The 1995 Mental Health (Patients in the Community) Act................ 166 ...... care16 and scandals involving serious neglect of, and crimes committed by, users in ...... users, from the historical literature's descriptions of lunatics and imbeciles to modern ...... sult of patronage from 16,000 officials in 1800, to 40,000 by 1850. There.
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The Governance Gap Central-local steering & mental health reform in Britain & Sweden
Wendy Maycraft Kall
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For Tilde, Tasha & Erik In memory of my father
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Contents
Abbreviations ................................................................................................. iv Glossary of English & Swedish terms .......................................................... iii Acknowledgments......................................................................................... iii Chapter 1 ......................................................................................................... 5 Introduction: The Governance Gap ................................................................ 5 The reform puzzle: similar reforms – two worlds ...................................... 7 Similar reforms? .................................................................................... 7 Reform results: two worlds? .................................................................. 8 Policy instrument: the hard & soft governance debate ....................... 12 The research problem: objectives & research questions .......................... 13 The Governance Gap: theoretical explanations........................................ 14 Policy instruments & good governance ............................................... 14 Dimensions of influence: a Triad of Influences ................................... 17 Scope limitations.................................................................................. 21 Research strategy: design & methods ...................................................... 23 Research design ................................................................................... 23 Methodological considerations ........................................................... 25 Structure and disposition of the book ....................................................... 36 Chapter 2 ....................................................................................................... 37 Reform & policy background: ...................................................................... 37 asylum to community care ............................................................................ 37 Mental health: international historical developments............................... 37 The traditional asylum model – historical perspectives ...................... 38 Creating the conditions for community mental care ................................ 42 Mental illness perceptions & social change ........................................ 42 New treatment methods ....................................................................... 45 Administrative change & mental care reform ..................................... 46 Summary – creating reform conditions ............................................... 49 The reform process in Britain & Sweden ................................................. 49 Organisation of health & social services in Britain & Sweden ........... 50 Britain: the Community Care reforms – policy development .............. 51
Sweden: mental health reform (psykiatrireformen) policy .................. 57 Conclusions: background & reform process ............................................ 61 Conditions for reform .......................................................................... 61 Reform process in Britain & Sweden – were the reforms similar? ..... 62 Chapter 3 ....................................................................................................... 65 The mental health reforms & steering instrument choice ............................. 65 Policy steering instruments ...................................................................... 65 Choosing steering instruments: carrots, sticks & sermons ................. 66 Britain: governance, steering & instrument choice .................................. 70 Regulatory steering.............................................................................. 70 Financial steering ................................................................................ 78 Information steering ............................................................................ 80 Sweden: governance, steering & instrument choice................................. 84 Regulatory steering.............................................................................. 84 Financial steering ................................................................................ 89 Information steering ............................................................................ 91 Conclusions: steering strategies in Britain & Sweden ............................. 95 Chapter 4 ....................................................................................................... 99 Constructing the invisible frame: .................................................................. 99 A Triad of Influences .................................................................................... 99 Influencing governance: public reforms & policy styles ....................... 100 Public management reform & policy instruments ............................. 100 National policy styles & steering choice ........................................... 104 Developing a typology: A Triad of Influences ....................................... 108 Administrative & institutional traditions influences .............................. 111 What is an administrative tradition? ................................................. 112 Prior research: administrative traditions .......................................... 113 Studying the influence of administrative traditions on steering ........ 117 Professions ............................................................................................. 120 What is a profession? ........................................................................ 121 Prior research: professions & the state............................................. 124 Studying the influence of professions on steering choice .................. 130 Policy framing ........................................................................................ 133 What is policy framing? ..................................................................... 133 Prior research: policy framing .......................................................... 134 Studying policy framing & steering choice........................................ 137 Constructing the Triad of Influences: conclusions ................................. 142 1. Administrative & institutional traditions.................................. 143 2. Professions ............................................................................... 143 3. Policy framing .......................................................................... 144
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Concluding remark ............................................................................ 146 Chapter 5 ..................................................................................................... 147 Administrative Traditions ........................................................................... 147 What is an Administrative Tradition?................................................ 147 Administrative Traditions in Britain: general conditions ....................... 148 General conditions: institutions, doctrines & conventions ............... 148 General conditions: historical legacies & state building .................. 151 General conditions: Administrative Traditions in Britain ................. 156 Administrative Traditions & mental health reform ................................ 159 1988 Community Care: Agenda for action (Griffiths report)............ 160 The Community Care reform proposals & 1990 Act ......................... 163 The 1995 Mental Health (Patients in the Community) Act ................ 166 Modernising mental health services: safe sound & supportive ......... 169 Modernising Social Services: promoting independence, improving protection and raising standards ....................................................... 173 Discussion: Administrative Traditions in Britain ................................... 177 The level of territorial centralisation in Britain ................................ 178 The level of executive control in Britain ............................................ 179 The level of formal sanctions in Britain ............................................ 180 Summary: Administrative Traditions & steering in Britain .............. 180 Administrative Traditions in Sweden ..................................................... 181 General conditions: institutions, doctrines & conventions ............... 181 General conditions: historical legacies & state building .................. 186 General conditions: Administrative Traditions in Sweden ................ 190 Administrative traditions & mental health reform ................................. 192 1992 The Mental Health Inquiry: Welfare & freedom of choice ....... 193 1994 Government reform proposition ............................................... 195 2001 The New Social Services Act..................................................... 198 2003 Parliamentary Mental Health Debate ...................................... 199 2006 Mental Health Tsar Reports ..................................................... 202 Discussion: administrative traditions in Sweden.................................... 205 The level of territorial centralisation in Sweden ............................... 206 The level of executive control in Sweden ........................................... 206 The level of formal sanctions in Sweden............................................ 207 Conclusions: Administrative Traditions & steering ............................... 207 The level of territorial centralisation ................................................ 207 The level of executive control over administration............................ 209 The level of formal sanctions ............................................................. 209 Conclusion: administrative tradition & steering choice ................... 210 Chapter 6 ..................................................................................................... 213 Professions .................................................................................................. 213
Operationalisation: influence of professions on steering choices ..... 213 Historical influences: the state & social work ........................................ 215 Historical influences: the state & social work in Britain .................. 216 Historical influences: the state & social work in Sweden ................. 221 Analysis: the state and social work – historical influences ............... 227 Professions & the mental health reform in Britain ................................. 231 The government attitude to the social work profession in Britain ..... 231 Influence of the social work profession in Britain ............................. 239 Professions & mental health reform ....................................................... 250 The government attitude to the social work profession in Sweden .... 250 Influence of the social work profession in Sweden ............................ 253 Analysis: professions, influence & the mental health ............................ 261 Conclusions: influence of professions on steering ................................. 264 Conclusions: professional influence in Britain ................................. 264 Conclusions: professional influence in Sweden................................. 266 Conclusions: the professional influence dimension........................... 268 Final conclusions: professions & governance strategy ..................... 269 Chapter 7 ..................................................................................................... 273 Policy framing............................................................................................. 273 Policy framing: operationalisation ......................................................... 274 Operationalisation & method ............................................................ 274 Selection of critical texts.................................................................... 278 Policy framing in Britain ........................................................................ 280 The problem definition....................................................................... 280 Constructing the user......................................................................... 285 State action required ......................................................................... 289 Policy framing & the role of the media ............................................. 292 Discussion – policy framing in Britain .............................................. 295 Policy framing in Sweden ...................................................................... 296 The problem definition....................................................................... 296 Constructing the user......................................................................... 299 State action required ......................................................................... 304 Policy framing & the role of the media ............................................. 309 Discussion – policy framing in Sweden ............................................. 312 Conclusions – policy framing in Britain & Sweden............................... 313 Comparison of framing findings – summary & discussion................ 313 Conclusions ....................................................................................... 315 Chapter 8 ..................................................................................................... 317 Discussion & Conclusions .......................................................................... 317 Governance Gap & Triad of Influence ....................................................... 317
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Empirical conclusions: the mental health reforms ................................. 318 The Triad of Influence & governance choices in Britain .................. 320 The Triad of Influences & governance choices in Sweden ................ 325 Contrasting governance & steering ........................................................ 328 Theoretical discussion & conclusions .................................................... 334 Hard & soft steering – steering instrument choice ............................ 334 National policy styles? – reviewing the evidence .............................. 336 The Triad of Influences & explaining steering styles ........................ 337 Overall findings & final conclusions ................................................. 344 Appendix A: Media review articles ............................................................ 347 References ................................................................................................... 351
Abbreviations
ASW BASW GSCC JP MHA MP NHS NPM SASW SOU
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Approved Social Worker (Britain – Mental Health Specialist) British Association of Social Workers General Social Care Council (Britain) Justice of the Peace (Lay Magistrate/ Administrator) Mental Health Act (Britain) Member of Parliament National Health Service (Britain) New Public Management Swedish Association of Social Workers Statens Offentiliga Utredningar (Sweden – government inquiry)
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Glossary of English & Swedish terms English
Swedish
Asylum County Council/ Health
Mentalsjukhus Authority1
Landsting
Disability Act
Lagen om stöd och service till visa funktionshindrade (LSS)
Executive Agency
Myndighet (Styrelse/Verk)
Freedom of action
Handlingsutrymme
Framework Legislation
Ramlagstiftning
Government Inquiry/Commission
Statens Offentliga Utredningar (SOU)
Home help/home care staff
Hemtjänsten
Instrument of Government
Regeringsform
Local Self-government
Kommunal självstyrelse
Management By Objectives (MBO)
Mål- och resultatstyrning
Mental Health Inquiry
Psykiatriutredning
Mental Health Proposal
Proposition 1993/94:218
Mental Health Reform/community care
Psykiatrireformen
Mental Health Tsar
Psykiatrisamordnare/Miltonutredning
National Board of Health & Welfare
Socialstyrelsen
Municipality
Kommun
Parliament (debate minutes)
Riksdagen (kammarens protokoll)
Peer support
Kamratstöd
Personal Representative
Personligt Ombud
Poor Relief/Poor Law
Fattigvård
Psychiatrically Disabled
Psykiatriska funktionshindrade
Social Affairs Minister
Socialminister
Social Care
Socialvård/socialomsorg
Stimulus finance
Stimulanspengar
Street Level Bureaucrat
Närbyråkrat/gräsrotsbyråkrat
Social Services Act
Socialtjänstlagen (SoL)
Social Services Department
Socialtjänsten
Swedish Association of Local Authorities & Regions
Sveriges Kommuner & Landsting
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The National Health Service (NHS) is not elected in Britain.
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Acknowledgments The teacher obviously thought that I was somewhat deranged! It was the year 2000 and I was sitting in the high school-level class aimed at those who had failed to pass the basic high school certificate taken by Swedish students at age 16. In the tiny town, population 5000, the college had no accelerated Swedish-language programmes. In fact, the adult education college shared premises with one of Sweden’s most famous psychiatric hospitals and some of my classmates were actually living the mental health reform, indeed some of them were still inpatients. That day the topic for discussion future career plans and goals, so I mentioned my long-standing career goal of taking a PhD in political science. However, by the look on people’s faces, I might have well professed the aim of taking a flight to Jupiter! Yet 10 years later here we are and I am writing the final pages of my PhD thesis in political science. It has been a long time in the making as the last decade has been filled with Swedish high school studies, updating my political science Bachelor degree and post-graduate studies. Therefore, this book is the culmination of a research ambition dating back almost 30 years and just like the Oscars, there are many people who need thanking. Behind every PhD there are supervisors and I am very grateful to of my supervisors Shirin Albäck Öberg and Paula Blomqvist who have been with me for the entire journey from start to finish. I am very thankful for their support during this PhD process. Their insights, knowledge and attention to detail have been invaluable to shaping this book, as well as the tough and searching questions, including some of their “so what – why is this important to political science?” questions, that have been an essential part of the intellectual and qualitative process that made this book possible. Even when I threw them the odd curve-ball such as my decision to completely re-design this PhD thesis just 12 months ago, they demonstrated their faith and trust in me and my PhD idea and now our journey together has reached fruition and I am thankful for their support. My PhD thesis also forms part of the multi-disciplinary project Democracy and Deprofessionalisation and I would like to thank my project colleagues that formed the magnificent-7 of the “Deproff-project”, Thomas Bull, Ylva Hasselberg, Shirin Ahlbäck Öberg; Niklas Stenlås, Olof Wilske, and Johanna Ringarp. I have really valued our meetings and discussions and the opportunity to gain a wider understanding from the perspectives of our different disciplines of political science, law, history and economic history. I have also enjoyed our dinners and informal discussions over a glass of wine. I would also like to thank all of the people who have read all of parts of this PhD along the way. I am especially grateful to those who attended my manuscript conference, Li Bennich-Björkman, Urban Markström, Ulrika iii
Winblad Spångberg and Bo Bengtsson. They took the time to read a complete, and much longer draft than this final book in just two weeks and offered so much invaluable advice. Other parts of this final book have been presented at conferences and seminars or commented on by others. So I thank all for taking time to give me, assistance or tips along the way. Personal thanks to Evert Vedung, Chris Ansell, Helena Wockelberg, Asbjørn Sonne Nørgaard, Sverker Gustavsson, Bob Smith, Christina Bergqvist, Sven Oskarsson, Hanna Martinek and Maria Heimer. Special thanks also to the “lower seminar”, Jenny Jansson and Maria Johansson, who took time out to read drafts and offer support at time when I really needed some help. There are so many people I need to thank, especially my colleagues here in the Department of Government. Space is too tight to mention everyone individually so thanks to all. Personal thanks to Johan Engvall, Jessica Giandomenico, Viviana Stechina, Lars Davidsson, Gunnar Myberg, Thomas Persson, Tanja Ohlsson Blandy, Johan Tralau, Nils Hertting, Gina Gustavsson, Johanna Söderström and the “fabulous” 2003 introduction group of Pär Zetterberg, Josefina Erikson, Elin Bjarnegård, Gelu Calacean and Björn Lindberg. Special thanks to those who supported me on the journey to get to Uppsala: Richard Evans, Pär Bäckehag, Ingeborg Björnbom, Per Berggren, Judith Narrowe, and Christina Romlid as well as fellow pre-seminar study group friends Andreas Jonsson and Axel Rühmann. In addition, thanks to Michael Howlett and Charles Kaye for including some of my early research in their anthology on mental health. I am also very grateful to Mandy Bengts who has worked so hard, and under pressure of my deadlines, on the language and grammar, and gratitude to Andrew Roberts for his generosity in allowing me to use his drawing on the cover of this book. A final thanks Per Strand who probably has absolutely no idea who I am but was instrumental in starting this process one freezing day in a lecture in Falun in 2001. There are also a few people that deserve my most heartfelt thanks and without whom there would have been no PhD thesis and that it my family who supported me through the process and through the tough times, the deadlines, the printing and the urgent 300km round trips to Uppsala. To Tilde who learned more than she ever wanted to know about footnotes by physically checking over 1000 footnotes to the references and Tasha to helped reference checking and making tea. And to Erik for your love and support in those times when the whole thing seemed impossible and for keeping everything running smoothly at home when I was locked away writing. I love you all and I couldn’t wish for a better family. Wendy Maycraft Kall, Dalarna, November 2010. Post script 28th November; of course as a PhD student you plan a smooth final stage of the PhD process and then the day before it is due to be handed in a freezing minus 10C snow day slip on the ice and you find out that it id possible for a knee to bend more that 45 degrees in the wrong direction so thanks to Erik and Shirin for crisis management – I’m so grateful. iv
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Chapter 1
Introduction: The Governance Gap This book is about governance and steering. In particular, it focuses on the opportunities that governments have to steer the actions of municipalities and other lower level agencies charged with implementing reforms, and on the dimensions that influence the government’s choice of governance strategies and steering instruments. In recent decades public management reforms have resulted in power dispersals as reform implementation has become decentralised and has become located at local levels. However, governments still have a keen interest in ensuring that national reform policies are implemented as they intended, on the ground, by lower levels. So the question is, how do governments achieve this when no they longer directly control the implementation chain and lack direct contacts with reform users who receive their services from local authorities, agencies and other providers? Prior public management reform research, especially New Public Management (NPM), suggested that adopting similar reform policies, based on business management principles, would create convergent governance and steering strategies, using similar rational government tools, not specific to a particular country. However, this expected convergence did not occur; in the past decade, research has shown many instances where national governments appear to choose similar reform policies, yet where differences emerge in the reform results.2 Instead of a convergence of rational business instruments, there is evidence that “nations matter”3 with differing national trajectories for implementation design and steering instruments despite similar policies. Feick argues that an “invisible frame” exists, structuring and framing policies in country specific ways.4 Thus the reform ideas and aims appear the same; the contents and measures are similar; yet the steering and implementation strategies diverge leading to different outputs and outcomes which scholars argue represent national policy reform patterns.5 2
See for example Hood 1991; Bevir et al 2003 pp.1-3; Pollitt & Bouckaert 2004 pp. 96-102; Pollitt and Summa 1997; Power 1997 p. 42; Feick 1992. 3 Feick 1992 p. 257. 4 Feick 1992 p. 262. 5 See for example discussion in Kelman 1981; Arentsen 1998; Bevir et al 2003; Bevir & Rhodes 2003; Pollitt & Bouckaert 2004; Painter & Peters 2010.
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The idea of national policy styles is not new; the concept has been debated since the 1980s, yet the literature tended to focus on the national policy styles of policy-making.6 However, in this study the focus is on implementation and steering issues; it aims to explain the puzzling differences of why where states appear to have decided for the same reform, significant differences of implementation governance occur? It is unclear whether these differences result from ‘disobedient lower level actors’ evading government intentions, or whether national steering strategy choices are also important. One under-researched issue is the existence of a ‘governance gap’ relating to the internal7 steering mechanisms that central government policy-makers can utilise in order to steer the actions of frontline implementers. The idea is that although policy-makers may choose the same types of policy reform, there may be different national preferences for governance and steering that create differing outputs and outcomes. Thus I study this ‘governance gap’ of steering relationships between central and local levels in order to understand why governments steer in the way they do and what influences instrument choice. One example, of reforms with similar objectives, yet divergent governance and steering strategies, were the mental health reforms8 in Britain9 and Sweden of the mid-1990s. These reforms transferred responsibility for the social care of the psychiatrically disabled from institutions and asylums to municipalities, aiming to create normal living for patients in the community. Mental health is an umbrella term, often used as shorthand, to describe a number of different services relating to illnesses, disorders and conditions of the mind rather than the body.10 Most often mental healthcare is regarded as twofold: firstly in terms of psychiatric and medical treatment needed to treat the effects of symptoms and to control the disorder; and secondly, the social care of the psychiatrically disabled, many of whom require support and care with daily-living tasks including housing and household tasks, daily activities, education and training as well as social contacts. This book focuses on a social care perspective of how the governments steered municipalities. Thus the aims are to analyse which dimensions form an invisible framework that influences government steering choices, in order to develop a model to help 6
See for example the study of European states by Richardson et al 1982. Internal steering relates to steering within the administrative system, for example, between state and administrative agencies or local government. External steering on the other hand, relates to the governments direct steering aimed at users and is not considered in this study. 8 Mental health reform is used to describe the mental health elements of the Care in the Community reforms in Britain and the mental health reform, or Psykiatrireformen in Sweden. 9 When I refer to Britain in this book, I am focussing on England and Wales as there were separate arrangements for Scotland and Northern Ireland. 10 There are many types of mental illness: psychotic disorders including schizophrenia; personality disorders; anxiety disorders, for example agoraphobia, post-traumatic stress disorder, obsessive compulsive disorder, types of depression, eating disorders etc. There are also mental disabilities including lifelong conditions such as Down’s syndrome, conditions that develop later such as Alzheimer’s syndrome, and developmental disorders or brain injuries such as cerebral palsy. There is also a range of neuropsychiatric disorders such as autism. 7
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understand why Britain chose hard governance, while Sweden chose soft governance to steer municipalities implementing the mental health reforms?.
The reform puzzle: similar reforms – two worlds The mental health reform was a perfect example of a ‘slow burn’ reform process, decades in the making. Although this book addresses the mental health reform from state-municipality governance and steering perspective and not a user-perspective, I will say a little about the reform outcomes for users and outputs for municipalities in the following section. My study of the cases of Britain and Sweden focuses on the decade from the early-1990s until the mid-2000s, although the idea of reform had been debated for decades. There was a broad political consensus that municipalities should have a greater mental health role, yet little reform activity occurred.11 Reform attempts appeared to get ‘stuck’ at a rhetorical level, with few concrete achievements owing to organisational and financial obstacles acting as a disincentive to municipal mental health services. However, in the late 1980s, pressures built to find enduring solutions rather than previous ad-hoc arrangements.12 Thus the mental health reforms aimed to create the conditions for the psychiatrically disabled to live in the community.
Similar reforms? In Britain and Sweden the mental health reforms had similar stated aims of normalising the psychiatrically disabled’s living arrangements and dividing responsibilities between local agencies: health services would remain responsible for medical care, while municipalities became responsible for social care.13 In both countries the reforms reflected popular public management reform ideas of the 1990s.14 First was decentralisation by the transfer of responsibility to lower level agencies: in the case of mental health specifically a municipalisation to local government. Second was a disaggregation where the full-service asylums were broken up and services divided among specialist agencies. Third efficiency and cost controls based on ideas that providing home-care services would be cheaper and more efficient than asy11
The reform ideas originated in the 1950s and 1960s when mental hospitals transferred from state to health authorities: See Mental Health History Timeline; SFS 1966:293. 12 These pressures are discussed in greater detail in Chapter 2: See for example Carrier & Kendall 1997 pp. 11-19; Rogers & Pilgrim 2001 pp. 61-84; Markström 2003 pp. 113-125. 13 Regeringens proposition 1993/94:218; NHS and Community Care Act 1990. 14 The community mental care reforms are not considered a specific example of a New Public Management reform owing to the basic idea of decentralisation of living arrangements and social care services existing in the decades prior to the NPM business management reforms. However, they do represent a type of reform that was popular at the time for breaking up monolithic services and developing more specialist sectorised organisations.
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lums. Thus the mental health reforms were not only constructed in a similar manner, but the timing and contents were also similar and implemented less than two years apart. Thus in summary the reforms were based on: Municipal responsibility: to finance and provide social care services; Community support: provide support services for community living; Cost savings: from asylum closures and cheaper domiciliary care.15
Reform results: two worlds? There were some similarities of outcomes for users including poor access to care16 and scandals involving serious neglect of, and crimes committed by, users in the community.17 However, there were also puzzling differences in reform results; despite similar aims, the reform created different worlds. The British “world” of mental health reform The reform in Britain was characterised by a strong bureaucratisation and centralisation with an emphasis on coercion. This impacted on both user outcomes and organisational results where government priorities dominated. In the long-term, the outcomes for users involved an erosion of rights, greater compulsion and low quality services. Some rights became conditional on users’ compliance with state agencies, while privatisation of user-care often emphasised cost control rather than quality in service markets and contracts. There was an increase in coercion and the psychiatrically disabled’s civil rights were contingent on compliance with state agencies. The idea of freedoms and community living soon gave way to a reform characterised by a public protection ethos that further restricted users’ citizenship rights, including the indefinite detention of certain groups even if no crime had been committed.18 Paradoxically, users who sought voluntary help had no right to 15
In Britain, the reform was introduced by the 1990 National Health Service (NHS) and Community Care Act, implemented on April 1 1993, and in Sweden the reform is based on Government Proposition 1993/94:218, Conditions of the Mentally Disordered (Regeringens Proposition: Psykiskt stördas villkor) and implemented from January 1 1995: Regeringens proposition 1993/94:218 p. 7-16; NHS and Community Care Act 1990 - III. 16 Criticisms related to practical issues such as need assessments; waiting times; tailored housing and activity services; poor access to psychiatry; and inter-agency coordination: See Social Services Inspectorate 2004a p. 24; Social Services Inspectorate 2005 pp. 9 & 26; Kaye and Howlett 2005 p. 52; Hadley & Clough 1997 p. 134; Carpenter & Sbaraini 1997; Socialstyrelsen 1999a pp. 8-13 & 57-63 & 106; Markström 2003 pp. 181-182; Socialstyrelsen 2005. 17 For debate and criticisms of high-profile cases regarding the psychiatrically disabled such as the murders of Jonathan Zito in Britain and Anna Lindh in Sweden: See Cold 1994 p. 449, Dagens Nyheter 21/5-03; Expressen/GT 25/5-03; Dagens Nyheter 27/9-03; Expressen 30/9-03 18 Risk and supervision in directive Local Authority Social Services Letter, LASS (94)4. See also Department of Health 1993b: Mental Health (Patients in the Community) Act 1995.The government rejected the idea of care rights: Independent 13/1-94; Independent 10/10-94; Independent 8/7-93; House of Commons 2000 questions 177-186 & 147. Interventions included assertive outreach; forced medication; statutory supervision; residence at specified
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receive it, yet when their condition deteriorated, they had no right to refuse treatment. Users were subjected to greater control than criminals, despite few having committed any crime. In Britain there was also strong an ideological commitment to a mixed economy of care meaning extensive privatisation and market mechanisms. State grants were conditional on contracting out direct care irrespective of user needs and care quality. The domiciliary care market was new and the contractors were untested, yet grant targets skewed the market to favour nonstate contractors rather than free competition.19 Many users were discharged into unsuitable and temporary accommodation without support, such as private bed and breakfast hotels.20 Thus user needs were subordinate to government preferences for market mechanisms. The British reform was characterised by bureaucratisation and centralisation in order to meet government requirements. Municipalities were obliged to follow central directives regarding market mechanisms, managerial procedures and structures. The ethos of social services departments shifted from traditions of professional and direct care organisations to market management organisations focussed on paperwork, contracting and resource rationing. Thus social services became enablers of care rather than direct-care providers. However, this emphasis on the market caused accountability problems for users. Some users received services from several different providers and it was difficult for users to identify who was responsible for the reform services they received between the plethora of agencies involved: state agencies,21 municipalities, health services and numerous contractors providing direct services. A final organisational result was the state-regulated specialist mental health professional role. Britain had a pre-existing statutory mental health role, Approved Social Worker (ASW),22 and a long tradition of the social work method casework23. However, government directives ordered a shift addresses; restrictions on movement; and powers for public authorities to enter homes. House of Commons 2000 para. 125-151; Social Services Inspectorate 2004a p. 3. For documents on new Mental Health Act on the Department of Health homepage, see section History of the Mental Health Act 2007: Department of Health homepage; The Mental Health Bill: Questions and Answers, Guardian 17/11-06. The Manic Depression Fellowship found 97% were reluctant to seek help owing to the threat of coercion. House of Commons 2000, Questions 177-186 & Memo Manic Depression Fellowship. See also Carpenter & Sbaraini 1997 p. 89. 19 Mixed economy of care discussed in Hadley & Clough 1997; Carpenter & Sbaraini 1997; Knapp et al 1997; Trnobranski 1995 House of Commons 2000 paragraph 43. 20 See Kaye & Howlett 2005 pp. 51-52. 21 Municipalities were required to develop standardised systems for care management, using formulae to categorise users into standardised priority bands: See Social Services Inspectorate 2004b; Hadley & Clough 1997; Means et al 2003. 22 The 1983 Mental Health Act required municipalities to appoint specialist mental health Approved Social Workers (ASW): See Institute of mental health practitioners: Guide to the Mental Health Acts; Community Care website: Careers in social work - Adult services. 23 Casework is a social work method focussed on an individual’s whole life situation: See Oxford English Dictionary: casework. It involves a holistic approach rather than a narrow focus on an acute or presenting problem.
