The crisis management teams in the five municipalities all had an operational core consisting of the mayor, the chief municipal executive, the district medical officer and relevant municipal executives. All described the collaboration as very positive and stated that the distribution of roles was clear. For example, one chief municipal executive (participant no. 8) stated that 'we distinguish between medical, political and administrative matters. These are clearly defined, and we do not trespass onto another's turf. It works well as a symphony'. The mayor or the chief municipal executive served as the formal head of the crisis management team, and it was clear that the district medical officers, with their competence in community medicine, played a key part in the decision-making processes as a medical advisor in the crisis management team:
'From day one, we made it very clear that this was an area that would be based on professional considerations. The district medical officer was therefore given a key position […] had a very weighty role […]. The decisions that were made were very largely based on the advice she gave.' (Mayor, participant no. 5)
The district medical officer is described as a premise-setter for the decisions that were made by the crisis management team, since the challenges posed by the pandemic required measures that were based on a medical rationale. This role was strengthened by the authorisations in the Act relating to control of communicable diseases.
'In practice, the district medical officers have all authorisations, so it's up to them to make individual decisions. He chose to consult us along the way.' (Deputy chief municipal executive, participant no. 3)
The district medical officers experienced a marked change in their daily work as a result of the pandemic. All of them described a huge workload with long days and many meetings, and they referred to 'the pandemic as all-consuming' (District medical officer, participant no. 9).
The hotline scheme meant that 'we were constantly on standby' (district medical officer, participant no. 1). Despite the huge workload, the district medical officers ascertained that the work related to the pandemic had been a positive experience. Good collaboration, influence and recognition of their competence as professionals were cited as reasons.
'You received a lot of support and were respected for your professional status […] I have very positive experiences from the collaboration with the municipality's administrative management and the mayor.' (District medical officer, participant no. 1)
The district medical officers' competence was requested both by the administration and the political leadership, and many of them felt that their participation in decision-making processes had made them more visible internally:
'From being an invisible infection control officer, I became highly visible vis-à-vis the political leadership in the municipality, i.e. the mayor, the deputy mayor and the emergency preparedness committee' (District medical officer, participant no. 1).
One district medical officer (participant no. 4) expressed it thus: 'I really believe that I have set the agenda. Of course with input from all the municipal executives who attended the meetings, but it wasIwho decided the direction.' The district medical officers had influence, and the quote illustrates the district medical officer's role as a professional premise-setter. This was described as a change from the time before the pandemic: 'Suddenly I was a very important part of the municipal administration' (district medical officer, participant no. 1).
The decision-making processes consisted of the district medical officer presenting medical considerations and proposals for decisions in the crisis management team. These were then jointly discussed before a decision was made. The municipal council was not closely involved in the decision-making processes, but was kept updated:
'The crisis management team decided on immediate measures […] And then it was largely about informing the municipal council about the situation and the measures that had been implemented.' (District medical officer, participant no. 9).
The rationale for this practice was the need to be able to operate quickly and effectively: '[It] would have been far too arduous to go through long political processes' (mayor, participant no. 13) and '[I] have never heard from the local council that the decision should have been made there. They felt that the district medical officer was doing his job and acting on the basis of medical considerations, rather than for us in the municipal council to speculate' (mayor, participant no. 2).
The municipalities in the study describe the practice of making decisions in the crisis management team as uncontroversial: 'There have never been any problems or questions in this regard. The mayor has kept the executive board informed […] It has gone smoothly' (deputy chief municipal executive, participant no. 3). When asked why there was little controversy regarding this practice, the reasons highlighted are trust and a shared understanding:
'The professional considerations and access to advice and guidance have been crucial, a high degree of trust. Politically, both locally and nationally, it is widely understood that during crises it is important to unite behind decisions and messages, even when we don't agree totally […] to appear outwardly as being in agreement, and not to start discussions on whether different strategies should have been chosen.' (Deputy mayor, participant no. 10)