User choice and the changing notion of social citizenship in Swedish elderly care

ABSTRACT

This article deals with the 2009 user choice reform in Swedish elderly care. It analyses how the tension between choice and older citizens’ equal access to good quality care was dealt with by the policymakers who introduced it. Three overarching research questions are addressed in the analysis: (i) what role and responsibilities did the Swedish user choice reform assign to the users and how did the policymakers view users’ ability to make an informed choice? (ii) How did the policymakers view the role and responsibilities of the local authorities and what tools were the local authorities given to ensure access to good quality elderly care for all citizens? (iii) Can the new user choice reform be said to contain a new notion of social citizenship for older people in Sweden? The findings suggest that while the user choice reform encouraged users to allocate resources and make free choices between providers, it also required users to become more responsible to ensure service quality. The reform also advocated that the local authorities should steer their elderly care sectors through partly new governance tools and secure quality foremost through the entering of contracts with authorized providers. The paper argues that, because of these required new roles and responsibilities, the Swedish user choice reform entails a more libertarian notion of social citizenship, requiring users to take on greater responsibility for their own well-being and protection against risks.

KEYWORDS:

• User choice in social care
• social citizenship
• social rights
• elderly care
• Swedish welfare state

Introduction

In recent decades, individual liberty and user empowerment has become increasingly important in many mature welfare states, manifested through new and updated policies for user choice of provider within social services such as health, education, and social care (Fotaki 2009). The idea behind user choice is that public and private providers compete for users within a system of public funding, where the allocation of resources is based on the choices of the users. The objective is to create competition for users and thereby increase their influence (Savas 2000; Le Grand 2007). It has also been suggested that choice reforms re-cast citizens, as recipients of welfare services, into the role of welfare consumers (Higgs 1998; Clarke et al. 2007; Newman and Tonkens 2011). As consumers, citizens are asked to be active, orient themselves in the market, and use their right to choose as a means to maximize their own welfare (Clarke et al. 2007; Johansson and Hvinden 2012). If one considers access to particular welfare services as a citizen’s right, the creation of the ‘citizen-consumer’ has given rise to questions regarding citizens’ ability to make use of their right to choose, and whether all individuals can make informed choices regarding their welfare (Newman and Tonkens 2011; Johansson and Hvinden 2012). If not, scholars have argued that some users risk ending up with service alternatives at the lower end of the quality scale. As such, user choice risks undermining citizens’ equal access to quality care and thus changing the content of vulnerable people citizenship rights (Mocan 2006; Eika 2010).

The potential benefits and drawbacks of user choice have not least been discussed in relation to elderly care where many users rely on the care of others to live an ordinary and dignified life. On the one hand, this sector is characterized by considerable power inequalities between the givers and receivers of care, making choice extra important (Glendinning 2008). Since elderly care services often comprise most aspects of a person’s living conditions for a prolonged period of time, a free choice of provider can be seen as especially important for the preservation of individual autonomy (Moberg, Blomqvist, and Winblad 2016). On the other hand, it has been argued that choice entails an increased risk for inequalities in service outcome, where vulnerable users with little capacity to choose are most at risk of ending up with low quality providers (Fotaki 2009; Eika 2010). This risk is clearly present in elderly care. Since elderly care users often are weak from old age or illness, it has been claimed that they have limited consumer sovereignty and that they are disadvantaged in comparison to other welfare users (Eika 2010; Meinow, Parker, and Thorslund 2011). This seeming conflict between the value of choice and the increased risk for inequalities in service outcome should present a challenge for policymakers who design user choice reforms in elderly care services. Especially in universal welfare systems like the Swedish one, where public provision has been seen as a means to ensure that all citizens have equal access to good quality care, policymakers should ponder the question of how choice reforms can be designed in order to reduce the risk that some elderly cannot effectively choose provider and thereby safeguard the quality of their care.

In this article, I ask how the policymakers who introduced the 2009 user choice reform in Swedish elderly care dealt with this tension between choice and older citizens’ equal access to good quality care. More precisely, I investigate how they envisioned quality to be ensured, what roles and responsibilities elderly care users and local authorities were expected to have in this process, and what these new roles mean for the notion of social citizenship of older people in Sweden. To investigate this, three research questions are addressed: (i) what role and responsibilities did the Swedish choice reform assign to the elderly care users and how did the policymakers view their ability to make an informed choice? (ii) How did the policymakers view the role and responsibilities of the local authorities and what tools were the local authorities given to ensure access to good quality elderly care for their residents? (iii) Can the new choice reform be said to contain a new notion of social citizenship for older people in Sweden? As such, the present study does not focus on the empirical effects of the choice reform. Rather, it investigates through what mechanisms the policymakers envisioned quality to be ensured and what this implies for the relationship between service users and the state.

