Introduction
This article focuses on user participation in welfare policies in Norway. It represents the first analysis looking at three user groups simultaneously. The analysis is based on data sources consisting of national documents; such data sources have to a large extent previously been neglected. Furthermore, the article's policy analysis has a historical perspective: we analyse how user participation has been constructed in public documents over the last 50 years.
Norway is a small northern European country with particular characteristics that affect how user participation policies manifest themselves in welfare services. Our discussion relates to social care services. These are funded and governed by state policy, but carried out in more than 400 relatively autonomous municipalities varying greatly in size and organisational models. Norwegian welfare policies are strongly influenced by social democratic politics with an emphasis on corporatism, a negotiating state, strong traditions of democracy, low levels of conflict on a societal level, and high ideals of equal opportunity for, amongst others, minority groups. Esping-Andersen, when pointing at the social democratic welfare regime, says that ‘This regime is virtually synonymous with the Nordic countries . . . Besides universalism; the social democratic welfare state is particularly committed to comprehensive risk coverage, generous benefit levels, and egalitarianism’ (Esping-Andersen, Reference Esping-Andersen1999: 78).
User participation has received attention in welfare policy over several decades. The concept first appeared in the 1970s (Barnes and Cotterell, Reference Barnes, Cotterell, Barnes and Cotterell2012; Beresford, Reference Beresford, Beresford and Carr2012). However, it was in the 1990s that user participation had its breakthrough and moved from ‘margin to mainstream’ (Barnes and Cotterell, Reference Barnes, Cotterell, Barnes and Cotterell2012: xv). Welfare politics concern the daily welfare practices being carried out in local settings by employees who engage with people using services directly, called ‘street-level bureaucrats’ (Lipsky, Reference Lipsky1980). Yet national policy documents are the basis for this daily practice, and its direction. The aim here is to report the findings of an analysis of such documents. This is important, because the policies presented in these documents impact on practice, although this practice is not part of the article's discussion.
Our analysis distinguishes between three different groups of service users: older people, disabled people, and people with mental health problems. These groups are chosen because they are key target groups of the social welfare policies.
Our methods for studying discourses are inspired by Bacchi's discourse analytical approach (Bacchi, Reference Bacchi1999). This ‘asks’ the documents what the presenting problems are, instead of focusing on the proposed solutions. By critically addressing problem construction, the various assumptions and preconditions of policies can be identified.
In the following sections we interrogate the history of user participation to account for the multiple discourses of user participation in a Norwegian welfare context. We outline the choice of a critical discourse analysis as our methodological approach before presenting the empirical findings from documents related to the three user groups.
User participation discourses
When the concept ‘user participation’ first appeared in public policy documents in the United Kingdom (UK) and United States (US), it was related to public planning and the development of local communities: ‘The modern history of participation really begins with those providing for public participation in planning’ (Beresford, Reference Beresford, Beresford and Carr2012:23). Participation primarily took place through representative bodies where the public could exert influence. In other words, this was representation at a system level. Barnes and Cotterell (Reference Barnes, Cotterell, Barnes and Cotterell2012: xv) note the first statutory recognition of user/patient participation in the UK welfare sector in 1974 with the establishment of Community Health Councils to safeguard patient interests in the NHS.
When the concept entered social welfare sectors of Europe in the 1990s, a change of perspective occurred as, simultaneously, participation became increasingly individualised. The focus was on individuals’ rights and opportunities to influence their own care services.
The literature often maintains a distinction between two different discourses on user participation: a ‘democratic’ or ‘rights-oriented’ one on one hand and a ‘consumer-oriented’ on the other (e.g. Braye, Reference Braye, Kemshall and Littlechild2000; Harrison et al., Reference Harrison, Dowswell and Milewa2002).
The democracy/rights discourse springs from the right of individuals to control their own lives, as full citizens in society. User participation becomes both a goal per se, for recognising users' citizen status, and a means to achieving this goal. In other words, such a perspective is valid beyond influence over service provision. It is about influence on policy development, resource allocation and governance.
The democratic/social rights discourse is tied to individual citizenship (Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007; Harrison et al., Reference Harrison, Dowswell and Milewa2002). The concept ‘citizen’ is interpreted in different ways, but it is fundamentally tied to the rights and duties of the individual in society. The emphasis on citizenship in the social welfare field has largely been based on the concept ‘social citizenship’ developed by Thomas H. Marshall in the 1950s (Marshall, Reference Marshall1992). This concept includes the individual's right to economic security and prosperity and to live in accordance with prevailing standards of society. Harrison et al. (Reference Harrison, Dowswell and Milewa2002) point out that this discussion later also emphasised citizens' duty to ‘take part in constructing and maintaining the community’ (p. 64). Citizens have not only a democratic right but also a duty to participate in society (Heater, Reference Heater1999).
