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Choice as governance in community mental health services
Umeå University, Faculty of Social Sciences, Department of Social Work.ORCID iD: 0000-0001-9836-6446
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In 2009, the Act on Freedom of Choice Systems (SFS 2008:962) wasestablished in Sweden, and this enabled municipalities to organise services aschoice models. This thesis describes and analyses the implementation of afreedom of choice system within community mental health services. Daycentre services were in focus, and a case study was conducted of a majormunicipality that sought to be a “world-class city” in regard to citizens’ choice.The experiences of policy makers, managers, professionals, and participantswere explored in interviews, and documents on a national, municipal, and citydistrict level, as well as homepages of providers of community mental healthservices, were all part of the study and were analysed using content-analysismethods.

The results showed that the freedom of choice system aimed for two objectives– improvements at the individual level and financial efficiency. In practice,financial efficiency was experienced as the main objective. Increased varietyof services was aimed for by the competitive model, but such variety was notobserved. Instead, services tended to be more similar than specialised.Concerning new providers, they were characterised as committedprofessionals running companies with strained economies. Participantsaffected by the reform expressed anxiety and worries due to theunpredictability and uncertainty embedded in the competitive choice model.Choice within the system concerned where to go, whereas participantsemphasised a wish to be able to influence the choice aspects of who carriedout the service and how much time to attend the services.

The conclusion was that the freedom of choice system was implemented as atechnology of governance to increase financial efficiency of services.Individual choice was not experienced as increased in any aspect except forthe choice of where to go. Instead, freedom of choice actually appeared todecrease due to standardisation and hierarchical structures. Aspects that werefound to be relevant when designing freedom of choice systems aiming toincrease individual freedom of choice were to address predictability andcontinuity, to address sustainable financial premises, to analyse the predictedimpact of administrative systems that are to be used, and to avoid the use of“hidden goals” in the policy-making process.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 93 p.
Series
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 85
Keyword [en]
freedom of choice systems, community mental health services
National Category
Social Work
Identifiers
URN: urn:nbn:se:umu:diva-135018ISBN: 978-91-7601-718-0 (print)OAI: oai:DiVA.org:umu-135018DiVA: diva2:1095831
Public defence
2017-06-09, Hörsal D, Samhällsvetarhuset, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2017-05-19 Created: 2017-05-16 Last updated: 2017-05-18Bibliographically approved
List of papers
1. Frames for choice and market characteristics - a Swedish case study of community mental health services in change
Open this publication in new window or tab >>Frames for choice and market characteristics - a Swedish case study of community mental health services in change
2015 (English)In: Nordic Social Work Research, ISSN 2156-857X, E-ISSN 2156-8588, Vol. 5, no 3, 227-243 p., 1059772Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe and analyse structural frames for choice, as well as characteristics of a free-choice market, implemented in community mental health services in Sweden. Day centres were focused. A case study was conducted. Documents were collected and semi-structured interviews were conducted with twenty-eight agents involved in the implementation process. Content analysis of data showed that users’ freedom of choice was influenced by detailed regulation. Freedom of choice was extended, but it was also substantially reduced. The gain or loss of freedom of choice depended on which aspects of the system were emphasised. Features, which could be interpreted as paternalistic, were once again structurally embedded, despite a system addressing individual freedom of choice. Further, the market did not seem to be adjusted for the average user of community mental health services.