Sweden is a particularly interesting case to study for two reasons. First, equal access to good quality care for all has long been an objective in Swedish elderly care. Perhaps more than in any other western country (outside of Scandinavia) the postwar Swedish welfare state was designed to ensure that older citizens, regardless of their family situation or ability to pay, have equal access to good quality elderly care (Anttonen 2002; Vabø and Szebehely 2012; Szebehely and Meagher 2018). To ensure these values, Swedish elderly care was funded and provided almost exclusively by the public sector. During the 1980s, however, this system was criticized for offering too little service flexibility. Since then, it has been a central policy goal to create more opportunity for privatization and user choice, especially among right-wing parties. In 2009, this process culminated in the enacting of a national legislation for user choice. At the same time, however, the values of universalism and social equality have remained strong in Sweden. Even the liberal-conservative government who introduced user choice stressed that the reform should not challenge the principles of public funding and equal access to care based on need (Government Bill 2008). Taken together, this implies that the Swedish policymakers should have been particularly concerned to balance choice with the objective of equality. Second, in terms of case selection, Sweden is considered a so-called ‘most-likely’ case. Given Sweden’s policy trajectory of heralding the values of universalism and social equality, Sweden can be seen as a country where it is most likely that the principle of user choice is problematized in relation to the right of elderly to receive care on equal conditions.

User choice and social citizenship

Theoretically, user choice is a model for social service delivery where service users are free to choose and re-choose among a multitude of public and private providers who are competing within a framework of public regulation and financing (Savas 2000; Le Grand 2007). As the theory proposes that providers be reimbursed based on how many users they attract, user choice creates no price competition but should rather be understood as a steering arrangement where providers compete through service quality and where their potential profit depends on them making their services more cost efficient (Le Grand 2007). As such, user choice is expected to strengthen the voices of users, increase efficiency in service provision, and to raise the general level of service quality.

The belief that user choice will lead to a general rise in service quality is based on the theoretical premise of a well-functioning market with active consumers. Service users are expected to use their right to choose and re-choose as a means to economically reward the best providers while at the same time punishing those providing low-quality services (Savas 2000; Le Grand 2007). From this perspective, it has been argued that user choice transfers regulatory power to the users, enabling them to pursue their interests while at the same time acting as a driving force for improving the quality of publicly funded services (Le Grand 2007; Hojlund 2009). Moreover, the theoretical assumption that users, acting as consumers, will enhance service quality through their choices, also requires that they actively choose the best service providers available (Dixon et al. 2010). The importance of informed decisions for user choice to positively affect quality has led to an extensive discussion about service users’ ability to evaluate different options, and whether all individuals can make informed choices (Eika 2010; Meinow et al. 2011). If not, critical scholars have argued that user choice not only leads to more autonomy for the individual user, but that it also risks undermining citizens’ equal access to welfare services, as their choices are likely to reflect social privileges such as education, income, and social class (Baxter, Glendinning, and Clarke 2008; Higgs 1998).

As user choice transfers regulatory power and responsibility to the individual users, scholars have argued that it also affects the role and the responsibilities of the state (Gilbert 2002). In a universal welfare system, public authorities are ultimately responsible for ensuring and developing service quality. However, since choice systems transfer part of this power to the service users, maintenance of quality becomes a shared responsibility between the state and the users, altering the tools through which the state can govern welfare services. This new notion of public governance has been formulated by Osborne and Gaebler (1992), who argued in favour of privatized provision and increased choice by claiming that the state should leave the direct planning and provision of welfare services to private sector contractors and limit their role to regulate and fund them; hence steering, not rowing. Moreover, it has also been argued that the state could act to ensure users access to quality care by facilitating their choice of provider. In the literature, access to relevant and reliable provider information is often stressed as one of the most important preconditions for facilitating choice (Hibbard and Peters 2003; Baxter, Glendinning, and Clarke 2008;). One possibility is thus that the state assumes responsibility for providing information about available providers and assists the users in accessing it, such as by interpreting and explaining its meaning (Siegrist 2006; Moberg, Blomqvist, and Winblad 2016).

Since user choice theoretically is expected to change the relationship between the state and the users of social services, it has also been asked whether choice reforms have the potential to transform the content of social rights, or citizenship, in contemporary welfare states. The term citizenship is not unequivocal but can be said to refer broadly to the legal status and the defined set of rights and obligations shared by those formally recognized to be citizens of a nation state (Pierson 2004). One theory that has been influential in shaping the understanding of citizenship in the post war welfare state is that of T.H. Marshall (1950). According to Marshall, there are three elements of citizenship: civil, political, and social. The civil and political elements are composed of individual rights and liberties such as freedom of speech, the right to own property, and the right to participate in the exercise of political power and in the process of shared decision-making. With the social element, Marshall refers to a whole range of rights from the ‘modicum of economic welfare and security to the right to share to the full in the social heritage and to live the life of a civilized being in accordance to the standards prevailing in society’ (Marshall 1950, 8). The social element of citizenship thus includes the rights necessary for all citizens to live a life of economic and social security, and is foremost created through institutions such as educational systems and social services (Marshall 1950). Owing to this, the element of social citizenship is related to the expansion of the modern welfare state, meaning that the range and content of social rights tends to differ between countries depending on how they have organized their welfare systems with regard to social security, redistributive benefits, cash entitlements and social services (Jenson 2012).

Marshall’s three elements of citizenship are interconnected in the sense that universal social rights equalize citizens’ opportunity to utilize their civil and political rights. As such, Marshall considered the expansion of universal social rights a precondition for a full and inclusive understanding of citizenship (Marshall 1950). At the same time, Marshall stressed that citizenship should not be treated merely as a set of state-provided rights, but as a relationship with rights and responsibilities for both citizens and the public. The right for universal education, for example, comes with the obligation of pupils to acquire the education and for adults to work and pay taxes (Marshall 1950). The social element of citizenship can hence be understood as the mutual rights and responsibilities held by the state and the citizens in the provision and allocation of welfare services. Pursuing this argument, it has been suggested that the content and transformation of social citizenship can be captured by analysing how specific policies change the balance of these rights and responsibilities, and under what conditions citizens become entitled to services and benefits (Gilbert 2012).