In the consumer discourse the individual user as a consumer of services is the focus (e.g. Braye, Reference Braye, Kemshall and Littlechild2000; Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007). This discourse is based on a view of users as competent, rational actors with the right to choose service providers within a service market. Participation is here limited to the service level, i.e. how services can best be adapted to users’ needs as consumers. The aim is to make the services more flexible, choice based, relevant, and better adapted to the users' needs and desires. User participation is primarily a means for achieving such goals.
Both the democracy discourse and the consumer discourse focus on how user participation will provide qualitatively better services, but they have different approaches (Alm Andreassen, Reference Alm Andreassen2004). While a democracy discourse primarily emphasises users’ constructive contributions to public decisions regarding policy and service development, the consumer perspective is primarily concerned with how services can become more efficient and better suited to the individual.
The international research literature stresses that the consumer discourse has been on the rise since the 1980s as part of a neoliberal development of welfare policies (Barnes and Cotterell, Reference Barnes, Cotterell, Barnes and Cotterell2012; Beresford, Reference Beresford, Beresford and Carr2012; MacGregor, Reference MacGregor1999; Western et al., Reference Western, Baxter, Pakulski, Tranter, Western, van Egmond, Chesters, Hosking, O'Flaherty and van Gellecum2007). However, some argue that in practice the democracy and consumer discourses often operate interchangeably. Beresford (Reference Beresford, Beresford and Carr2012: 26) highlights the fundamental ideological divides between discourses, but acknowledges that ‘the gulf [between them] often [has] been blurred by their shared reliance on the common language of participation and involvement.’
In recent years, user participation has included a co-production discourse. ‘Co-production’ is referred to as an important element in both the Clinton and Obama administrations’ welfare policies in the US (Alford, Reference Alford2009). In a European context co-production in different wrappings is seen as a leading concept in welfare production (Pestoff, Reference Pestoff, Pestoff, Brandsen and Verschuere2012). In the UK, co-production has been a theme in welfare policy throughout changing governments since New Labour developed the concept in 2007 (Carr, Reference Carr, Beresford and Carr2012). Originally, co-production between service providers and service users was the focus. Later, it was expanded to include relatives, NGOs and civil society as key actors in the co-production of services (Pestoff, Reference Pestoff, Pestoff, Brandsen and Verschuere2012; Realpe and Wallace, Reference Realpe and Wallace2010).
The co-production perspective emerges in opposition to both a traditional, hierarchical active service provider/passive user recipient model, and a market model in which the user's role is limited to being a consumer of services (Hunter and Ritchie, Reference Hunter and Ritchie2007; Pestoff, Reference Pestoff2006). The users are seen as equal partners: citizens with the right to influence their services (representing also a democracy dimension) and with resources and competence that can improve services (representing also a consumer dimension). At the same time, duty and responsibility in the role as a (participating) citizen are emphasised. Users and professionals are sometimes presented as having complementary competences (Bovaird and Löffler, Reference Bovaird, Löffler, Pestoff, Brandsen and Verschuere2012; Realpe and Wallace, Reference Realpe and Wallace2010). By entering relationships promoting co-production users, in theory, get both qualitatively better and more democratic services.
User participation in the Norwegian context
In the 1990s a user participation concept was increasingly articulated in public documents related to social welfare policies. Earlier, the main focus lay elsewhere. The White Paper St. Meld. 25 (2005–2006) divides the development of the post-war welfare state period into four phases: The first three are characterised by the establishment of the welfare state, the expansion of the welfare state, and municipalisation of the welfare services. It is during the final period from the mid-1990s, characterised by renewal and efficiency, that the concept of user participation receives attention.
