A discourse analytical framework

The discourse approach stresses the understanding of social phenomena as socially constructed in a specific historical time and context. While varying, discourse analyses are all inspired by Foucault's theories. In Foucault's terms, simply expressed, a discourse is ‘a certain way of talking about and understanding the world (or a part of the world)’ (Jørgensen and Philips, Reference Jørgensen and Phillips2002: 9). Discourse analysis can be applied to different data, but it particularly relates to text and rhetoric as is the case here, where policy rhetoric is the analysis objective. Inspired by Foucault, Bachhi (Reference Bacchi2009) has provided tools for analysing policy documents. Her main idea is to turn away from focusing on what the documents say about specific political problem solving, to focusing on the problem and how this is constructed in a specific way and for specific reasons. Bacchi criticises an evidence-based (positivistic) approach, replacing this with a social construction approach. Methodologically, she suggests this main analytical question: ‘What is the problem represented to be?’.

Inspired by these ideas, we have applied these questions: Which main problem does the document present? And in order to ‘find’ this problem, we have asked: What is presented as the solution to this problem? The solution presented in the document will contribute analytically to pointing out the problem. A final Bacchi-inspired question we have used is: What is left unproblematic in problem discussion? Rather than this being about leaving out some topics, which is always the case, analyses never covering the ‘total’, it is about pointing out those topics that, if included, would have weakened the policy argument. We have then added a question regarding the role older people are given, because insight into this adds to the problem-questioning analysis, being part of the picture. Summarised, our method is a qualitative document analysis, using critical questions to understand the assumptions behind the policy text, then discussing welfare discourses over time.

Perspectives on user participation

Due to the nature of the phenomenon of ‘user participation’ – which includes different ‘degrees’ of participation’ (Arnstein, Reference Arnstein1969) – there is no uniform definition of this term and it can include different expressions like ‘user involvement’ or ‘user influence’. The literature presents different welfare discourses. The oldest – relating to the post-war period – is inspired by Marshall's classical idea about the historical development of civil, political and (relevant here) social welfare rights (Marshall, Reference Marshall1950). Here, user participation means developing a full citizenship through rights, representing a democratic discourse focusing on full membership of society. This discourse points at the state as responsible for its citizens; a political discourse always being based on an idea of the state/individual relationship and its power distribution. The democratic discourse stresses the strongest state responsibility. In a social democratic approach, this implies that services are universal, but typically of fairly basic standard, and that the services are then often determined by ‘experts’ (Le Grand, Reference Le Grand1997: 156), potentially making the users ‘pawns’. However, if the users are actively involved in decision making, the literature relates to Hirschman's (1970) concept of ‘voice’ (e.g. Newman and Tonkens, Reference Newman and Tonkens2011; Dent and Pahor, Reference Dent and Pahor2015), although ‘voice’, in terms of citizen involvement, can develop into different democratic models (Alm Andreassen, Reference Alm Andreassen2018). ‘The ‘pawns’–‘voice’ contrast – representing passive recipients versus individuals with influence – illustrates an important point about the ambiguity of this, and the other discourses.’

A very different discourse is developed later, historically related to the New Public Management (NPM) approach inspired by private sector ideas (Christensen and Pilling, Reference Christensen and Pilling2014). This approach makes the users consumers of welfare services, implying a choice logic (Dent and Pahor, Reference Dent and Pahor2015). However, the literature points at important nuances. For example, analysis of healthcare policy documents starting from 1944 in the UK point out a choice logic in terms of responsiveness – which makes the services increasingly responsive to users’ needs (Greener, Reference Greener2009; Greener and Powell, Reference Greener and Powell2009). This choice logic was first about choosing a long-term association with welfare professionals, then about making easier and faster choices/changes, and later again about choices within a market including competition between providers (Greener, Reference Greener2009: 319), representing a more pure form of consumerism. Although these changes were found within health services, they show important variations in the choice-logics possible for welfare services and are relevant here. Greener (Reference Greener2009) points to a development over time from long-term relationships – stressing Hirschman's ‘voice’ combined with compulsory ‘loyalty’ to public services – moving to relationships with preference for ‘exit’ through individual patient choices. ‘Exit’ is typically linked to individual choices and navigation in a market. The different consumerism strengths are also discussed in the literature through role- and discourse-combinations such as citizen-consumers (Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007), or consumer-citizens (Fotaki, Reference Fotaki2011), combining voice and choice/exit, and state and market. Related to the various choice politics, the literature, importantly, also points out that these are often pure rhetoric, avoiding learning from non-successful choice-scheme experiences (Fotaki, Reference Fotaki2007:1071). When the consumer discourse stresses competence and individual decisions in the user role, the state responsibility is weakened.