In the Nordic political setting, the understanding of social citizenship has been strongly associated with the specific welfare systems that were created in this area during the postwar era. In contrast to more liberal and conservative welfare regimes, the Nordic countries developed comprehensive and universalist systems of public welfare service provision that not only offered citizens access to education and healthcare, but also gave them equal access to social care services, such as elderly care (Anttonen 2002; Moberg 2017). By creating public systems for elderly care provision that were made available to all citizens, the Nordic countries extended the meaning of social citizenship, with the result that equal access to quality care was made a social right for all elderly. In contrast to more liberal and conservative welfare states, this came to mean that eligibility to publicly funded elderly care should rest on personal needs, rather than family structures or ability to pay (Anttonen 2002; Moberg 2017).

When choice models are implemented in welfare service systems based on universalism and direct public provision, scholars have argued that they, at least in theory, have the potential to change the content of social citizenship. The first implication of how choice policies could transform the content of social citizenship is that they, at least in part, tend to redefine citizens into consumers of welfare services (Clarke et al. 2007). As consumers of welfare services, the theory suggests that citizens should be free to choose and re-choose among a range of welfare services, including ones provided by private actors (Johansson and Hvinden 2012). To treat the utilization of social welfare foremost as a matter of consumption also implies that citizens’ right to welfare services is considered an individual rather than a collective right. Thus, it has been theorized that the creation of citizen-consumers implies that the concept of social citizenship is re-defined as a relationship between the state and the individual, rather than the state and the collective public (Clarke et al. 2007; Hojlund 2009). Moreover, seeing citizens as consumers of public services also implies that they have to be active, by making choices, to fully make use of their citizenship rights (Johansson and Hvinden 2012; Newman and Tonkens 2011).

The second implication of how choice could alter the content of social citizenship has to do with the individualized responsibility for service quality and one’s own well-being. According to Higgs (1998), this indicates that not only do citizens have to become more active to fully make use of their social rights; they also become responsible for the outcome of their choices, for example, if they select the ‘wrong’ provider, who offers poor quality service. Thus, choice implies more freedom for the individual citizen to choose a service provider that meets his or her individual preferences, but it also involves the risk of making bad choices (Higgs 1998). This argument has also been stressed by Rostgaard (2006), who argues that when citizens become more responsible for designing their own social welfare through user choice, they are also exposed to a higher degree of uncertainty involved in the risk of making bad choices.

In sum, it is apparent at least in theory that the introduction of user choice can alter the rights and responsibilities of service users and the state in the provision of welfare services, in such a way that it transforms the content of social citizenship (Newman and Tonkens 2011; Blomqvist 2013). Empirically, however, choice systems can be designed and implemented in different ways, implying that the new roles of service users and the state do not have to adhere to the theoretical model outlined above. As such, it remains an empirical question whether choice policies in universal welfare states like Sweden are designed in such a way that they actually change the conditions under which the elderly are expected to access good quality care and thereby change the notion of social rights for older citizens.

To study change in social citizenship

One way to study whether the content of social citizenship is affected by country-specific policy change is to employ the distinction between the socio-liberal, the libertarian, and the republican conceptions of citizenship (Miller 2000; Johansson and Hvinden 2005, 2012). The socio-liberal conception of citizenship implies that all members of a society should equally enjoy a minimum level of rights (such as economic security, care, and protection against risks) and in return fulfil legal duties and normative obligations vis-à-vis the state (Miller 2000; Johansson and Hvinden 2005). The exact content of the citizens’ rights and obligations may vary depending on, for example, the generosity of the welfare system. In general, however, the socio-liberal conception of citizenship can be understood as a relationship between the state and the citizens where the state undertakes the responsibility to provide a certain set of benefits and services, such as elderly care, to all citizens on equal conditions. In return, the citizens are expected to utilize the services offered by the state and to contribute to the welfare of society by paying taxes (Miller 2000; Johansson and Hvinden 2012).

In contrast, the libertarian conception of citizenship views the relationship between the state and the individual citizen more narrowly, with a stronger emphasis on the self-responsibility and autonomy of the individual (Johansson and Hvinden 2012). Apart from the state’s role to enforce basic personal and property rights, it is less obvious which services and goods should be provided by the state (Miller 2000). Rather, people should take more responsibility for their own well-being and protection against risks. To enforce this more individuated responsibility with regard to welfare services, the libertarian notion of citizenship stresses that individuals should enjoy consumer-sovereignty and greater scope for exercising individual choice and be treated as knowledgeable consumers in a mixed welfare market. (Johansson and Hvinden 2005, 2012). Thus, the role of the state is not necessarily to perform services but to enable a variety of providers that citizens can choose from (Johansson and Hvinden 2005, 2012).