Even though other issues were more prominent in the earlier phases, this does not mean there was no user focus. St. Meld. 25 (2005–2006) detects a change from the 1970s in ideology and values towards user groups' rights. Concepts other than user participation were used during this period, e.g. ‘co-determination’ and ‘influence’. Alm Andreassen (Reference Alm Andreassen2004) compares this development to the rise of workers’ rights to influence matters concerning them. She notes that the importance of user experiences received political support and a particular shape in Norway due to its tradition of a negotiating state and political ambitions of democratisation. Specifically, participation should take place via interest organisations, representation on boards and committees, and comments on public consultation papers. In other words, participation at the system level is important, and the corporatist arrangements from work life and industry are expanded into a ‘general corporatism in public administration’ (Alm Andreassen Reference Alm Andreassen2004: 89, our translation).
When user influence received greater emphasis in Norwegian welfare policies this was also influenced by international trends. These included new social movements, such as the women's movement and civil rights movement, emerging among people developing a collective identity to mobilise resistance against what they perceived as injustice and oppression (Skrentny, Reference Skrentny2002). In the social welfare field this trend was particularly evident among disabled people and people with mental health problems. The movements represented special interest organisations promoting justice and equality (Alm Andreassen, Reference Alm Andreassen and Norvoll2013; Froestad and Ravneberg, Reference Froestad and Ravneberg1991).
Throughout the 1980s an ideological shift in welfare policy regarding the relationship between service users and the public production of services occurred in Norway. The public sector was regarded as costly, unwieldy, inefficient and paternalistic. Growing demands for modernisation, renewal and rationalisation emerged. An important influence came from ‘New Public Management’ thinking (NPM). This was inspired by the private sector and emphasised a market orientation that viewed service users as customers (Klausen and Ståhlberg, Reference Klausen and Ståhlberg1998; Ramsdal and Skorstad, Reference Ramsdal and Skorstad2004). The role of public administration as a service producer came more to the fore, and user orientation became individualised. Movement from influence towards participation in the implementation of service production took place. In other words, user participation is now focussed at the individual level.
Alm Andreassen (Reference Alm Andreassen and Norvoll2013: 308) argues that the consumer orientation in Norway should not simply be understood in the light of market orientation inspired by NPM thinking. User orientation in this perspective was not about making the state a ‘supermarket state’ but rather an attempt to make the state more ‘responsive’ in terms of listening to users and understandings their needs. One might say that this constitutes a type of social democratic response to NPM thinking, taking into account the importance of social democracy in the development of Norwegian welfare policies. Consumer thinking can thus not only be construed as marketisation/customerisation, but includes also a democratic aspect.
The shift towards an individual-based orientation did not imply that the emphasis on co-determination and influence at the system level ceased. Corporatist thinking continued and became institutionalised in the coming decades. This took place by establishing statutory user councils or committees at both the municipal and other service delivery levels (e.g. hospitals).
Corresponding to international developments, a co-production discourse has increasingly left its mark on welfare policies in Norway in recent years. Political recognition came in the Official Norwegian Report Innovation in Care (NOU 2011: 11), and co-production has since been a fundamental perspective in public documents related to social care. The mobilisation of interconnected resources between public services and users, family, networks and communities is advocated. Through such an initiative ‘new relations between users, relatives, employees in the sector concerned, experts and other relevant stakeholders’ (NOU 2011: 11, p.56, our translation) are expected to develop. At the same time, the individual's responsibility to participate actively in his/her community is emphasised.
Though new understandings of participation have appeared, this does not mean that the ‘old’ have disappeared. Within Norwegian welfare policy, understandings and justifications of participation with different ideological roots operate interchangeably, although the centre of gravity shifts (Alm Andreassen, Reference Alm Andreassen2004). In summary, different approaches to user participation compete for hegemony from the 1990s onwards.
A critical discourse analytical approach to policy documents
Discourses can be defined as particular ways to talk about and understand the world, or a section of the world (Jørgensen and Phillips, Reference Jørgensen and Phillips1999: 9). Discourses not only reflect social events or social relations: they construct and constitute them (Fairclough, Reference Fairclough1992). Policy documents as governance tools occur in a specific social and historical context, and are produced by various discursive practices (Bacchi, Reference Bacchi1999). By critically analysing policy documents, dominant and subordinate discourses and various control mechanisms may be uncovered (Bacchi, Reference Bacchi1999). Discourse analysis can thus be a tool to gain insight into the relationship between policy texts and their relation to the social structure and political system. Such analysis may shed light on how different groups in society have unequal influence or attention as expressed in the authorities’ texts (Ulleberg, Reference Ulleberg2007).