A third discourse contrasts with the market model. It has no particular focus on users as consumers but neither does it maintain the traditional approach to welfare professionals as experts with users (passively) receiving help (Hunter and Ritchie, Reference Hunter and Ritchie2007). The focus rather is on state/local authorities–user partnership; users are e.g. engaged in the delivery of their services in partnership with professionals (Dent and Pahor, Reference Dent and Pahor2015, Alm Andreassen, Reference Alm Andreassen2018). While associated with power-sharing, this is also about pushing the user to take more responsibility for their own needs, individually, e.g. ‘the expert patient’ (Dent and Pahor, Reference Dent and Pahor2015) or collectively, e.g. ‘self help groups’ (Fotaki, Reference Fotaki2011). However, the state/local authorities are still a strong part of the cooperation. The literature again points to possible overlapping roles dependent on context, with one relevant option being about the citizen as a co-producer, strengthening the citizen's ‘voice’ in a context of collectivism (rather than individualism) (Fotaki, Reference Fotaki2011: 947). Alm Andreassen (Reference Alm Andreassen2018) suggests three democratic/co-production models of citizen involvement: advisory bodies of services users; panels of the general public; service users as (ideally paid) (co-)workers in service delivery. The literature also points to the risk, in a market context, of forced co-production, turning the co-producer into a ‘responsibilised’ (individually dis-empowered) agent, with little choice (Fotaki, Reference Fotaki2011: 947). Again, there are potentials of both empowering and dis-empowering users. In our analytical discussion, we will use these three presented discourses and their nuances.

The Norwegian and English context

Norway is one of the richest and most democratic countries worldwide with no colonialism in its history and a welfare state with a forerunner status. In 2016 total public social expenditure was 25.1% of GDP in Norway and 21.5% in the United Kingdom (UK) (OECD, 2016); with Norway's expenditure increasing since 2009, while UK's has fallen since 2013. In Norway, assessments of whether one can be allocated welfare services are based on needs (not means-testing), making services independent of class, gender, ethnicity and location. Social care services for older people developed in the post-war period, through local municipal governance, the largest extensions taking place in the 1970s. While first dominated by institutional/residential care, priority was later given to home-based care (Borgan, Reference Borgan2012). Although including some periods of right-wing policy-based governments – as is the case currently – the social care policy overall has been dominated by Social Democratic politics. Therefore, the inclusion of for-profit market actors has remained low (Vabø et al., Reference Vabø, Christensen, Jacobsen, Trætteberg, Meagher and Szebehely2013). Important Norwegian cultural values include a strong norm of equality, particularly regarding gender, avoidance of social class differences and a broad support for the welfare state. Within social care for older people, this implies accepting public rather than family care, as this encourages women in maintaining their relation to the labour market rather than doing unpaid care, thereby strengthening the gender equality norm (Christensen and Syltevik, Reference Christensen and Syltevik2013).

The English picture is different. England is the largest country in the UK, with a history of colonialism, although decolonisation followed the Second World War. After the war, the Labour party gained victory and instituted public policies for which it is often claimed that there was ‘a post-war consensus’. These policies introduced the welfare state, including establishing the National Health Service (NHS), free of charge at the point of delivery. Historically social support had been provided by voluntary action and the Poor Law which, in the 19^th century, was intended to be very harsh to deter the ‘feckless’. Post-war reforms made local authorities responsible for services (Glasby, Reference Glasby2012); from 1968, local authorities were given general powers to promote older peoples’ welfare, and provision of home help services became mandatory. Cultural values stressed that services are best provided by family or voluntary organisations (Means et al., Reference Means, Morbey and Smith2002), although a post-war commitment to publicly provided services existed. Social service provision by for-profit organisations started in the 1980s, and was encouraged by the Conservative government in the 1990 NHS and Community Care Act. In 2014–15 local authorities’ gross total costs for their own provision of adult social care (excluding capital charges) were only a third of their expenditure on provision by others (NHS Digital, 2015). Unlike the NHS, there have always been mean-tested charges for social services, targeting those most in need.