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from traditional professional and clinical roles as direct user-care was redefined as unskilled tasks and contracted out to private companies and voluntary groups. Instead, government directives emphasised municipal social workers in managerial roles such as market management, expert supervision and risk-management.24 Thus in Britain there was a strong social work role, but one that was determined and regulated by the state. The Swedish “world” of mental health reform In Sweden the reform was characterised by extensive local freedoms and flexibilities. However, local freedoms and low levels of central guidance also meant extensive variations and fragmentation in reform’s interpretation, content and structures for both users and organisations. The main user outcomes were that the rights of the Disability Act were difficult for users to enforce in practice; the framework legislation gave municipalities’ extensive flexibility to interpret the Act, resulting in wide variations of interpretation.25 It was assumed that creating legal rights for users to receive disability and social services would ensure municipal compliance. However, the courts as enforcers of the Disability Act turned out to be a toothless instrument; even where users obtained a favourable court decision, in more than a third of cases municipalities ignored the judgement. There were no penalties for municipalities included in the Act as the government had failed to envisage municipal disobedience of court decisions.26 Thus despite an emphasis on users’ citizenship rights, implementation was sometimes patchy and without strong sanctions. In addition, while independent services were an option for municipalities, unlike Britain it was not obligatory. The early services were often public or combined with voluntary projects, although many projects closed when state funding ended.27 In the long-term, some municipalities contracted domiciliary care to private companies, but this was a local municipal decision, not a government directive. In Sweden organisational results were dominated by municipalities’ extensive local organisational freedoms and flexibilities, contrasting with state direction in Britain. Framework legislation gave scope for municipalities’ own interpretations of reform legislation to determine service ambition, con-
24
Kemshall 2002 pp. 92–102. The Social Services Act (SoL) gave “reasonable” living standards, while the Disability Act (LSS) requires “good”: See Socialstyrelsen 1999a pp. 50 & 112. 26 Based on a National Board of Health and Welfare review of Disability Act cases. An appeal attempt to Sweden’s Supreme Court to force specific performance using debt recovery law (utsökningbalken) failed by a three to two majority: See Socialstyrelsen 1999a pp. 127-134. 27 See Proposition 1993/94:218 pp. 26 & 87-89. Evaluations concluded that peer support (Kamratstöd) user-led groups provided activities that enhanced users’ quality of life. Municipalities did not accept responsibility for voluntary services; indeed some resented competition from voluntary groups: See Socialstyrelsen 1999 pp. 149-174. 25
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Introduction: The Governance Gap
tent and structures.28 However, a consequence of local flexibility was a high level of variation and fragmentation. State finance also had the unintended consequence of creating numerous multi-agency projects outside mainstream structures. Many closed after three years as municipalities and state-agencies failed to take financial responsibility for them.29 In Sweden the loose steering arrangements also created accountability problems for users with wide variations as services were divided between a variety of departments, units and projects.30 In addition, the stimulus finance projects often created services in temporary, multi-disciplinary projects which further blurred accountability.31 Users had to navigate complex decentralised organisations and projects, with wide variations in actors, ambition, content and quality of care and support. In Sweden, unlike Britain, there were not state-determined professional reform roles; thus staffing was decided by each municipality. Few Swedish social workers were trained in mental health,32 and many played only limited and mostly administrative reform roles.33 Direct care was often provided by unqualified staff,34 and municipalities often ‘bought in’ expertise by recruiting former asylum staff with medical training rather than developing social perspectives. However, the government did create one social work role, Personal Representatives (Personligt Ombud), yet the role was located outside Social Services and not reserved for social workers.35 Thus staffing policies varied between individual municipalities; yet the specific social staffing role was located outside municipalities despite their social care responsibility. “Two worlds” discussion Despite similarities in the aims and content of the reforms, the outcomes and results reveal puzzling differences. There is evidence that the different outcomes may be linked to government governance and steering strategies. In Britain central priorities dominated user outcomes and organisational results. These appear linked to the government’s strong role in directing the reform, 28
Municipalitites had different structures and organisations; eight years on, only 50% had inventories users in the area: See Socialstyrelsen 1997a p. 98; Socialstyrelsen 1997b p. 25; Socialstyrelsen 1999a pp. 128-129 & 134; Socialstyrelsen 2003 pp. 36-45; Socialstyrelsen 2005 p. 49. Some services involved paper transfers, complete with staff, from county to municipality rather social perspective services; 50% of activities and 33% of housing, transferred on paper: See Socialstyrelsen 2005 pp. 12-13, 49-53 & 179; SOU 2006:100 pp. 157-166. 29 Reform evaluations and the Board’s General Director warned that project survival was doubtful: Socialstyrelsen 1996a p. 25 & 52; Dagens Nyheter 8/5-98a. See also Socialstyrelsen 1998 pp. 8-9, 56-58; Socialstyrelsen 2003 pp. 124-125; SOU 2006:100 pp. 507-510. 30 See for example discussion in Socialstyrelsen 1998 p 147-8. 31 The Mental Health Tsar argued that stimulus finance created short-term projects involving multiple actors rather than stable long-term care structures: See SOU 2006:100 pp. 507-510. 32 See Socialstyrelsen 2005 pp. 144-145; SOU 2006:100 pp. 455-470, 33 See Socialstyrelsen 2005 pp. 161 & 178-180. 34 Home-help workers were unprepared to support the seriously ill, and were used to doing housework for “healthy and happy pensioners”: Dagens Nyheter 23/3-03 (my translation). 35 The Personal Representative role aimed to provide user-centred support and to resolve obstacles created by other agencies’ poor expertise: See Socialstyrelsen 1999a pp. 134-147.
11
The Governance Gap
using harder top-down36 steering strategies. In Sweden detailed decisions were devolved to municipalities, and the government adopted softer, bottomup steering strategies. Therefore, differences appear linked to the centrallocal steering relationship: a governance gap consisting of steering strategies and instruments chosen to fill the gap between state and municipality. Thus this study aims to increase understanding of the choice of governance and steering strategies selected by the two governments to steer local government responsible for implementing the mental health reform.
Policy instrument: the hard & soft governance debate It was seen previously that the mental health reforms in Britain and Sweden led to “two worlds” of outcomes and results. These appeared linked to two divergent worlds of steering and instrument choices; Britain chose harder, centrally steered instruments whereas Sweden selected softer, looser steering instruments based on local freedoms and flexibilities. Therefore, in other words Britain preferred hard governance, while Sweden preferred soft. Public management reforms have had different consequences for governance and steering strategies, and governance literature sometimes refers to steering in terms of hard and soft governance. The idea of hard governance is not a return to the traditional ‘Weberian’ hierarchy of bureaucratic state steering; instead, it refers to the use of direct and compulsory steering forms to ensure frontline agency compliance. Thus hard governance often occurs where the state combines decentralised implementation with regulatory recentralisation; the government devolves power and certain administrative tasks to frontline implementers, yet demands compliance with centralised rules and regulations.37 Lower level powers and freedoms are restricted by the framework, albeit using indirect mechanisms. Therefore, the use of incentives and freedoms for compliance combined with prescriptive standards and sanctions is summarised by King as “soft words and big sticks”.38 Soft governance is harder to define but usually refers to non-binding selfregulation forms and “learning” processes based on flexible instruments, information and guidance.39 Soft governance is a bottom-up mechanism that 36
Top-down models reflect a strict hierarchy, mechanical compliance, but low discretion. Bottom-up models focus on lower-level discretion: Weber 1987 (trans) pp. 58-77; Pressman & Wildavsky 1984 pp. 87-124; Winblad Spångberg 2003 pp. 52-56; Wockelberg 2003 pp. 29-30 & 318; Barrett 2004; Sabatier 1986; Rothstein 2002 p. 98; Lipsky 1980; Hjern1982. 37 Hard steering includes regulation, rules, earmarked finance, audit and inspection; targets. See Regulatory State research, Majone 1997; Scott 2004; Moran 2002 & 2007; and New Instruments Regulation, Knill & Lenschow 2004 pp. 219-223. 38 King 2007. 39 The steering instruments of soft steering might includes: self-governance; informative mechanisms; best-practice guidance; monitoring; and peer pressure. Soft steering is discussed in Winblad 2007; soft law in Mörth 2006; and the models of self-regulation and the open method of coordination (OMC) in Knill & Lenschow 2004 pp. 219-224.
12
Introduction: The Governance Gap induces compliance through persuasion, although the “shadow of the state” remains to remind agencies that the state could choose to intervene.40 Thus soft governance is loose and flexible, granting frontline agencies freedoms and discretion to formulate implementation strategies. The prior literature on soft and hard governance has not been linked to the policy steering instrument discourse, with the exception of general ideas of a progression from softer information instruments to harder regulation forms. However, in the empirical overview above, it appears that the differing reform results were linked to steering choices: Britain chose coercive and binding strategies linked to hard governance, whereas Sweden selected flexible instruments linked to soft governance. Therefore, a more detailed analysis of the steering instruments selected by both governments is needed to identify and classify the instruments used. Yet the relationship between hard and soft governance and choice of policy steering instruments has not been fully operationalised in previous literature, and no typology exists to help me sort and classify the reform’s steering instruments in terms of hard and soft governance. Therefore, it is necessary to construct a model for classifying policy steering instruments in terms of hard and soft governance in order to analyse the actual steering instruments chosen for the mental health reforms in Britain and Sweden.
The research problem: objectives & research questions The research aim of this book is to contribute to the development of a theory relating to modes of governance, and in particular contribute to the development of a theory of governance and steering strategy selection. The overall objective is to understand what dimensions influence governments’ choices of steering strategy and selection of specific steering instruments. I have formulated this overall aim into the following research question: Why did the British Government choose hard internal governance and steering strategies while the Swedish Government chose soft for the mental health reforms? Therefore, the objective of this thesis is theory development. It will identify and analyse dimensions that may influence the state’s choice of governance strategies and policy steering instruments in order to steer the actions of lower levels responsible for reform implementation. In order to study these questions, I focus on steering relationships between central government policy-makers and municipalities responsible for implementing mental health reforms. Thus my argument in this PhD thesis is that in order to understand policy reforms, it is necessary to understand what 40
Knill & Lenschow 2004 pp. 220-222. See also Winblad 2007 pp. 142-145.
13
The Governance Gap happens in the “governance black box” between the reform decision and implementation. I contend that the government’s choice to select certain types and forms of governance and steering strategies while ignoring others has a strong influence on reform outcomes and results. Therefore, this book focuses on the governance gap between central policy-makers and lower level implementers in order to analyse what influences the selection of governance strategy and policy steering instruments. However, it is important to point out that my main research interest with this PhD thesis is theory development, not theory testing to establish strict causality. The previous literature has included some suggestions as to what may have influenced governance and steering strategy choice, yet there has been little theory development relating to hard and soft steering and few empirical studies, and this remains an under-researched area. My focus is to develop a theory that can be used as the basis of a theoretically guided discussion of the empirical case of the mental health reforms in Britain and Sweden. This study will increase understanding of empirical mechanisms to determine whether the theoretical model can serve as the basis of future testing. Therefore, the aim of this study is theory and hypothesis development in order to identify and develop theoretically a number of dimensions that might influence the choice of governance and steering strategy.
The Governance Gap: theoretical explanations The empirical overview discussion earlier in the chapter revealed that despite the similarities of the reform aims and contents, reform results diverged and there appeared to be significant differences in relationships between government and implementing municipalities. It is this governance gap between central and local government that is the focus of this study. Thus although this book is about the implementation phase, the aim is not to study frontline implementation direct to reforms users, but instead to analyse modes of governance and influences on government steering strategies; even where implementation occurs at lower levels, governments do have an interest in ensuring that national policies, approved by Parliament, are implemented by lower levels as intended. Therefore, the book focuses on what influences governments to choose in the way that they do when it comes to selecting steering strategies and instruments to fill this governance gap between the state and lower level implementation agencies.
Policy instruments & good governance Policy instruments and issues of hard and soft steering are related to statelocal agency relationships and ultimately performance assessments of
14
Introduction: The Governance Gap
whether reforms achieved good governance.41 Pierre and Peters describe governance as “notoriously slippery”,42 lacking a universally accepted definition. Therefore, I use using a simple, state-centric definition of governance as a steering mechanism where I focus on relationships and steering instruments selected by the governments in Britain and Sweden to steer the mental health reforms. Thus in this study I use the following definition: governance is the steering relationship between the centre and lower level agencies. Policy steering instruments are a central part of the policy process where governments choose concrete strategies to implement reform programmes. Bemelmans-Videc identifies two types of policy instruments: internal instruments where governments steer frontline agencies; and external instruments that are used to steer reform users directly.43 This book focuses on internal steering: the strategies chosen to fill the governance gap between policy-makers and implementers. Vedung argues that the choice of steering strategy is the central mechanism for governments to steer the implementation of national policies and that “choosing the most appropriate combination is one of the most intricate and important in strategic political planning.”44 However, despite governance strategy instrument choice being the central link between policy-makers and frontline reform implementation, Howlett and Vedung both contend that instrument choice is something of a “missing link”, an under-researched area of political science and public administration.45 Thus Vedung argues that the “systematic, empirical study of policy instruments still has hardly got off the ground”.46 In recent years, typical policy reform studies have focussed on relationships between reform objectives and outcomes, not the “black box” mechanisms of implementation phase steering. However, as I demonstrated in the empirical section above, analysing the aims and outcomes of the mental health reform left us merely with a puzzle; similar reform aims did not result in similar outcomes. Therefore, the black box must be analysed in order to understand the reform. Policy steering instrument types: “carrots, sticks & sermons” Governments have an extensive choice of tools and instruments that can be utilised for implementing policy reforms. Although the exact number and type are hotly debated among policy instrument researchers,47 there is broad agreement on three broad categories of regulatory, financial and information instruments.48 Bemelmans-Videc and Vedung describe the main policy steer41
See Linder & Peters 1989 p. 41; May 2003 p. 229; Bemelmans-Videc 1998 p. 7. Pierre & Peters 2000 p. 7. 43 See for example Bemelmans-Videc 1998 p. 3-4. 44 Vedung 1998b p. 21. 45 Howlett 2009 p. 84; Vedung 1998b p. 50. 46 Vedung 1998b p. 50. 47 An overview of this debate is presented in Chapter 3. 48 See for example Vedung 1998; Howlett 2009 p. 82. 42
15
The Governance Gap ing instruments as “carrots, stick and sermons”. Carrots are incentive steering forms, often financial, where the addressee is induced to comply. Sticks are regulatory, and use binding instruments to force compliance. Sermons are based on information-steering and aim to persuade compliance by exhortations and education.49 Each category contains a variety of concrete instruments, and in addition, organisational structures must be created as a precondition for using these instruments.50 The concepts of policy steering instruments will be discussed in more detail in Chapter 3; however, it is clear that governments have many options for steering, using harder or softer instruments.51 This study focuses on the governance and steering strategies chosen by Britain and Sweden for steering the mental health reform, and the factors which may have influenced governance and steering strategy choices. Governance, steering & reform The public management reform and NPM literature emphasise changed relationships between central policy-makers and frontline implementers that resulted from devolving implementation to local government: the shift from government to governance.52 Although concepts governance are discussed in more detail in Chapter 4, a central idea is that governance reforms represented a steering dilemma for the state; the state wanted to achieve national policy goals, yet had no direct contact with frontline services as relationships between central and local actors were less hierarchical. Therefore, the main means by which governments could influence implementation was by the choice of steering instruments. Pierre asserts that the governance problem concerns the state’s steering capacity.53 The architects of NPM reforms assumed that steering strategies would converge as governments adopted similar business model reforms. Thus research interest in steering declined as the literature was dominated by NPM models based on assertions that instrument choice was a mechanical process.54 However, the evidence of recent decades is that there is no single uncontested road to reform; despite seemingly similar reform objectives, worldwide governance strategies have di-
49
Carrots include benefits and taxes: Sticks, use binding legislation and rules: Sermons use persuasion and information: See Bemelmans-Videc 1998 p. 9; Vedung 1998b pp. 50-51. 50 Some literature also includes organisation as a steering instrument category such as Howlett 2009 pp. 80-81. However, Vedung contends that organisation is not independent but exists on a different level as a prerequisite to other categories: Vedung 1998b p. 51. I follow Vedung and is limit my study to regulatory, financial and information steering to avoid duplication. 51 See Heidenheimer 1990 p. 3 in Bemelmans-Videc 1998 p. 2. 52 Changed central-local relationships resulting from, decentralised organisations; coordinating over organisational boundaries; and direct implementation using public, private and voluntary actors: See Pierre & Peters 2000 pp. 2-7 & 15-24; Pierre 2000 p. 3-6 53 Pierre 2000 p. 3. 54 See for example discussion in May 2003 p. 225.
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Introduction: The Governance Gap
verged.55 Thus these differences in reform results have renewed research interest in instrument choice and national policy styles. Thus in this study I reject the ideas espoused by NPM and business focussed literature that steering instruments selection is a strictly mechanical, process based on a single-set of rational instruments. As I discussed earlier, the similar reform aims in Britain and Sweden did not lead to similar results; there were different national preferences. However, few studies have operationalised and analysed influences on steering instrument selection as structured comparative studies. Therefore, I aim to analyse these issues and add to the literature on governance and steering instrument theory.
Dimensions of influence: a Triad of Influences This book focuses on developing the theoretical approaches to governance and steering choices model by identifying which dimensions may be influential in determining governments’ preferences for hard and soft steering strategies. Earlier research relating to policy instrument choices contains a number of suggestions of factors and dimensions that may influence governance and steering choices and this earlier theoretical literature will be reviewed more fully in Chapter 4. However, when it comes to the influences on internal governance and steering strategies between the state and local government there appear to be three dimension-types are repeatedly suggested. The first relates to the historical legacies of the state-building process and factors such as institutional developments and administrative doctrines and culture which form Administrative Traditions. The second dimension-type relates to the policy process, which is often mediated by professions, especially in the case of welfare policy. Thus the prevailing professional culture, norms and powers and level of trust between state and professions, means that Professions are a potential influence on governance strategies. The final dimension-type is based on ideas that politicians’ ideological beliefs and values are an active and dynamic influence on policy instrument choices, which create a Policy Frame and preferences for particular steering strategies.56 Therefore, this Triad of Influences offers three dimensions that may increase our understanding of governance and steering strategy choices, and will form the basis of this study. The three dimensions can be summarised as follows: i. An administrative and institutional traditions dimension: based on the path dependency of historical legacies; ii. A professional dimension: based on the influence of the main professions involved in the field in shaping steering strategy; 55
For example literature by Bemelmans-Videc 1998; Linder & Peters 1989; Arentsen 1998 discuss policy instrument choice in general terms as related to national policy style. 56 See Peters 2002; Bemelmans-Videc 1998; Salamon 2002a; Salamon 2002b; Vedung 1998; Rist 1998; May 2002; Ringeling 2002; Feick 1992; Linder & Peters 1989 Howlett 1991.
17
The Governance Gap A policy framing dimension: based on ideas that the government’s attitude to the policy problem, sector and users is reflected in how it chooses to steer. Few of these dimensions have been fully operationationalised theoretically or analysed empirically from governance and steering perspectives; however, the convergence of the dimensions in different literature leads me to believe that they will form a fruitful starting point basis for my theoretical development and analysis of hard and soft steering in relation to the mental health reforms. These dimensions will be formulated and operationalised theoretically in more detail Chapter 4, and analysed in relation to the empirical case of the mental health reforms in Chapters 5-7. However, I outline my research approach to these dimensions in the sections below. iii.
Administrative & institutional traditions Administrative traditions are historical and institutional legacies, and constitutional doctrines that combine to form a framework that guides the government’s choice of governance and steering instruments. Prior research on administrative traditions, for example by Peters, Lijphart, Pollitt, Knill, Von Thiel, Bevir and Rhodes, is based on the notion that path dependencies exist between the historical, institutional legacies and current administrative and steering choices. These path dependencies create preferences for familiar, well-trodden ‘paths’ that are well-known and accepted as legitimate. The current choices of similar reform types such as decentralisation, market mechanisms and disaggregation will display variations in results as traditions influence government interpretation and steering choices.57 Therefore, while public management trends with convergent ideas may come and go; differences remain owing to the effects of these underlying legacies that influence the capacity and content of governance. The path dependency is not, however, completely deterministic; governments may change path or develop new traditions. However, decisions often broadly conform to the predictable pattern of the administrative traditions.58 The administrative traditions may influence governance and steering choices by guiding decision makers to follow accepted steering patterns. Therefore, I believe that the dimension of administrative traditions should be perceived as mechanisms that constitute an outer framework: a filtration mechanism through which new ideas, ideologies and pressures for reform are considered and interpreted. The idea of an influence from administrative traditions is not a new concept; however, most previous studies have focussed on NPM inspired designs of comparing of aims and results rather than steering mechanisms. However, my study focuses on a steering perspective; holding constant the 57
See Peters 2001 & 2005; Pollitt & Bouckaert 2004; Pollitt & Summa 1997; Knill 2001; Van Thiel 2006; Bevir & Rhodes 2003; Lijphart 1999. 58 See Knill 2001 pp. 21-3; Thoenig 2003 pp. 128-9; Pollitt and Bouckaert 2004 p. 23.
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Introduction: The Governance Gap
policy formulation phase by using reforms with similar aims and contents, and analysing the choice of hard and soft steering from an ‘administrative traditions’ dimension which is an under-researched issue. In addition, new research casts doubts on the hegemony of administrative traditions as an explanation of reform results. Peters and Painter’s 2010 book concludes that there is no clear pattern regarding the explanatory power of administrative traditions and that “there can be no clear statement either that traditions determine policy choices”. 59 Therefore, it appears that this is a timely moment to conduct a structured comparative study to increase understanding of the relationships between administrative traditions and steering choices. Summary: Dimension one – Administrative Traditions The first dimension of my research strategy is that the steering differences may reflect differing administrative traditions relating to institutional and administrative customs and cultures. This dimension will be formulated in more detail in Chapter 4: however, the areas that I consider may influence central-local steering relationships include: the level of territorial centralisation; the level of executive power; and the ability of the centre to impose sanctions on lower levels of government. Professions Professions have a central role in welfare reform decision-making;60 indeed, the debate between issues of democratic versus expert power has existed since antiquity.61 Linder and Peters argue that professional power and preferences influence government perceptions of policy sectors and how they choose to steer.62 The importance of professions is related to perceptions of legitimacy in the provision of welfare service, and how this influences steering decisions. Abbott contends that issues of professional legitimacy and influence are also dependent on state attitudes and acceptance of professional authority; professional legitimacy can also be affected, in positive and negative terms, by cultural and value changes.63 However, the role of professions is one that while suggested in a steering context, has not been operationalised or analysed empirically.
