Citizen or consumer – developing a democratic and market discourse of personalisation policies

Central to Esping-Andersen's (Reference Esping-Andersen1999) comparative analysis of welfare regime types are the three basic institutions for covering people's welfare needs: the state, the market and the family. In the social democratic variant that Norway represents, the intention is that welfare policies should support people in being as independent as possible of the market as well as the family; therefore welfare services are generally generous and comprehensive. In contrast, liberal welfare regimes ‘reflect a political commitment to minimise the state, to individualise risks, and to promote market solutions. As such, they disfavour citizens' entitlements’ (Esping-Andersen, Reference Esping-Andersen1999: 75). This points to a difference concerning the political understanding of the role of the state that is important in regard to the way personalisation policies are implemented.

By highlighting the personalisation policy, what Newman and Clarke (Reference Newman and Clarke2009) call a politic of public, variations regarding ‘public’ (as more than state responsibility) are brought to the front. Based on the different ways ‘public’ has been constructed (Newman and Clarke, Reference Newman and Clarke2009: 14–15), they present so-called discursive chains (summarising key institutions and factors), of which two are relevant here. One equates ‘publicness’ with the state (public = public sector = state) while another (public = legal and democratic values = public sphere) equates public as a domain clearly differentiated from private beliefs and interests and commercialised relations of the market. The first chain deals with the issue of accountability and emphasises public (state) responsibility, opening discussions about how this is challenged by, e.g., including into this public responsibility private business ideas about management, market mechanisms and hybrids like public/private partnerships. The other chain represents the idea that specific values are related to the public sphere and that democratic values are central and different from private interests. The idea is that these democratic values will strengthen equality. Very different values, such as private interests, including for example (individual) consumer interests, will therefore challenge this chain. These discursive chains represent a way of clarifying the different angles of the politics of the ‘public’ and their challenges; in brief these angles concern the accountable state and democratic values respectively. Both elements are part of what we refer to as a democratic discourse in the following, a discourse that is simultaneously challenged by a market discourse. Within the policies of personalisation, these discourses have their historical origins in discourses pointing to the different roles of the user: as citizen or consumer.

One historical origin is related to the Independent Living Movement in the United States in the late 1960s. This social movement aimed at achieving civil rights and full social inclusion for disabled people, that is their independence (Morris, Reference Morris1993; Oliver, Reference Oliver1990; Shakespeare, Reference Shakespeare2006). It fought against the situation faced by disabled people in society: that the only care services offered were places in long-term care institutions and that professionals held all the power in regard to both their medical and social needs. The basic ideas of this discourse are therefore social justice, rights for minorities and self-determination, giving disabled people, not experts, power over their own lives. This discourse relates to the social interpretation of disability (Oliver, Reference Oliver1990) and requires public (state) responsibility in creating a social environment providing opportunities for all people. From the start, the Independent Living Movement focused on daily assistance in disabled people's lives as one key issue for independence. The disability movements in both the UK and in Norway, therefore, became key actors in developing cash-for-care schemes (Andersen et al., Reference Andersen, Askheim, Begg and Guldvik2006; Shakespeare, Reference Shakespeare2006; Zarb and Nadash, Reference Zarb and Nadash1994). Inspired by the idea of discursive chains, we find that the one constructed by the Independent Living Movement is the following chain: citizen = rights = (welfare)state.

