This blog is based on article in the Journal of Social Policy. Click here to access the article.
The importance of service-user participation has been growing in the care services, but what possibilities do service users have to influence them? How the users are able to exert an influence in practice will to a certain degree be decided by the relation between the user and the care workers. However, this relationship takes place within certain structures that constitute the framework for how the user influence can be expressed and what the users may influence. In the service-delivery process, there are different structural factors that affect the users’ possibilities for influence.
In Norway, municipalities have full responsibility for the provision of both institutions and home-based care services for inhabitants. Municipalities have extensive autonomy in how they meet their obligations to provide welfare services. Even though there are several laws regulating user participation in municipal care services, in practice there is considerable latitude concerning user influence at the local level. The article has its basis in a study of municipal care services for adults, comprising home-based services (home help and home nursing), nursing homes and care services for people with intellectual disabilities. The dataset consists of interviews with managers at different levels of these areas of services, and it is the managers’ experiences and considerations that have been studied. The research question asked is as follows: how do the managers consider user influence, and how do structural factors in different care services affect the possibilities for user influence?
Structural factors are discussed in relation to different user typologies: the traditional understanding of the user as a receiver of services (client), the market-oriented understanding of the user as a customer and the understanding of user as co-producer of services. An essential component in a user-oriented perspective is that the services ought to be individually adjusted. It is important to distinguish between two aspects of individual adjustment of services. The first aspect concerns individual adjustment based on what the service user wants, namely, user influence. The second aspect covers what the user needs, which is based on a professional assessment of what the user can do him- or herself and what assistance the user requires. The exercise of professional discretion includes both the ‘wants’ and ‘needs’ aspects. When the users are understood as clients, one can expect more paternalism and emphases on professional discretion, a focus on ‘needs’ over ‘wants’, and a standardisation of services and influence through ‘voice’. In the customer perspective, influence through ‘choice’ will be important, ‘wants’ overshadow ‘needs’, and there will be a reduction of professional discretion. The view of the user as co-producer will emphasise influence through dialogue, a mix of ‘needs’ and ‘wants’, power sharing between users and professionals and expectations that the users will take an active part in the delivery of services.
The study analyses user influence as an important aspect of individual adjustment of services in the municipal care sector. When the managers speak in general terms, they claim the services have been more individualised and user influence has increased over time. However, a critical analysis of the actual stages and elements in the service-delivery process has revealed structural factors that contribute to a limitation of the individual adjustment of services. Established structures and frameworks determine users’ opportunities to influence the service-delivery process. I have developed the phrase ‘the scope of possibilities for user influence’ in order to characterise the latitude that established structures have for the users’ possibilities to exercise their influence on allocation and provision. The most important restrictive factors are the existing set of choices of municipal services, the service structure, how the individual decisions of services are formulated, the standardisation of services, the increasing time pressure as well as the work routines and patterns of practice and the care workers’ norms. In the short run, these elements will appear as stable, even though there might be room for actors to challenge the frames or to exercise discretion within the frames. In the long run, changes of the structures will be possible if municipal politicians have the will to change them.
The article also contributes to a further understanding of the relationship between the different typologies of the service users and the structural features. Even though we find elements from different user typologies, the conclusion is that the understanding of the user as a client is dominant. There seems to be a growing understanding of the user as co-producer, while the customer perspective is of marginal importance. These findings indicate that the Norwegian welfare system differ from the development of marketisation which has been the case in many other European countries.
About the author
Jan Andersen is Associate Professor at the Inland Norway University of Applied Sciences.