59
Peters and Painter included an anthology of 14 single case studies: 2010 pp. 234-237. Brante argues that the post-1945 welfare state development gave professionals a significant influence over the policy process, and that professional knowledge and expertise became a new form of authority and instrument of state power: Brante 1989 pp. 37-38. 61 Since antiquity philosophers debated whether decisions should be made by experts, based on ideas of suitability to govern, specialist expertise or knowledge results in effective decision-making; and democracy with collective decision-making based on equal participation rights: Sabine & Thorson 1973 pp. 54-55; Gaus 2003 p. 165; Copp 1993 p. 111. 62 Linder & Peters argue for example that lawyers may emphasise legal, regulatory steering, whereas economists favour financial instruments: 1989 p. 50. 63 See Abbott 1988 p. 184. 60
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The Governance Gap
The dimension of professions focuses on the relationship between government and professions. The nature of professional influence will be developed more fully theoretically in Chapter 4 and analysed empirically in Chapter 6. However, there are two broad types of influence. The first is based on the bureau-professional model and ideas of professions exerting influence as result of the state needing professional knowledge and expertise and granting professions power and freedom.64 The state devolved central decisionmaking authority on the basis of trust in the profession; thus there are high levels of professional discretion and soft steering strategies. The second mechanism relates to the government’s need for professional expertise and skills but where the government’s attitudes to, and trust in, the profession result in a state created and regulated role based on hard steering strategies such as detailed rules or legislation. Thus the profession is still influential but the government retains control. Therefore, professions are potentially key actors influencing reform strategy, and the state-professions relationship may influence the selection of governance and steering strategy between government and municipalities. Summary: Dimension two – Professions The second dimension was the professions implementing welfare policies may have influenced the government’s choice of steering strategies for the mental health reforms. Professional influence is complex and is based on inter-relationships between the state and the profession rather than a simple one-way direct form of influence. Professions may exert influence as a result of being trusted partners of the state and thus granted freedom from steering. On the other hand the influence may where their knowledge and skills are utilised by the state in order to achieve state objectives, but kept under democratic control through detailed steering. Therefore, the role of professions may influence government choices of hard and soft steering strategies. Policy framing Policy framing is based in the idea that governance does not exist in a vacuum and that the underlying political discourse of politicians’ norms and values can create a framework that may influence the need for a certain type of steering. There may be differences in how the problem is perceived, different views of the client group or different concepts of ‘appropriate’ government action. Rein for example discussed how mental health can be framed in different ways depending on whether emphasis is placed on it as a medical, homelessness, or criminality problem;65 all of which require different responses from government. Policy framing therefore, relates to the construc64 See
discussion of the term bureau-profession in Clarke and Newman 1997 pp. 6-8. See also Immergut’s discussion of professional strategy: 1992 p. 16. 65 See Rein 2006 p. 398.
20
Introduction: The Governance Gap tion of a “programme theory” consisting of beliefs, assumptions and values that guides government interventions.66 Vedung summarises programme theory as policy-makers’ underpinning empirical and normative beliefs and assumptions about the reform.67 Thus the underlying logic or cognitive map of ideological assumptions and theories links reform policies and steering instruments. Therefore, steering mechanisms adopted may be influenced by the government’s policy frame. Policy framing is therefore, a type of underlying visionary discourse68 that underpins reform. It is an important element of shaping a reform programme and as such, the policy framing discourse is not a neutral problem description. Bacchi argues that contrary to the traditional theories of policy processes, governments are not merely responsive to policy problems that “exist ‘out there’ in the community”. The government constructs and frames problems in accordance with its preferred policy and steering solutions.69 According to Stone, policy framing is where governments construct “causal stories”, to “deliberately portray” policy problems and users “in ways calculated to gain support for their side”.70 Therefore, the policy-makers framing may create an imperative for different governance and steering strategies. Summary: Dimension three – Policy Framing This dimension therefore, analyses the extent that steering differences reflected the different underlying policy framing discourses. This dimension will be developed in more detail in Chapter 4; however, my analytical model will consider three central elements: firstly definition and framing of the problem to be solved; secondly the way that the discourse describes the users or recipients of the reform; and finally the need for state action or intervention and the types of reform measures proposed. Thus the ways in which problems and causes are framed have constructed differing expectations as well as the type of interventions and steering instruments required.
Scope limitations The discussions in the sections above reveal that this book lies on the boundaries of several research discourses. Thus it was necessary to define and decide what is included within the scope of this study. This PhD thesis focuses on steering relationships between central and local government - the governance gap –unlike a traditional implementation study that focuses on user outcomes. Thus while the choice of governance and steering strategies certainly had consequences for users and municipalities, these outcomes, 66
See discussion in Vedung 1998a pp. 123-124; Owen & Rogers 1999 pp. 194-197. Vedung 1998a p. 124 (my translation). 68 The term visionary discourse is used by Hall and Löfgren 2006. 69 See Bacchi 2000. 70 See Stone 1989 p. 282. 67
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The Governance Gap
they are not my main focus. However, the increased understanding of steering mechanisms will also contribute to enhanced interpretation of user outcomes and organisational impacts of steering strategy choice. In the previous section I identified three dimensions that form the main theoretical focus of my study. This does not mean that alternative dimensions were not considered as having potential explanatory power owing to many similarities in the cases of Britain and Swede, Therefore, after careful consideration these were rejected as having low levels of influence, as they did not appear to assist in understanding the selection of different governance and steering strategies. The influence of social cleavages was suggested by Linders and Peters, Arentsen, and Bemelmans-Videc, based on ideas that language, religious and territorial cleavages may result in governments choosing less visible steering instruments in order to obscure the consequences of policies and steering for particular groups in society.71 Yet these types of cleavage are not strong in Britain and Sweden; later in this chapter in the methodology section I will explain why I consider Britain and Sweden to be well-matched cases. Resource constraints are discussed by Linders and Peters.72 Yet again I consider that Britain and Sweden faced similar conditions at the time of the mental health reform: both faced recession; and both suffered monetary crises where their currencies were subjected to international currency speculation at the time of the reform.73 Therefore, both countries were under pressure to reduce public expenditure. Party politics was analysed, yet once again there was strong convergence between Britain and Sweden; in both countries the reform was formulated by right-wing, Conservative-led governments, yet primarily implemented under left-led, Social Democratic or Labour parties.74 Thus the ‘political colour’ in power does not account for the steering differences. User group influence was also considered; Linder and Peters suggest clientele may influence instrument choice.75 However, I regard this factor as less likely for the mental health reforms for two reasons. Firstly my study is based on internal steering instruments between government and lower level agencies rather than external, direct, steering directed at users. I believe that users would be more likely to attempt to influence the direct instruments rather than the indirect municipal steering instruments. Secondly my review of the literature on user outcomes 71
See Linder and Peters 1989 p. 50; see also Bemelmans-Videc 1998 p. 13. See also Arentsen’s 1998 discussion of the case of Belgium being influenced by social cleavages. 72 See Linder and Peters 1989 pp. 50-51. 73 In September 1992, both countries suffered international currency speculation, forcing Britain to leave the European Exchange Rate Mechanism and the Swedish crown to devalue. 74 The British reform was developed by the Conservative governments of Thatcher and Major and in Sweden by Bildt’s Moderaterna (Conservative) government. Long-term reform implementation until 2006 occurred predominantly under Labour/Social Democratic governments: in Britain Blair’s Labour government was responsible from 1997-2006 and in Sweden the Carlsson and Persson Social Democratic governments between 1995 and 2006. 75 See Linder and Peters 1989 p. 50.
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Introduction: The Governance Gap
points to similarities in both countries where users had low status and a low level of reform influence.76 Thus this factor does not appear a significant difference. Therefore, having reviewed some of the main alternatives, none appear more promising than the three dimensions chosen for this book. The book also analyses the reforms from a social-care perspective, focussing on the steering relationships between the state and municipal social services departments. Medical and psychiatric treatment will not be considered, and the organisation of health and psychiatric services is included only where it tangents or impacts on the role of social services departments. In accordance with the emphasis on municipal social care and social services departments and in addition, the book focuses on the role of social workers as the key professionals within the social services sphere. In this study the terms professional social work and social worker relate to graduate-level staff holding relevant social work degrees such as a BA or BSc in Social Work in Britain or the Socionom programme in Sweden.
Research strategy: design & methods This study is designed as a case study of comparative governance and steering processes, which appear to be under-researched areas of public administration; my discussions earlier in this chapter reveal a lack of genuinely comparative, systematic studies into the processes of governance from a steering perspective.77 Much of the existing literature has focussed on individual cases or ‘comparative’ anthologies by several scholars. However, despite covering similar administrative themes, different anthology scholars often took individual approaches, based on different operationalisations of the dimensions, models and empirical data: thus there was often a comparability problem. This book therefore, aims to contribute to political science and public administration literature both theoretically and empirically, through developing theoretical dimensions that influence modes of governance in order to enhance understanding steering strategy choices, as well as analysing the empirical mechanisms of the mental health reforms, that led to Britain selecting hard steering strategies while Sweden chose soft.
Research design The design of this study is to analyse the way that the three dimensions that I have chosen (administrative traditions, professions and policy framing) influence the choice of governance and steering strategies to steer lower level 76
See Rogers & Pilgrim 2001; Markström 2003; Social Services Inspectorate 2004a; Socialstyrelsen 2005b. 77 See Winter 2003.
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The Governance Gap
agencies, and whether these dimensions increase our understanding of why Britain selected hard governance while Sweden chose soft instruments for steering the mental health reforms?. The study will consist of three steps. The first step is to categorise the governance and steering instruments used in Britain and Sweden in order to identify what the steering instruments selected were and in order to substantiate my assertion that Britain chose hard instruments while Sweden chose soft. There are currently few studies connecting steering strategy choices to the concepts of hard and soft steering. Much of the prior research assumed steering strategy choices were linear progressions from the ‘soft’ information category, through incentive instruments, to ‘hard’ regulation.78 However, my argument is that a scale exists within each category where harder and softer options are available to policymakers; yet the lack of prior research means that there are no existing models linking connect policy instrument choices to hard and soft steering for me to use. Therefore, an initial step is to construct my own steering focussed ideal-type model in Chapter 3 in order to connect the two theoretical discourses of policy instrument types with the hard and soft governance discourse and steering. This model is then used to sort and classify the steering instruments used by Britain and Sweden for the mental health reform. The second step is to develop the theoretical dimensions that may influence governance and steering choice. There are many suggestions in previous research, which alluded to possible influences on a government’s choice of governance and steering strategies,79 however, there is little theoretical and empirical research where these ideas were operationalised and analysed empirically. In the previous section I identified three dimensions that may increase understanding of government’s selections of hard and soft steering strategies. Therefore, in Chapter 4 I construct three theoretical models for the dimensions of administrative traditions, professions and policy framing. The final step of my research design is to use the models constructed to as the basis of a theoretically guided comparative analysis of the events and mechanisms of the mental health reforms. I will carry out the comparative analysis individually for each dimension in order to help me appraise to what extent each dimension helps us understand the differences in steering. In addition, in Chapter 8 I carry out “within-case” analyses of Britain and Sweden separately to appraise the relative strength of each dimension for each national case, as well as possible inter-relationships between the dimensions: whether one dimension dominates or several combine to influence governance strategy. Thus the design can be summarised in the following figure:
78 79
See for example Bemelmans-Videc 1998; Vedung 1998. See for example Bemelmans-Videc 1998; Linder & Peters 1989; Peters 2002.
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Introduction: The Governance Gap
Figure 1: Research design Britain Influencing perspectives Britain & Sweden Similar Mental Health reform policies
Hard Governance
- Administrative traditions - Professions - Policy framing
Sweden Soft Governance
Methodological considerations The purpose of this study is to contribute to theory development through the generation of hypotheses and theoretically guided models that can contribute to an explanatory theory of governance and steering strategy by the identification of dimensions that may form part of the causal mechanisms. Thus the study will aid understanding of the processes and mechanisms of governance and steering processes. However, as discussed previously, my aim is to generate theories and to use the theoretical dimensions to describe and analyse the reform mechanisms, and not to test theory in order to substantiate a particular causal relationship. Given that my intention is to develop theory and to gain detailed understanding of the mechanisms that influence governance and steering strategy, according to Collier and Bengtsson,80 qualitative methods are the most appropriate for researching these phenomena and for focussing on the “thick issues” of detailed understanding, knowledge and interpretation of the specific cases and identifying the mechanisms. Therefore, I have chosen qualitative methods as the basis of my study in order to understand the influences that resulted in hard and soft governance choices. The case study approach & case selection The study uses the case study approach focussing on a qualitative, comparative and ‘small n’ intensive analysis in order to facilitate a greater in-depth understanding of the processes and mechanisms of the governance and steering instruments and strategies adopted in Britain and Sweden. This study uses the design that George and Bennett call a heuristic case study design, which used for theoretical development to order to identify causal explanations and mechanisms;81 in this study the dimensions that influences the divergent governance and steering strategies. The case study approach facilitates an in-depth analysis of the mental health reforms using a theoretically guided and structured approach based on the three theoretical dimensions previously discussed. In addition, the case study approach contributes to the 80 81
See discussion in Collier et al 2004 pp. 248-249; Bengtsson 1999. George and Bennett 2005 p. 75.
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The Governance Gap
generation of hypotheses and development of theory. The advantage of a qualitative, theoretically guided study is that it provides a holistic and detailed analysis of events and it identifies of critical events or decision points. Thus the analysis of processes and mechanisms can assist in the generation of theory by the identification of potential causal paths and explanations.82 The research design has certain similarities to Mill’s method of difference, advanced in A System of Logic (1843) as I am attempting to identify dimensions that may explain the differences observed in governance and steering strategy. Mill’s method relies on finding cases that are identical in all but a single divergent independent variable which is identified as the explanatory factor for the difference.83 However, Mill’s method is impossible to replicate in reality because of the demands of controlling for all possible alternative explanations and the method’s strict application of finding cases that differ in just one element which is virtually impossible in practice. Therefore, George and Bennett argue that the shortcomings of Mill’s methods can be overcome through the selection of comparable cases, cases that have many similar characteristics but that differ in the area to be studied.84 Thus in the cases of the mental health reforms in Britain and Sweden display considerable commonality in many characteristics, but differ in their choices of governance and steering strategies for the mental health reforms. Therefore, case selection for my study was based identifying two similar reforms, within a comparable time-scale, in countries with similar welfare systems, where services followed a similar path of historical development, and where the reforms involved steering relationships between government and lower level agencies. Britain and Sweden appear to be good choices for comparison, both in terms of the national characteristics and also in terms of similarities relating to the mental health reforms. Britain and Sweden are both European welfare states with publicly funded welfare services. In addition, both countries are unitary states based parliamentary systems of government. In both countries social services are organised as publicly funded local services by elected municipalities with social services departments in which the main profession is social work. As mentioned in the previous sections, both countries faced similar party-political and economic conditions at the time of the mental health reform.
82
According to George & Bennett 2005, a case study approach can be advantageous for the conceptual validity of difficult-to-measure social science concepts; for developing new hypotheses, analysis of causal mechanisms; and for assessing complex causal relationships pp. 19-22 & 75. See also Bennett & Elman 2006. 83 See discussion of Mill’s theory and its limitations in George and Bennett 2005 pp. 154-160; Esaiasson et al 2005 pp. 128-132; Stechina 2008 p. 18. 84 The comparative method using comparable cases was developed by Lijphart 1975 p. 159, whereas the term controlled comparison was developed by Eggan 1954, discussed in George and Bennett 2005. George and Bennett argue in favour of the term controlled comparison as it emphasised the importance of the researcher controlling the cases and variables.
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Introduction: The Governance Gap
In addition to the similarities of Britain and Sweden as comparative countries, it was also important to select a reform case with as many similar characteristics as possible in order to isolate governance and steering strategies as a major area of difference. Once again the mental health reforms in Britain and Sweden display many likenesses as reforms with similar backgrounds, ideas, organisations and timescales. Although I discuss the background in more detail in Chapter 2, I will outline briefly these similarities. The reforms had similar backgrounds where large-scale asylums were developed in the 19th century under state control passed from state to health services in the 1950s and 1960s. In addition, Britain and Sweden both had long-standing stated community care policy aims, yet neither country achieved strong concrete results prior to the late 1980s. In Britain and Sweden the mental health reforms were based on similar reform ideas linked to normalisation with the underlying notion that the psychiatrically disabled should live in their own homes in the community, or in homely conditions, supported by municipal social services. The organisation of the reform was also based on municipalisation in both countries resulting from the separation of medical and social-care services, with municipalities becoming organisationally and financially responsible for the social care of the psychiatrically disabled. The reform timescale was also very similar: both counties established mental health commissions in the late 1980s, where both recommended community care reforms. Reform implementation occurred within two years: in Britain on April 1, 1993 and in Sweden on January 1, 1995. It is therefore, clear that Britain and Sweden were well-matched and comparable cases, both in terms of the basic structures and government levels involved and also in terms of the specific features of the reform. A final note to selecting mental health as a comparative case is that mental health is an area of welfare largely ignored by political science in comparison to fashionable areas of welfare policy such as health, education and social insurance. Mental health and poor relief were early examples of state involvement in welfare policy with the creation of 19th century workhouses and ‘lunatic asylums’.85 However, mental health has certain areas of significance from a political science perspective. Mental health is an area where key welfare issues converge such as healthcare, social care, social exclusion and disability policies. Mental health policy impacts on how communities perceive and care for those on society’s margins and those who behave differently from society’s norms. In addition, mental health is often a political hot potato: users are portrayed either as policy victims, neglected and abandoned by society;86 or as policy risks as perpetrators of serious crimes.87 In recent years mental health has become a highly politicised policy sector in 85
See for example Rogers and Pilgrim 2001 p. 13; Thorslund 2007 p. 105. See for example Fowles 1993 p. 61. 87 Kaye and Howlett 2005. 86
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The Governance Gap
both Britain and Sweden, characterised by high-profile appointments of Mental Health Tsars, Task Forces and Commissions yet is often described as a “Cinderella” service:88 low-prioritised, stigmatised and underfunded. However, within political science, mental health has also achieved its own Cinderella status as a low-prioritised, under-researched area, despite its political importance. Thus this book aims to contribute to an understanding of mental health policy from a political science perspective. Structured, focussed comparison The method for this case will be based on a structured focussed comparison of the mental health reforms in Britain and Sweden, based George and Bennett’s arguments that comparative case studies should be structured around specific questions to guide the analysis in order to ensure that they are focussed on central aspects or events to understand the mechanisms.89 By using standardised questions and focussing on key characteristics the level of comparability increases as cases are compared using the same questions and at similar points. This overcomes some of the weaknesses of traditional single case studies and anthology research whereby cross-case comparisons are difficult and it is difficult to identify key events and theoretical dimensions amid the ‘story telling’.90 The use of controlled comparison method will not control for all conceivable explanatory factors. However, George and Bennett argue that there is consensus among case study researchers that a combination of methods using within-case and cross-case is best for identifying inferences and causal mechanisms.91 Following Stechina’s approach, the cases studies are complemented by within-case analysis in order to attempt to identify the significance of the within-case, inter-dimension interactions.92 Therefore, I intend to develop a structured and focussed approach to the case of mental health reform. I have identified three dimensions based on the main theoretical discourses that I believe may offer potential explanations to the selection of hard and soft steering strategies. In Chapter 4, according to George and Bennett’s approach, a process tracing logic is applied to identify the processes, mechanisms and key event of the cases in order to understand the causal chain.93 Bengtsson and Ruonavaara argue that process tracing can be used in comparative studies in order to identify path dependency by comparing theoretical and chronological dimensions in order to draw general 88
Mental health was referred to as a Cinderella service. See BBC online 9/7-01. George & Bennett 2005 pp. 151-153. 90 George 1979 p. 62. 91 See discussion in George & Bennett 2005 pp. 17-19. 92 This method is applicable to analyse cases of divergent governance and to analyse the relationships between perspectives. Stechina argues this method allows the causal paths relating to different dimensions to be analysed and the relative significance of interactions between perspectives and the role played in political contexts to be analysed: 2008 pp. 23-24. 93 George & Bennett argue that process tracing can be used to identify causal patterns or variables: 2005 p. 206. 89
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Introduction: The Governance Gap
inference. Comparative process tracing requires two stages: firstly a structured study of the processes and mechanisms to be studied through the construction of a theoretical framework; and secondly the systematic comparison of the cases.94 I analyse the three theoretical discourses to formulate a number of indicators or central questions for each dimension in order to structure my empirical analysis. This structure is then applied to the empirical data of the mental health reforms focussing on the mechanisms and processes of the steering relationship between state and municipalities. In particular, I have chosen to focus on what I consider to be windows of opportunity for steering change; key events where the governance and steering strategy could have changed. My analysis focuses on understanding why governance strategy did, or did not, change at these critical points in order identify the processes and mechanisms of governance. Thus this approach will provide a theoretically guided and structured analysis and description of the central case study features which will enable the development of theory. The use of within-case analysis helps to overcome any methodological difficulties arising from the book focussing on three dimensions of influence on government steering strategies that may also inter-act. Within-case methods will identify and analyse relationships between dimensions. Bengtsson and Ruonavaara argue that periodisation is important to the study of policy processes and mechanisms.95 My research design and method is also longitudinal; thus the chosen periodisation is a period of approximately one decade of reform implementation; for both countries I focus on the initial reform implementation and long-term steering over 10 years. Therefore, the time period studied covers approximately the mid-1990s to the mid2000s, taking account of marginally different implementation dates. This enables me to focus on several important aspects of the governance and steering mechanisms relating to whether steering changed, and the ways in which the governments chose to change or did not change steering strategies in response to events that created windows of opportunity for change. However, it has not always been easy to determine a ‘fixed’ finish point; in some cases where policy developments were well-underway before the end of my period.96 I have chosen to follow up and to discuss the salient points for governance and steering of these later policy developments.
94
Bengtsson & Ruonavaara argue against strictly deterministic path dependency where everything is determined by history; instead, they contend that there is a softer form of path dependence where there is a high level of probability that events follow general historical patterns: 2010 pp. 1-7. 95 See Bengtsson & Ruonavaara 2010 pp. 12-14. 96 There were policy developments underway such as the new Mental Health Act (MHA) in Britain commencing in 1999 yet not finalised until 2007, and the Mental Health Tsar report in Sweden, commissioned in 2003 yet not published until 2006.
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The Governance Gap Methods & Materials: three dimensions – three approaches This study researches why governments use certain steering instruments in order to steer a reform’s governance and implementation process from three dimensions. As mentioned in the previous sections, the influences, singly or in combination, of the dimensions of administrative traditions, political discourse and professional power will be examined. However, this triad of influences requires different methods to study each of the three dimensions, although there will be significant commonality in the data examined. Triangulation The existence of three smaller case studies using different theoretical dimensions, requiring different research approaches and materials, means that in some cases triangulation will be required to obtain a more rounded view of the research object than if studied using a single dimension, method or data source.97 Becker and Bryman define triangulation as “the use of more than one method or more than one source of data to investigate the same research question”.98 There are several different types of triangulation and this study utilises several of these:99 firstly the study will utilise methodological triangulation as the different dimensions of influence relating to the triad of influence require differing research methods and more than one method. Secondly the premise of the study is that there are differing theoretical assumptions that might explain the puzzle of the different steering instruments. Thus the choice of steering instruments is investigated from a perspective of theoretical triangulation where the theoretical explanatory powers of the three dimensions are assessed both individually and as within-case analysis to assess the level of explanatory power.100 Finally, where appropriate, the method of data triangulation will be utilised whereby the results are integrated and compared with research results from secondary sources in order to confirm the empirical findings. According to Becker and Bryman, one of the advantages of triangulation is that the use of multiple data and method types, helps to resolve issues of validity and reliability traditionally associated with case study designs because the triangulation of methods and data
97
Cohen & Manion 1994 p. 233. Becker & Bryman 2004 p. 408. 99 The aim of triangulation is to get a holistic view of a research object by studying it from several perspectives. There are several types of triangulation including: data triangulation where data-collection occurs from different sources or includes sampling strategies at different times to cross check each other; methodological triangulation where a research object is studied using different methods to cross-check each other – for example qualitative and quantitative; theoretical triangulation where a research object is studied from more than one theoretical perspective; investigator triangulation where several investigators collect and interpret data; and space triangulation for withincase studies where cross-cultural perspectives are used. See for example Cohen & Manion 1994 pp. 235-238; Bryman (electronic) p. 2. 100 Cohen & Manion 1994 pp. 233-236. 98
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Introduction: The Governance Gap
increases the credibility and certainty of the research results.101 Therefore, in a study, such as this, involving three smaller studies from different perspectives, the use of triangulation strategies gives additional assurance to the results. Materials In accordance with the research design that focuses on the controlled comparison of cases, it is also important that the materials are also controlled and comparative in order to facilitate a like-with-like approach and comparison. Given that the study focuses on three dimensions, there are slightly different data requirements for each method. As my purpose is to develop theory, it was important to obtain similar empirical data for both studies. My study is based on a document study, focussing on official publications. I had initially intended to use interview methods in some areas; however, there were difficulties identifying key informants; although I was able to identify certain informants in the case of Sweden, in the case of the British reform in the late 1980s and early 1990s there was a higher culture of secrecy and it was unusual at the time for civil servants to be identified or for politicians to make themselves available to PhD students. In addition, approaches to both professional associations failed to identify people who could be interviewed on the professions’ influencing strategy. There was also a general reservation about the accuracy of interviews and of my study relying on interview subjects’ memories, and recollections of events that date back over 20 years. Therefore, I considered it a sound strategy to base the materials for my study on documents produced contemporaneously with the major reform events. This also had the advantage that the same underlying documents sources could be used for all dimensions where relevant. The main source of data has been official documents produced by official sources. These have been used in both process tracing and text analysis studies. The documents comprise legislative documents such as Government legislative proposals/bills, Acts of Parliament, the reports of official inquiries and Commissions, where available, relevant government directives and steering documents, and where possible the oral and written evidence submitted by inquiry witnesses. Use has also been made of audits, follow-ups and evaluations of the reforms carried out by executive ‘arm’s length’ agencies regarding the reform’s implementation. These official documents provide a wealth of information about the reform from both government intentions and issues of the practical implementation. A second important source of data has been newspaper articles as a useful mechanism for crosschecking data from the reports and also for following the wider debate on the reform that is not always reflected in official publications. In many cases key actors commented on the reform and central events in the press: for example, 101
Becker & Bryman 2004 p. 98-99.