In contrast to this grass-roots pressure, from below, on a citizen = rights = state chain, another, that we suggest calling a consumer = choice = market chain, is constructed from above. This was a result of dominating policies responding mainly to two challenges in many European countries: one concerning the need to provide support for older people with increasing life expectancy (accompanied by increasing labour market participation by women and consequently fewer women available to provide unpaid care) and another concerning the increasing costs related to these future circumstances, making it important to look at welfare services promising cost reductions. The political ideas that inspired many European countries’ response to these demographic and economic issues came to be known as New Public Management (NPM). NPM ideas were found in the private market sector, thereby transferred to the public sector, and strongly influenced the (new) ways of delivering public services. This development seems to have started in the UK but spread to many OECD countries (Hood, Reference Hood1991). In the public sector, NPM involved the separation of the purchaser from the provider role, the growth of contractual or semi-contractual arrangements, the creation of a market or quasi-market, performance assessment, and an emphasis on the public as customers who were offered choice (Stewart and Walsh, Reference Stewart and Walsh1992). Though this was highly developed in the UK, it affected even strongly social democratic Norway. As already mentioned, one of the key NPM ideas is the market inspired idea about the role of the customer. And because the field in which the customer acts is a private market, the discourse relevant here is a market discourse. In contrast to the democracy discourse, the market discourse puts the welfare recipient in the role of a customer who should always have the option of choosing between different services in a (free) market, and, importantly, should have sufficient choices. The public authorities should be limited and access to a market should be available so that the individual can act as a customer. In the democracy discourse, in contrast, there is no intention of limiting public responsibility but rather one of making the public authorities responsible for the social inclusion of all people.

Summarised, the key elements of our theoretical framework consist of a democratic discourse pointing to a citizen = rights = state chain and a market discourse pointing rather at a customer = choice = market chain. However, while the discourses have very different ideological and political roots, they are basically pointing at one common idea: the idea of individual freedom. Both discourse chains provide a suggestion on how to encourage individual freedom, but they suggest two very different routes: one through the state, the other through the market. They also suggest two very different contents to freedom, one about democratic values and inclusion in society and the other about making individual choices within a free market. Our following context analysis (based on empirical evidence) of the cash-for-care welfare scheme (Norway/England comparison) will show that these conceptual distinctions are ideal typical constructs (Weber, Reference Weber1994). While separated as theoretical ideas, in policy practice they are mixed, thereby crossing the discourses. We will begin our comparative analysis by indicating important changes in the role of the public sector as state, crucial for the development of personalisation policies in the long-term care sector.

A changing public sector = state role: providing welfare services at arm's length

Due to major pieces of legislation in the 1980s and early 1990s, starting with the Municipal Health Act of 1982, Norway developed a strong municipal responsibility for long-term care services. Two important characteristics of the Norwegian municipalities have been developed by these reforms. One is the development of municipal autonomy representing a large degree of freedom for the many Norwegian municipalities (in 2013: 428) to organise their services so that they could fit local choices, conditions and political orientations. The other development concerns a change in their type of responsibility, which became very clear in a preparation paper for the new common law for social and medical long-term care services (Municipal Health and Social Care Act of 2011) implemented in 2012. In the preparation paper, the role of municipalities was explicitly called a ‘make sure’ role, stressing a supervisory role (Prop. 91 L 2010–2011: paragraph 1.2). While the municipality has full responsibility for securing the services that people need, including their quality, it is not necessarily the municipality itself that provides these services. This is an important legislation-based option that makes it possible to contract external actors, including for-profit companies, to provide or support the services municipalities are obliged to offer by law, thereby gradually opening up the possible development of a care market. The previous laws indeed also incorporated this option of including private actors, and some of the externalisation of services to for-private actors had already started in the 1990s. At this time, an important organisational preparation for the externalisation option in long-term care-services came from the NPM inspired purchaser–provider model separating the administration and the carrying out of services into two different units. One unit, always municipal, orders the services, including the preparation of legally based requisitions. The other unit provides the services, and this unit can be either municipal or private (Nesheim and Vathne, Reference Nesheim and Vathne2000: 7). The ‘make sure’ role includes the maintenance and control of contracts with external actors. In other words, municipalities place themselves at an arm’s-length from services for which they are fully responsible (Christensen, Reference Christensen2012).

At the heart of these changes in Norwegian long-term care services, therefore, is this trend towards the municipalities being ‘enablers’ rather than ‘providers’. Put together with the increasing pressure for user involvement, sometimes called user empowerment (Askheim and Starrin, Reference Askheim and Starrin2007) during the 1990s and 2000s, this crucially shapes the platform for personalisation policies like cash-for-care as there is no barrier to including the user her/himself as well in this process of externalising responsibility.