Last, the republican notion of citizenship relates to the representation of citizens in the affairs of their community. It emphasizes that citizens are expected to identify with their community and that they should be committed to promoting its common good through active participation in its political and social life (Miller 2000; Johansson and Hvinden 2012). Republican citizenship can thereby be understood as the individual citizen’s duty to participate in deliberation and decision-making, as well as a notion of co-responsibility in relation to the provision of welfare services (Miller 2000; Johansson and Hvinden 2005, 2012). In that sense, citizens have the right and the duty to partake in the production of welfare services, and one of the most important tasks for the state is thus to enable arenas for citizens coproduction and user involvement. (Table 1) presents a summary of the three conceptions of citizenship and what role the state and welfare users are expected to play in the provision of social services.

Table 1. Three conceptions of citizenship and the expected roles of users and the state.

Conception of citizenship	Role of the citizen	Role of the state
Socio-liberal citizenship	Claim access to public welfare when in need and utilize the offered services. Contribute to the public system by paying taxes.	Provide good quality services to all citizens on equal conditions.
Libertarian citizenship	Choose a welfare provider of good quality that meets individual needs and preferences.	Enable a variation of welfare providers. Possibly secure a quality baseline.
Republican citizenship	Engage in the production of welfare services through deliberative decision-making and co-production.	Enable arenas for deliberation, co-production and user involvement.

The Swedish transition towards increased choice in elderly care

The modern Swedish welfare state, as it emerged in the postwar era, was designed not only to protect its citizens from income loss through relatively generous systems for social protection and income replacement, but also to create a comprehensive and universal system for providing public welfare services, such as health, education, and social care (Blomqvist 2004; Blomqvist and Palme 2020). The political idea behind the extensive system for social service provision was that the state should provide high-quality services that would meet the needs of all citizens, regardless of their ability to pay. By including all citizens in the public system for social services, it was not only expected that the legitimacy of the services would increase, but also that the citizens’ will to fund the services through income taxation would remain high (Rothstein 1998). In this way, the government saw the public service sector as contributing to the overarching political goal of social equality and re-distribution of risks and opportunity in society. This political logic implied that the social welfare services should be public, both with regard to their funding and their provision, and the state thus took on the role of provider (directly or through local authorities) of carefully planned services (Blomqvist 2004; Blomqvist and Palme 2020; Rothstein 1998). During the 1980s, however, criticism against the system increased, focusing foremost on the lack of economic efficiency, service flexibility, and user influence (Blomqvist and Rothstein 2000).

In response to this critique, various reforms aiming for economic efficiency, service diversity, and user involvement were implemented in the social service system. The first step in this direction was taken in 1992, when it became legal for local authorities to contract out the provision of health care and social care services, such as elderly care and childcare, to private actors, including for-profit firms (Blomqvist 2004; Government Bill 1992). The same year, the government also introduced a nationwide school voucher system, making it possible for parents and pupils to choose from a variety of public and private schools in the local school market. Since then, Swedish policymakers have continued to gradually expand the opportunity for privatized provision and user choice in the welfare service sector. Especially during the last decade, national choice reforms have been introduced on a broad scale in areas such as health and social care, making it possible for local authorities to create new markets for the provision of welfare services (Blomqvist 2013).

The trend towards increased choice and privatized provision has been particularly salient in Swedish elderly care (Erlandsson et al. 2013; Moberg 2017). The Swedish elderly care system is organized through the 290 local authorities, the so called municipalities, and financed through local income tax (70%), together with a smaller share of state grants (20%) and user fees (10%) (Blomqvist and Winblad 2020). The system is universal in that the services are available to all elderly citizens and permanent residents with an assessed need for care.

In Swedish elderly care, the opportunities for user choice have traditionally been few, and private alternatives to public provision highly marginalized. Until the early 1990s, Swedish elderly care was almost exclusively a public service, provided directly by the municipalities (Trydegård 2001; Blomqvist and Winblad 2020). Over the following decades, however, the share of private providers has grown steadily, and in 2018, 23% of home-care users and 19% of users of residential care received privately provided elderly care (The Association of Private Care Providers 2019).

Although it has been legally possible to contract out elderly care services since 1992, it was not until 2009 that the Swedish Parliament enacted national legislation on user choice. Through the so-called Act on Free Choice Systems (Lagen om valfrihetssystem), the government wanted to facilitate the implementation of user choice. Additionally, the act aimed to eliminate local differences with regard to how user choice until then had been organized, for example by making it mandatory for municipalities to offer a non-choice alternative for those users who did not want to exercise their right to choose (Erlandsson et al. 2013; Dunér, Bjälkebring, and Johansson 2019). Through the Act on Free Choice Systems (hereafter the Free Choice Act), the Swedish Parliament thus created a legal framework through which municipalities could implement user choice in their provision of elderly care. This framework meant that all private providers who met certain basic requirements would be made available to elderly care users and that the choices of the users thereafter should allocate resources within the system (Jordahl and Persson 2020; Moberg, Blomqvist, and Winblad 2016). The funding of the system, however, remained public and a maximum fee reform from 2002 caps the user fees, whose levels are regulated by the Social Service Act (Erlandsson et al. 2013). In this way, the local choice systems create competition between public and private providers, not based on price but on the preferences of the users. Public and private providers are thus integrated into the same publicly regulated system where they are treated equally in terms of regulation, opportunities for users to choose amongst them, and the conditions for financial reimbursement from public authorities (Moberg, Blomqvist, and Winblad 2016). The prime objectives behind the reform were to make it easier for private providers to establish on the publicly funded care market, to enhance user choice and control, and to improve service quality (Government Bill 2008).