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The Governance Gap
Ministers, professions, managers and users. Thus the use of newspaper articles has provided a wider perspective on the reforms than the official documents alone aimed to obtain a rounded view of the reform: in Britain the online archives of both broadsheet and tabloid newspapers were searched; and in Sweden the academic search engine PressText was used to generate articles from a variety of media sources. Finally secondary sources were used. Although there are no studies that replicate all the theoretical and empirical goals of this study, there are other research projects and articles addressing some of the issues that I take up and these have been used where appropriate to confirm of challenge my findings. Three dimensions – three approaches to methods & materials In the sections above I have discussed how I intend to analyse the three dimensions of administrative traditions, professions and policy framing in order as influences on governance and steering strategy. These dimensions each require their own methodological approaches, although there are certain similarities. The actual theoretical approaches and development of theoretically guided frameworks will be discussed and developed in Chapter 4. In addition, precise approaches, method and material will be discussed in each of the empirical chapters. Thus an overview: Administrative traditions The dimension administrative traditions requires that the mechanisms and processes of the reform be identified and evaluated in order to determine the extent to which these legacies of constitutional and administrative traditions influence the current governance and steering choices. Thus this approach is based on historical influences on current events. Process tracing will be used to identify the sequence of events and patterns in a structured manner. In Chapter 4 a theoretically guided framework of indicators and questions is developed in order to guide and structure the analysis of the empirical reform mechanisms. In Chapter 5 the impact of administrative traditions is analysed. Firstly a historical overview of the key events in the historical events of the government and administrative structures is constructed from secondary historical texts. This will enable me to identify the central characteristics and patterns of the administrative systems in Britain and Sweden relating to the indicators and questions developed in the theoretical framework. Secondly documents relating to the mental health reforms are compared with these expected patterns and mechanisms in order to analyse the extent to which the reforms in each country conformed to the expected pattern based on administrative traditions. The materials to be examined will focus on a structured comparison of official documents and newspaper articles. My analysis of the 10-year period focuses on what I consider to be central decision points when the government changed its governance and steer32
Introduction: The Governance Gap
ing strategy or when there was a strong possibility of change in order to analyse the processes by which change occurred or did not occur. Professions The purpose of this approach is to study the type of influence exerted directly and indirectly by professions over steering choices. Once again in Chapter 4 a theoretically guided instrument of analysis will be constructed in order to determine the relative influence of state and professions, and will focus on two types of professional influence: the direct influence exerted by professions on government; and the government’s legitimating of the profession in terms of granting freedoms from steering such as those previously discussed in the bureau-professional model. In Chapter 6 the analysis will again be carried out at two levels: firstly a historical overview using process tracing methods that identify key events in the historical development of the social work profession of both countries that may be pertinent to the professions position from a steering perspective; secondly I use the indictors and theoretical framework to analyse a profession’s influence on reform steering both from the government’s perspective of the roles created and the need for professional expertise, as well as from the direct attempts by the profession to influence the reform. The method used will again be based on process tracing and the identification of critical events in the relationship between state and profession that may influence governance and steering choice. This dimension uses official publications and reform documents produced by government and profession where available. For the Swedish Association of Social Workers (Akademikerförbundet-SSR) I analysed their archived documents held in the TAM archive for professions and administrators. The British Association of Social Work informed me that they had no archive or library covering this period; however, I have obtained documents from a number of sources including the British Library and an online network for mental health social workers. In addition, I have used social work newspapers such as the Community Care and Socionom. In order to triangulate my findings, I have also utilised secondary sources such as academic journals and editorials such as the British Journal of Social Work and Practice. Policy framing This final dimension aims to analyse how the government frames the problem, the users and the need for government steering instruments and intends to show that even where governments may have the same stated policy objectives, the implicit norms and values created by differing policy frames create a logic for certain types of governance and steering choices. I research this dimension by analysing the way in which governments framed and argued in documents relating to the mental health reforms. In Chapter 4 I develop an ideal-type model that will enable me to classify and analyse texts 33
The Governance Gap relating to the ‘care ideology’ framed by the government particularly how the policy problem is defined, how users are portrayed and what type of government action is necessary. Governments may use frames in the policy process in order to define, analyse and assign responsibilities for creating and solving the policy problem. The type of political discourse used, and the way in which governments frame policy problems and goals are used to build political and public consensus both for the policy decision itself and the underlying governance and steering norms.102 This ideal-type model is then used to analyse central decision points where I consider the governance and steering strategy might have changed. My research strategy is based on text and document analysis using government-produced documents in order to trace the government’s own framing logic. This will be studied using texts from pre-reform inquiries to establish a baseline for government framing, the government policy responses and then policy texts at key decision-making moments where a window of opportunity for a change of framing existed to analyse whether differences in policy framing existed. My focus is on government policy statements rather than third-party documents such as evaluation or audit reports. For Sweden this was a problem owing to the dearth of new policy initiatives in the long-term implementation. However, one major event that occurred in 2003 was the murder of Foreign Minister Anna Lindh in a Stockholm department store by a man suffering mental illness. As a consequence, an emergency mental health debate occurred in Parliament three weeks later to discuss policy. I considered that this represented a major window of opportunity for steering change and a critical event for mental health policy. Thus I have included in my analysis the official debate transcript in order to analyse Ministerial framing of mental health policy. Central definitions There are several terms that require definition, in particular definitions relating to the reforms users and relating to the term community care. These two aspects are central to my study, yet both terms are contested and without accepted definitions. Thus I will clarify how I intend to use them. User definition: the psychiatrically disabled The mental health literature contains a huge number of terms for the reform users, from the historical literature’s descriptions of lunatics and imbeciles to modern literature’s numerous terms such as mentally/psychiatrically ill, disordered, disturbed and disabled. The term I have chosen to use in this PhD thesis is psychiatrically disabled103 to refer to those with long-term mental illnesses that substantially interfere with normal life and activities including: work, education, socialising and communicating. 102 103
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See for example the discussion in Schön & Rein 1994 pp. 31-32; Fischer 2003 p. 144. Based on the definition by Boston University Center of Psychiatric rehabilitation.
Introduction: The Governance Gap
Definition of community care An important element of the scope of this study is to define the term community care. This issue is complex, as the term is not used consistently by governments or researchers. The term is used to describe widely differing phenomena covering a wide range of differing care philosophies and practices. Robertson argues that the term community has a confusing duality: it can mean shared social and cultural values or more simply people sharing the same territorial space. He argues that meaningful community care occurs only with the first definition, where social and cultural attachments and a sense of community exist.104 However, many countries use the term community care to describe the second, thus “community” related to locating institutions in the community, not normal living as community members.105 Community care was also used rhetorically in many countries, as a term that fitted well with the public management reform emphasis on services near to users; a British Parliamentary committee argued that the term had become a “slogan”.106 Thus community care was often used rhetorically as an idealised political metaphor creating images of traditional village civil society, with communities supporting the weak and sick. In some cases the rhetoric of the ‘community’ was used to conceal practices that resulted in the abandonment of users or the ‘old maid game’.107 Langan argues that “‘the community’ became the solution to every social problem of the 1980s and 1990s”.108 The geographical definitions dominated in many countries; community care was institutional albeit located in residential areas, but residents often had little contact with the outside community. In the mental health reforms, Britain and Sweden adopted similar definitions of community care as normal living, whereby the psychiatrically disabled were offered “normalised” living forms or small home-like group living arrangements with domiciliary support. Therefore, this is the definition to be adopted in this book, based on British reform documents, where community care is defined as “to live as independently as possible in their own homes or in “homely” settings in the community.”109 However, it is important to note that this definition was not universally adopted in all countries. 104
Robertson discusses community care using German sociological definitions: Gemeinschaft means organic and cultural coherence; Gesellschaft is sharing territory: 1994 p. 760. 105 See for example House of Commons Social Services Committee 1985; Markström 2003 pp. 88-9 & 112-20; Goodwin 1997 p. 10-25; Means et al 2003. 106 House of Commons Social Services Committee 1985 p. x. 107 The Old Maid Game, (Svartepetter) is a card game where players play to avoid being left with the Old Maid card. In mental health agencies also attempted to avoid being left with expensive and complex clients. The community care was justified using rhetoric of the local community rallying around to provide care and support from such as family, friends, neighbours and churches. Yet it was not always clear what community care actually was and who was ultimately responsible for providing it, creating fears that public agencies were attempting to shift responsibilities to untrained and unpaid carers. 108 Langan 2000 p. 156. 109 Her Majesty’s Government 1989 p. 3.
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The Governance Gap
Structure and disposition of the book This chapter has presented the research question and strategy for this book. In this section I outline the rest of the book and the contents of each chapter. Chapter 2: I discuss the background to the reforms including the international trends and the convergence of reform pressures relating to social change; availability of drug and psychological treatments; and public management reforms, all of which altered perceptions of traditional ‘full service’ asylums. The chapter will also outline the post-war reform process in Britain and Sweden that culminated in the mental health reforms. Chapter 3: here I discuss the concept of policy instrument choices and hard and soft steering in terms of “carrots, sticks and sermons”, and construct an ideal-type model in order to categorise the instrument choices in Britain and Sweden.110 I analyse the governance and steering strategies used in Britain and Sweden to establish that, notwithstanding the similarity in the reforms’ aims and contents, the governance strategies diverged; Britain chose ‘hard’ strategies while Sweden chose ‘soft’ governance. Chapter 4: I discuss the theoretical discourses relating to my study and I use the prior research and literature to develop a theoretically guided framework for my study in order to analyse the three different dimensions of the triad of influence; administrative traditions, professions and policy framing. Chapters 5-7: I use the frameworks developed in Chapter 4 in order to carry out a theoretically guided structured comparison of the three dimensions using qualitative methods in order to analyse the mechanisms that influenced governance and steering in the mental health reforms. Chapter 8: I discuss my results as a whole, analysing the results of the comparative study of the two cases according to the three dimensions, and in addition, I discuss the cases of Britain and Sweden individually using within-case analysis. I also draw conclusions on the theoretical and empirical contributions of my study.
110
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See Bemelmans-Videc et al 1998.
[Type text]
Chapter 2
Reform & policy background: asylum to community care This chapter considers the background of the mental health reforms in Britain and Sweden by considering the wider context of mental health service development. In particular I consider the convergence of several specific mental health reform pressures in the early 1990s in Britain and Sweden. The chapter contains three sections relating this context. The first section gives an international historical overview of mental healthcare development, identifying mental health as an early area of state involvement in welfare policy. The second section discusses the convergence of specific reform pressures in the post-war period, focussing on social and attitudinal change, new treatments, and financial and administrative pressures for change. The third section outlines the long reform process in Britain and Sweden that resulted in the mental health reforms of the mid 1990s. As discussed in Chapter 1, political science and policy literature relating to mental health is limited; therefore, this chapter utilises literature from many sources. One central text is Goodwin’s Comparative Mental Health Policy (1997) as a major source of information on international and comparative mental health, as well as books relating to the specific historical policy developments in Britain and Sweden by Rodgers and Pilgrim (2001), Markström (2003), Means et al (2003), and Lennestig and Schön (2005), as well as other research and literature on specific topics. In addition, I have used two historical policy timelines: The Mental Health History Timeline produced by Andrew Roberts of Middlesex University in Britain; and the timeline of the National Association of Social and Mental Health (Riksförbundet för Social och Mental Hälsa) in Sweden.
Mental health: international historical developments In order to understand the steering of the mental health reforms in Britain and Sweden, it is essential to obtain an understanding of wider historical 37
The Governance Gap
context that saw a shift from institutional, hospital-based, psychiatric care to community-care models in Western countries. Thus the reforms in Britain and Sweden are not isolated cases but need to be considered as part of a broader historical trend that saw the decline of traditional, isolated asylums and the adoption of community care policies for the psychiatrically disordered to live in society.
The traditional asylum model – historical perspectives The creation of institutions to house the psychiatrically disabled dates back to medieval times, with madhouses built to house lunatics.111 By the mid 18th century most western countries had established madhouses, but services were not usually state coordinated, but involved ad-hoc arrangements between charities, religious orders, and local and parish councils.112 The conditions in these early unregulated mental institutions were harsh: they lacked both therapies and treatments. By the late 18th century there were calls for reform on moral and religious grounds;113 however, these arguments receded in the early 19th century when the state became involved in mental health. The rise of the asylum in the 19th Century In the 19th century mental illness definitions were not based on scientific diagnoses but were regarded as inherited biological characteristics and character flaws. These early diagnoses were often vaguely formulated, for example mentally defective, feeble-minded and moral imbeciles.114 Mental illness categories were broad and included unusual social behaviours, physical illnesses, learning disabilities, social problems and deviation from societal norms and behaviour codes.115 Thus definitions of mental illness and poverty overlapped; the poor and homeless were often classified as mentally ill and committed to asylums for life. Mental illnesses were considered hereditary, and diagnoses were often framed in moral and social terms as it was thought families of good character did not suffer mental illness. Asylums were also exploited by families to rid themselves of troublesome relatives, referred to by Skull as “warehouses of the unwanted”.116 Thus in the 19th century mental illness was regarded as an inborn character flaw, and the acceptance of social, economic and medical definitions created a need for institutions to accommodate the rising numbers classified as ‘mentally ill’. 111
Early examples: Bethlem madhouse in Britain (1403) and Casa de Orates in Spain (1408). Goodwin 1997 p. 6; Rogers and Pilgrim 2001 pp. 41-42; Carrier and Kendall 1997 pp. 3-5. 113 The debate emanated in France concerning the “moral” treatment of mental illness. The British Quakers advocated humane treatments based on work and exercise. 114 See for example Means 2003 pp. 26-28. 115 Diagnoses were broad and physical illnesses such as epilepsy were considered a mental illness as well as social problems such as ‘being strange’, ‘unwillingness to work’, and ‘loose morals’ etc: See Means et al 2003 p. 28; Lennestig & Schön 2005 p. 133 (my translation). 116 Scull 1993 cited in Means et al 2003 p. 27. 112
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Reform & Policy Background The 19th century’s changing economic and demographic structures increased the demand for mental institutions and for state action. In traditional agrarian societies many with mental illness lived in their own rural communities. However, industrialisation and urbanisation meant families were unable to combine traditional ‘community care’ with cramped urban living conditions and long factory hours. In addition, the biological theories of inherited mental illness meant that governments advocated segregation to prevent spread and contamination of these character flaws to the general population.117 Thus the state’s need for institutions to segregate the psychiatrically disabled created an impetus for the institutional model of asylums in remote rural locations. From the 19th century onwards, state involvement in mental health increased; many western governments legislated to establish state asylums that were built in cooperation with religious orders and charities. Thus mental health was one of the earliest forms of state involvement in welfare interventions and the state became a central actor in policy formulation and in establishing institutions for the psychiatrically disabled. Asylums dominated mental care for over a century. The term asylum literally means sanctuary, refuge or safe haven,118 which gives clues to the original philosophy of philanthropists and politicians who envisaged tranquil therapeutic communities for those deemed unable to cope in urban society. The philosophy was based on the perceived dual benefits of peaceful rural locations and hard physical labour. However, these benevolent visions were also imbued with less compassionate class, religious and biological beliefs. Thus while asylums were often built in grand architectural styles, the façades disguised custodial, prison-like regimes.119 Asylums were isolated in closed and self-sufficient communities, where the thousands of inmates had little contact with the outside world and few therapies were available.120 Despite quasi-medical aims, most asylums developed into bureaucratic and custodial segregation regimes, providing mass institutional care with little scope for individual need or tailored treatments: being committed to the asylum was usually for life. The asylum was also paternalistic with a training and compliance philosophy of rewards and punishments. Patients had few rights, so abuse and neglect went undetected. The rapid asylum expansion of 19th century provision created rising inmate numbers, poor conditions and overcrowding. State policies emphasised containment, incarceration and social control.121 Therefore, traditional asylums reflected a state segregation policy that contained patients like prisoners rather than treating them as patients.
117
See for example Goodwin 1997 pp. 7 & 26. See Oxford English Dictionary: asylum. 119 See for example Rogers and Pilgrim 2001 pp. 45-50. 120 The ‘treatments’ relied on physical isolation, restraint or cold water to control patients. 121 Rogers and Pilgrim 2001 pp. 13 & 41-68; Carrier and Kendall 1997 pp. 3-8; Markström 2003 pp. 87-8; Dalademokraten 9/1-02; Goodwin 1997 p. 6-7; Means et al 2003 pp. 26-32. 118
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The Governance Gap The result was institutionalisation within the asylum’s regime, with many spending most of their lives in the asylum. The early 20th century saw challenges to traditional biological definitions of mental illness. In many Western countries the aftermath of the First World War challenged traditional assumptions of mental illness. Shellshock affected soldiers and officers alike, irrespective of social class or family background, and included middle- and upper class officers of good character from good families. For the first time some officers were treated in outpatient clinics rather than in asylums. Thus biological theories based on inherited character flaws were undermined by the recognition that mental illnesses affected all sections of society, not only pauper lunatics. However, for most people this debate changed nothing as the asylum policy was retained for the general public.122 Shellshock affecting officers was regarded as a separate issue to mental illness among ordinarily citizens and could be treated outside hospital. Yet the importance of wartime experiences was the recognition that community treatment was possible at all. However, not all developments in the early 20th century were positive; biological theories remained, with mental hygiene theories and eugenics policies gaining ground in Europe during the 1920s and 1930s, especially in Nazi Germany. The asylums remained the dominant treatment model, although services gradually became medicalised, although the treatments were crude and were often dangerous.123 In the early 20th century many treatments lacked proven efficacy and many patient deaths124 were caused by treatments and poor asylum conditions. Yet despite poor results there were few demands for reform as there was no organised patient lobby, psychiatrists had high status, and there was little public support for mental health reform. Thus reform was problematic for politicians, with few incentives and huge potential political risks.125 Once again after the Second World War officers were offered outpatient treatments, but not the general public. The number of asylum patients continued to rise and peaked in the 1950s.126 Internationally there was increasing recognition that the vast isolated 19th century mental asylums did not a therapeutic environment and were in need of reform. The decline of the asylum & the rise of community care In the 1950s, patient numbers peaked; there were growing criticisms of the asylum system and concerns over patients’ maltreatment. In many countries 122
Rogers & Pilgrim 2001 pp. 52-54. Treatments were often dangerous such as paraldehyde, chloral-hydrate, bromide, opiates, lobotomies, insulin comas, psycho surgery and unmodified electro convulsive therapy. 124 In the 1920s-1930s, 9,000 patients per year died in Britain: Rogers & Pilgrim 2001 p. 56. 125 See Rogers & Pilgrim 2001 pp. 56-57; Lennestig & Schön 2005 pp. 29-31, 54, & 64. 126 Asylum numbers peaked in the 1950s; in Britain there were 154,000 asylum patients in 1954 and in Sweden 34,000 in 1960. Figures from: Goodwin 1997 p. 12; Kaye & Howlett 2005 p. 50; Markström 2003 p. 112. 123
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Reform & Policy Background
patient rights were debated, with limited formal legal safeguards were introduced such as a right of appeal against detention. Traditional perceptions of psychiatric illness as requiring lifelong compulsory hospital treatment changed; many countries passed legislation allowing temporary and voluntary treatment.127 Thus traditional rationale for asylum care waned and pressure for reform increased. The 1960s and 1970s saw greater acceptance for alternative lifestyles and behaviours; poverty and social problems were no longer attributed to character flaws and mental illnesses. By the 1970s many countries questioned whether a full-service asylum model combining medical, social and occupational needs in single institutions was outdated. Many countries reorganised healthcare using sectorisation principles of local services rather than large scale institutions. Thus full-service asylums did not fit into this care model as health services re-organised to focus on “corebusiness”.128 Many psychiatrists relocated to General Hospitals leaving the asylums with fewer, often poorly trained and paid staff.129 Internationally the pace of change was uneven. There were radical community care reforms such as the Trieste project in Italy.130 However, in other countries entrenched and powerful interests hindered reform.131 Therefore, although there was a general international trend toward community-based mental care, not all countries followed the same trajectory. Summary: historical dimensions This section has provided a ‘broad brush’ overview the historical development over several centuries, demonstrating a general historical tendency for fashions and trends in mental healthcare that trickled-down across Western countries. It also demonstrated that notwithstanding the general lack of political scientist interest in mental health, asylums and mental health were in fact among the earliest, yet least fashionable of the state welfare policies. 127
See discussion in Goodwin 1997 p. 9. The term Core Business was developed by Clarke and Newman and related to public agencies focusing on main services aims and withdrawing/contracting peripheral activities that did not directly contribute to main aims: 1997 pp. 78-79. In mental health psychiatry saw its core business role as medical treatment, not social, housing or occupational activities. 129 Many countries, including the USA, France, Holland, Italy, Canada, Denmark, Sweden and Britain, redesigned health services according to principles of sectorisation. See for example Markström 2003 pp. 93-4; Rogers and Pilgrim 2001 pp. 61-71; Goodwin 1997 pp. 12-25. However, mental health work was often poorly professionalised an unskilled. For example in rural municipality of Säter in Sweden mineworkers were offered asylum jobs at the asylum (Säterssjukhus) after mine in the nearby village of Bispberg closed based on assumptions that what was needed for psychiatric work was big, strong men.. 130 The Trieste project 1978 became an international community care model based on the “Law 180” project that transferred services to district hospitals and outpatient clinics. Policymakers envisaged that mental hospitals would close within a decade. Yet the Trieste project was less successful in other Italian cities: Kaye and Howlett 2005 pp. 47-48; von Hall 2004. 131 In countries such as Germany and Spain the state had a lower capacity to steer owing to powerful private, local and voluntary interests. In addition, legacies of dictatorship regimes also influenced perceptions of mental illness: Goodwin 1997 pp. 15-17 & 19-20. 128
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The Governance Gap
The original mental health theories were based on biological determinism and class-based assumptions; psychiatric illnesses were regarded as hereditary defects. Industrialisation in the 19th century created the need for the state to act to segregate the mentally ill in remote asylums, although treatments were few and conditions were harsh. The experience of two world wars began a process that challenged the asylum model; biological models were undermined as mental illnesses resulting from wartime experiences existed over social class boundaries, and new treatment models were created to allow officers to be treated outside the asylum. Developments after 1945 emphasised the reality that the traditional asylum model no longer appeared to ‘fit’ the needs of Western countries.
Creating the conditions for community mental care The mental health reforms in Britain and Sweden were the result of a convergence of reform pressures in the 1980s and 1990s. Here I map and explore the three main trends: firstly changing social attitudes and mental illness perceptions; secondly new treatment availability; and finally administrative and financial pressures. These developments were not restricted to Britain and Sweden, but existed as general trends in Western countries. These ideological, social and medical ideas challenged traditional assumptions and norms for mental healthcare, thereby creating conditions for the emergence of reform ideas relating to community-based services.