A common belief is that the aim of policy formulation is to solve specific problems in society. Politics are manifested in policy documents such as reports, White Papers or Bills and Acts. Bacchi (Reference Bacchi1999) suggests that instead of looking at the corrective measures presented, one should pose the question: what are the documents addressing as ‘the problem’. ‘The problems’ as they appear in policy proposals are made explicit or implicit through their proposed solutions. In other words, proposed actions indicate what one thinks must be changed through the policy proposals. In this way, the problem's understanding is made part of policy formulation. By asking critical questions about what the problem represents, various preconditions and assumptions behind the policy can be identified.
User participation discourses in public documents
Our discourse analysis focuses on selected texts produced between the latter half of the 1960s and 2013. The documents are White Papers, reports and action plans. They are texts commissioned by the government and important because they include suggestions for future policies in the fields they concern. Our document selection for the three target groups are based on two criteria. One is that they should represent the most politically influential documents over a period of time leading up to the present. The other is that they should be as explicitly as possible directed at the respective user groups. The analysis of such a variety of texts over time makes it possible to detect changes in the problem representations related to users and user participation. This includes both continuity and change.
Older people
In the oldest documents (see Table 1, A1), the main problem is presented as a risk of social disintegration. The documents describe how the attitudes towards older people have evolved: from a society that once needed older people to take care of the transmission of traditions, to a society where they are left out and must be helped by family or society. Such a situation is now challenged:
Old age was previously perceived as a passive life phase, where one should rest and take it easy. Now it is believed that this life phase too should be as active as possible, for both body and soul. (Proposal I, 1966: 12, our translation).
Overview of selected national documents directed at the three user groups:
User participation is not yet a concept that has entered the welfare political vocabulary. It is a lack of integration of older people as citizens that is presented as the problem. In the policy documents (Table 1, A1) the cause of this passivity and disintegration is particularly related to institutional care.
One must face that institutional care could entail drawbacks for older people and can contribute to making them deteriorate faster than would otherwise happen. The older person is torn away from [his/her] former environment, and placed in an institution along with other frail older people, and to a great extent loses connection with life outside the institution . . . (St. Meld. 59 (1967–68): 3, our translation)
However, in these documents it is still acknowledged that, for some older people, institutional care is unavoidable because ‘many older people will be too frail to live at home’ (Proposal II 1969: 10). Also, the argument for participation through corporatist representation is advocated for older people in institutional care. Creating conditions for ‘democracy in older people's homes’ (St. Meld. 22 (1975–76): 68, our translation), and providing ‘the pensioners with real opportunity to be involved in the decisions concerning the institution’ (St. Meld. 22 (1975–76): 68), point to the potential of establishing cooperative councils in older people's institutions. Although many of the older people are frail, they are acknowledged as citizens entitled to the opportunity for real co-determination.
In The Action Plan for Eldercare from the late 1990s (see Table 1, B1) the problem presented now concerns older people as individuals who do not have the option of choosing to stay at home for as long as possible or receive adapted accommodation if this is what they need (St. Meld. 50 (1996–97): 25). This Action Plan focuses on the development of social welfare services aimed at older people to accommodate their right to choose how they will be cared for in old age. Whereas ‘user participation’ appears just twice, ‘co-determination’ is highlighted several times. Mostly this involves ensuring that older people are able to make informed choices regarding their services. However, because the freedom of choice for future cohorts of older people may be curtailed due to a lack of expansion of care services, the cause of the problem is presented as a resource problem tied to services and housing. This is what the Action Plan is meant to address.
Tomorrow's Care is the title of a White Paper from 2012–13 (see Table 1, C1) that is not primarily concerned with older people's care but, due to this group's majority position in social care services, the situation for older people plays a central role. The problem presented in 2012/13 is that the Norwegian society faces a new generation which has resources that are as yet unexploited. The White Paper presents future older people as ‘the new generation of older people’.
The new generation of older people live longer due to better health, and they face old age with entirely different resources than previous generations. The new generation of older people have higher levels of education as well as a better economic situation, living conditions and functional ability than any previous generation of older people. They are also more used to technology and want to make more decisions on their own (p. 11, our translation).
It is thus expected that they manage the problems and health challenges of old age differently from previous generations. Instead of looking at the increasing aging population as a problem for the welfare services, the White Paper presents this as a possibility.