It was not made mandatory for the municipalities to implement choice systems in their provision of elderly care, but those who do so must follow the regulations of the Free Choice Act. By 2019, approximately 159 of 290 municipalities had introduced user choice in home-based elderly care and 21 municipalities offered choice in their residential care for the elderly.

Method, materials and framework of analysis

The method used in this study is interpretive policy analysis, a systematic analysis of the content and design of political reforms in order to illuminate the underlying assumptions and values on which they rest. Interpretive policy analysis is based on the assumption that the construction and development of political reforms reveals political intentions and values, and that policy design thus conditions the implementation and effects of a specific reform (Blackmore and Lauder 2005).

In order to determine how the policymakers who designed the free choice act dealt with the tension between the values of choice and older citizens’ equal access to good quality elderly care, the analysis is structured around the three research questions posted in the beginning of this paper: (i) What role and responsibilities did the Swedish choice reform assign to the users and how did the policymakers view users’ ability to make an informed choice? (ii) How did the policymakers view the role and responsibilities of the local authorities and what tools were the local authorities given to ensure access to good quality elderly care for all citizens? (iii) Can the new choice reform be said to contain a new notion of social citizenship for older people in Sweden?

The main empirical materials used to answer these questions consist of the government bill that presented the Free Choice Act, and the Act itself (Government Bill 2008; SFS 2008:962). To address the question whether the choice reform contain a new notion of social citizenship for the elderly in Sweden, the Free Choice Act will be contrasted with the Swedish Social Service Act (SFS 2001:453). The Social Service Act (SSA) is the main framework legislation that regulates all social care services in Sweden and can thus be said to comprise the overarching understanding of social citizenship of elderly in Sweden. To assess whether the two legislations contain different notions of social citizenship, the comparison focuses on the conditions under which elderly can access good quality care. More specifically, it analyses what rights and responsibilities service users and the state are expected to have in the provision and allocation of elderly care services, according to the SSA and the Free Choice Act respectively.

To understand the underlying values of the SSA, which was introduced in 1982, the analysis also draws on the government bill introducing it (Government Bill 1979). Government bills often constitute the end-product in governments’ work to propose new legislation to the national parliament, and are preceded by commission inquiries and other preparatory work. While preparatory work can uncover important aspects of a policy process, they typically contain policy proposals not included in the final law proposition. In contrast, the bills constitute the documents in which governments’ arguments and political intentions of a specific reform change are elaborated. Since this paper focuses on how the content of social citizenship is manifested in national laws, the empirical material is limited to the legal acts and the bills preceding them. To include other preparatory work could impose validity problems, where assessments about the social citizenship of elderly might be based on policy proposals that never became law.

Whereas it only took the government approximately one year to prepare the government bill for user choice, the SSA was the product of an 11-year commission inquiry. The inquiry ran over four different governments – two social democratic, one centre, and one liberal government – and resulted in a government bill covering approximately 1500 pages. Since 1979, political support for the SSA has remained strong and the reasoning and assumptions expressed in the government bill from 1979 are still relevant for the governing of Swedish elderly care.

To structure the analysis of the empirical materials, an analytical framework was constructed in which the three overarching research questions were broken down into more specific questions (see Table 2). During the reading of the government bills and the acts, these questions were asked to the material in order to uncover how the policymakers envisioned the role and responsibility of elderly care users and the municipalities, and to assess whether the choice reform contained a new notion of social citizenship for older people in Sweden. In order to further clarify my interpretations of the empirical material, quotes will be presented throughout the analysis.

Table 2. Analytical framework.

Research question	Questions asked of the empirical material	Empirical material used
What role and responsibilities did the Swedish choice reform assign to the users and how did the policymakers view their ability to make an informed choice?	Did the reform allow elderly care users to choose and re-choose service provider? Did the policymakers consider users to use their choice as a means to safeguard individual preferences, or to steer overall quality levels? Under what conditions did the policymakers consider elderly care uses capable of making an active and informed choice of provider?	The Free Choice Act and the bill introducing it
How did the policymakers view the role and responsibilities of the municipalities and what tools were they given to ensure access to good quality elderly care for all citizens	Did the choice reform alter the municipal responsibility for ensuring quality of elderly care services? Through what governance tools did the policymakers expect municipalities to steer the supply and quality of elderly care providers? Did the policymakers expect municipalities to facilitate the choice of elderly care users?	The Free Choice Act and the bill introducing it
Can the new choice reform be said to contain a new notion of social citizenship for older people in Sweden?	Under what conditions should elderly citizens have access to publicly funded elderly care? How should older citizens’ need for care and assistance be met? How and by whom should the quality of elderly care services be ensured?	The Free Choice Act and the bill introducing it The Social Service Act and the bill introducing it

User choice and its implications for service users, local authorities, and the notion of social citizenship

The new role of elderly care users

One prominent way in which the policymakers of the Swedish choice reform aimed to alter the role of service users was to give them the right to choose their elderly care provider freely, rather than acting as passive receivers of publicly appointed care. The choices of the users should then be applied to reimburse providers, in most cases based on a pre-set formula which also considers the extent of their care needs (Government Bill 2008, 80–81). The choice reform thus implied that the users could exercise their right to choose as a means to reward the providers they perceived as the best (Government Bill 2008, 112). According to the policymakers, this would empower the users in relation to the local authorities, not only by allowing them to steer the supply of elderly care, but also to ‘define the meaning of good quality’ within the system as a whole (Government Bill 2008, 87).