Mental illness perceptions & social change Mental healthcare is not only a medical issue. It also has a social and cultural dimension relating to what is considered normality by society. Therefore, the prevailing societal attitudes to psychiatric illnesses as well as the expectations of the state’s role in regulating social behaviour are important aspects in creating pressures for- or obstructing- mental health reform. Changing attitudes & definitions of mental illness In the post Second World War period definitions of psychiatric illnesses changed, which in turn influenced perceptions of the asylum. The development of the welfare state, in particular the creation of municipal social services departments, changed attitudes to mental health in many Western countries by challenging the connection between social problems and mental illness that dominated the early class-based and biological mental illness definitions. Thus many problems previously diagnosed as mental illnesses, such as poverty, social behaviour and chronic unemployment, were redefined as social problems requiring community support rather than incarceration in the asylum. After 1945 psychiatry became more scientific and medi42
Reform & Policy Background
calised, with a reduction in vague, unscientific diagnoses. Perceptions about regarding lifestyles and behaviours changed so that a lack of compliance to societal norms was not regarded as a mental illness. The organisation of welfare state healthcare schemes also had implications for psychiatry breaking its traditional isolation and integrating mental health with somatic healthcare structures, thereby facilitating theoretical, professional and diagnostic developments.132 Social mental illness models were also developed. In particular the antipsychiatry movement emphasised the social causes of mental illness created by societal structures, demographic change, relationship breakdown and personal crisis. It also challenged traditional psychiatry and its medical domination, regarding asylums as anti-therapeutic.133 By the late 1970s attitudes to psychiatric disability were changing both within and outside the system as asylum staff and media began to challenge dominant asylum norms and the aim and nature of the asylum’s role, in particular criticising the disabling effects of asylum norms and staff attitudes that hindered the patient’s attempts to reintegrate into society.134 Thus the increasing challenges to the therapeutic effects of asylum care created pressures to shift away from the traditional domination of in-patient asylum care. Civil rights & state social control Civil rights and issues relating to citizenship rights for disadvantaged groups also gained prominence in the post-war debate, increasing reform pressures. Clarke and Newman discuss an increased emphasis on individual rights and choices whereby standardised welfare policies and paternalistic expert cultures were challenged.135 There was also a move from traditional moral judgements and the use of asylums as a form of coercive state social control, often based on custodial rather than therapeutic aims. Instead mental health began to be perceived from a civil and human rights perspective. In particular Marxist scholars criticised the state’s role in mental health and the loss of rights for those forcibly detained in asylums, arguing that the asylum was used as capitalist social regulation and a means to control those who deviated from society’s norms.136 The 1960s onwards also saw changing state132
See Lennestig & Schön 2005 p. 81; Bennett 1993 pp. 11-14; Busfield 1997 pp. 241-2. Anti-psychiatry scholars Laing, Cooper and Esterson focussed on social causes of mental illness. Barton and Goffman criticised paternalism for creating patient passivity: See discussion in Goodwin 1997 pp. 34-39; Rogers and Pilgrim 2001 p. 66; Markström 2003 pp. 90-91. 134 Examples can be found in many sources. In Britain, Thomas (1987) describes asylum life in the 1970s and staff attitudes to the psychiatrically disabled. There was a culture that disregarded patient opinions. In Sweden Lennestig & Schön outline a case from newspaper articles from the asylum in Säter in the 1970s where negative staff attitudes hindered patient recovery and community reintegration: 2005 pp. 117-122. 135 According to Clarke & Newman (1997) the traditional welfare models were challenged by right and left, and the situation of the disabled questioned: See pp. 4 & 11. 136 These arguments were a theme in Marxist critiques of western capitalist states based on concepts of alienation and consumerism where regimented industrial society created a loss of 133
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The Governance Gap
citizen relationships with general relaxations of social controls and increased tolerance for cultural and individual diversity and heterogeneity. The asylum was associated with reduced rights and oppressive state social control, especially in relation to the use of closed psychiatry in Eastern Europe to silence citizens’ dissent. Attitudes to coercive treatments and closed care began to change.137 There was therefore, a duality in the debate: despite the media and political debates in many countries concerning asylum issues such as coercion, patient rights and neglect scandals, the public tolerance of the psychiatrically disabled remained low and there were expectations that the state would control risky behaviours of the psychiatrically disabled.138 Normalisation & disability rights The growing civil rights debate was reflected in concepts of normalisation within disability research from the 1960s onwards, based on ideas that the psychiatrically disabled should be perceived as minorities with equal citizenship rights to live in the community. Normalisation concepts were linked to social models of mental health where community living was considered more humane and therapeutic than institutional regimes. Thus normalisation advocated replacing the segregation and isolation of the asylum with community integration and participation. Although initially normalisation principles focussed on physical disabilities, the debate expanded to include the psychiatrically disabled.139 Thus for the first time this group was viewed as capable of living normally in the community, aided by support services. According to O’Brien the normalisation concept could be applied to five areas: Community presence, giving users rights to live within communities rather than living in segregation; Competence, providing necessary support for community living; Choice, allowing the disabled to make their own decisions; Respect, valuing the disabled as equal members of society; and finally Relationships, encouraging the disabled to form relationships and mix with non-disabled people.140 Thus this international development of normalisation concepts and disability rights movements was influential in creating the conditions for mental health reform. Previous moral and biological concepts of a homogenous society based on a single ‘correct’ conception of normality were rejected. Normalisation concepts emphasised that society should embrace diversity and even though the psychiatrically disabled might display different behaviours, they had equal citizenship rights to live in society.
autonomy and prescribed roles based on class, gender and ethnicity: See Goodwin 1997 pp. 80-82; Rogers and Pilgrim 2001 p. 55; Wood 1993 p. 23. 137 The use of psychiatry by regimes in Nazi Germany and the Soviet Union to quell dissent led to an international human rights debate: see Goodwin 1997 pp. 9-23. 138 See Rogers and Pilgrim 2001 p. 66; Goodwin 1997 p 82; Markström 2003 pp. 92 & 95. 139 See Brown and Walmsley 1997; Bachrach 1997 pp. 23-25. 140 O’Brien’s normalisation criteria for mental disability cited in Sharkey 2000 pp. 111-112.
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Reform & Policy Background
New treatment methods One argument frequently advanced to explain mental health reforms was the availability of new drug treatments. Thus this section will explore how new, more effective treatment methods contributed to the conditions for mental health reform, such as drugs and psychological therapies that did not depend on physically isolating patients from society, thus enabling treatments to be available on an outpatient basis in the community. Drug therapies The so-called pharmacological revolution141 of new drug therapies is often cited as facilitating mental health reform based on ideas that new drugs made mental illnesses treatable outside the asylum. After 1945 scientific advances resulted in new medications for previously untreatable conditions: for example neuroleptic drugs for psychosis and drugs for schizophrenia and depression. The drugs meant that isolation and containment were no longer the only means for treating psychiatric illnesses, making outpatient treatments a possibility for certain patient groups. The 1950s was also a time of strong belief in using science to solve society’s problems; President Kennedy embraced drug treatments as a cure: “most of the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society”.142 Thus there was optimism that scientific and pharmacological advances would cure mental illness and make the asylum obsolete. However, despite assertions that new drugs enabled community-care policies, the reality is more complex. There is no consensus among researchers concerning causal relationships between drug therapies and asylum closure. Goodwin asserts that early anti-psychotic drugs were often less effective than generally believed, yet the strong trust in science in the 1950s meant that few studies were carried out to demonstrate benefits of the drugs; most studies showed only marginal benefits, and some failed to demonstrate any correlation between drugs and improved treatment outcomes.143 In addition, to controversies over drug efficacy, the literature identifies a timing problem relating to assertions that drug treatments led to deinstitutionalisation: in some countries asylum bed reductions occurred prior to the drugs becoming available; in others discharge rates were unaffected by the drugs; and in some countries asylum admissions increased for decades after drug treatments were developed. Thus the correlation between drug treatments and community care is unclear and is not a complete reform explanation.144 How141
The term pharmacological revolution is used in Rogers and Pilgrim 2001 p. 72. President Kennedy – cited in Goodwin pp. 29-30. 143 Studies of drug treatments showed as follows: in 25% of cases gave beneficial effects, 50% little or no change, and in 25% drug treatments were harmful. Goodwin 1997 p. 31. 144 See Goodwin 1997 pp. 29-33; Bennett 1993 p. 12; Busfield 1997 pp. 237-238; Rogers & Pilgrim 2001 pp. 61-62 & 72; Markström 2003 p. 90; Lennestig & Schön 2005 pp. 135-136. 142
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The Governance Gap
ever, drugs did contribute to changed perceptions from previous models of psychiatric illness as incurable and permanent; the new drugs increased acceptance of treatment outside the asylum in outpatient clinics. Psychological therapies In addition, to drug treatment, new psychological therapies were developed for treating mental illness in the post-war era as an alternative to the asylum, as ideas that the asylum might have negative effects began to infiltrate psychiatry.145 The discourse of psychiatry developed to include psychological theories such as behavioural and psychodynamic theories146 with non-drug based treatments such as psychotherapy and cognitive behavioural therapy offering alternative forms of treatment for certain types of mental illness.147 As with drug treatments, psychological therapies did not require patients confinement in closed wards, and many could be treated as outpatients.
Administrative change & mental care reform There were also wider international administrative policy developments influencing reform policies. Specifically, changes to the organisational, economic and professional frameworks had both direct and indirect effects, thereby creating opportunities for mental health community-care policies. Organisational change: redesigning healthcare policy The period between the 1960s and the 1990s saw many public sector organisational changes in Western countries that influenced mental health reform. Firstly, the development of welfare policy, including both universalist welfare states and insurance schemes, increased access to healthcare and reduced asylum admissions caused by poverty. Secondly, sectorisation influenced the organisation of healthcare in many countries and transferred healthcare responsibility to smaller geographically defined areas, which increased integration between somatic and psychiatric services. Thirdly, community mental health services developed in many countries, thus creating local services in General Hospitals or outpatient clinics, as well as mental health roles for general practitioners. These organisational and policy changes meant that the role of remote asylums was less obvious in structures that emphasised local care models. Thus the organisational developments reduced the asylum’s dominant position as sole provider of psychiatric services. Organisational decentralisation also influenced perceptions of community care; if patients could be treated locally, why should they not also live in the community? 145
See for example Busfield 1997 p. 242; Lennestig & Schön 2005 pp. 132-135. Psychological treatment such as those advanced by Sigmund Freud and Carl Jung. 147 See for example Rogers and Pilgrim 2001 p. 73; Bennett 1993 p. 13. 146
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Reform & Policy Background Economic issues – the financial crisis & the asylum Economic arguments are also frequently advanced as causing mental health reform. Explanations by scholars such as Scull focus on decarceration caused by the high costs of asylum systems. He argues that rapid increases in welfare state expenditure resulted in fiscal crises where it became difficult for governments to justify maintaining expensive and segregated asylums, when domiciliary services would be cheaper.148 Thus this argument contends that mental health reform emanated from political and economic expediency to cut costs. Goodwin points out that there is some evidence for economic factors playing a role, yet actual results are mixed. Research results do not demonstrate the causative relationship as strongly as suggested by radical theories, the empirical data does not fully support the hypothesis that countries with rapid public expenditure increases and budget deficits were early to reform. While some countries with rapidly expanding public expenditure such as Italy and Sweden, did reform early, other similar countries such as France, did not. In addition, other countries that were early to reform, such as USA and Britain, actually had relatively slow public expenditure growth. Thus no clear pattern exists between public expenditure deficits and the introduction of community care policies. There were also ideas that community care would be cheaper than the asylum, but again the pattern is unclear as research evidence suggests that governments failed to compare like with like provision; cost reduction estimates were achieved by reducing service levels, while studies showed that high quality community services were more expensive. However, despite the level cost savings being a contested issue, policy-makers often emphasised that high quality services would be achieved at lower costs.149 Thus it is problematic to analyse economic arguments relating to community care policies owing to difficulties of isolating cause and effect. While it is clear that the introduction of community care coincided with financial crises in many countries, there is no clear causative link as deinstitutionalisation policies commenced prior to the 1970s. Therefore, although economic considerations were part of the debate surrounding the introduction of community mental care, a direct pattern of causation cannot be identified given the existence of many other factors that influenced mental health reforms. Professional issues: the changing nature of mental health professions The conditions for mental health reform were also influenced by professional developments. In the closed asylums, mental care was the monopoly of psychiatrists and medical culture; psychiatrists were the central authority on mental health, conferring autonomy and decision-making power. As men148
See Busfield 1997 pp. 237-40; Rogers and Pilgrim 2001 pp. 72-73 & 143-156; Goodwin 1997 pp. 12-25 & 84-91. 149 See discussion in Goodwin 1997 pp. 51-65.
47
The Governance Gap tioned in the historical section, traditional 19th century psychiatry focussed on biological perceptions and was initially slow to accept non-medical approaches to mental illness such as psychological and social theories. However, social changes challenging the professional monopoly of the asylum model grew.150 In addition, the development of welfare states resulted in new professions becoming active in the mental health, which created potential professional power dispersal. There were professional challenges from within healthcare structures. Psychiatric nurses played subordinate roles in asylums, yet outpatient clinics and community work increased their options for working independently of psychiatrists even though their profession was rooted in the medical model. Clinical psychologists developed as a professional group with the increased recognition of psychological models and therapies as alternatives to traditional psychiatry. General practitioners (GPs) obtained new roles treating mild mental illnesses as a result of sectorisation and decentralisation reforms. Professions also developed outside healthcare. Social workers challenged the traditional status of psychiatry and, unlike the other professions, were not rooted in the asylum and medical models. There were also other occupational groups and paraprofessionals, with varying levels of knowledge and training, such as counsellors, community workers and volunteers.151 Therefore, the shift from asylums led to professional dispersal; traditional asylum-based psychiatry was eroded by the move to community services in non-hospital settings. These changes meant that hospitals were no longer the automatic option for treating mental illness. The adoption of mental health community services required greater professional cooperation, although boundaries were often unclear and areas of expertise contested. However, coordinating professional working between professions trained in different models was complex, with the potential for inter-professional rivalry and conflict; psychiatrists often opposed reform and fought to maintain their position. There was also antagonism between psychiatrists and social workers; some social workers were committed to social models and opposed all drug and coercive treatments, whereas psychiatrists were disdainful of social work’s lack of medical training.152 Thus in many countries, the professional sphere was increasingly crowded, and interactions were characterised by mutual suspicion, rivalry and conflict rather than the seamless cooperative working envisaged by policy-makers; as new professions emerged, they attempted to position themselves within the mental care field, which often triggered inter-professional rivalry.
150
See Rogers & Pilgrim 2001 pp. 20-21 & 92-93 Goodwin 1997 p.138; Pilgrim 1997 p 245. See for example Rogers & Pilgrim pp. 20-25; Strain et al 2006. 152 See for example Goodwin 1997 pp. 138-140. 151
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Summary – creating reform conditions In this section three major pressures for mental healthcare reform have been discussed, thus demonstrating that the reform pressures did not come from a single source, but from the combination of several factors. The first element was social change and changing attitudes in society to mental illness, reflecting changing philosophies to mental illness and the decline in biological theories. The experience of the wars led to understanding that mental illness resulted from traumatic events or chemical imbalances and could be treated in the community. The state’s role in social control of citizens was also challenged, and social theories of mental illness emerged. In addition, individual rights, and disability and normalisation theories meant that isolated institutions were no longer considered optimal therapeutic environments. Thus these social trends that challenged traditional perceptions and ideas of community care gained ground. A second element was the development of new treatments with new drugs and psychological therapies not requiring inpatient care. While arguments exist concerning the exact causative link and timing between drug treatments and international community care trends, it is clear that drug treatments allowed some patients to be treated outside hospital and thus had some impact. The final element was administrative and welfare reform after 1945 with welfare systems that removed asylums as solutions to poverty. Reorganisation and sectorisation favoured decentralisation and acute services; thus the rationale for isolated hospitals declined, especially given the costs of maintaining the remote 19th century asylums. The professional arena also became more crowned owing to new professions such as social work and psychology challenging the traditional dominance of psychiatrists. The administrative and organisational reforms of healthcare also exerted reform pressures where the asylum did not have a place in the new model. Therefore, the three strands of social change, developments of new treatments and organisational change in healthcare created a trilogy of pressures for reform that converged in the 1980s and 1990s.
The reform process in Britain & Sweden In Chapter 1 I discussed how the mental health reforms in Sweden were based on similar reform ideas and contents and how in both countries the reforms were decades in the making. Therefore, although the research in this book focuses on the government choice of steering strategies and policy instruments relating to the implementation period from the mid-1990s to the mid-2000s, it is important to understand the background and context and the fact that these were similar reforms. Thus this section will trace the reform process in Britain and Sweden in order to identify the key characteristics and similarities of the aims and contents of the reform in each country. 49
The Governance Gap
Organisation of health & social services in Britain & Sweden The community mental care reform was designed so that health and social care agencies should share responsibility for mental health services. Although this book focuses on the governance gap of the steering relationships between government and municipalities, I trace the roles and responsibilities of mental healthcare provision which were similar in both countries: county and regional health authorities organised psychiatric services whereas municipal social services departments were responsible for social care. Organisation of municipal social services in Britain & Sweden In Britain when the reforms occurred, municipal government structures were themselves in a state of reform as unitary authorities were being created to replace two tier structures. Thus at the time of the reform there was a hybrid structure of unitary municipalities, two-tier Shire authorities, Metropolitan Districts and London Boroughs, described by Wilson and Game as a “dog’s breakfast” and lacking a coherent and uniform organisation.153 Municipalities were required to have Social Services Departments to provide social care services there the main services were elderly, child, family and disability care. In Britain most municipal finance is determined by the central government and in the mid-1990s only 15% of municipal income was determined locally while 85% came from government grants and centrally determined taxes.154 Sweden is divided into 290 municipal councils (kommuner), which have the responsibility for organising local services including social care services. As in Britain, municipalities are required to provide social care and to support the disabled, elderly, children, substance abusers and those who lack their own resources. Unlike Britain, most municipal income in Sweden is generated locally, from local income taxes as well as from fees and charges that total 80-85% of finance, and only around 15-20% coming from the state in the form of general and earmarked grants.155 Organisation of health services in Britain & Sweden In Britain the health services were provided by the National Health Service (NHS). The NHS was established in 1948 and offers citizens free medical care regardless of ability to pay. Despite being a national health service, it is organised on a regional and county basis, under the administrative control of the Department of Health. In Britain, at the time of the reform, a major reor-
153
See discussion of municipal reorganisation and structure: Wilson & Game 2006 pp. 60-67. Wilson and Game state that in 1992-93 locally determined finance (community charge) amounted to 15%; general state grants 31%; earmarked grants 23% and centrally determined business property taxes (uniform business rates) 31%: 2006 p. 218. 155 Statistics from Sveriges Kommuner & Landsting (Swedish Association of Local Authorities & Regions) 2005 p. 12. 154
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ganisation of health services was underway and at the time of the reform:156 there were 14 regional health Authorities157 and 192 district health authorities.158 Health Authorities were not elected bodies; instead authority members were appointed by the Minister, and usually included medical, trade union and municipal representatives, but were accountable to the Department of Health. In Britain health authorities had no taxation powers and were financed by central government; 95% of finance came from central grants and allocations from national taxation and social insurance. In Sweden health service structures have remained stable and organised on a county basis under the auspices of 21 county councils (Landsting).159 Swedish health services are decentralised and controlled by elected county councils, unlike the appointed boards in Britain. The county councils are responsible for planning and coordinating healthcare within the area. Swedish county health authorities are primarily financed by county income taxes, which account for 75% of income. Approximately 20% of finance comes from general and earmarked government grants, while circa 5% comes from patient fees. In both countries despite most healthcare being provided by the public sector, private healthcare providera coexist alongside public providers.
Britain: the Community Care reforms – policy development Although a new mental health policy was formally adopted in Britain in 1990, reform had been debated for decades. As previously discussed, until 1945 mental health in Britain was dominated by asylums, and in the 1950s the number of asylum beds peaked at 150,000. However, during the 1950s and 1960s reforming the asylum model was debated. A general community policy was espoused by politicians, whereby mental health would become more integrated in health services, yet few concrete reforms were achieved. In 1957 The Percy Commission investigated mental health and recommended that mental illnesses should be organised in the same way as other somatic illnesses, with as many patients as possible treated in the community. Yet there were tensions between doctors, who wanted a greater medicalisation of mental health, and lawyers and social workers, who favoured a greater legal security in decision-making. In the final recommendations, which became a new Mental Health Act in 1959, doctors were the main winners. The new Act emphasised decentralisation with the transfer of asylums from state con156
The reforms occurred via the 1990 NHS and Community Care Act which also involved the reorganisation of NHS, including the introduction of market mechanisms. 157 The Regional Health Authority coordinated policies and finance between government and districts. Key functions were strategic planning, policy coordination, implementation advice, control of capital projects, finance to districts, and monitoring and control tasks. 158 District Health Authorities usually corresponded to counties or larger cities. The 192 districts were responsible for providing hospital and community health services to the public. 159 Sweden has 18 County Councils (Landsting), two regions and the island of Gotland.