User participation and user control are concepts that play a pivotal role in this White Paper. The underlying policy is partly to enhance the quality of services and partly to increase the power of users. The White Paper marks a separation between user participation and user control. For older people user participation emerges as desirable, but it is explicitly underlined that the user's influence is limited because the service provider has professional expertise. Therefore, ‘[t]he quality of service . . . [is created] through the dialogue between user and service provider by which user knowledge balances expert knowledge’ (Meld. St. 29 (2012–2013): 53–54, our translation).
When it comes to user-controlled schemes, the White Paper highlights that their realisations have primarily been fought for by (younger) disabled people, but that it does not seem unlikely that the future generation of older people can achieve such control: ‘There is reason to assume that they (disabled people) will eventually be joined by the new generation of older people who have other resources to meet old age and will not accept being side lined’ (p. 53, our translation). This can be interpreted as a counterweight to today's older people, where the presented problem is that they are not sufficiently competent and lack the resources to control their services. They can have forms of user participation, but service providers should take professional responsibility for services.
While user participation as a rhetorical strategy is central in this White Paper, user participation is related clearly to co-responsibility; older people are responsible for their old age themselves and must actively participate in the development of social welfare services upon which they may, at some point, rely.
The expectation of responsibility is portrayed almost as an obligation to be active and participate. Society will ‘not accept that senior life should be lived secluded from societal obligations and responsibilities’ (Meld. St. 29 (2012–2013): 56, our translation). It will be important for a future old age policy therefore to facilitate society in such a way that the new senior population can participate in it and use their resources.
In summary, user participation in the field of older people is tied to a democracy discourse where older people are portrayed as citizens in terms of being members of society. A movement from separation to integration is discerned, and even in the early documents of this period the focus is on the active, participatory citizen These are fundamental perspectives in the policy documents which continue throughout the period. But at the same time as the citizen perspective persists in the 1990s, a consumer perspective emerges. The right to choose becomes more important, particularly in terms of living arrangements, but also in terms of services. A common feature of the discourses, though, is that demands are directed at the welfare state's public services, requiring them to facilitate the option for users to participate and have influence. In the 2010s, a clear change in the discourse occurs. The focus is now primarily directed towards the coming generations of older people. They are presented as far more competent and resourceful than current older people, which helps make them able to control their services to a greater extent. Moreover, the responsibility/duty dimension clearly enters the stage. Focus is directed towards individual resources, duty, and responsibility to prevent health problems and to relieve demand on services. This chimes with Heater's (Reference Heater1999) understanding of citizenship emphasising individual rights as well as obligations. Future older people become a key group in the co-production discourse as presented in the White Paper Meld. St. 29 (2012–2013).
Disabled people
In the 1960s and 70s the literature reveals increasing awareness of rights and resources among disabled people. Two White Papers constitute the basis for the analysis of this early period (see Table 1, A2). A dominating view of disabled people as a social group not being able to assert their interests in society is presented as a main problem. This is due to a medical view of disability as a defect of the individual. Consequently, disabled people are marginalised from ordinary society. The White Papers argue that disabled people should be entitled to the same standard of living as others and that unnecessary distinctions between disabled people and others should be avoided. ‘Normalization’ is introduced as an aim for disabled people's living conditions in order for them to access general services.
White Paper 23 (1977–1978) defines disability as an interaction between the individual and society. Influence and co-determination rights are thematised for the first time, coinciding with the first application of the concept of ‘user’.
Disability organisations are presented as important stakeholders in the creation of co-determination:
The organizations should in principle act as social policy pressure organizations. Today there is agreement that the ‘user groups’ themselves have a right to influence their situation, and that they in a number of areas are the most competent in pointing out needs and deficiencies, and proposing adequate solutions (White Paper 23, p. 15, our translation).
The White Paper expresses awareness about disabled people as a social group with common experiences and interests (Young, Reference Young1990). The solution proposed is that disability organisations will participate at the system level to contribute to the development of policies.
The 1990s are dominated by three action plans for disabled people (see Table 1, B2). User participation is employed for the first time as a concept in the plan for 1990–1993. The problem is presented as disabled people's lack of participation in decision processes concerning them. The plan highlights that ‘only when disabled people's interests are respected in the decision making process as for non-disabled people can we expect to get a policy that takes into account the rights and needs of disabled people’ (p. 24, our translation).
Simultaneously as the system perspective is maintained, the individual perspective becomes more prominent in the Action Plan from 1994–1997. Here, the lack of user participation at the individual level emerges as a theme for the first time. It is emphasised that individuals who rely on public services can have their say about what is desirable and in what form. In the 1990s user participation gains such a pivotal role that training in user participation is among the new priority areas in the action plan period. Projects are initiated to teach government agency staff and politicians how conditions should be facilitated to ensure disabled people's participation in democratic processes (p. 50).