Before we describe the English enabling role, we will stress two more Norwegian characteristics. One is that the externalisation of long-term care services is still at a very low level. According to the latest national statistics (SSB, 2012a), only 8.1 per cent of the sector's services are purchased from private actors, even including non-profit providers. The other characteristic is that although the NPM inspiration of, e.g., the purchaser–provider split plays a crucial role in the changes in Norwegian long-term care, and more than half the people in Norway live in a municipality with a purchaser–provider split, many municipalities do not use it for externalisation to private companies but rather for monitoring services (Gammelsæter, Reference Gammelsæther2006).

A change comparable to the Norwegian ‘make sure’ role was introduced much earlier in England. In December 1986, Sir Roy Griffiths, deputy Chairman and Managing Director of Sainsbury’s, was commissioned by Margaret Thatcher's Conservative government to undertake an overview of community care services and to make recommendations on how resources might be used more effectively. In line with the government's policy of market liberalism, he advocated an ‘enabling’ role: ‘It is vital that social services authorities should see themselves as the arrangers and purchasers of care services – not as monopolistic providers’ (Griffiths, Reference Griffiths1988, 5: para 3.4). The Griffiths’ recommendations provided the foundation for the 1989 White Paper (Secretaries of State for Health, Social Security, Wales and Scotland, 1989) Caring for People: Community Care in the Next Decade and Beyond and for future developments in social care. The White Paper endorsed Griffiths’ conception of the local authority as an enabling authority, stating that stimulating non-statutory service providers would produce a wider choice of services, meet individual needs in a more flexible innovative way and introduce competition between providers, resulting in more cost-effective services. Local authorities would be expected to make clear in their community care plans how they would make increased use of, and stimulate, the non-statutory sector, especially in non-residential care, where it was little developed. Most of Griffiths’ recommendations were implemented in the National Health Service and Community Care Act, 1990. After the passing of this Act, the UK government produced several guidance documents emphasising the importance of separating purchasing and provider roles, explaining that need could be better assessed when this was not carried out by the provider. There was to be more choice of provision, but the choice was to be made by the local authority professionals ‘taking into account’ the wishes of the individual and the carer. Nevertheless these changes provided the basis for the possibility later, under pressure from disability campaigners, that individuals might choose what should be purchased with the budget allocated to them.

Since the Act, local authorities have increasingly purchased services from independent providers. In 1991–92, 93 per cent of local authority spending on services in England and Wales went to their own services (public support for independent residential care was at this time centrally funded) (Audit Commission, 1992). In 2010–11, only 31.6 per cent of English local authorities' adult services expenditure (including assessment and care management) went on their own services (HSCIC, 2012). Unlike in Norway, marketisation dominates care provision. There are some noteworthy similarities with Norway regarding the change towards state responsibility at arm's length. However, there is a time difference as well as a difference in scope, and the political faith in markets and choices – a market discourse – is much deeper.

At-arm’s-length services – new manager and employer roles for users

The user-controlled personal assistance model in Norway, BPA, became legalised in 2000, when it was added to § 4–2, a of the Social Services Act: The services include ‘practical support and training, including user-controlled personal assistance, to those with special needs of assistance due to illness, impairment, age or for other reasons’. This means that the municipalities should offer BPA in line with other social care services in § 4–2, such as home help services. When the new Health and Social Care Act was passed in 2011, BPA obtained its own article: § 3–8, obliging municipalities to offer BPA ‘in terms of practical support and training, organised as user-controlled personal assistance’. Of interest here is that the concept of ‘personal assistance’ now appears as the main concept in the article where the different care services are mentioned (§ 3–2, 6 b): ‘personal assistance, including practical support and training’. Apparently, therefore, the philosophy of personalisation has influenced how future care services should be understood: as services where people take on more responsibility for themselves, that is at an arm's length from public responsibility. Until 2006, the decisive criterion for BPA was whether the user could act as manager of their assistants. Since 2006, another person can take on the managerial role for or with the user (Rundskriv I-15/2005). This extends the group for whom there is arm's length responsibility, but it is the municipality that judges managerial competence.