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The Governance Gap
trol to County Health Authorities, thereby increasing medical powers. A New Hospital Plan in 1962 included a government discourse of “normalising” mental healthcare into hospital systems and community, although significant mental health management responsibility transferred to psychiatrists. Thus the actions of policy-makers appeared contradictory; on the one hand there was community care rhetoric, while on the other the powers of asylum doctors increased. Thus despite the discourse of the community, little was achieved as most mental healthcare remained hospital-based. Even where patients did transfer to the ‘community’, usually it was to other institutions such as general hospitals and residential care homes. At this time inpatient admissions remained high and no asylums closed.160 In the 1970s institutional asylum care continued to dominate; however, reforms occurred for some groups. Until the 1970s children with learning disabilities and mental illness were placed in asylums and had no right to go to school. It was not until 1971 that municipalities became responsible for educating psychiatrically disabled children, reducing the number of children entering asylums.161 Some services relocated to general hospitals in the 1970s, and there were also campaigns to normalise the psychiatrically disabled’s treatment. However, this modest reform created unintended consequences and an asylum crisis as service relocation to local hospitals drained asylums of expertise as psychiatrists found that general hospitals conferred higher status and improved working conditions. In addition, the oil crises of the 1970s and subsequent public expenditure cuts left many patients with chronic conditions in rundown institutions, vulnerable to neglect and abuse. In 1975 the Minister responsible for mental health, Barbara Castle, presented a policy statement reaffirming a community care commitment, yet with the caveat that reform depended on economic improvement; thus the policy was given the derogatory nicknamed Castles in the air.162 The government’s political commitment to mental health reform was unclear; financial allocation systems favoured asylums. However, during the 1970s health authorities began to discharge patients; by 1975 there were 20,000 fewer patients compared with 1970; yet for those discharged, few suitable services existed.163 The 1980s was a time of major health and social service reform, and mental health was considered a prime reform object on ideological and cost grounds.164 Major healthcare reforms in the 1980s favoured acute services over chronic illness. Despite the community care rhetoric, finance systems still favoured asylums, which received 85% of funding. Thus services were a 160
See for example The Mental Health Timeline; Rogers and Pilgrim 2001 pp. 61-65. The Jay Report 1979 stated that fewer psychiatrically disabled children entered institutions after 1971 when municipalities took over education: Mental Health History Timeline. 162 Castles in the air depicts a person daydreaming about something unobtainable. 163 See Mental Health History Timeline; Rogers and Pilgrim 2001 pp. 61-68. 164 The Thatcher government rejected “cradle to the grave” welfare states advocating limited services imitating business management: See Clarke and Newman 1997 pp. 78-79. 161
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patchwork of asylums, acute psychiatric services, NHS care homes and limited municipal day and residential services. Community care was a policy problem for the government; reform was opposed by the medical profession and was not a public priority. In fact segregating the mentally ill was popular with the public.165 Thus despite the rhetoric of community care, hospitals dominated; most “community” care was institutional, albeit in located in loca residential and hospital settings. The 1981 Parkinson Report stated that despite community care being official government policy since 1959, little had been achieved. The report argued that the lack of action was in danger of discrediting the policy as decision-makers at lower levels did not believe that the government was committed to reform. There were also underlying structural problems as money and expertise were not transferred to the community, leaving patients without adequate support. The report’s recommendation was for an active government commitment to municipal community care.166 Thus over 20 years of official ‘community care’ policy resulted in few municipalities being involved in mental health. Reform policy development process In the 1980s there was movement towards reform with a number of critical legislative interventions and evaluation reports calling for reform. 1983 Mental Health Act The Mental Health Act of 1983 was a potential reform opportunity to redress the balance between hospital and community care, yet it focussed on inpatient care, with limited community care content. One community reform in the Act was the creation of specialist mental health social workers, Approved Social Workers (ASW). This created a statutory municipal social work role as municipal Social Services Departments were required to employ ASWs. In addition, the Mental Health Act Commission was established to monitor patient care and to investigate individual complaints, although the individual focus precluded investigations of systemic asylum abuses.167 Thus despite the community care rhetoric, policy remained focussed on inpatient care. 1985 Parliamentary Social Services Committee: Community Care Report In 1985 the Parliamentary Social Services Committee criticised the lack of action towards achieving the community care policy. It concluded that community care remained a distant ambition, since 92% of the mentally ill and 71% of the psychiatrically disabled remained in institutions.168 Among the particular obstacles for community care policy noted by the committee were 165
Rogers and Pilgrim 2001 pp. 69-76. The Parkinson Report: outlined in the Mental Health History Timeline. 167 The Mental Health Act 1983: section 117; The Mental Health Act Commission homepage: See also discussion in Rogers and Pilgrim 2001 pp. 74-81. 168 Statistics derived from the House of Commons Social Services Committee 1985 Annex 1a. 166
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The Governance Gap
the inflexible government finance rules requiring hospital closures, prior to funding of community services. The rules stated that patients must be discharged before community services could be developed, thus requiring patients to be discharged with no support. Thus government regulations restricted the transfer of funds to municipalities. The Committee also found that municipal mental health responsibilities were unclear; there was little direction from the state regarding what municipalities should do, and mental health had low municipal priority:169 “there has been no clear understanding as to what sort of services a local authority is expected to provide, and little or no lead from either central government or the NHS.”170 Thus despite general reform aims supporting community care, the government provided little active encouragement or finance, so achievements were modest. 1986 the Audit Commission Report In 1986 an Audit Commission Report criticised the slow progress of community care policy and concluded that nothing had improved in the almost two years since the Parliamentary report. In the previous decade, although 25,000 hospital beds closed, only 9,000 community care places were created. The Audit Commission concluded that government funding was inconsistent with the stated policy aims, as hospital funding rose by £100 million per year in the decade since 1976. There was also organisational confusion between actors with differing resource allocation systems, priorities, structures and cultures. However, the Audit Commission argued that central financial rules were the key impediment to community care. The government’s regulations penalised municipal investment in community care and created a paradox; municipalities were criticised by the government for the expenditure increases made to create community care services, whereas the NHS was praised for the ‘savings’ made by closing asylums. Municipalities were penalised through financial sanctions and service development depended on municipalities cutting costs elsewhere or increasing local taxes. However, a so-called perverse incentive meant that if municipalities failed to provide services and users were placed in institutional care homes, these costs would be financed by central government directly at zero cost to municipalities. 171 Thus the rules discouraged municipal involvement in community care: no funding was received until after asylums closed; finance rules penalised community care investment; and municipalities that provided no services and forced people into institutions, had the bill paid by central government. The Audit Commission concluded that community care could achieve significant cost savings, calculating that independent living with support services
169
House of Commons Social Services Committee 1985: pp. lvii-lviii & ciii. House of Commons Social Services Committee 1985: pp. cii. 171 Audit Commission 1986 pp. 2-3, 30-37, & 59. 170
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Reform & Policy Background
would cost less than half the amount of an asylum place.172 Therefore, the Audit Commission’s figures promised significant cost savings as a result of transferring patients to their own homes to be cared for by municipal social services. Community care policy was still under discussion in the 1980s; however, asylum discharges continued to increase; the number of beds declined by over 40% during the 1980s.173 The bed reductions were carried out as a gradual run-down of services and the first asylum did not close until 1986. However, the availability of support services was patchy and in many cases patients were abandoned.174 Therefore, there was no systematic community care policy and most municipalities provided few services. The Griffiths Report & policy reform The government response to the Audit Commission criticisms was to appoint a Community Care Commission in 1988 to evaluate reform policy led by Sir Roy Griffiths.175 The Commission was tasked with reviewing existing policy arrangements and recommending reform. The final Griffiths Report argued that despite over 30 years of official community care policy, there were huge gaps between rhetoric and reality. Reform was obstructed by several factors: municipal responsibility was unclear; there poor coordination between health and social service agencies; and funding systems were roadblocks to reform. Thus people with similar needs were allocated different services and housing seemingly at random. The Griffiths Report recommended separating medical and social care functions and reiterated the Audit Commission’s 1986 conclusion that government rules had hindered municipal community care. Griffiths recommended a genuine decentralisation from state and county to municipality, with decisions made near to users, arguing that services “should be as local as possible and with the locally elected authority. It cannot be managed in detail from Whitehall”. In addition, he concluded that the government must clarify actors’ roles so that “local responsibility for delivery of community care objectives is clear beyond doubt.” Griffiths also emphasised the use of independent voluntary and private care-providers and transitional grants to fund community service development prior to discharge. However, he also warned the government to formulate realistic expectations for municipalities as to what level of services they were expected to achieve within budget.176 Griffiths’ main recommendations were as follows: Firstly, separation and sharing of community care responsibility between the NHS and Audit Commission’s calculation of average costs per week: Asylum £255; Institutional/residential care £200; Own home, domiciliary support £133: Audit Commission 1986 p. 11. 173 Asylum in-patient beds declined after the 1950s: in 1954 there were 154,000 beds. This fell to 87,000 in 1980 and 50,000 in 1992: See Kaye & Howlett 2005 p. 50. 174 Robertson 1994; Carrier & Kendall 1997 pp. 15-16; Kaye & Howlett 2005 pp. 49-51. 175 Griffiths was managing director of the supermarket chain Sainsbury’s. His appointment reflected a government trend of using business managers in public sector reforms. 176 Griffiths 1988 pp. iv-ix & 1-10. 172
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The Governance Gap
municipalities. Secondly, municipalities would be financially and organisationally responsible for social care services. Thirdly, government should provide specific grants and restrict state funded institutional care. Fourthly, the government would need to demonstrate a high-level of political commitment for community by the creation of a Minister for Community Care. Finally, direct care would be provided by unskilled staff and a new role of ‘community carers’ should be created.177 Government reform policy: Bill – Caring for People The government broadly accepted the Griffiths Report’s findings and proposed new legislation. The bill Caring for People recommended independent living for the psychiatrically disabled in “their own homes or in “homely” settings in the community.”178 In Britain the community mental care reforms were introduced as part of an Act that contained a package of health and social care reforms.179 The bill aimed to change social care provision and funding as well to clarify actors’ roles and responsibilities. The government’s main community care objectives were as follows:180 Domiciliary care: earlier community care policies were reiterated with a new emphasis on independent living with social support services. Separation of medical and social care: social care responsibility would transfer to municipalities and the NHS responsible for medical care. Municipal financial responsibility: municipalities were to be financially responsible for social care and housing.181 Requirement to promote independent provision: municipalities were expected to promote independent private and voluntary care providers. Transitional and transfer funding: the government proposed specific transitional grants to encourage collaboration between municipal and NHS agencies. Residential care funding would be included in the general Revenue Support Grant. Staff training: to improve skills and competence, the government announced a new Social Work Diploma and vocational qualifications.182 Supervision and monitoring: municipal planning and performance were to be monitored by the Social Services Inspectorate. Municipalities were responsible for inspecting independent contractors.
Recommendations listed Griffiths 1988 pp. vi –xi. Her Majesty’s Government 1989 p. 3. 179 The Bill contained community care proposals for municipal responsibility for three groups: mental health, elder care and physically disabled. In Sweden elder and physically disability reform occurred as a separate Ädel reform three years prior to the mental health reform. 180 Her Majesty’s Government 1989. 181 This proposal was aimed at reducing the perverse incentive to use institutional care funded by the central Social Insurance Agency: See Her Majesty’s Government 1989 pp. 64-65. 182 See Her Majesty’s Government 1989 pp. 67-68. 177 178
56
Reform & Policy Background The government’s proposals became the National Health Service and Community Care Act 1990. Final implementation was delayed for political reasons, extending the implementation phase to three years. The reform was implemented on April 1st, 1993 when municipalities took formal responsibility for community care social services.183
Sweden: mental health reform (psykiatrireformen) policy In Sweden, as in Britain, the road to the community mental care reforms was also long and gradual. Until the 1960s mental healthcare was under state control, with most psychiatrically disabled confined to asylums. As mentioned in previous sections, changing attitudes influenced reform, not least when a case against Sweden in the European Court claimed Sweden had the highest percentage of population committed to asylums in Europe.184 As in Britain mental health reform occurred in several phases: mental health was decentralised in 1967 when asylums transferred from the state to county health services, and the Act mentioned the possibility of care outside asylums. However, the legislation’s provisions made it clear that psychiatrists and the medical model were dominant in mental health.185 In the 1970s the National Board of Health and Welfare (Socialstyrelsen) recommended organisational changes to mental health to increase municipal involvement and improve coordination. Some community projects started, yet despite the ‘community’ rhetoric, the pace of change was slow. In 1973 the Board also produced a new report on mental health organisation. Compared with Britain, asylum beds declined at a slower rate in Sweden; in 1973 there were 37,700 in-patient beds, just 950, or 3%, fewer than 1967. However, the report reiterated a commitment to community care and recommended the abolition of asylums within 20-25 years.186 Yet as in Britain, achievements were modest. By 1976 no major asylum had closed: the rate of asylum admissions had more than doubled and two thirds of psychiatric patients remained in asylums. Thus like Britain, despite a long-standing general policy commitment, there were few concrete achievements. The policy development process in the 1980s The 1980s was also a time of health and social services reform in Sweden, as in Britain. Despite the general community mental health policy, there ap183
The full implementation of Community Care was delayed for political reasons by the government owing to conflicts over the introduction of the Poll Tax, a flat rate personal tax, to finance municipalities. Poll Tax protests led to riots on the streets and community care would create local tax increases. Thus reform implementation was delayed even though discharges had started: See for example Wilson & Game 2006 pp. 217-220; Murphy 1991. 184 See RSMH website: history. 185 Lag (1966:293); See also Dalademokraten 9/1-02. 186 Report Mental Healthcare’s Goals and Organisation (Den psykiatriska vårdens målsättning och organisation): See RSMH history timeline.
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The Governance Gap
peared to be a lack of action on the ground, and several reports focussed on the need to expand outpatient and community care. Just as in Britain, few community medical and social services existed for psychiatric disability. 1980 Social Services Act The 1980 Social Services Act (Socialtjänstlagen) implemented in 1982 appeared to be a major development for mental health reform by creating a municipal responsibility for the social care of the psychiatrically disabled. However, inter-organisation obstacles hindered patient discharges and few services were actually established.187 As in Britain, there were few incentives for Swedish municipalities to increase mental health services. The user group, the National Association for Mental and Social Health, criticised the lack of results in “The Way Back” (Vägen tillbaka) campaign, claiming that 10,000 people remained in asylums owing to a lack of municipal services, and poor coordination between counties and municipalities. The Association campaigned for the discharge of patients not requiring medical treatment between 1980 and 1985, criticising mental health policy as “empty words and meaningless promises”.188 As in Britain, after a slow start, dehospitalisation accelerated in Sweden during the 1980s, although the first asylum did not close until 1987. In most cases patients were not transferred to their own homes: but to other forms of institutional care including psychiatric wards and care homes, others were abandoned to fend for themselves.189 Despite the 1980 Act, Brinck wrote over a decade later in 1994 that few community services existed and many were still “under development.”190 Therefore, the lack of municipal mental health services meant that discharge was often followed by the revolving door of readmission. In the late 1980s it was estimated that at least 7,000 patients remained in asylums for social reasons, such as a lack of suitable accommodation as well as organisational confusion relating to which services health and social services should provide. Municipalities were often negative to the cost implications of mental health services and, as in Britain, not providing services meant that patients remained in institutions at no cost to the municipality.191 Therefore, despite the 1980 Social Services Act, there was little significant increase in municipal mental health services. The Act did not address practicalities, and many municipalities did not include mental illness within disability definitions. The official community care rhetoric did not match reality. A new reform process began in the late 1980s to increase the role of municipalities in disability care. In contrast to Britain, Sweden’s reform oc187
See Brinck 1994; Markström 2003 pp. 120-124. See the RSMH history timeline (my translation). 189 See Brink 1994; RSMH history timeline. 190 Brinck 1994 p. 258. 191 In 1987 around 100 psychiatrically disabled lived in group homes and few social activities existed: RSMH timeline; Brinck 1994; Topor 1998 pp. 72-74; Markström 2003 pp. 122-123. 188
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Reform & Policy Background
curred in two stages: The 1992 Ädel Reform transferred old-age and physical disability care from health to municipalities. Thus Sweden had previously experienced this type of reform prior to the mental health reform. Mental Health Inquiry: Welfare & Freedom of Choice Within a year of the British Commission, Sweden established its own Commission192 to examine mental health reform in 1989. As in Britain, the Swedish Inquiry found that municipal mental health roles were unclear with services difficult to access and user needs unmet. The Inquiry identified similar problems in Sweden to those identified in Britain; despite the intentions of the 1980 Social Services Act, many municipalities appeared unclear as to their mental health responsibilities. The Inquiry argued for a greater social perspective in services, yet roles were poorly defined with few incentives for change as the 1980 Act had not resolved coordination issues. Municipal mental health services scarcely increased and were not prioritised, and the psychiatrically disabled were often excluded from disability definitions. In 1992 the final Inquiry report, Welfare and Freedom of Choice,193 emphasised mental illness was a disability, and required normalisation and tailored services to enable the psychiatrically disabled to live as other citizens.194 The Inquiry argued that mental health should be brought into line with other disability services by introducing with legally binding rights and clarifying roles to improve coordination between state, county and municipal actors. It was recommended that social needs should be recognised as a separate, specialist organisation and that municipalities should become financially and operationally responsible for those patients who were medically treated by remained in asylums. A series of transitional grants were proposed to assist the start-up costs for both municipalities and voluntary groups to provide support services. The Commission also proposed government grants for staff-development to improve mental health competence and rehabilitation to develop workplace skills among the psychiatrically disabled.195 Therefore, the Inquiry report emphasised a disability perspective for mental health services based on binding disability rights and a social perspective. Government Proposition: The Conditions of the Mentally Disordered The government responded with a form Proposition for mental health reform: The Mentally Disordered’s Conditions.196 The government accepted 192
This is based on SOU 1992:73 - Välfärd och Valfrihet (Welfare & Freedom of Choice). SOU 1992:73. 194 Disability rights recommended by the Inquiry included the same rights, duties and treatment as other citizens; the right to receive need-tailored services; the right to choice: the right to normal living; and the right to receive services that respected the psychiatrically disabled’s independence, integrity and welfare. SOU 1992:73 p. 20. 195 See the recommendations SOU 1992:73 pp. 23-61. 196 Regeringens Proposition 1993/94:218 Psykiskt stördas villkor. 193
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The Governance Gap the Inquiry’s recommendations for mental health reform and also the analysis that definitions and requirements of previous community care policies were inadequate and that implementation had been poor. Thus the government broadly accepted that while inpatient beds had declined in the past 25 years, social care services lagged behind, and some patients were forced to remain in institutions. The main reform proposals were as follows: 197 Normalisation policy with disability status: the government emphasised that severe mental illness should be regarded as a disability and that patients should receive disability services that guaranteed a good standard of living and an own home in the community with social support services. Separation of medical and social care: municipal responsibility for social care was underlined whereas counties retained medical care services. Municipal financial responsibility: new legislation would clarify municipal financial responsibility for medically treated patients; municipalities would be charged for patients remaining in hospital on social grounds.198 Transitional funding – stimulus finance: 955 million kronor in transitional stimulus finance for three years would provide funding for short-term projects to ‘pump prime’ service development. Use of the independent sector: the government emphasised voluntary and user-led services such as peer-support services. The government also stated that independent contractors could be used to provide services.199 Staff competence development and training: the stimulus finance included staff training funding for developing working methods. Personal Representatives: pilot projects were established for case workers to provide qualified and professional support.200 Monitoring and supervision: the National Board of Health and Welfare would be responsible for evaluating implementation.201 Emphasis on work and rehabilitation: coordination between health, social services, the Social Insurance (Försäkringskassan) Agency and Employment Agency (Arbetsförmedlingen).202 The government proposition was less radical than the Inquiry’s recommendations; in particular disability rights were muted; rights, freedoms and choices were not specified in detail; and the reform’s target group of “fully medically treated” patients was not defined by the Proposition. The govern197
See recommendations contained in Regeringens Proposition 1993/94:218. The government proposed clarification of municipal financial responsibility through the Municipal Financial Liability (Certain Forms of Health and Medical Care) Act (Lagen om kommunernas betalningsansvar för viss hälso- och sjukvård). See Regeringens Proposition 1993/94:218 p. 40. 199 The government reserved some stimulus finance to establish user-led services such as peer-support (Kamratstöd) services. In addition, contractors could be used to provide services: See Regeringens Proposition 1993/94:218 pp. 26 & 87-89. 200 Regeringens Proposition 1993/94:218 pp. 29-34 & 92. 201 Regeringens Proposition 1993/94:218 pp. 98-100. 202 Regeringens Proposition 1993/94:218 pp. 50-56. 198
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Reform & Policy Background
ment proposed that issues of the interpretation of terminology should be discussed by the National Board of Health and Welfare within the scope of their evaluations of the earlier Ädel reform.203 Markström described the government’s arm’s length policy as a “wait and see” approach.204 In contrast to Britain, the Swedish reform was not based on new legislation but on minor adjustments to the framework legislation of existing Municipal, Social Services and Disability Acts. Thus the government was responsible only for general policies and guidelines, while interpretation and formulating service content was devolved to municipalities, counties and other actors.205 The government’s proposals were accepted by the Parliamentary Social Committee despite some concern about the government’s failure to provide detailed guidance. In particular there were concerns that the application of disability legislation to the psychiatrically disabled was unspecified, and that the division of responsibilities between municipalities and counties remained unclear, despite role clarification as the stated reason for the reform.206 However, the proposition was approved with few changes and was implemented just over six months later on January 1st, 1995.
Conclusions: background & reform process This chapter has established two points of central importance for this book: firstly that Britain and Sweden were subject to similar international trends to reform mental health; and secondly that both countries formulated mental health reform policies with similar aims and contents.
Conditions for reform The background discussion above shows that internationally a number of key reform pressures converged in the 1980s and 1990s, facilitating the conditions for mental health reform. These conditions are not mutually exclusive, but work in synergy to create pressure for reform. The first issue was that social change created pressure for reform as after 1945 perceptions of citizens’ rights and disabilities began to change and normalisation models developed. In addition, the state’s role as an agent of social control over citizens was increasingly challenged. The second issue was the availability 203
See Regeringens Proposition 1993/94:218 p. 40. Markström 2003 p. 174 (my translation). 205 The lack of new legislation for the reform contrasts to compulsory inpatient care. At the same time the mental health reform was under consideration, there was new legislation relating to compulsory inpatient care with two new Acts: the Compulsory Psychiatric Care Act (Lagen om psykiatrisk tvångsvård SFS 1991:1128) and The Forensic Psychiatry Act, (Lagen om Rättspsykiatrisk vård SFS 1991:1129). 206 Sveriges Riksdag, Socialutskottet 1993/94:SoU28 pp. 1-2. 204
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The Governance Gap
of new treatment methods, especially drug and psychological therapies. Although the exact timing and efficacy of drugs are contested as reform explanations, medication created preconditions for certain types of patients to live in the community. The final issue was the impact of administrative reform as a reform pressure: reorganisation and sectorisation meant that the asylum model did not fit into healthcare’s new structures. This created a debate about where the psychiatrically disabled should live. There were also structural changes in professional perceptions and roles: psychiatrists’ authority was no longer automatic and unquestioned, and new community-based professions started staking a claim to the mental health sphere. In addition, 19th century asylums were expensive for governments to maintain as a time of financial crisis, thus creating further reform pressures. Therefore, Britain and Sweden were part of an international movement by Western countries after 1945 to reform mental health and reduce the number of patients in asylums.
Reform process in Britain & Sweden – were the reforms similar? The development of mental health policy after 1945 in Sweden and Britain displayed many similarities; both countries had longstanding official “community care” policies, both wanted increased municipal involvement in mental health, and in both countries little actual progress was achieved. In both Britain and Sweden there were healthcare reforms and a shift to sectorisation, yet asylums proved difficult to close owing to unclear responsibilities with financial, professional and cultural conflicts hampering community care policies. By the 1980s the asylum “full-service” model of medical, social and occupational services in remote locations did not ‘fit’ with healthcare models where organisational and management reforms emphasised local and acute medical services. Thus in Britain and Sweden traditional asylum models and associated costs proved difficult to justify at a time when policy reforms were influenced by business management ideas such as decentralisation, disaggregation, individualisation and market mechanisms. The reform policies formulated in Britain and Sweden bore strong similarities in the central reform aims and contents. There were minor differences of emphasis: while both countries included independent actors, the strong “market-speak” in Britain was toned down in Sweden to focus on the voluntary sector; in Sweden the ‘work-line’ of rehabilitation and work were emphasised more than in Britain, although the long-term implementation documents saw this become important Britain as well. Therefore, the reform process was similar in both countries and, despite minor differences in emphasis, the central reform aims and content were essentially the same: Separation of medical from social care; Municipalities became responsible for social care services and assumed financial responsibility for treated psychiatric patients;
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Reform & Policy Background
Transfer of responsibility for medically treated patients from County Health authorities to local government community care services; The government to provide transitional finance to start-up services; The government’s emphasis on diversity of provision and involvement of voluntary and private services; The need for staff training to develop the competence required for the new social care services; Implementation would be monitored by central agencies responsible for social services and social care regulation.
Thus it is clear that the community mental care reforms bore striking similarities and that the essential reform content was basically the same in both Sweden and Britain.
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[Type text]
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Reform & Policy Background
Chapter 3
The mental health reforms & steering instrument choice The puzzle discussed in Chapter 1 was that despite formulating reforms with essentially the same reform aims and contents, the governments of Britain and Sweden made different instrument selections in the governance gap between central and municipal governments with which to steer the lower level agencies charged with implementing the reform. This chapter discusses the idea of the governance gap in the mental health reforms in more detail, and in particular the idea that Britain chose hard steering strategies and instruments whereas Sweden chose soft. The discussions will be twofold: the first discusses policy steering instruments and develops an instrument for analysing steering choices; while the second analyses government–steering and instrument choices for the mental health reform for the short and long-term implementation phases covering a decade after the reforms. Studying a longer term implementation perspective will enable me to consider whether the choices of policy steering instruments changed as a result of earlier outcomes, or whether the pattern of instrument choices was enduring. This will enable the determination of what differences, if any, exist in the choice of steering instruments used to steer the reform in Britain and Sweden and the effects of these different modes of governance and steering.
Policy steering instruments The discussion of user outcomes and organisational results of the mental health reforms in Britain and Sweden in Chapter 1 revealed divergent results despite the similarities of the reforms’ objectives and content, and identified the possibility of a link between reform results and government steering. Although the research question focuses on the influences on steering strategy selection, this chapter is devoted to identifying the contents of the governance gap and the policy steering instruments selected by the two governments to fill the gap, in order to analyse the premise that Britain chose hard/harder steering types whereas Sweden chose soft/softer. This first sec65
The Governance Gap
tion constructs a model that helps classify and sort the steering and government strategies adopted by Sweden and Britain into hard and soft steering. In this book I focus on what is referred to as internal steering instruments in the prior literature on policy steering and governance. According to Bemelmans-Videc, steering instruments can be internal or external. Internal steering instruments are used by governments to steer the administrative system tasked with implementing the reform by influencing the behaviour of implementing organisations and actors. External steering refers to the way that governments directly attempt to influence the reform’s target users via for example, direct services, cash-benefits and information campaigns.207 Much of the previous work has focussed on a management by objectives approach of linking reform aims to user outcomes, which often ignores what occurs in the “black box” of the steering relationships between state and lower level agencies. However, in this book it is precisely the “black box” of the governance gap that I am interested in. In the case of mental health reform, despite these being national reforms, the two governments had no direct relationship with reform users as implementation was devolved to lower level agencies. Thus the government had little opportunity to steer user outcomes directly: the main opportunity for the government to direct the reform was via its choice of instruments to steer the implementing municipalities.
Choosing steering instruments: carrots, sticks & sermons Policy steering instruments are the ways in which governments exercise power to achieve their goals. Governments have many types of steering and governance instruments at their disposal, although according to May, the exact number and categories are contested within policy instrument research. Thus many different definitions exist regarding the scope and range of policy steering instruments. These range from minimalist definitions, such as Brighton and Brown’s (1980) twofold categorisation of instruments as penalties or incentives, to Kirschen’s (1964) scheme of 63 mostly economic, policy instruments.208 Thus while policy instrument classification is contested, most scholars agree that the main types include regulation, incentive and information steering strategies. Vedung and Bemelmans-Videc refer to these as carrots, sticks and sermons: the ‘stick’ is steering by regulation, the ‘carrot’ is incentive steering, often financial, and the ‘sermons’ are the use of information to persuade the addressees to adopt the government’s preferred strategy. However, the existing literature usually assumes a progression of instrument strength from soft to hard; Bemelmans-Videc and Vedung argue that governments utilise policy instruments from least coercive to more coercive mechanisms, although there can be positive and negative instru207 208
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See discussion of internal and external steering in Bemelmans-Videc 1998 pp. 3-4. See May 2003 pp. 225-226. See also Vedung 1998; Salamon 2002a.