In the Action Plan 1998–2001 disabled people as a resource enters more strongly. This plan underlines the importance of disabled people influencing decision makers and service providers with their experience-based knowledge, thereby making the services qualitatively better. Throughout the 1990s, the problem is presented as being that public services are not well adapted to the individual's needs. User participation is meant to ensure the transfer of experience to improve the quality of services. The texts reveal a shift where justifications for user participation are increasingly linked to aspects of benefit for public administration and service producers, not benefit for the users. The solution here lies in training disabled people, service providers and politicians in user participation, so that services can be adapted to the individual user.
Legislation and legal matters become prominent features in the 2000s (see Table 1, C2). Discrimination barriers are presented as the problem during this period. The lack of equality between disabled people and other citizens is constructed as a problem of discrimination and the solution is twofold, including legislation on one hand and formal bodies for participation on the other. The White Paper (Meld. St. 40 (2002–2003)) is based explicitly on the Official Norwegian Report from 2001 in terms of its understanding of disability and user participation. The text in NOU 2001: 22 constructs disabled people explicitly as citizens with the same rights as other citizens in all arenas of life, in accordance with the United Nations’ Convention on Human Rights. This concerns a construction following the relational model (see e.g. Shakespeare, Reference Shakespeare2006), thereby making it visible that the problems are socially created.
The White Paper from 2002–2003 proposes the introduction of anti-discrimination legislation, strengthening existing legislation and establishing a supervisory authority for disability rights. Furthermore, it suggests institutionalising cooperation between representatives of disability organisations, politicians and public administrators.
To summarize, a democracy discourse is the primary basis for user participation in policy documents in the different phases studied, but elements of the discourse have different foci. Overall disabled people should be seen as full citizens with the right to participate in society. In the first phase (the 1970s) the discourse in this field is dominated by a corporatist thinking in which participation takes place through representation with the role and significance of user organisations accentuated. These perspectives continue into subsequent periods. In the 1990s the individual perspective gains ground. Disabled people are seen as service users as well as users with rights to influence their services. What is highlighted here is the way the authorities should utilise the competences and resources of disabled people in the future development of services as well as in policies affecting disabled people. The consumer perspective remains marginal. In the final phase a growing impatience is expressed regarding further disability rights that have not been fulfilled. There is increased effort to enact and implement legislation to bring about change.
Mental Health
The theme of participation is barely touched upon in the mental health services before the Circular from 1981 issued by the Ministry of Social Affairs (see Table 1, A3). The Circular states that ‘in all contexts where initiatives are planned or implemented for the benefit of people with mental health problems, a clear requirement is that they themselves are consulted. As far as possible, these initiatives should be in accordance with their wishes’ (p. 23, our translation). The Circular also mentions local interest groups comprising former or current patients and their relatives, and the nationwide special interest organisation Mental Helse (Mental Health), founded in 1978.
Also in the mental health field user participation as a concept emerges in documents from the 1990s. Through The Escalation Plan for Mental Health from 1997–98 (see Table 1, B3) user participation can be seen as firmly on the agenda. The Escalation Plan follows the White Paper from 1996–1997. The basic problem as presented is the view that mental health is a neglected area with shortcomings in all stages of the treatment chain. People with mental health problems are presented as a marginalised oppressed group. According to the White Paper, services should be based on users’ needs, and users should take an active part in planning. Based on the White Paper, Parliament requested the Government to produce an action plan for psychiatry.
The Escalation Plan lasts 10 years, beginning in 1998. The overall goal is to create a comprehensive and coherent treatment network in which the user perspective is central and constant. The resources devoted to the services should increase significantly, and user participation should be fundamental to the development of services:
The user perspective is central to the Government's policy. User participation is based on respect for the individual human being and is in our society an end in and of itself. Open administration and participation in public planning are examples in this regard. Moreover, users have experience and knowledge about how the service offerings function. This represents an important supplement to professionals, politicians and administration and may help in the planning, design and operation of improved services (p. 2, our translation).
Subsequent documents largely refer to The Escalation Plan or documents following up the Plan. A fundamental understanding of the problem is the view of people with mental health problems as citizens. The active, participatory citizen is presented as the ideal for user participation. Therefore, the objective of user participation should be to promote independence, autonomy and life-coping skills.