According to the latest figures from 2010 (Johansen et al., Reference Johansen, Askheim, Andersen and Guldvik2010), most BPA usersFootnote ¹ in Norway had either the municipality (54 per cent) or the user-led cooperative Uloba (33 per cent) employing their personal assistants, while 11 per cent did this on their own, or by using private companies (2 per cent). In Norway, the emphasis is on the person (or someone on their behalf) managing their own care, employing personal assistants being only one option for doing this. This can be interpreted as a way of making the at-arm’s-length service available to many people. Cash-for-care services in Norway still let the public (here the municipalities) play a key role, by carrying out the employer role, though less so when people choose the non-profit (contracted) support organisation Uloba, and even less so when the user takes over the employer role her/himself. The Norwegian case shows the possibility of personalising services without making ‘the arm’ too long for the majority of the users, but this is obviously easier in a context with an undeveloped care provider market.

In England, cash payments to disabled people under the age of sixty-five were legalised in the Community Care (Direct Payments) Act 1996. Worries about a cost explosion were mitigated and the policy fitted in with the Conservative government's agenda of emphasis on the consumer and transfer of provision to the private sector. Although the Labour government, which came into office in 1997, criticised the previous government's ‘devotion to privatisation of care provision’ (Secretary of State for Health, 1998), there was no radical change in the social care agenda. It emphasised independence and encouraged direct payments as a means of achieving this, including their extension to older people. In 2003–04, it became mandatory for local authorities to offer direct payments to people assessed as being in need of community services (changes were made in 2009 so payments could be made to a nominated ‘suitable person’ where the service user lacks capacity). Direct payments users have mainly been employers of their personal assistants, though some have used the money to contract with care agencies or to meet their social care needs in other ways.

Research has indicated very positive views of direct payments users (Glendinning, Reference Glendinning2008), similarly to Norway. In Improving the Life Chances of Disabled People (Prime Minister's Strategy Unit, 2005) the Labour government launched the idea of individual budgets, which would give greater choice to people who did not want to manage a budget, and bring together different sources of funding. The government was strongly influenced by In Control, a partnership inspired by the Independent Living Movement that set up pilots of what they termed ‘self-directed support’, initially for people with learning disabilities with a few local authorities. The idea was for service users to play an active role in determining the services needed to support them, from assessment to planning the meeting of needs. Crucially, to exercise control, they should know how much funding they were to be allocated, and this should be related to need, not service cost, and used flexibly. A programme of individual budgets pilots in England had largely positive findings (Glendinning et al., Reference Glendinning, Challis, Fernandez, Jacobs, Jones, Knapp, Manthorpe, Moran, Netten, Stevens and Wilberforce2008), but it was found that integrating the various funding streams could not happen without legislative and administrative changes.

Remarkably different from the Norwegian policy is the focus on social care money, and in December 2007 a commitment to provide personal budgets (using social care funding) in England was set out in Putting People First (HM Government, 2007). Personal budgets can be taken as direct (cash) payments by the person (or since 2009 a ‘suitable person’ where they lack capacity), or held by the council (or a third party provider), but the individual should have choice and control over how the budget is used (ADASS, 2009). This policy was endorsed by the Coalition government which came into office in 2010, and which called for there to be 100 per cent take-up of personal budgets by 2013 (amended to 70 per cent, 31 October 2012), preferably as direct payments (Department of Health, 2010a). While there has been a large increase of people receiving community care in England in terms of ‘self-directed support’ between 2009–10 and 2012–13, from 11.5 per cent to 55 per cent, it was still only 14 per cent who were receiving direct payments in 2012–13 (HSCIC, 2013).