Keyword
social policy, mental health, organisation, choice, quasi-market
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-119914 (URN)10.1080/2156857X.2015.1059772 (DOI)
Available from: 2016-05-02 Created: 2016-05-02 Last updated: 2017-05-16Bibliographically approved
2. Freedom of choice or cost efficiency?: the implementation of a free-choice market system in community mental health services in Sweden
Open this publication in new window or tab >>Freedom of choice or cost efficiency?: the implementation of a free-choice market system in community mental health services in Sweden
2016 (English)In: Scandinavian Journal of Disability Research, ISSN 1501-7419, E-ISSN 1745-3011, Vol. 18, no 2, 129-141 p.Article in journal (Refereed) Published
Abstract [en]

This case study investigates the implementation of a free-choice market system in community mental health services using the example of day centres for people with psychiatric disabilities. It was conducted in a major city that was about to implement a free-choice market system due to a new legislation that made it feasible. Eighteen semi-structured interviews were conducted. Agents situated in different parts of the organization were interviewed one year before and two years after the free-choice system was launched in 2010. Data showed a top–down political process. A majority of the intentions of the legislation advocated individual autonomy as the market system's main purpose; only one concerned organizational efficiency. Data reflected, however, that financial efficiency dominated the agents' experiences of the implemented system. The twofold market purpose was clearly reflected in the interviews. Front-line staff hoped for improvements mainly for the users, whereas managers mainly focused on the market as a resource allocator.

Keyword
community mental health, free-choice market system, implementation
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-95156 (URN)10.1080/15017419.2014.995220 (DOI)000377393000004 ()
Projects
Daglig sysselsättning för personer med psykisk funktionsnedsättnintg. En studie om verksamhetsområdets karaktär och om reformers påverkan.
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0142
Available from: 2014-10-23 Created: 2014-10-23 Last updated: 2017-05-16Bibliographically approved
3. Implementation of choice from participants' perspectives: a study of community mental healthcare reform in Sweden
Open this publication in new window or tab >>Implementation of choice from participants' perspectives: a study of community mental healthcare reform in Sweden
2016 (English)In: Journal of Social Work in Disability & Rehabilitation, ISSN 1536-710X, E-ISSN 1536-7118, Vol. 15, no 2, 116-133 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to explore participants' experiences and opinions about a free-choice system in relation to policy objectives articulated by the national government and local authorities. A case study was conducted. Thirty-five informants participated. Qualitative interviews were undertaken. Results are discussed on how to address different dimensions of choice, not only where, but also what, by whom, how much, and when. They also concern how to design systems that in some ways ensure predictability and continuity to avoid unwanted harm caused by the unpredictability embedded in competitive choice systems. Finally, different aspects of quality need to be addressed.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2016
Keyword
Choice, community mental health, community mental health reform, day center, free-choice system, implementation, participants' perspectives, qualitative research
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-119917 (URN)10.1080/1536710X.2016.1162121 (DOI)000387348100003 ()26959298 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0142
Available from: 2016-05-02 Created: 2016-05-02 Last updated: 2017-05-18Bibliographically approved
4. Competing Logics and Idealistic Professionalism: Development of a Swedish Community Mental Health Serivce Market
Open this publication in new window or tab >>Competing Logics and Idealistic Professionalism: Development of a Swedish Community Mental Health Serivce Market
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The aim of this study was to explore the longitudinal development of an organisational fieldafter the implementation of a freedom-of-choice system in terms of the range and characteristicsof providers and services as well as the dynamics and professionalism that appeared as a resultof these changes. Our findings suggest that the expected effects of the reform in terms of varietyof providers and services within the organizational field did not materialise due to a lack ofmarket competition. Providers complemented each other rather than competed with each other,and the logics of care, choice, and advocacy challenged each other within the quasi-market. Allinformants described financial conditions in the market as extremely strained. Strong personalcommitment characterized providers entering and exiting the market, and this strongcommitment suggests a nuanced professionalism we refer to as idealistic professionalism. Agap was found between policy goals and experiences among stakeholders, and efficiency wasfound to be the policy goal achieved most often in practice. This raises the questions of howthe Swedish community mental health service market will develop in the future and what theimplications are for the participants.

Keyword
community nmental health service market, development, logics, professionalism
National Category
Social Sciences
Identifiers
urn:nbn:se:umu:diva-135017 (URN)
Available from: 2017-05-16 Created: 2017-05-16 Last updated: 2017-05-18

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