member institutions in the network identify people who are more isolated and who are interested in receiving this type of help. The experience has been very successful. This intervention is not aimed at substituting the work of professionals, but to integrate it, as this professional points out: The institutions keep providing the home help services, but the home help services don't also allow for appropriate caring. This includes bathing, house cleaning, (…) preparing meals, taking the person to the doctor or to schedule a medical appointment, but it doesn't include reading a book or keeping company. This is not possible. Therefore, this project includes the training of volunteers... there is a triage through a psychologist in order to understand the motivation and the competences that a person has for this type of work, isn't there? Then the individuals are trained, very much on the bases of the kind of activity they can develop, and especially on the limits to take into consideration when entering somebody's house, on the respect necessary in regard to the service user's privacy.
The "home workshop" is also a service created within the context of the interinstitutional partnership. The Municipality donated a car which was modified and transformed into a kind of mobile workshop. Santa Casa da Misericórdia hired a workman who goes to older people's houses to fix bath taps, paint walls, etc., all the ordinary small house repairs which a frail older person will not be able to do anymore. The organization of joint services is a very material expression of partnership. Joint training on specific issues of shared interest is also an important part of the activities of this interinstitutional network. In this respect, an important action, involving a participatory process, was the creation of the "Charter of Principle of Home Assistance".

Charter of Principle of Home Assistance
In 1999, during the European Year of Active ageing and Solidarity among generations, the members of "Grupo Concelhio de Idosos" (older people's Municipal group) decided to create a Charter of Principles of Home Intervention, through a participatory process: I wish to say another thing that made me very proud (…) we created our Charter of Principles of Home Intervention. This was also a process with a lot of participation. It was like this: We thought it was very important that the institutions providing the services understood the notion of what it means to respect service users when the institutions go to their houses. To enter into a person's home, to bring food, or help bathing, is even more so, isn't it? It is necessary that these people who help -and they are often people with little training, aren't they?-, that their institution has instruments to train these people and to make them understand the importance of respecting the privacy and autonomy of service users.
The process started with interviews to service users and their families, carried out by the home helpers who enter the house of service users, together with the professionals who coordinate the institutions providing services: And therefore, we also did a process of the following type: we interviewed the service users who had abilities..., people who are bedridden -aren't they? -but who still have their wits about them, … who are autonomous at a mental and psychological level, who were able to cooperate. We asked them to propose some problems they could identify … problems or issues that they thought important to pursue. … We did these same interviews with their families. These interviews were carried out by the home helpers who go to the houses of service users together with the professionals who coordinate the institutions. With all this we were able to identify some issues.
The involvement of the team in the interview process was itself a consciousness raising and training activity in regard to the rights of frail older people. A public meeting was then organized in which all institutions providing services were formally asked to sign the Charter: Then we organized a meeting with everyone in order to give back this-didn't we? -and we got to a Principle to a Charter of Principles … and we organized an official session with all the partners in the network to sign this Charterwasn't that so? -to make themselves responsible for carrying out in practice this Charter of Principles, let's say so. I think that it is something that doesn't exist anywhere else.
The organization of joint services is an important part of the network activities, but the central objective of the network intervention is definitely to bring to life a participatory needs assessment and a planning process, at the community level, in relation to the ageing population.

Joint Service Planning Process
The interinstitutional network works on the basis of a Local Gerontological Plan, through which middle term objectives are jointly established. The Plan is developed through an exploratory stage and a planning stage. The exploratory stage consists of a participatory process in which professionals, end users and active citizens are involved in a kind of needs assessment in relation to the older population of the local community: In recent years we also activated a process of creation of ... we call it our Local Gerontological Plan. Therefore, what we wanted in the end was to have a plan that would guide us in the middle term, let's say, not only year by year, isn't that so? in our intervention. Therefore, we carried out a small approximate analysis of the situation of older people in the municipality. We identified some main problems and needs (…) This work took some time. First of all, due to the fact that we are not a University and we are not only doing a study. Each one of us has countless tasks. (...) Also because it was a highly participatory process in all its phases (…) Therefore when I talk of diagnostico (needs assessment), I mean (...) we got data from the census, data of different origins, but we also collected some data on the main needs and problems, housing conditions, etc., of the service users who are generally the most vulnerable and poor older people in the municipality.
The participatory process of the needs assessment involved the delivery of a questionnaire to service users. Then, the results of the data collection were presented in a public meeting. The various institutions were also invited to work with service users in the needs assessment concerning the human rights of older persons as established by the United Nations 7 . This process emerges not only aimed at pointing out specific needs and problems of service users, but also as a way to raise awareness regarding human rights. The service users were invited to reflect on their rights as citizens: In the first phase, we used a questionnaire, (...) in order to identify their living conditions, for example (…) whether or not they have sanitary facilities, whether they live in an owned house, by themselves or with their family, whether or not they have children, whether they are on speaking terms with their children or not, etc. Right. Then we had a restitution of the data, a presentation of the results to the people. Something else we did was: we followed the United Nations principles for older persons, based on these principles we worked on the interinstitutional network with the objective that each institution could work a bit with their service users in order to identify the main needs and problems that are relevant in relation to each principle. (…) Older people (…) have the right to dignified housing conditions (…) as is stated there.
This needs assessment participatory process enabled the identification of a large number of issues. A public meeting was organized in which the results of the inquiry were presented and the main line of action was discussed with the population, in particular, there were three main lines of action identified: 1) Accessibility and Autonomy; 2) Active aging; 3) Family relations, as pointed out by this professional during an interview: What did the people identify as a problem? People identified (…) innumerable things. (…) Since there were various similar proposals, we tried to condense them, during the editing process, in order to obtain something that was not too big or too repetitive, (…)-After this, we organized a participatory forum in which those people -the individuals who wished to participate (…) to whom we said: what you said was this, do you identify with it? Do you wish to add something or not? (…) In this forum we were then able to organize our work. We identified the lines of strength among those that were raised. There were three lines of strength. One was related to the issue of accessibility and autonomy. The other was related to active ageing and the third one, (…) to family relations. (...) Therefore in this forum we organized three workshops. People would register in the one they preferred and so they were discussing these issues, these big topics on the basis of what had already been identified. Therefore, it was a different way of working.
The outstanding aspect in this interinstitutional experience is the contribution to the democratization of services in relation to the ageing population, that is in the users' participation in the decision-making process in relation to service delivery (Katan, 1991). Users and the general public are invited to participate and discuss the needs assessment and the definition of the intervention objectives. Improving efficiency and efficacy of the provision and tailoring of services to service users can be seen as side effects of this democratization process. Despite the financial difficulties which Portuguese institutions have to face and the consequent limited services that are offered to the ageing population, the participatory process activated by this interinstitutional network may be of interest to any European country aiming to democratize its social intervention and help older adults aging-in-place (McDonough & Davitt, 2011) within inclusive communities.