Contrasting with the English cash-for-care variants, which all stress the importance of knowing the amount of the cash payments/the budget available and having some choice and control over how this is used, the Norwegian system rather stresses people's control of their help: they are managers of their care workers (sometimes with the help of a relative if they are mentally disabled), but they do not have the same decision making over how services are to be provided (see below) and they are less likely to be employers in terms of budget administrators. In England, the budget administration role is accommodated by a market of providers.

Money or control – the role and impact of support organisations

One user-led organisation, Uloba, was, for almost a decade, the only external organisation contracted by municipalities in Norway to provide support for BPA users, a third of all municipalities developing contracts with it. While Uloba employs the personal assistants, BPA users have full control over their management. This situation of homogenous support, including furthermore half of it being public in-house, over a long period, is very different from the much more variable cash-for-care support in England.

A survey of support organisations for direct payments users carried out in 2004–05 (Davey et al., Reference Davey, Snell, Fernández, Knapp, Tobin, Jolly, Perkins, Kendall, Pearson, Vick, Swift, Mercer and Priestley2007) found a diversity of organisations, two-thirds in England commissioned by the council, mostly local groups serving one council (including Centres for Independent Living and other user-led organisations) or member groups or affiliates of national organisations; none at the time were for-profit organisations, though there have been some since. Some councils contracted more than one organisation; a few provided in-house support. The types of services offered varied widely, depending largely on specification by the council, most focussing on promotion of direct payments and support with their initial set-up. Less than a quarter in England contracted and paid the care workers and placed them under the control of the service user. A survey (IFF Research, 2008) of direct payments users in England found that only 42 per cent received ongoing support in legal and financial aspects of employing personal assistants, about a quarter receiving this from direct payments support organisations.

Think Local Act Personal (2012), a national partnership organisation promoting personalisation in England, has called for growth and increased diversity of direct payments support, adapted to the needs of particular groups, with the drive towards personal budgets, particularly direct payments. They found a need for greater availability of information about different ways to use direct payments, of ways to reduce or remove employer responsibility, and of a continuing source of support in case things go wrong. They also found, as had Davey et al. (Reference Davey, Snell, Fernández, Knapp, Tobin, Jolly, Perkins, Kendall, Pearson, Vick, Swift, Mercer and Priestley2007), a reluctance by councils to fund external organisations to provide support at the initial stages in determining a person's budget, as this might lead to challenging the council's offer.

It is an important but paradoxical context characteristic of the drive towards personal budgets that they are accommodated by a requirement for a variety of support organisations but simultaneously, in the government preferred case of direct payments, a majority of people are taking on the responsibility themselves (or with assistance). At the end of the day, the English personalised policy, contrasting with the Norwegian, in the case of direct payments means either oneself (or one's representative) taking on all the duties, or being a customer in the care market, or a mix of these. The option of managed personal budgets was meant to provide choice and control without this responsibility, moving nearer to the Norwegian model, though this may not work out in practice.

Users are increasingly choosing Uloba as employer in Norway. They are found to be significantly more satisfied with this employment model than those who have chosen the municipality as employer (Johansen et al., Reference Johansen, Askheim, Andersen and Guldvik2010: 59–60). Uloba users also experience more influence on which services they are allocated by the municipalities (as this sometimes consists of a package of different kinds of services) and on the tasks of their personal assistants (Johansen et al., Reference Johansen, Askheim, Andersen and Guldvik2010: 52 and 54). These figures seem to confirm that the choice of employer has an impact on how much personalisation the user will experience. The municipality may treat BPA more in line with traditional services – as this is their expertise – while Uloba is rooted in a different Independent Living ideology and is therefore fully oriented towards the requirements of an independent life. However, BPA more generally, when compared to traditional services, seems to have an impact on the amount of hours allocated: Johansen et al. (Reference Johansen, Askheim, Andersen and Guldvik2010: 22) found that 62 per cent of BPA users in 2010 received more hours when they transferred from traditional to BPA services, although this number was much lower than in 2002, when 90 per cent reported this. Thus, an arm's length service, aiming at more personalised services, can positively impact the hours allocated and influence the services.