A premise of this understanding is that people with mental health problems are a group lacking sufficient impact on society's institutions. Therefore, The Escalation Plan emphasises the importance of user organisations and recommends that they should be strengthened. A significant part of user participation is seen as taking place through representation. The need for training user representatives to be participants in various bodies is underlined and The Escalation Plan encourages the establishment of ‘user controlled centres’ where user organisations determine such centres’ design. Simultaneously, the importance of organised self-help groups is emphasised.
The emphasis on citizenship in the mental health field can also be seen as a manifestation of a preoccupation with normalising views of mental illness. The aim is that people with mental health problems should be seen as citizens with resources to ‘live the most normal life possible and be well integrated in the society and culture one is part of’ (St. Meld. 25 (1996–97): 18, our translation). The Escalation Plan highlights that user participation can contribute to greater openness about mental health problems, and ‘give these [mental health problems] a face and contribute to an attitude that “we, too, are able”’ (St. prp. 63 (1997–98): 6, our translation). The problem is presented as being that people with mental health problems have been treated as deviants, lacking the resources to participate in society.
The philosophy of normalisation also implies a normalisation of service provision. Patients’ rights within the mental health services, it is argued, should be strengthened through introducing more legal equality between patients with mental and somatic disorders (Ot.prp. 65 (2005–2006)). The view of users of welfare services as competent citizens is also related to a revaluation of their competences in the development of services. Users are presented as ‘specialists in their lives’, while workers are specialists in their professional areas (St. Meld. 25 (1996–97): 29). But user participation can also have ‘instrumental effects’ by including ‘therapeutic effects’ for those involved. Participation here is seen as a strategy that enables those with mental health issues to cope with life.
Furthermore, in the mental health field, it is emphasised that user participation ought to take place through situations of trust and co-operation between users and service providers. The importance of utilising complementary competence between service users and service providers through respectful cooperation is stressed. Cooperation is expected at both individual and system level. The Norwegian Directorate for Health and Social Affairs’ report from 2006 (see Table 1, C3) declares that, on the individual level, user participation is not a scheme about freedom of choice, but rather a method of cooperation and consultation, in which treatment systems and their users meet. At the system level, user participation means that users enter an equal partnership with the service system by actively participating in the planning and decision-making processes.
In summary, the focus on user participation emerges later in the mental health field than for older and disabled people. But when it enters, it receives considerable attention. A rights-based, democratic discourse is dominant. At the system level, the corporatist tradition of user participation through representation is stressed. At the individual level, there is emphasis on raising the status of people with mental health problems and portraying them as full citizens. This way, policy makers seek to destigmatize and normalise the view of mental illness. Simultaneously, the competence and resources of users are re-valued. Through user participation, both at individual and system levels, policy aims to ensure that the quality of services improves. There is a strong emphasis on how user participation must take place in cooperation between the service system, the users and users’ organisations. Harmony is stressed. Possible contradictions and tensions between user interests and the interests of the public services, or conflicts over the definition of mental health problems and treatment, are problematised to a very limited extent.
Continuity and change, commonalities and differences
The analysis of the policy documents can be summarized in three conclusions. Firstly, there are clear discourse similarities between the documents relating to the three target groups. Secondly, a significant continuity in how user participation is presented is evident across the target groups during the period under study. The trends, regarding user participation in general social welfare policy, are manifested in the documents relating to older people, disabled people and people with mental health problems. Nonetheless, this occurs to varying degrees. Thirdly, the documents reveal some important differences in how the discourses are manifested between the three target groups.
Across the target groups, a democratic discourse stands out as dominant. This is a discourse which is manifested from the early documents until the present. The problem is presented as follows: marginalised groups ought to have their full rights and be integrated into society as citizens. The solutions take the form of representative bodies and an emphasis on user organisations as instruments in promoting participation. In the 1990s, attention shifts towards the right to user participation at the individual level. The problem is then presented to be that services are poorly adapted to users' wishes and needs. Service users have a democratic right as citizens to influence their care.
In the democracy discourse, the active, participating citizen is constructed as ideal. Lack of participation is attributed to social marginalisation denying opportunities and rights to participate. For older people, however, the argument is partly presented in terms of a traditional, prejudiced way of thinking about older people who, after an active working life, are assumed to enter a secluded life as pensioners. With regard to the future generation of older people, this way of thinking is rather presented as a problem and the welfare system should therefore make it possible and desirable for older people to live a responsible/participating life.