Discussion
The 1st "Rede Social" (Interinstitutional Network) Programme Evaluation was carried out by an external agency: Centro de Estudos Territoriais/ ISCTE http://cet.iscte.pt/en/index.html (Amor, 2005). It provides a general acknowledgment of a positive implementation process with an important impact, that is, a policy that was promoting "an integrated and systemic approach to social development and improvement of the well-being of the population" (CET, 2005 p.8). But the report also described its difficulties and vulnerabilities, denouncing a deficit in the provision of services, due to the increased number of municipalities participating in the Rede Social programme (Interinstitutional Network), the absence of regulations to implement RCM no. 197/97 and of the nonexistence of formal and publicly visible interministerial liking. In fact, the management of the programme, entrusted to a specific Ministry, gave a (incorrect) signal to the territory that it was an initiative which was restricted to social intervention. This was in fact a signal contrary to what the Rede Social (Interinstitutional Network) aimed at stimulating "the need for integrated social policies" (Castro et al., 2009, p.31).
Specifically, the programme proposed integrated territorial intervention, including various sectorial areas such as social intervention, health, education, employment and training and housing, among others. The managing agency, the "IDS", was under the Ministry of Social Solidarity and Security and this had as a consequence the fact that many agencies in the network started to think that the main responsibility of the Rede Social, in terms of intervention, was restricted to social intervention. In relation to this process, one of the weakest aspects of the Rede Social has been the monitoring and evaluation of its implementation.
Since the start of monitoring and the evaluation of the interinstitutional networks, activities had been included in the initial guideline documents for the implementation of the programme. Moreover, the policy document (Order in Council) Portaria no. 141/2002, 12 February, included financial support specifically for the evaluation of local interinstitutional networks. But in fact, as the study by Alves, Martins and Cheta (2007, p.53) points out: "in the majority of the situations covered by the research (55% of cases) there were no procedures set up to evaluate the work carried out." In the situations in which evaluation activities were carried out, the most used model was auto-evaluation.
The most recent external evaluation rightly underlines the maintenance of this weakness of the interinstitutional networks (Godinho & Henriques, 2012, p.114). The main reasons identified for a lack of monitoring and evaluation are the level of maturity of the organizational structure of the network and actual technical capability to achieve this. This does not mean that there are no positive experiences of interinstitutional networks which have monitoring and evaluation procedures that are regularly used.
This brief presentation of the Programme has enabled us to identify some strong points such as an interinstitutional working culture and a growing implementation of joint work in social intervention planning. These aspects were highlighted in the first external evaluation and also in the research carried out by Alves, Martins and Cheta (2007). The strengthening of relations between the interinstitutional networks and other local networks is also visible, as Godinho and Henriques (2012, p.187) point out: A methodology of joint work, combining top-down and bottom-up instruments, that is, in the relation between ISS, I.P.-Autarquias-IPSS (Social Security-Municipalities-Services Providers) in the support of the work of the interinstitutional networks (top-down), and the acknowledgment of the local participation as generating planning and producing initiatives, knowledge and decisions (bottom-up).
The interinstitutional network activity is still quite "enclosed and invisible" in spite of having had positive institutional repercussions. Its effects have in general less visibility in relation to the impact in the quality of life of the population and mobilizing their participation. There is also some resistance in local and central administration in relation to interinstitutional networks as the main partners in relation to planning in the social area. Moreover, the lack of linking between local, municipal and supramunicipal levels is certainly an important preoccupation. In this context, Godinho and Henriques, (2012) propose some future challenges, which in brief are: 1) to link the Interinstitutional Network with the Portuguese participation in the 2020 Strategy and with structural funds; 2) to promote suitable resources for the needs of interinstitutional networks; 3) to improve the capacity for strategic and participatory planning (reaching the service end users and the population) and strengthen the monitoring and evaluation of technical teams. A general effort in all these areas could imply a new legal framing of such interinstitutional networks (Godinho & Henriques, 2012).

Conclusion
In this article we presented the experience of an interinstitutional network in intervention with older people, the "Grupo Concelhio de Idosos"