In summary, Norway and England represent different historical, welfare political and cultural contexts for making user participation a key policy phenomenon over time. The different eldercare contexts can be described by using the ‘total social organisation of labour’ framework (Lyon and Glucksmann, Reference Lyon and Glucksmann2008), exploring the predominance of paid/unpaid and formal/informal care work in different provision types (public sector, market, family/household and voluntary sector). While both countries strengthened their public sector, England developed a stronger informal economy relying more on unpaid care work in family/household and the voluntary sector. The cultural widespread value of equality, including the avoidance of social class differences, contributes to explain Norway's weakly developed involvement of markets, as these are typically maintaining and stimulating class differences. England, in contrast, strongly included what could be called formal, but market based, (in general terms) paid social care work.

Selection of documents for the policy analysis

Our selection focuses on White papers, due to their significant impact on changing policies. The first selection criterion was that the document should have a particular focus on older people or include all service user groups, with older people being the largest. The next criterion was – inspired by the important discourse-related issue of historical time and changes (Jørgensen and Philips, Reference Jørgensen and Phillips2002) – to cover different historical times. In a Norwegian White paper, the historical development of social care services is divided into three phases: an establishment phase, an expansion phase and a current consolidation phase (St.Meld.25, 2005–06). For comparability, we used this same classification for the analysis of English papers.

As user participation policies develop gradually, it is important to include early documents. In Norway these consist of two Proposals (Proposal I, 1966; Proposal II, 1969) provided by a committee on eldercare. The importance of these proposals is their follow-up by two White papers: in 1967–68 On Support Arrangements for Homes Footnote ³, about home-based care, and On Elders in Society 1975–76, about older people in society. Together, these documents represent an early action plan for Norwegian eldercare, here the establishment phase. The earliest relevant English White paper discussing social care and support of older people is Growing Older (Secretaries of State for Social Services, Scotland, Wales and Northern Ireland, 1981).

The next important White paper in Norway directed at older people is Action Plan for Eldercare. Safety – respect – quality, (St.Meld.50, 1996–7), outlining the main historical plan for service expansion. As the user participation policy is introduced in the 1990s in Norway (Alm Andreassen, Reference Alm Andreassen2004), this White paper represents the Norwegian implementation, or expansion, phase. Two critical White papers relate to developments of social services in England, both covering all adult user groups. Caring for People (Secretaries of State for Health, Social Security, Wales and Scotland, 1989) deals with overcoming an unintended bias towards residential care, sees encouragement of non-statutory provision as the way to offer more choice, and makes users into consumers given a choice of services. Modernising Social Services (Secretary of State for Health, 1998) goes further in wanting users, including older people, to have greater control over their services.

While the other selected Norwegian papers relate to older people specifically, the last document, Tomorrow's Care (Meld.St.29, 2012–2013), relates to all user groups. This is presented as a paper about future possibilities, including looking at innovative solutions for tomorrow's eldercare involving user participation. It represents the current time phase. Two White papers, Our Health, Our Care, Our Say (Secretary of State for Health, 2006) and Caring for Our Future (Secretary of State for Health, 2012), represent the current consolidation phase for England and, like the Norwegian paper, represent all user groups. Both set out intentions to extend user choice and control over services.

TABLE 1.

Overview of selected national documents

Due to the importance of the original language (Norwegian/English) for a policy rhetoric analysis, one author has analysed all the selected documents (Christensen, with Fluge co-analysing the Norwegian documents, cf. note 1), while the co-author (Pilling) concentrated on the English documents. This ensures analytical comparative continuity rather than two separated analyses, with the advantage of including expert knowledge about the Norwegian and English social care sectors respectively.