Reform & Policy Background
ments.209 Therefore, much of the existing policy instruments literature considers that, for example, regulation is automatically hard steering, whereas information steering is soft. Thus existing research assumes the following progression:
Information
Financial incentive
Regulation
(sermons)
(carrots)
(sticks)
soft steering
medium steering
hard steering
Diagram 3.1: Policy instrument progression
Therefore, I believe that differences exist within each category and that harder and softer instrument types may coexist, and that within each category there may be harder and softer instrument types. For example, regulatory instruments are binding rules and regulations, and are classified as hard steering instruments, yet there is a significant difference in the level of “hardness” of an act of Parliament that, on the one hand are prescriptive and detailed, and on the other hand, framework legislation that is loosely formulated and flexible. Thus in contrast to many policy instrument researchers, instead of perceiving each category to be part of a soft to hard steering progression, I regard policy steering instruments as a scale where harder and softer options are available to governments within each category; when considering ‘the stick’ it is important to remember that not all sticks are mighty oak branches; green twigs are also types of stick. For example, in the mental health reforms, legislation was used as a regulatory steering instrument, usually considered hard steering, but my argument is that different types of legislation represent different types of ‘hardness’. However, the idea of hard and soft governance coexisting within the same category does not appear to have been developed within policy instruments research so no ready-made typology exists for use in this chapter. Therefore, in order to analyse the mental health reforms, and as one of the theoretical contributions of this PhD thesis, I develop a new model to reflect my idea that softer and harder instrument choices exist within each category. This will help me differentiate the actual types of steering strategies used for the mental health reforms for the three categories mentioned above.
209
See for example Bemelmans-Videc 1998 p.4; Vedung 1998 pp. 41-50. For discussion of affirmative and negative instruments see Bemelmans-Videc & Vedung 1998 pp. 250-257. This view is supported by van der Doelan, who argues that policy instruments can vary and can be ‘simulative’ or ‘repressive’: van der Doelen 1998 pp. 132-133.
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The Governance Gap Regulatory steering: “the stick” Regulatory steering refers to regulatory instruments such as legislation, rules, directives and regulations that are binding on implementers whereby government steering requires lower level actors to follow the regulation.210 The primary and traditional state regulatory steering instrument is legislation but could also include other formal directives and rules. In addition, other types of regulatory steering occur through regulatory and control systems such as targets and directives. In prior policy instrument research, regulatory steering is usually considered a hard and coercive steering form, yet in recent decades new, less coercive types of legislation and directives have been adopted as a result of public management reforms. These new steering types, such as framework legislation and management by objectives, set out general aims and values and, while formally binding, allow implementers greater freedoms to determine implementation details. Incentive or financial steering: “the carrot” Incentive steering describes incentive-based, often financial, steering strategies where governments give or remove resources to steer behaviour.211 Traditionally steering is based on positive financial incentives to induce compliance from implementing agencies or instruments such as vouchers, benefits and services. However, financial steering can also be negative such as taxes, fees, charges and duties, and include penalties and sanctions, incurring negative financial consequences for non-compliance.212 Governments can use earmarked finance to steer agencies in certain directions or to avoid others. For this category there has been general agreement among researchers that incentive and/or financial steering can involve harder and softer instruments. Information steering: “the sermon” Information steering strategies are non-binding communication types. They are used by governments to communicate with implementing agencies and/ or citizens; to influence behaviour or actions; and to persuade lower level actors to follow the state’s preferred strategy.213 According to Vedung, there are numerous information instruments including brochures, fliers, advertising, audits, inspections and training.214 Prior research usually classified information as soft steering instruments: according to Vedung and van der Doelen ‘the most lenient tool of government’.215 Information steering is usu210
See Bemelmans-Videc 1998 p. 10. See Bemelmans-Videc 1998 p. 11. 212 See discussion: Vedung 1998 pp. 43-48; van der Doelen 1998 pp. 132-134. 213 Instruments are often used to describe the ways in which the government communicates directly with users, whereas this book focuses on the relationship between government and municipalities. See Bemelmans-Videc 1998 p. 11. 214 See Vedung 1998 pp. 33. 215 See discussion in Vedung & van der Doelen 1998 p. 104. 211
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ally considered soft as information is non-binding on addressees: however, my interpretation is that even within this category there are what I consider to be harder and softer forms, ranging from pure information to harder forms where threats and strings are attached. In this chapter these instruments focus on the information provided to municipalities from the centre including monitoring and audit agencies and other forms of information. Discussion: policy instrument selection – hard & soft steering There are, therefore, a wide number and many types of policy instruments, and the main difference between the categories of policy instruments discussed is the degree of compulsion on the addressee. Much of the existing literature assume that states move up a ‘ladder’ when choosing policy instruments from least binding to most binding. Some researchers have already discussed the idea of positive and negative instruments forms, especially in relation to financial/incentive instruments.216 In the sections above, however, I have developed the argument further and linked policy steering instruments to concepts of hard and soft steering. I argue that harder and softer instrument choices exist in each of the three categories of regulatory, incentive and information instruments. In my model each category represents a scale and contains both harder and softer instruments. Therefore, even when the government chooses the categories of regulatory or information instruments, there is a scale of harder and softer instrument choices in each category. I have constructed a new model to reflect harder and softer choices within each category and this model is summarised in the following table: Table 3.1: Summary policy instruments – hard & soft steering Instrument type Regulatory “the stick”
Hard steering
Financial/incentive “the carrot”
Information “the sermon”
216
Soft steering
Legislation with high level of detail and obligation. Directives and binding guidelines.
Negative incentives based on compliance and threats. Financial penalties and sanctions. Theoretically voluntary information but with threats and conditions attached.
Incentives and ‘free money’ general grants and subsidies with few strings attached.
General information. Mild persuasion forms based on ‘learning’ strategies.
Framework legislation with low level of detail and obligation. Imprecise guidelines.
Bemelmans-Videc & Vedung 1998 p. 250 diagram 11.1.
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The Governance Gap
In the following sections I will analyse the choice of steering instruments for the mental health reforms in order to establish whether Britain and Sweden favoured harder or softer steering instruments.
Britain: governance, steering & instrument choice In Britain the reform steering in the short- and long-term occurred during a turbulent public policy period, where a plethora of reforms and frequent policy revisions took place. To make the mental health reform comprehensible, it has been necessary to streamline the multiple reforms and instruments by making selections; in cases of multiple instruments, such as directives, samples were used. 217 The Department of Health argued there was “a significantly strengthened ‘chain of command’ from the Secretary of State to the field”, emphasising central steering and control mechanisms.
Regulatory steering Regulatory reform steering Britain was unstable, even chaotic, owing to a constant stream of new government regulations forcing reactions from municipalities. The government adopted an interventionist stance, showing readiness to use formal legislative and regulatory steering mechanisms to ensure municipal compliance; there were a “plethora”218 of changes with high levels of compulsion. The tempo of legislative and regulatory steering remained high after 1997 despite the change of government. The table below is by no means exhaustive, but summarises the main regulatory steering instruments in the reform legislation between 1990 and 2005:
Table 3.2: Legislative & policy initiatives in Britain Year 1983
1990
1991
217
Policy initiative Mental Health Act
Regulation type Legislation
National Health Service & Community Care Act Care Programme Approach (CPA) Community Care Review of Residential Homes Provision and
Legislation Directive LASS(90)11 Directive LAC(91)
Main contents Mainly related to inpatients Creation of mental health Approved Social Workers with statutory functions Community Care legislation Internal market legislation Statutory Care planning to support municipal Care Management Directives on use of residential homes and independent sector
For example the number of directives such as Local Authority Circulars (LAC) and Local Authority Social Services Letters are too numerous to include here and a sample has been taken from the Department of Health’s website. 218 See 6 & Peck 2004.
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Reform & Policy Background
1992
1993
1994
1995
1997
1998
1999
Transfers White Paper: The health of the nation Housing & Community Care Social care for adults with learning disabilities (mental handicap) Community care plans (consultation) directions
Bill – legislative proposal Directive LAC(92)12 Directive LAC(92)15
Directive LAC(93)4
Supervised Discharge – guidance and implementation of Supervision registers
Directive LASSL(94)14
Community Care plans (independent sector non-residential care) direction Mental Health (Patients in the Community) Act
Directive LAC(94)12
Community Care plans from 1996/97 The patient's charter good practice in mental health services: a collection of good practice in the provision of community mental health services White Paper: NHS
Directive LAC(95)19
Modernising mental health: safe, sound and supportive
Legislative proposal
Modernising social services
Legislative proposal
Health Act 1999
Legislation
Review of Mental Health Act
Review to create policy proposal
National Health Service Framework
Directive
Legislation
Directive
Bill – legislative proposal
Mental illness to be prioritised Directive to use domiciliary services and duty of coordination. Directives to municipalities on service planning Central directives relating to service planning and duty to consult with independent sector Directions on community discharge. All deaths associated with community mental care to be investigated in statutory homicide inquiries. Municipalities and NHS must identify, register and supervise high-risk patients Municipalities required to include statement regarding plans to purchase non-residential services from the independent sector Supervised discharge orders Aftercare planning requirement Requirements for community care planning Targets and time limits for municipalities to contact patients released from hospital
Abolition of internal market . New “root and branch” reform of mental health. Use of evidence based care Failures of community mental care catalogued Increased public safety emphasis – “safe” even comes first in title. Structural reforms Increased central control over: services targets/star ratings professional – controls Legal changes to increase collaboration between health and social services Recommendations for new legislation Increased community compulsion Mental health and official priority Detailed/prescribed service standards
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The Governance Gap
2000
2001
A new approach to social services performance Care standards Act 2000
LAC(99)27
White paper: reform of the Mental Health Act
Bill – legislative proposal
NHS Plan
Directive
Health & Social Care Act 2001 plus guidance
Legislation
Legislation
Requirement to establish multidisciplinary Local Implementation Teams (LIT) Increased performance management Development of new set of national performance indicators for municipal social services Increased inspection & regulation Social Work to be regulated by executive agency New legal framework Proposed indefinite detention of personality disorder patients based on risk assessment even where no crime committed Reduced emphasis on patients’ safeguards and principles Establishment of multidisciplinary Mental Healthcare Trust Municipal Star system/ league tables & specific mental health targets: 3 stars - increased autonomy 0 stars - central intervention Increased integration of municipalities and health services Legal framework for Care Trusts General Social Care Council: established for: Compulsory registration for social workers; Approval of social work degrees; and Code of Conduct
White Paper: shifting the Balance of Power
2002
Bill – legislative proposal
Draft Mental Health Act National Institute for Clinical Excellence (NICE) established
2003
72
Wanless report
Policy proposals
Health & Social Care (Community Health Standards Act) 2003
Legislation
National Institute for Mental Health established to provide evidence based methods and implementation guidance New structures for health services: Department of Health’s regional offices abolished. Health authority mergers Wide ranging criticisms of draft government forced to withdraw Clinical guidance/directions on mental health treatment. Health authorities three months to implement High-quality services require increased finance. Government commitment to increased funding New organisational structures for health services New inspection systems for health
Reform & Policy Background
2004
2005
Department of Health – planning and priority framework 2003-2006
Directive
White Paper: Mental Health Act
Bill – policy proposal
Office of the Deputy Prime Minister: Social Exclusion Report – Mental health & social exclusion Community care assessment directions 2004 Mental Capacity Act
Directive
Directive LAC(2004)23
and social care: Commission for Social Care Inspection (CSCI) Commission for Healthcare Audit & Inspection (CHAI) Implementation framework for the NHS plan Mental health a stated priority Still contested but redrafted Social Work role ASW to be replaced with Approved Mental Health Professional (AMHP) Action plan to increase participation by the psychiatrically disabled in the workforce
Directions on assessment
Legal framework to protect vulnerable groups
Regulatory steering: the early years The early years of the reform under the Conservative Government between 1993 and 1997 saw a significant level of government regulatory activity in the form of legislation, and central directives provided detailed directives for municipalities. The primary focus of these steering instruments was increased supervision and coercion while ensuring that government cost control targets were achieved. The 1990 National Health Service & Community Care Act219 was the primary legislative steering document for the community mental care reforms, yet contained a bundle of reforms in a single Act. Thus municipalities were implementing several reforms simultaneously. Unlike Sweden which implemented community care in two stages, Britain’s community care reforms for the psychiatrically disabled, physically disabled and elderly were contained in this single Act, which also contained NHS organisational reforms including the NHS internal market. Thus despite the reform’s stated decentralisation aims, the government used strong, formal legislative steering and detailed regulation to steer the reform. Within a few months of the reform, legislation was proposed to increase control; the 1995 Mental Health (Patients in the community) Act created statutory supervision roles for municipalities. Government steering focused on municipal application of coercive control mechanisms rather than increased care available to users in the community. Less than a year after the reform, there were fears of serious crime, many of which occurred when patients were released without 219
See 1990 NHS and Community Care Act.
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The Governance Gap
proper support prior to full reform implementation. However, these crimes became strongly associated with the reform. 220 Government steering also occurred via multiple directives issued to municipalities in the form of Local Authority Circulars (LAC) and Local Authority Social Services Letters (LASS). These provided instructions and directions for reform interpretation and specific government requirements. An analysis of a small sample of ten221 circulars reveals that while the government referred to them as “guidance”, they are clearly Ministerial directives as many circulars contained directions made with reference to Ministerial powers.222 The circulars prescribed Ministerial requirements223 and examples include powers for central departments to inspect municipal community care plans; obligations to involve independent actors; and detailed directions of standardised planning formats.224 Thus the government utilised regulatory instruments to steer implementation and exert control, despite the stated decentralisation policy. Many directives were aimed at municipal administration rather than at users. The government directed municipalities to organise services that focused on greatest need and high risk, thus excluding the majority. Traditional municipal services, such as counselling and preventative work, were downgraded or abolished under the new contracting systems.225 Social Services Department Directors wrote to Ministers expressing concerns over unmet needs.226 The reply from the Department of Health directed municipalities to be evasive with users regarding the services they could not afford, and to avoid informing users of assessed needs that cannot be financed to avoid being sued for maladministration.227 In 1997 new regulations incorporated community mental care services in the Patient’s Charter 220
The government proposal to legislate patients supervision and control in the community was announced in directive LASS(94)4 issued in 1994, which became codified into the Mental Health (Patients in the Community) Act 1995. However, Ministers rejected calls to guarantee minimum standards of care for community social care services. See LASS(94)4; Mental Health (Patients in the Community) Act 1995; Independent 5/1-93; 13/1-94; 10/10-94. 221 Ten circulars were selected at random using the department health website and the search term community mental care. See LASS(90)11; LAC(91)12; LAC(92)12; LAC(92)15; LAC (93)4; LAC(94)12; LASS(94)4; LAC(95)19; LAC(99)27; LAC(04)23. 222 See for example Audit Commission 1992 pp. 21-22; LAC(91)12; LAC(92)12; LAC (92)15; LAC(93)4; LAC(94)12; LASSL(94)4; LAC(95)19. 223 In the small sample examined, directives included housing provision; transfer of municipal services to the private sector and requirement to purchase 85% of services from independent contractors; consultation with independent contractors and purchasing care for the psychiatrically disabled; discharging the psychiatrically disabled and cooperation with county health services. See for example LAC(91)12; LAC(92)12; LAC (92)15; LAC(93)4; LASSL(94)4; HSG(94)27. See also prior discussion in Independent 13/1-94. 224 For example minimum key components found in LAC(95)19, Annex A give detailed requirement for municipal Community Care plans, linked to national policy objectives. There was little freedom for municipalities to tailor planning to local conditions. 225 Department of Health 1994 p. 16; Henwood 1995 p. 14; Independent 29/3-93a. 226 By unmet needs the Directors referred to needs identified in needs assessments but not achievable within budgets. 227 The Department of Health guidance is confirmed by news reports: Independent 12/3-93.
74
Reform & Policy Background which could have increased rights. However, ‘guaranteed standards’ related more to municipal administration than to service quality.228 In Britain the government used legislation to regulate staff roles, and municipal social workers had specific statutory roles in Britain. Pre-existing legislation, the 1983 Mental Health Act, obliged municipalities to recruit mental health social workers, Approved Social Workers (ASW), with statutory roles to supervise post-discharge care and with legal powers to readmit patients. In addition, municipalities were required to recruit qualified social workers for other tasks under the Mental Health Act such as producing social reports and statutory aftercare.229 Social workers were required to follow the care programme approach, a managerial role that included planning, contracting, coordinating and monitoring care services.230 The Department of Health also commissioned feasibility studies from private consultants into developing state standards and codes of conduct for social work staff.231 Therefore, the staffing and professional arrangements were subject to formal, often legislative, steering. Regulatory steering: the later years In 1997 the New Labour Government had improved mental health services as a key policy commitment. However, regulatory steering remained a major aspect of long-term implementation. The new government launched multiple legislative and regulatory initiatives, too numerous to discuss each in detail. However, these regulatory mechanisms can be divided into five categories. There were Institutional initiatives, including laws and regulations to create new local implementation organisations to community mental care, creating a multitude of new institutional structures.232 Secondly there was an emphasis on Inspection & regulation, with new steering instruments such as prescriptive targets and league tables, where poor performing municipalities 228
The charter focussed on high-risk patients. It had strict time limits, but was unfunded. It guaranteed social support; for urgent cases home visits within four hours and 48 hours for non-urgent cases; no discharge where there was any public risk; limited waiting times; access to lawyers: and a mental health tribunal. The Patient’s Charter was introduced by the Conservative Government in 1991 based on individual patient rights, although mental health was not added until 1995. However, it was formally abolished by the Labour Government in two stages; rights were weakened in 1997 and fully abolished after the NHS Plan in 2000. Thus the Mental Health Charter was never fully implemented owing to the change of government. 229 Community Care website: careers in adult services (downloaded 15/1-07); Institute of Mental Health Practitioners: Guide to the Mental Health Acts. 230 See LASS(90) 11. 231 Department of Health website: Reports of two studies in 1996 on standard setting in social services by Price Waterhouse and The National Institute for Social Work. 232 See for example: The Modernisation Initiative (Department of Health 1998 & Department of Transport Local Government & the Regions 1998); The Health Act 1999 which proposed new structures for health and social care collaboration; The National Service Framework 1999 which created local implementation teams for services; The NHS Plan 2000 created the possibility for collaboration between health and social services in Mental Health and Primary Care Trusts with the new legal framework codified via the 2001 Health & Social Care Act.
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The Governance Gap
were subject to increased state intervention, and audit and inspection by central agencies increased, thus reducing municipal flexibility and independence.233 Third was greater Individualisation and coercion emphasising service individual duty of users to comply with authorities, and for municipalities to monitor compliance. Thus the government regulatory steering prescribed a more coercive approach.234 Fourth was emphasis on independent provision continued with the use of private and voluntary sector service providers, although the market rhetoric was toned down.235 Finally, the regulation of staffing continued with increased professional controls where the government introduced instruments to control the social work profession.236 The 2000 Care Standards Act established the General Social Care Council, to regulate social work and social care staff; from 2003 social work staff were required to register with the council and comply with professional conduct standards.237 New initiatives, such as the Graduate Primary Care Mental Health Workers scheme, were introduced to provide evaluation, audit and “brief therapies”.238 Thus there was an emphasis on state rather than professional control over social work.
233
See for example the Modernisation Initiative (Department of Health 1998a & Department of Transport Local Government & the Regions 1998); The National Service Framework 1999 which prescribed mental health priorities and targets; The Care Standards Act 2000 prescribed social care staff training and compulsory registration; The NHS Plan 2000 introduced league tables and star ratings for social services. In addition, a large number of ‘audit’ bodies were established to audit, monitor and control the performance of municipalities and social work staff including: Audit Commission, General Social Care Council, National Institute for Mental Health, and Social Services Inspectorate (became the Commission for Social Care Inspection in 2004, and Care Quality Commission in 2009). 234 Coercive mechanisms were emphasised such as assertive outreach and forced treatment. The regulatory instruments emphasised the ‘duty’ of the psychiatrically disabled to comply with public authorities and the individual’s responsibility for his/her treatment. There were also controversial proposals for the indefinite detention of some mentally disordered persons without any crime being committed. See for example Modernisation Initiative Department of Health 1998a & Department of Transport Local Government & the Regions 1998; Review of the Mental Health Act 1999b; White Paper – the reform of the Mental Health Act 2000; Draft Mental Health Act 2002; Mental Capacity Act 2005. 235 Private and voluntary services were emphasised in Modernising Mental Health and Modernising Social Services: Department of Health 1998a & Department of Transport Local Government & the Regions 1998. 236 The Care Standards Act 2000 and General Social Care Council GSCC in 2001 brought social work under state control. The GSCC determined content of university degrees and professional standards. The Draft Mental Health Act 2004, later to become the 2007 Mental Health Act removed the social work mental health work monopoly. The term Approved Social Worker (ASW) was replaced with Approved Mental Health Professional (AMHP), which opened up this role to other professions, most commonly nurses, psychologists and occupational therapists thus losing the distinctly social emphasis of the role. 237 The Care Standards Act 2000 made it mandatory for social workers to register with the General Social Care Council (GSCC). The council was appointed by the Health Minister where lay members were the majority: General Social Care Council website – about us. 238 This graduate initiative involved a one-year mental health training course. Graduates obtained limited competence without recognized professional status: See Strain et al 2006.
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Reform & Policy Background
From 1997 government policy became couched in risk terms. The emphasis on risk and coercion increased with enhanced surveillance and coercive treatment strategies including assertive outreach and compulsory community treatment; treatments and services could be forced on users under threat of hospital detention for those that failed to comply. The Department of Health adopted a new language of risk and coercion, outlining the government’s plans to impose a duty of “compliance” on patients. Patients would have a duty to comply with decisions made by public authorities regarding treatment, and in addition, other conditions could be on where users were permitted to live and a requirement of users to allow authorities to enter their homes. Failure to comply compulsory supervision- or assertive outreach orders could result in users being returned to psychiatric hospitals.239 The Labour government also utilised hard forms of regulatory steering to steer municipal organisation of mental care services. The 1999 National Service Framework specified standards for municipal organisation of services.240 Municipalities were required to improve coordination by Local Implementation Teams241 and to produce Local Implementation Plans242 that translated national standards, or milestones, into specific local targets and organisations.243 The 1999 Health Act steered the formal integration of health services and municipal social care services in a single organisation using pooled budgets, service mergers and ‘lead commissioning’.244 The 2000 NHS Plan formalised the mergers between municipal and health services into Care Trusts245 to create integrated organisations. There were also strongly coercive steering elements, such as government powers to intervene and force the merger of municipal and health services based on poor inspection reports.246 In 2003 Care Trusts and municipalities were required to produce joint Local Delivery Plans to demonstrate their shared responsibility for community mental care services.247 However, municipalities queried gov-
239
Department of Health Memorandum, in House of Commons 2000, Annex B. Care management emphasised management and administrative roles for social workers in service planning including care services, risk-management, accommodation, domiciliary services, occupational and educational services, cultural and hobby services, income and social contacts. See Department of Health 1999a p. 53. 241 Local Implementation teams or LIT were multi-disciplinary joint health and social care organisations, to improve coordination between health and social care services. 242 Local Implementation Plans aimed to improve joint planning and integration relating to services, organisations and professions between NHS and social services by ordering local priorities in accordance with government standards: Department of Health 1999 pp. 90-92. 243 Department of Health 1999a pp. 83-92. 244 Lead commissioning was where either health or social services purchased services on behalf of both organisations. 245 Care Trusts provided community care services through mergers of health and social services; for example Mental Care Trusts and Primary Care Trusts. In 2006 there were 74 mental health trusts and 10 social care trusts: statistics from NHS in England website (31/1-07). 246 See Department of Health 2000a pp. 70 & 73. See also Department of Health 2000b. 247 See Social Services Inspectorate 2004a p. 22. 240
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The Governance Gap ernment steering to “manufacture major structural change”.248 Therefore, despite the emphasis on local partnership, the government used harder regulatory mechanisms to steer municipal organisation with a strong emphasis on compliance with national standards and goals. Summary: Regulatory steering In Britain government regulatory steering focussed on hard steering forms, evidenced by its proclivity for legislation, formal directives and rules. The government adopted an interventionist approach with a plethora of new regulatory initiatives forcing municipalities to constantly adapt and respond to new directives. The regulatory arena was complex and chaotic with new mental health legislation issued in some cases several times per year. The government’s use of hard steering instruments to exert control over the psychiatrically disabled continued throughout the decade examined in this book. Therefore, in Britain the stated reform decentralisation aims were overshadowed by highly centralised regulatory steering. There were a few softer steering forms such as the voluntary creation of Care Trusts, although even here, there were government powers to forcibly create trusts. Government steering restricted the ability of municipalities to formulate services in accordance with local needs and conditions. Thus strong regulatory steering was used by government to direct and standardise municipal activities.
Financial steering In Britain financial steering mechanisms, such as grants and financial incentives, were frequently used policy steering instruments. However, they were often conditional on municipalities achieving central objectives and aimed to overcome the previously unsuccessful financial arrangements.249 Yet even in the planning phase there were references to the culture of “mutual financial mistrust between central and local government”.250 Financial steering: the early years In Britain municipal implementation depended on government funding as 80% of municipal finance was from central sources; thus finance was a key steering mechanism. One government goal was to remove the ‘perverse incentive’ favouring state financed institutional care over municipal care. Thus the legislation required that all social care should be financed by municipalities, and finance was allocated via the Revenue Support grant. However, community care funding was not earmarked, and thus not guaranteed to be 248
Joannides, Association of Directors of Social Services, oral evidence cited in House of Commons 2000 paragraph 50 (oral evidence question 501). 249 Traditional joint finance hindered municipal services as it was used predominantly by the NHS with insufficient bridging funds: See Department of Health 1990 pp. 10 & 16-17. 250 See for example Department of Health 1990 p. 17.