By making users allocate financial resources amongst providers, the policymakers did not only expect users to safeguard their own preferences, but that the safeguarding of their preferences also would lead to increased quality within the elderly care system as a whole. Since the providers must attract customers to increase their revenues, the policymakers argued that increased consumer power on behalf of the users would make the providers improve their quality as a means to keep and attract new customers (Government Bill 2008, 21). Consistently describing a market logic, the reform bill portrayed the users primarily as customers of elderly care, expecting them to ‘exit’ one provider and ‘re-choose’ another if discontent. With users sending this kind of market signal, it was argued, care providers would respond to the risk of losing customers by tailoring their services to the needs and preferences of the elderly users:

One of the fundamental pillars in a choice system is the individual’s right to re-choose service provider if he or she so wishes. The right to re-choose means that the providers need to care about their users in order not to lose them as “customers” and thereby reduce their revenue. Since the supplier should have a reasonable interest in keeping their customers, the right to exit will thus ultimately lead to better service quality (Government Bill 2008, 94).

According to the Swedish policymakers, consumer power was expected to empower elderly care users, allowing them to affect the efficiency and quality development within the system. However, for user choice to improve service quality, it was stressed that the users have to be ‘rational’ and informed when choosing their provider:

A precondition for a system with user choice to have a positive impact on quality, user influence, and cost efficiency is that the user is given a real opportunity to choose provider. To choose requires that the user is given the opportunity to make rational choices based on their own needs and preferences. This requires accessible and comparable information about the options (Government Bill 2008, 90).

To summarize, the Swedish choice reform was designed to change the role of elderly care users in two ways. First, it transferred the right to allocate public resources between the providers from the municipalities to the individual users. Second, by exercising their right to choose and re-choose provider, the users are expected to reward the best performing providers and thereby safeguard their own preferences as well as define and increase the overall quality levels within the system. This implies that the choice reform not only advocates a new role for elderly care users by inducing them to make active choices, but also makes them indirectly responsible for ensuring and developing service quality.

The new role of local authorities

The most prominent way in which the policymakers of the Swedish choice reform aimed to alter the role of the local authorities was by turning them into contractors of elderly care services and giving them a new and uniform legal framework within which to organize the procurement of care services. Although local authorities had been able to contract out social services prior to the choice reform, the Free Choice Act stipulated that if they wanted to implement user choice, they were obliged to authorize all willing providers who met the establishment requirements. Furthermore, the Free Choice Act stressed that public providers should be governed on the same conditions as the private ones. This indicates a significant policy shift compared to the previous system, where municipalities not only governed elderly care services, but in most cases also provided them directly through their own organization.

/ … / in-house providers and external providers should be treated equally. This means that the contracting authority should, to the extent possible, give the in-house providers the same conditions and make the same demands that are being made on the private providers (Government Bill 2008, 62).

In addition, it was emphasized by the policymakers that it would remain a municipal responsibility to ensure that the providers comply with national laws and regulations (Government Bill 2008, 73). Although the policymakers wanted service users to have more control over elderly care quality, this implies that the municipalities are ultimately responsible to ensure that all elderly care is of good quality. According to the policymakers, the municipalities should meet this responsibility by formulating the requirements under which providers become authorized:

The basic principle in a choice system is that the individual user can choose their provider from a variety of municipally approved and contracted providers. The relationship between the contracting municipality and the providers is based on a civil agreement signed between the parties. Through the agreement, the municipality shall ensure that the individual users receive the kind of care and support that is specified in national laws and through the municipalities’ own establishment criteria (Government Bill 2008, 54f).

Furthermore, the Free Choice Act also stipulated that local authorities should facilitate older citizens’ choice of provider by offering them access to information about the available alternatives, thereby making it possible to compare providers. Moreover, the information should be customized to the individual needs of the elderly user, meaning that it should be available in different languages and adaptable to different forms of disabilities (Government Bill 2008, 145). There are two reasons why the information should be supplied by the municipalities rather than by the service providers themselves. First, it should be a municipal duty to provide information since the municipalities are ultimately responsible for the quality of publicly funded elderly care. Second, the policymakers stressed that ‘the services often are indispensable for the user, and that the choice of provider might have serious consequences for the individual’ (Government Bill 2008, 90). Since the choice of provider is so important for the individual users, the policymakers argued that normal marketing systems must be complemented with reliable and objective information (Government Bill 2008, 97). Based on these considerations, the policymakers stressed that the municipalities should be legally responsible to supply the users with objective, relevant, comparable, comprehensible, and accessible information regarding all providers available in the choice system (Government Bill 2008, 95). When required, municipalities should also mediate the written information verbally (Government Bill 2008, 91, 145).

Finally, the choice reform also changed the role of the local authorities by stressing their responsibility to evaluate and monitor the contracted services within the choice system, in effect to scrutinize whether the providers complied with their contractual agreements (Government Bill 2008, 80). Evaluating the provision of elderly care services was also a municipal responsibility prior to the choice reform. What changed, however, was that monitoring in a choice system should be based on contractual agreements, rather than service quality in general:

An important factor for a system with user choice to work / … / is that the monitoring and control of both private and in-house providers work well. The public agency is responsible for controlling that all requirements specified in the tender documents are met throughout the contract period. If they are not met, the agency shall take the necessary measures, and ultimately terminate the contract (Government Bill 2008, 153).