From a citizen perspective there is also a strong perception that users through active participation will improve services. Consequently, user participation appears to be a ‘win-win’ situation for both users and the service system. The authorities are therefore also on the side of users in their efforts to promote user participation. It is interesting, however, that this perspective is emphasised more strongly for people with mental health problems and disabilities than for older people. Today's older people are to a great extent portrayed as individuals with limited resources and capacity to contribute to their services. Only when the ‘new generation of older people’, with their greater resources, enters the picture is there confidence in the user participation of this group.
An important difference between the target groups is that, in the last period where co-production is the focus, only the documents directed at older people stress rights accompanied by obligations and responsibilities. For disabled people and people with mental health problems the rights to participation and inclusion are highlighted, but without referring to responsibility. This is the clearest discursive difference in the argument. For older people it also implies a clear shift compared to previous documents. In so far as the obligation/responsibility-dimension is not highlighted in the same way for disabled people and people with mental health problems this can be related to the portrayal of them as marginalised and oppressed groups. Hence, the fulfilment of fundamental rights becomes the focus. When the obligation/responsibility-dimension is applied to older people this is contextualised in terms of their positioning as a majority group within social care services, and as a group that will increase strongly in the future. The White Paper Meld.St. 26 (2014–2015) Future Primary Health Services – Closeness and Wholeness states that the growth in demand for services in the municipalities creates sustainability challenges. Such a discourse stresses the problems of staff recruitment and the costs. Therefore, it is argued, it will be important to mobilise older people to participate and take responsibility for their welfare, ensuring the future sustainability of the welfare state.
The consumer discourse related to user participation is constructed in the documents analysed through the emphasis on users' right to influence through choice. This discourse appears clearest in the documents from the 1990s aimed at older people, with a focus on the right to choose living arrangements and be able to make informed choices concerning services. Only to a limited extent can a consumer discourse be identified in the documents relating to disabled people and people with mental health problems. However, pure market thinking has also not achieved a prominent position in the area of services for older people. Szebehely and Meagher (Reference Szebehely, Meager, Meager and Szebehely2013) point out that a market approach to eldercare is far more extensive in the neighbouring countries Sweden and Finland than in Norway; thereby pointing at possible discourse differences even within Nordic countries. This is also in line with Alm Andreassen's point that the consumer orientation in Norway is less about a neo-liberal market orientation than an attempt to make the state more ‘responsive’ by listening to users and understanding their needs (Alm Andreassen, Reference Alm Andreassen and Norvoll2013). When the consumer discourse appears in the policy documents it seems very much a hybrid between a consumer discourse and a democratic social rights discourse (cf. Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007).
A general feature of the documents aimed at all three target groups is a harmonious orientation. Users and the service system are presented as having common interests and goals, without this assumption being problematised. This characterises the presentation of user participation at the system as well as the individual level. Harmonious thinking is a common feature of all periods, but is most explicitly expressed in the period in which the co-production discourse has impact. In this respect the Norwegian policy documents differ from much of the international literature on user participation which is characterised by conflict between users/user-organisations and authorities, with authorities being seen as adversaries rather than alliance partners.
A key explanation for the stronger consensus orientation in the Norwegian context is that its user participation discourses are framed by a social democratic welfare state model. The corporatist principle, that began in the 1950s through the establishment of ‘collegial bodies’ (our translation) with representation from a wide variety of interest groups and organisations, receives strong political support (Nordby, Reference Nordby1994). The Nordic social democratic welfare state ideal is an influential context (cf. Esping-Andersen, Reference Esping-Andersen1999), here, for the development of user participation discourses. The fundamental ideal underpinning such consensus is of a society in which citizens take responsibility for each other and cooperate for the common good.
Conclusion
Over a period of 50 years in the context of Norwegian social policies aimed at older people, disabled people and people with mental health problems, the democracy/social rights-based discourse is dominant and persistent. Through this discourse, the active, participatory citizen/user is constructed as an ideal. For tomorrow's older people, their rights are also related to duty and responsibility. The consumer discourse is most evident for older people, especially in the middle phase in the 1990s, while its influence for disabled people and persons with mental health problems has been modest. Non-conflictual or harmonious thinking appears the political ideal for user participation within all three groups. Generally, given the continuity of the democracy discourse, Norwegian user-participation policies are central to a social democratic public policy, with service users and authorities portrayed as equal partners.