While surveys in England (Poll and Duffy, Reference Poll and Duffy2008; Hatton and Waters, Reference Hatton and Waters2011, Reference Hatton and Waters2013) have found a majority of people reporting improvements in a number of aspects of their lives since having a personal budget, it should be noted that in the 2011 Hatton and Waters study, those with payments paid to them directly had more positive outcomes than other groups, and there was also a tendency in this direction in their 2013 study. As they point out in the latter study, only 11 per cent in their sample of personal budget holders had a council-managed budget, unlike the situation in England in 2012–13 where this was 77 per cent (HSCIC, 2013). The earlier Hatton and Waters study provides evidence of the benefits of support from an organisation independent of the council/NHS at the support planning stage – those receiving this (only 15 per cent) having more positive outcomes, though the later study found little difference in the benefits of support from different sources. However, a demonstration project comparing user-led-organisation (ULO) support planning and brokerage with that of the council in three localities (Office for Disability Issues, 2011) found ULO planning gave people a greater feeling of control and freedom (as in Norway), that more people using ULOs chose direct payments and that ULOs were felt to be more helpful in all aspects of managing a personal budget.

‘Right’ and ‘choice’ crossing discourses

As a politically strongly social democratic country, with a centre–left government recently ending its second period, one should expect the citizen = rights = state chain to be fully developed in Norway, but it is not. People in Norway so far have not had a right to BPA, only the right to be assessed for social services, among them BPA. Although the municipalities have to provide information about BPA (according to the 2000 guidelines [Rundskriv I-20/2000] and also the new Health and Social Care Act 2011), it is still the municipality that makes the decision on BPA. It also decides which services are appropriate for each individual based on an assessment of their needs, and the amount of hours to allocate, on ‘an acceptable level’ according to the municipal assessment. Interestingly, although user involvement and user influence are stressed clearly in the legislative history of the new Health and Social Care Act 2011 (Prop. 91 L 2010–11), there is no direct wording of this in the new law except in the Objects clause (§ 1–1, 5 and § 1–1, 6) where it says that the service should be ‘adapted to the individual's needs’ and that ‘the service offer shall take into account respect for the integrity and dignity of each individual’. This means that the personalisation process for the user starts after the municipality's decision to allocate BPA, whether BPA shall be included in a package of different kinds of services and the amount of help to be provided. In this sense, the Norwegian system represents a paternalistic bureaucratic system, giving power to municipalities (here equalling the state) primarily and only secondly to the users, at the end of an assessment process.

In England, people, if eligible for social care, have the right to direct payments (or an approved ‘suitable person’ if they lack capacity, and with a few exceptions, mainly for people subject to certain criminal justice orders), and have entitlement to a personal budget under the forthcoming Care Act in England. However, the eligibility for social care in England depends on means as well as assessment of need (while in Norway it is only on need). Financial assessment is supposed to take place only after assessment of need (Department of Health, 2010b) but research documents that people with financial ability to pay are only rarely assessed for need or offered support (Henwood and Hudson, Reference Henwood and Hudson2008). So in reality they often cannot make an informed choice about how best to provide for their care needs.Footnote ² While currently guidance is provided to English councils on needs eligibility by the Fair Access to Care Services Framework, introduced in 2003 (updated 2010), councils decide on the level of need at which they will provide support, most applying very restrictive criteria (AgeUK, 2013).Footnote ³

Local authorities have a duty to carry out an assessment of need for any person who may require adult social care services under the NHS and Community Care Act 1990. While self-assessment has recently been encouraged (e.g., in Putting People First), ‘pure’ self-assessment by the individual is not legal. ADASS have recommended that assessment should be led by the person as far as possible, with appropriate support and lead to an ‘indicative budget’ linking levels of need to money, giving the person rough guidance on the amount they can expect to receive from the council. So, in contrast to Norway, personalisation should start with assessment and resources to meet needs expressed in a budget, not hours of support (ADASS, 2009). However, in some councils there may be large differences between indicative and actual budgets (Slasberg et al., Reference Slasberg, Beresford and Schofield2012). Councils vary considerably in how the personal budget process is carried out and a lack of clarity has been reported as common, particularly on how the budget can be spent (Hatton and Waters, Reference Hatton and Waters2011, Reference Hatton and Waters2013).