In sum, the choice reform was designed to change the role of local authorities in three ways. First, their main tool to govern the elderly care sector and secure service quality is through the process of public procurement and the entering of contracts with authorized providers. Second, to facilitate an informed choice of provider on behalf of the users, and thus equalize older citizens’ ability to choose a good quality provider, the municipalities have become responsible for supplying the users with information about the available providers. Third, the choice reform has also altered the municipalities’ ability to retrospectively control and evaluate the provision of elderly care. Rather than evaluating the general quality within the system, the choice reform requires that the municipalities should control whether the providers comply with their contractual agreement.

Does the new choice reform contain a new notion of social citizenship for the elderly?

As we have seen, the choice reform entailed new roles for both elderly care users and the local authorities. In this last section, I raise the question of whether these new roles were designed in such a way that the reform also can be said to contain a new notion of social citizenship for the elderly, that is, the conditions under which they can access good quality elderly care that meet their needs for care and assistance. To achieve this, the Free Choice Act will be contrasted with the Social Services Act (SSA), the framework legislation that regulates the provision of all social care services in Sweden.

The SSA states that the municipalities are responsible for ensuring that all older citizens have access to publicly funded elderly care services, and that they receive the care and support they need to ‘execute their daily living activities’ (Government Bill 1979, 182; SFS, 2001:453, 4 chap. 1§). The SSA also stipulates that municipalities should ensure that all publicly funded elderly care is of ‘good quality’ (SFS, 2001:453, 3 chap. 3§). Hence, the SSA sees elderly care provision as an obligation of the municipalities, with no indications of obligations of the users of being active in ensuring that their needs are met, or that the quality of their care is good. On the contrary, the SSA makes clear that it is the municipalities who should investigate the needs of the elderly population within their jurisdiction (SFS, 2001:453, 5 chap. 6§). In addition, the SSA stresses the municipal responsibility to plan the provision of elderly care so that ‘all elderly can live a dignified life and experience wellness’ (SFS, 2001:453, 5 chap. 4§). In sum, the SSA does not directly discuss the role of the citizens. If anything, citizens and elderly care users are considered receivers of care that the municipality assess them entitled to. The role of the municipalities presented in SSA, however, corresponds well to the socio-liberal understanding of citizenship, highlighting their obligation to fund and provide good quality elderly care for all older citizens in need of it.

When the Free Choice Act was introduced, an additional layer of legislation was added to the elderly care sector, in practice forcing the municipalities to comply with both. However, the Free Choice Act uses an altogether different language concerning the responsibilities of local authorities and care users. Rather than emphasizing the municipal responsibility to ensure that citizens have equal access to quality care, the Free Choice Act and the bill that introduced it stressed the importance of users being active in their choices so that the efficiency and quality of service provision could increase. In contrast to the SSA, the Free Choice Act can foremost be said to focus on how the users should act in order to ensure their access to quality care, indicating that emphasis has shifted from the municipal obligations to the users’ own responsibilities. Although the Free Choice Act did not formally alter the principle that the municipalities are ultimately responsible to ensure that all elderly care users have access to good quality care on equal conditions, their ability to do so altered. It is now through contracts, rather than direct steering through resource allocation and provision that they can guide and monitor care providers. Moreover, the Free Choice Act made it clear that it is the users who are expected to discriminate among the available providers in such a way that the quality of the services is ensured and even developed. In that sense, the Free Choice Act not only gives elderly care users consumer power, it also makes them more responsible for the quality of the services they receive.

Taken together, this implies that the Free Choice Act embodies a form of citizenship where citizens need to be more active and use their consumer power in order to realize their social rights. Moreover, the role of the local authorities has altered. Although the Choice reform does not change the municipalities’ formal responsibility to ensure good quality care, it is not through in-house provision but rather by enabling a variety of providers and by making comparable provider information available to the elderly care users that local authorities are expected to fulfil this obligation. Through the Free Choice Act, it thus increasingly becomes an individual responsibility of the service users to ensure that their chosen provider can meet their needs and that the quality of the services provided is good. Referring back to the threefold conception of citizenship presented by Johansson and Hvinden (2005, 2012) and Miller (2000), this suggests that the choice reform follows a more libertarian notion of citizenship, where citizens are considered self-sufficient enough to take on a greater responsibility for their own well-being and protect themselves against risks. In comparison, the SSA appears to embody a more socio-liberal understanding of citizenship, emphasizing the obligations that fall on the state (or local authorities). Thus, when the Free Choice Act complemented the SSA, the content of social citizenship for the elderly in Sweden became more libertarian. Paradoxically, however, the extent to which the social rights have become more libertarian appears to vary locally, as only about half of the municipalities have implemented the Free Choice Act.