Early establishment phase

Implementation or expansion phase

Current consolidation phase

Comparative discussion

We will now relate our discourse analytical findings to the literature's discussion of user participation discourses and their variations. Despite a difference in implementation time, we have found a democratic discourse in both countries in the early phase, but with differences between the two. While the Norwegian one appears as a citizen discourse due to democratic ideas about respecting and including people in society through, for example, user-representatives (e.g. ‘work councils’), even if they are living in institutions, the English one points instead at a local community member discourse (including available lay people), making citizens also co-producers of social support and voluntary services. Older people are respected as society members but this respect is used for arguing that they should be co-participants, together with their kinship and networks. In this sense, there is an important difference in the early democratic Norwegian/English discourse. The Norwegian moves in the classic democratic direction of rights and influence – including what Alm Andreassen (Reference Alm Andreassen2018) describes as a democratic involvement through spokespersons – and the English rather in the direction of what is much later in English policy named the ‘Big Society’ (we find historical political roots of the Coalition government's policy idea in 1980s national documents). The English case represents a combination of what Alm Andreassen (Reference Alm Andreassen2018) calls a democratic involvement of ‘generalised publics of lay people’ and a co-production model about older people as co-workers together with their networks (although here unpaid). Our findings show the early ambiguity in both countries, between respecting older people as in need of receiving social care (‘pawns’) and giving older people, in different terms, simultaneously a ‘voice’ (Le Grand, Reference Le Grand1997; Newman and Tonkens, Reference Newman and Tonkens2011; Dent and Pahor, Reference Dent and Pahor2015). This ambiguity is stronger in formal social care in Norway, while in England it is stronger in informal social care.

In the expansion phase, we again find a similarity in discourses, now concentrated in the consumer discourse but, again, there are variations. The Norwegian version of this discourse concerns safe choices in regard to being able to choose to stay at home if this is, as generally anticipated, the wish of older people. This is associated with long-term/loyal relationships to the welfare system, with no provider competition included in this choice logic (Fotaki, Reference Fotaki2011). The English version stresses what we would call a supported choice discourse. While the ‘safe choices’ discourse expresses a social democratic or early choice logic, the ‘supported choice discourse’ rather takes into account the many actors involved. This increasingly includes for-profit actors to avoid local authority monopoly of social care services, a key English policy goal at this time. The related choice logic represents a choice-and-exit variation including provider competition in a market (Greener, Reference Greener2009). However, the co-production discourse is not left out but is, rather, incorporated into the policy of choice, with consumers being encouraged to be co-producers (Fotaki, Reference Fotaki2011). This is near to the co-worker model (Alm Andreassen, Reference Alm Andreassen2018) due to emphasis on more user control of service provision/delivery supported by carers and others, particularly in the later part of this phase.

An important difference between the Norwegian and English consumer discourse is also that the Norwegian one is temporary, replaced by the co-production discourse in the last phase. The Norwegian co-production discourse is a co-responsibility discourse, now nearer the co-worker model described by Alm Andreassen (Reference Alm Andreassen2018). This is particularly due to the increasing stress on using seniors’ resources and the growing idea of rehabilitation as a means of bringing into the services these ‘seniors’ as active and resourceful users (Newman and Tonkens, Reference Newman and Tonkens2011), thereby actually ‘working’ for the state, although unpaid (Lyon and Glucksmann, Reference Lyon and Glucksmann2008). The co-production discourse also remains in the English rhetoric in current times but, unlike the Norwegian version, there is also a strong choice discourse, making older people consumers navigating in a market like ‘queens’ on the chess board (Le Grand, Reference Le Grand2003). While there is a policy stress on co-production in terms of involving the users directly, like co-workers (Alm Andreassen, Reference Alm Andreassen2018), in their services through personalisation policies encouraging direct payments and personal budgets, there is also a strong tendency to bring in more choices through more social care providers, which is also an important aspect of personalisation. The middle phase stress on choices is thus a key issue in the phase following and older people may potentially also sometimes be like consumer-citizens (Fotaki, Reference Fotaki2011), combining individually choice-and-exit-in-a-market with being forced to become responsibilised agents, with limited resources and choices (Fotaki, Reference Fotaki2011; Alm Andreassen, Reference Alm Andreassen2018).

As a rhetoric analysis our findings also included language changes. In the Norwegian documents this is relatively clear, starting with the term ‘pensioners’ (respected for their contribution to society), then changing to ‘individual users’ (underlining an early choice logic) and in current times making them ‘seniors’, expressing the new expectations of older people to be independent and resourceful. The early English document mostly uses the term ‘elderly people’, but the later documents predominantly use ‘people’ and ‘individuals’, referring to all adults user groups, or sometimes ‘older people’ when referring specifically to that group. ‘People’ appears to underline the continuous co-production idea, and ‘individuals’ the choice logic, strongly emphasised from the implementation phase.