Comparing access to cash-for-care in Norway and England, there is so far no BPA right in Norway but a right to be assessed on the basis of one's needs only, while a contrasting situation is in force in England: there is a right to cash-for-care but there are barriers to support in terms both of financial circumstances and eligibility of needs. This definitely crosses the (theoretical) discourse borders between citizen–rights and consumer–choices and takes us to our discussion of the borders of personalisation policy.

Personalisation policy in practice – risks of crossing discourse borders

While the separation of a democratic discourse, comprising a citizen = rights = state chain and a liberal consumer = choice = market chain, makes sense ideologically and theoretically and also represents a good point of departure for the analysis of a welfare scheme within different welfare regime contexts, the policy when implemented is complex. There is no doubt about the stronger English market discourse and emphasis on the cash-for-care user as a consumer given a budget to control (with/without support), but this is not the end of the story. Borrowed from the democratic discourse, the English case gives people a right – as called for also by the disability movement – to get cash-for-care but simultaneously creates barriers to access this right. This ‘right’, when forcing the cash-for-care model on all social care users, furthermore implies that the consumer role is seen as relevant as a prototype for social care users. While the origins of the cash-for-care welfare scheme had strong support from physically disabled people and, later, from advocates for people with learning disabilities, it is no coincidence that the take-up of direct payments among younger people (eighteen to sixty-four) in these groups has been the highest with that among older people much lower. Research evidence suggests that this group has the least positive outcome of cash-for-care (Glendinning et al., Reference Glendinning, Challis, Fernandez, Jacobs, Jones, Knapp, Manthorpe, Moran, Netten, Stevens and Wilberforce2008; Hatton and Waters, Reference Hatton and Waters2011, Reference Hatton and Waters2013). The 2013 survey found that though outcomes were generally positive for older people, they were less so than for other groups in crucial aspects, such as mental wellbeing and having control over support. In most aspects, people with council-managed budgets were less likely to report positive outcomes and these are currently predominant in England, particularly for older people. Other studies have found that in practice there may be little difference between council-managed budgets and traditional services (Equality and Human Rights Commission, 2011; Newbronner et al., Reference Newbronner, Chamberlain, Bosanquet, Bartlett, Sass and Glendinning2011). Reasons suggested for lower take-up of direct payments by older people include assessment taking place at times of crisis, rendering decision-making more difficult; concern over responsibility of managing the budget; fears of abuse (Alzheimer's Society, 2011; Equality and Human Rights Commission, 2011); or being discouraged from taking them up by the council (Newbronner et al., Reference Newbronner, Chamberlain, Bosanquet, Bartlett, Sass and Glendinning2011). In this context, this is about more than a disadvantaged group of older people. This is about a system not fitting all, as the original intention was to support younger disabled people in living a more independent life, while for some older people what is most important is continuity of care, and for this to fit in with the person's routine (Sykes and Groom, Reference Sykes and Groom2011). Although the Norwegian paternalistic bureaucratic model can be criticised, it is also a way of protecting those clients (particularly some older people) that this system does not fit. The English policy way of interpreting ‘choice’ has a strong focus on the choice of provider, but to live an independent life may not be dependent on this choice but rather on gaining control of one's individual life. If they lived up to their original conception, council-managed budgets would provide this. In this sense, the (Norwegian) democratic case borrows the ‘choice’ originally related to the market discourse chain and creates what could be called a ‘citizen choice’ due to a context without a care market. While the context risk of borrowing the ‘right’ in the English case is the market, creating, potentially, inequalities of accessibility, the risk of borrowing the ‘choice’ in the Norwegian case is the development of bureaucracy that makes it difficult to influence, in particular, the allocation of services.