Concluding discussion

The aim of this article has been to analyse the tension between the values of choice and older citizens’ equal access to good quality care under the 2009 user choice reform in Swedish elderly care. More precisely, the article asked how policymakers envisioned quality to be ensured through the new choice reform, what roles and responsibilities the service users and the municipalities were expected to have in this process, and what these new roles meant for the notion of social citizenship for older people in Sweden. With regard to the service users, the findings showed that the policymakers behind the Free Choice Act aimed for them to have a new and more active role in the provision of elderly care services, especially with regard to ensure service quality through their choices. By creating a system where the service users allocate public resources between competing providers through their choices, the policymakers provided them with the responsibility not only to choose a provider that could meet their individual preferences, but also to choose wisely so that the overall service quality within the system would improve. This new role, however, is only effective in local authorities that have chosen to implement the Free Choice Act. In the remaining municipalities, the responsibility for quality insurance still rests with the local authority, meaning that the users do not have the same individuated responsibility for their well-being, but also that they lack the right to influence their care by choosing or, if discontent, re-choose service provider.

With regard to the local authorities, the choice reform did not alter their legal responsibility for maintaining elderly care quality. Although the policymakers aimed for the users to become more active in the development and safeguarding of elderly care quality, the Free Choice Act emphasized that it is still a municipal responsibility to ensure that their elderly care services are of good quality. The results of this study show, however, that municipalities who introduce user choice are intended to use new governance tools to steer their elderly care sectors. Rather than directly providing elderly care services, the choice reform meant that the municipalities foremost should act as procurers by entering contracts with care providers and monitoring them afterwards. Moreover, they were expected to facilitate an informed choice of provider on behalf of the users by compiling timely and relevant quality information. Taken together, this suggests that the new role of municipalities focuses more on enabling citizens to steer and enhance service quality. As such, the policymakers behind the choice reform thus advocated a system where municipalities are less involved in the direct provision of elderly care and users become increasingly responsible themselves for ensuring that their needs are met.

With regard to the social citizenship of older people in need of care, the new relationship between the service users and the municipalities suggests that the Free Choice Act entails a more libertarian notion of social citizenship compared to the more socio-liberal citizenship ideas embodied by the SSA. According to this new and more libertarian understanding of social rights, elderly care users are considered more capable of taking on greater responsibility for their own well-being and for the overall quality of elderly care services. The greatest difference between the Free Choice Act and the SSA is thus in how they view the role of the local authorities, and in particular what responsibility the authorities should have for service quality. Whereas the SSA states that service quality should be ensured and developed by the municipalities, the Free Choice Act stresses that this foremost should be accomplished through the users’ choice of provider and that the municipalities should facilitate this by entering and monitoring contracts, and by providing the users with relevant information. Since the choice reform has not altered or removed the SSA, this implies that municipalities which have implemented user choice must apply both of these laws simultaneously. This dual regulation of elderly care raises the question whether municipalities have the ability to use the new governance tools as intended by the Swedish policymakers. If not, the municipalities might be faced with a tension between the organizational demands stipulated in the Free Choice Act and their legislative responsibility to ensure that all elderly in their geographical area have equal access to quality care.

According to previous research, it has proven inherently difficult to ensure service quality through the entering and monitoring of contracts, especially in services like elderly care (Blank and Eggink 2001). Since services typically are complex and need to be tailored to the individual needs of each user, it is difficult to formulate their exact content in advance. This makes it difficult for the contractors to specify what results the providers should achieve, and on what quality indicators their performance should be evaluated (Hart 2003; Van Slyke 2003; Brown, Potoski, and Van Slyke 2007). Moreover, empirical studies from local authorities in Sweden show that the difficulty in formulating monitorable contracts might lead to either vaguely formulated contracts, or to increased regulation since the contractors, in this case the municipalities, tend to regulate the provision and process of care, rather than its quality outcome (Isaksson, Blomqvist, and Winblad 2018). In contrast to contracted result criteria, process-specific contracts specify how services should be provided, suggesting that it becomes more difficult for the users to influence the supply and quality of elderly care services (Winblad, Mankell, and Olsson 2015a, 2015b). Moreover, empirical research suggests that it has been difficult for the municipalities to provide the users with adequate information about the available providers (Moberg, Blomqvist, and Winblad 2016). Taken together, these findings from previous research suggest that it is difficult for municipalities to use their new governance tool to ensure the objective with the SSA without impairing the right of the elderly to influence the supply and quality of service providers. Whether municipalities experience such a tension between the SSA and the Free Choice Act, however, is an empirical question that constitutes an important avenue for further research.

Finally, the results presented in this article have wider implications than for Sweden only. Although the desire to enhance choice on behalf elderly care users has been particularly salient in Sweden, the values of universalism and equality have remained strong. Thus, it is hard to believe that Swedish policymakers have been less concerned to balance choice with the value of equal access to good quality elderly care compared to their counterparts in other countries. Following this logic, it is a plausible conclusion that increased reliance on choice in other welfare states also tends to promote a more libertarian understanding of social citizenship. More in-depth studies comparing the choice reforms in the other Scandinavian countries, however, are called for. Given the design and scope of their welfare systems, these countries could also be regarded ‘most likely cases’ for balancing the values of choice and equity, suggesting that potential differences in their reform design could illuminate possible solutions for how to combine the ideal of equal access to good quality care with increased user choice.

Acknowledgments

I gratefully acknowledge financial support for the study from The Swedish Research Council for Health, Working Life and Welfare (Dnr: 2014-01381).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Swedish Research Council for Health, Working Life and Welfare [2014-01381].