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Reform & Policy Background
spent on social care services. There was a risk of leakage away from mental health services.251 In addition, government funding still prioritised inpatient care; the 10% of patients in hospital settings were allocated 75% of funding, while the 90% in the community shared just 25%.252 The government also failed to ensure that expenditure savings by state and the NHS passed to community care;253 the many new initiatives requiring municipal action were usually un-funded.254 Therefore, most municipalities received less government finance than anticipated, and central priorities emphasised risk focussed services for the minority, rather than social care for the majority. Government financial steering also ensured that independent contractors were guaranteed a significant reform role, despite the lack of established independent social care providers for mental health and domiciliary services. Government steering required that municipalities should actively promote the development of an independent social care market; a government directive required that 85% of transitional funding must be spent on private and voluntary services or financial penalties would be incurred. Thus the market was not based on fair and open competition in users’ interests; independent actors were favoured and existing municipal services were not allowed to compete on equal terms with the emerging private market.255 Therefore, the government used financial steering mechanisms to support its ideological commitment to the market and favoured external contractors. Financial steering: the later years The Labour Government increased the finance available to municipalities, but used instruments in order to steer outcomes. The government signalled that the investment had strings attached, with benefits for compliance and penalties for those not meeting requirements. Government financial steering was through earmarked finance conditional on meeting government directives and targets. New initiatives such as the policy set out in Modernising Mental Health Services and the subsequent National Service Framework (NSF) showed that finance was earmarked for risk reducing “safe care” services.256 A number of directives and circulars also linked finance to compliance with government conditions.257 Therefore, the use of financial steering 251
See for example Audit Commission 1992 p 8. See also Independent 2/7-92. Statistics cited in Independent 17/3-95. 253 The perverse incentive meant that institutional care was funded directly by the Social Security Agency the reform passed responsibility to municipalities. However, there were disagreements over amounts to be transferred from the state to municipalities. The Department of Social Security devised its own funding formula to calculate residential costs which were lower than the prices charged by homes, previously paid by the state. Families and users themselves were expected to pay the difference: Independent 19/3-93. 254 Independent 13/8-93a; 13/8-93b; 20/4-94. 255 See HM Government 1989 pp. 22-23; Audit Commission 1992 pp. 41-53; Department of Health 1994 pp. 14-15, LAC(93); Social Services Director; Hadley & Clough 1997 p. 30. 256 Department of Health 1998a paragraphs 4.68-4.69 & 5.9. 257 See for example LAC(98)11; LAC(2005)11. 252
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The Governance Gap
instrument continued unabated with the government using carrot and stick instruments: financial incentives for those authorities that complied and met targets, but sanctions for those that did not. The Labour Government placed less overt emphasis on the private sector: however, the private and voluntary sectors’ involvement continued in ‘partnership’ activities, with ‘commissioned’ services also involving contractual care arrangements.258 Therefore, although the language changed, the mixed economy remained. Summary – Financial steering The British government used a number of financial steering instruments in order to ensure municipal compliance with government reform objectives. Many instruments were coercive or negative in terms of the strings attached. Financial steering instruments were also used in order to steer municipalities to establish an independent social care market; however, the market created was based on unequal access rather than free competition as quotas were used to ensure that the independent sector received 85% of transitional finance. Therefore, financial steering forced municipalities in Britain to achieve central objectives and failed to result in the type of freedoms to tailor services to local conditions mentioned in the government’s reform proposals. It became clear that user needs were of secondary importance to government financial objective. Many of the instruments employed were negative or harder steering types.
Information steering Information steering involved mechanisms whereby the government attempted to steer by persuasion. The reform in Britain produced many types of government information; the ones discussed here are best practice guidance, performance information and homicide inquiry reports. Information steering: the early years In Britain the government used information as a steering mechanism based on government norms and requirements.259 There were many publications and instruments such as “good practice guidance” commissioned from private business consultants.260 The guidance aimed to steer municipalities to produce similar documents and information. The Audit Commission exhorted municipalities to adopt a “corporate approach” for social services based on business norms and market roles including “market mapping” to develop 258
The number of independent contractors rose under Labour. By 2006 70% of all adult social care expenditure was on private and voluntary services, an increase from 59% in 2001: Commission for Social Care Inspection 2006 p. 28. 259 See Audit Commission 1992 pp. 1-2; Audit Commission 1993 p. 3. 260 Good practice guidance consisted of business school-type advice on a rational planning process produced by accountants Price Waterhouse: See Department of Health 1993a.
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Reform & Policy Background “market supply indicators” to improve knowledge of “local care markets” for contracting and monitoring.261 Steering focused on the development of market and managerial norms instead of traditional professional norms of social services department. The use of private consultancy firms rather than state agencies to produce government best practice guidelines also raises democratic issues. Information instruments were produced by commercial interests that operated as municipal advisors. However, the question of conflict of interest and whether a single firm obtains a market advantage was apparently not raised at the time. The content of information steering contained guidance for municipalities for the production of standardised information for planning, market mechanisms, and quantitative performance indicators.262 Despite the stated intention to “spread good practice”, information instruments also appeared to focus on increasing standardised information and documentation that state agencies required for evaluations, inspections and audits.263 Therefore, the main focus of municipal ‘guidance’ was the need of central agencies for data in standardised formats. In the early years information instruments were used as financial sermons to persuade municipalities that user-need should be related to available budgets.264 In 1993 the Audit Commission advised municipalities that procedures were necessary to ensure that “needs to not generate expenditure that exceeds budgets” and recommended four resource rationing strategies: available resources determine “need” definitions; a specified per capita amount of service should be quantified; choosing not to meet identified needs; and the use of charging policies to generate income or discourage service take-up.265 Authorities should aim to set criteria to allow through just enough people with needs to exactly meet the budget …. authorities are concentrating on the needs of the most disadvantaged, the eligibility criteria will only include those at the top.266
As previously mentioned, municipalities were guided by the Department of Health to hide or obscure needs and services that they could not afford.267 Thus this information contained important norms that user-needs were secondary to cost controls. This sent the message that municipalities should restrict services to meet financial targets. 261
See for example Audit Commission 1992 p. 2; See Audit Commission 1997. Henwood discusses numerical data such as contract compliance audits; care plan reviews; inspection reports; performance statistics: See Henwood 1995 pp. 34-35. See also Audit Commission 1992; Audit Commission 1993. 263 See for example Department of Health 1990 p. 9; Audit Commission 1992 p. 61-62; Department of Health 1994 p. 10; Audit Commission 1993 pp. 2 &14. 264 This type of steering could be considered as a financial ‘sermon’ using exhortations and information to steer behaviour: See Bemelmans-Videc 1998 p. 12. 265 Audit Commission 1993 p. 3-4. 266 Audit Commission 1993 pp. 4-5. 267 See Independent 12/3-93. 262
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The Governance Gap
Information steering: the later years In the later years there was a strong focus on information steering through central audit and inspection agencies such as the Audit Commission and the Social Services Inspectorate, which produced evaluations and league tables. In addition, the General Social Care Council produced professional codes. Steering using performance indicators of centrally determined standards of good performance became an important form of information steering under the Labour Government. Municipalities were required to produce information relating to national standards and targets which were reviewed by the Department of Health, the Audit Commission and Social Services Inspectors.268 The acceptability of local variation declined as there was an increased focus on standardised performance indicators under the Modernisation Initiative and National Service Framework.269 The government issued detailed guidance in 1999 requiring municipalities to publish key performance information determined by the government.270 The system of information steering became even more centralised and prescriptive after the 2000 Care Standards Act where Ministers determined national minimum standards for community care.271 The Act required that municipalities produce standardised information which would be used to compile league tables and steer behaviour by classifying municipalities with zero to three stars, in the same way as hotel ratings by using information from a variety of sources: performance indicators, inspection and monitoring reports. This form of steering linked the publication of indicators to incentives and threats: three ‘star’ municipalities would receive increased independence and reduced monitoring, whereas zero ‘star’ authorities faced the threat of increased government intervention.272 The Chief Inspector of Social Services emphasised that star ratings were media friendly; a “simple statement about the performance of a fundamentally complex service” that was received favourably by the media.273 The government signalled intentions to
268
See Department of Transport Local Government & the Regions 1998 paragraph 7.17. Department of Health 1998a paragraph 5.22-5.28; National Service Framework 1999 pp. 85 & 94-95. 270 Municipalities were required to produce information on admission statistics, unit costs, support types, waiting times, inspection, ethnicity and assessments. See LAC (99)27. 271 Care Standards Act 2000 Part II, section 23. 272 Municipalities that were awarded three stars obtained greater freedoms and fewer inspections, while for zero star municipalities there were increased inspections and government powers to enforce performance improvement using private sector consultants: See Department of Health 2002; Social Services Inspectorate 2003. 273 Chief Inspector of Social Services: Citation in Cutler & Waine 2003 p. 126. However, compare with Cutler and Waine’s argument that the media friendliness obscured the true complexity, and judgement and interpretations that lay behind each star. Although star ratings appeared scientific, they were formulated from limited data and based on numerous interpretations and judgements. In order to fully understand performance, it was necessary to consult 4,551 publications. Cutler & Waine 2003 pp. 126-127; See also Community Care 30/5-02. 269
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Reform & Policy Background
take action against municipalities failing to follow guidelines. Thus information had conditions attached for non compliance. Information steering: Homicide inquiries The Homicide Inquiry system existed for the whole period discussed and was used as a means of information steering. The reports contained information to municipalities concerning how services and staff should be organised and supervised. From 1994 onwards the government required health services and municipalities to establish independent homicide274 inquiries relating to murders committed by the mentally ill. The purpose was to investigate events and apportion organisational and professional blame.275 The published reports were available, not only for the authorities involved, but as information to influence the actions of other municipalities. The reports were closely scrutinised by the media and politicians. Professionals were urged to follow recommendations, and to justify why lessons of previous inquiries had not been learned.276 Inquiry teams consisted of lawyers, medical- and social care professionals that determine the cause of the incident and apportion blame. However, despite the fact that the government used the inquiry systems as a form of quasi-judicial best practice guidance, there were no rules to ensure legal and procedural security or basic legal rights for staff. Summary: Information steering In Britain information steering was used to steer municipal behaviour. Although some information appeared supportive and neutral, further examination reveals underlying normative assumptions that expected municipalities to adhere to the guidance. In the early years there was information produced to support best practice for the reforms; however, this guidance focussed on underlying norms of business management and market models to persuade municipalities to produce standardised information for central agencies. There was also a strong cost emphasis containing norms to persuade municipal decision-makers that user need was not the primary concern and that budgets and cost targets should be adhered to. The reform’s later years attached conditions, or strings, to information. Compliant municipalities were awarded freedoms, while the threat of government intervention for failure to comply remained. The outputs of central audit and inspection agencies contained unwritten rules for municipal behaviour that had a steering effect; performance indicators and star ratings were simple and media friendly, yet obscured the complexity and subjective nature of the underlying assumptions 274
The psychiatrically disabled commit 30-50 of 800 annual murders: BBC News Online 23/12-04. 275 The remit was wide-ranging and included planning, risk assessments, adequacy of treatments, care and supervision, collaboration, communication and documentation as well as the level and suitability of staff qualifications and training. Buchanan 1999 pp. 1089-1090. 276 See for example Independent 16/6-98; 20/4-99.
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The Governance Gap
as well as the fact that indicators focussed on government priorities. The homicide inquiry reports were used also for information steering. Although the reports appeared as rational, even judicial, evaluations of events, the underlying inquiry mechanisms lacked consistency and legal safeguards. In many respects the inquiries were biased against professionals whose career could depend on the report contents. The reports created the normative assumption that all tragedies were preventable and caused by professional error. Thus while in the early years information steering tended to occupy a mid position between hard and soft steering with persuasive and norm giving exhortations, by the later years there was a tendency for harder forms with conditionalities or threat attached: based on carrots and sticks.
Sweden: governance, steering & instrument choice The Swedish reform was characterised by much more stability and less government intervention than occurred in Britain. Indeed from the government’s behaviour and choice of steering instruments, it was not easy to determine that this was a national reform as the role of defining, interpreting and developing the reform was devolved to lower levels.
Regulatory steering In the previous chapter on Britain, the government used harder regulatory steering instruments, emphasising mandatory directives, coercive mechanisms and government interventions. In Sweden, however, the National Board of Health and Welfare argued that “a low level of central steering denotes the construction of the reform”.277 The State provided general norms but few binding regulations.278 Thus the reform’s interpretation and formulation occurred at lower levels, dependent on the extent to which local politicians, most of whom did not want the reform, prioritised mental health. Regulatory steering: the early years The main regulatory steering form in Sweden was legislation, based on four Acts of Parliament which remained the basis of the reform for the decade studied. Unlike Britain, the Swedish reform was not based on new legislation. Instead regulatory steering involved clarifying and adapting existing legislation: Disability Act (Lagen om stöd och service till vissa funktionshindrade, LSS), Social Services Act (Socialtjänstlagen, SoL), Health Service Act (Hälso- och sjukvårdslagen, HSL), and Municipal Financial Liability (Certain Forms of Health and Medical Care) Act (Lagen om kommunernas be277 278
84
Comment made in an evaluation report: Socialstyrelsen 2003 p 60 (my translation). Socialstyrelsen 2003 p 60.
Reform & Policy Background
talningsansvar för viss hälso- och sjukvård). The most important of these Acts, The Disability Act and the Social Services Act were framework legislation, containing broad policy goals without detailed regulations. The Social Services Act conferred a right to public assistance and a reasonable living standard if the individual was unable to meet own needs; municipalities were required to determine needs and to provide services to meet identified needs.279 The Disability Act applied for persons with “permanent” mental and physical disabilities; unlike the Social Services Act, conferred rights to good living standards.280 The Health Service Act clarified the municipalities’ healthcare responsibilities for those living in residential accommodation.281 Finally, the Municipal Financial Liability Act required municipalities to take financial responsibility for “fully medically treated” patients.282 Unlike Britain where the government was reactive and the tempo of regulatory change was high, in Sweden these Acts remained the regulatory basis for the reform for the decade studied in this book with the exception of a revised Social Services Act in 2001. Unlike Britain, regulatory steering in Sweden was stable basis. The main elements of regulatory steering are summarised below: Table 3.3: Legislative & policy initiatives in Sweden Year 1980
Policy initiative Social Services Act
Regulation type Legislation
Main contents Regulations for public social assistance to provide reasonable living standards.
1982
Health Services Act
Legislation
Healthcare regulations. Municipal responsibility for residential accommodation.
1990
Municipal Financial Liability Act
Legislation
Municipal responsibility for fully medically treated patients.
1993
Disability Act
Legislation
Rights based legislation. Municipalities must provide good living standards for the disabled.
2001
Social Services Act
Legislation
Clarification of municipal role. New right for users to appeal decisions.
279
Services might include adapted housing and living arrangements, home help services, daily activities and also the provision of sheltered and residential accommodation where needed. See SoL SFS 1980:620 1-5§ & 21§; Socialstyrelsen homepage. 280 The Disability Act was based on the principles of normal living and disability rights, previously discussed in Chapter 2, such as the right to influence over services and the right to individual planning. Service users had the right to qualified support including personal assistance, companion and contact person, the right to accommodation with support services, respite care and adapted housing. LSS SFS1993:387; Socialstyrelsen homepage. 281 Hälso & sjukvårdslagen, HSL SFS 1982:763 18-21§. 282 SFS 1990 Lagen om kommunernas betalningsansvar för viss hälso och sjukvård.
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The framework form of the legislation meant that the government did not steer the reform’s interpretation. It was up to municipalities to determine the applicability of the Acts to mental health as the terms “reasonable” and “good” living standards were not defined.283 Therefore, despite the regulatory stability, it was unclear what service standards were required. In Sweden, unlike Britain, the government did not issue supplementary regulations specifically relating to the mental health reform. It is common for the National Board of Health and Welfare to issue specific directives (författningar) or general guidance (allmänna råd) for health and municipal authorities implementing welfare reforms. However, unlike the reform in Britain, there was no specific guidance issued for municipalities regarding the reform.284 The only guidance was the regular evaluation reports produced by the National Board of Health and Welfare, which will be discussed in the section on information steering. Therefore, the Swedish government utilised softer steering instruments and the reform was based on flexible framework legislation, open to variations in municipal interpretation. There was an absence of the type of binding and coercive directives used in Britain. Legislative steering & terminology A particular problem in Sweden was that the government’s framework legislation failed to use consistent terminology. Thus implementing agencies could develop differing interpretations regarding service eligibility.285 The problems can be illustrated through the different definitions of service users in main reform documents:286 The Proposition: “persons with long term and serious mental disorders”; The Disability Act: “Persons with permanent disabilities … causing considerable difficulties in daily life and therefore, an extensive need of support and services”; The Social Services Act: “Persons with psychiatric disabilities”; The Municipal Financial Liability Act: “Medically fully treated patients in psychiatric care, i.e. long term mentally disordered persons who have been in continuous inpatient care for more than three months in psychiatric clinics”.287
283
Socialstyrelsen 1998 pp. 71-75. The government did not issue guidance in conjunction with the reform such as rules, general guidance or handbooks. E-mail A Printz 12/6-09; see also Socialstyrelsen 1997b pp. 21-22. Compare with interpretations guidance and published handbooks available to authorities implementing compulsory care, Compulsory Psychiatric Care Act (Lagen om psykiatrisk tvångsvård SFS 1991:1128) and the Forensic Psychiatry Act (Lagen om Rättspsykiatrisk vård SFS 1991:1129) which contained legal texts and interpretations. See for example SOSFS 1999:19; Fröberg 1991. 285 Socialstyrelsen 1997a p. 106. 286 Socialstyrelsen 1996a p. 48. 287 See for example Socialstyrelsen 1996a p. 48 (act wording - my translations). 284
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Reform & Policy Background
Thus the use of differing definitions in regulatory documents created steering confusion regarding statutory eligibility under the different Acts. The government’s lack of consistency concerning the target group eligible for services meant that interpretation rested solely with municipalities. Two terms in particular caused interpretational difficulties: “fully medically treated” and “permanent disability”. The term “fully medically treated” sounded strictly medical but was not, and created different expectations in different agencies: for county psychiatry fully medically treated meant patients no longer requiring 24-hour hospital care, although most required lifelong care; yet municipalities interpreted the term as essentially healthy people who needed limited social support.288 In 1999 the National Board of Health and Welfare recommended that the government should define terms and clarify actors’ roles.289 However, this did not occur. It was also unclear how the term “permanent disability” and its sub-categories “considerable difficulties” and “extensive needs” applied to mental health, as existing disability definitions, based on physical disability, were difficult to apply, and the government issued no guidance on mental disability. Thus municipalities used different interpretations for eligibility, with some using restrictive definitions that excluded the psychiatrically disabled.290 Thus the failure of government to define reform terms meant the that reform commenced with differing definitions among implementing actors that were never resolved. Regulation & staff In Sweden, unlike Britain, regulatory steering was not used for staffing or professional roles; no qualifications or knowledge were specified. The reform proposition suggested that municipalities could obtain mental health expertise through training or by recruiting former asylum staff.291 There was some general guidance, but not specific to mental health, such as guidance (allmänna råd) for the Social Services Act, stating that municipalities recruit staff with adequate competence and suitability.292 Unlike Britain, there were no requirements that municipalities employ specialist mental health social workers. There were general central directives under Sarah’s Law (Lex Sarah) whereby municipal professionals have a duty to report mistreatment or poor conditions by care providers.293 However, the regulation relies on self reporting, and thus depends on the willingness of municipal professionals to report themselves, rather than direct government inspections and controls. The government’s reform proposition did create a new social work role of care, coordination and advocacy around user’s needs: the Personal Repre288
See for example Socialstyrelsen 1996a p. 49; See also Dagens Nyheter 8/5-98a & 12/1-98. Socialstyrelsen 1999a p. 111. 290 Socialstyrelsen 1996a p. 49; Socialstyrelsen 1999a pp. 60 & 118-122. 291 See Regeringens Proposition 1993/94:218 p. 92. 292 See Social Services Act 1980:629 (Socialtjänstlagen) & Socialstyrelsen 2000. 293 See Lex Sarah – Socialstyrelsen website. 289
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The Governance Gap
sentative (Personligt Ombud). However, the government created Personal Representatives in separate organisations, outside municipal structures.294 Personal Representatives focussed on users’ individual needs and improved service coordination between state, county and municipality.295 The scheme recognised that existing reform agencies were not providing coordinated, holistic care, thus Personal Representatives were an interesting professional development based on traditional social work skills of user-centred work and case management. However, the government preferred not to clarify existing professional roles and instead chose to create a new role outside social services structures, which was not reserved for social workers (socionom). Regulatory steering: the later years In contrast to Britain, there was little regulatory change in Sweden. Despite the reports by the National Board of Health and Welfare recommending increased regulation, the only legislative change was the new Social Services Act in 2001 which was not specifically focussed on mental health apart from a general user right of appeal.296 Therefore, in contrast to the regulatory environment in Britain, and the plethora of regulatory adjustments, regulatory steering in Sweden was stable, although it also meant that definitional problems were not clarified. A decade after the reform’s implementation, municipalities were still unsure of basic definitions and of who was eligible for services under the Acts.297 The National Board of Health and Welfare and the Mental Health Tsar (psykiatrisamordnare) both recommended that the government needed to steer the reform more actively and exert goal-oriented leadership to define and clarify requirements for municipalities. However, the government failed to introduce new regulatory steering specifically for mental health between 1995 and 2006.298 In contrast to the tendency in Britain for direct and constant government action to resolve problems and criticisms of the reform, in Sweden the government took little action to actively steer municipalities by issuing guidance, clarification or new legislation. One indirect regulatory steering form, occurring throughout in the Swedish reform, was an indirect corporatist steering form whereby the Swedish Local Government Association (Svenska Kommunförbundet) representing 294
The Personal Representative scheme started as a stimulus finance pilot projects but continued in the long term: Socialstyrelsen 1999b p 30. 295 See Socialstyrelsen 1998 pp. 162-165; TT 16/12-98; Dagens Nyheter 17/12-98. 296 A new Social Services Act (Socialtjänstlagen) in 2001 replaced the 1980 Act with few changes relating to mental disorder. Several provisions that strengthened user rights: the right to appeal decisions to the courts, changed fees and charges, requirements to support victims of crime; and a new role for the County Administrative Board (Länsstyrelsen) to monitor and evaluate social services departments. See Socialstyrelsen 2002 p. 5. 297 Socialstyrelsen 2005 p. 14. 298 According to Anders Milton the Mental Health Tsar, there needed to be improvements to the equality of access nationally, improved method steering and more active monitoring and accountability. SOU 2006:100 pp. 491 & 509. See also Socialstyrelsen 2005 pp. 192-195.
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Reform & Policy Background municipal employers acted as the ‘go-between’ between government and municipalities and its role includes issuing guidance for its members regarding reform implementation. The association is a private employers’ organisation with considerable influence since it holds direct discussions with government and recommends concrete action to its members, for example by producing guidance circulars. The Association’s recommendations are not binding but tend to be followed by municipalities.299 In the absence of any state regulatory guidance, it was instead the Local Government Association that produced guidance on assessment and interpretation of the disability legislation for the psychiatrically disabled.300 Thus the Association appeared to have a semi-official position in Sweden giving advice and producing guidance that in Britain was provided by state regulatory agencies. Summary: Regulatory steering In contrast to the situation in Britain where there was considerable government intervention, the regulatory steering in Sweden was loose and laissezfaire by comparison. The legislative basis of the reform was stable and services were not based on new, mental health specific legislation. Although this had certain advantages of stability and familiarity, many municipalities were uncertain how to adapt pre-existing legislation to the psychiatrically disabled. The use of framework legislation and the lack of specific reform directives meant that each municipality made their own interpretations of the reform. Even when the problems became apparent, the government stressed that interpreting and developing the reform was a municipal responsibility.301 Nor did the government act on the recommendations to clarify the reform made by the National Board of Health and Welfare. Thus in Sweden there were low levels of regulatory steering and direction from the state.
Financial steering Financial steering mechanisms were also a feature of the reform in Sweden. Although in contrast to Britain, financial steering focussed on incentive based schemes rather than prescriptive government controls. Financial steering: the early years In contrast to Britain, Swedish municipalities have income taxation powers and are less financially dependent on central government. This reduced the government’s ability to use finance as a steering form control; less than 20% of municipal income is from the state. However, the government did use 299
See for example Svenska Kommunförbundet circulars 1993:85; 1994:110; 1995:47; 1995:100; 1998:188; 2000:14; Petersson 2001 pp. 249-250; Gustafsson 1999 pp. 317-318. 300 See Svenska Kommunförbundet 2001. 301 See for example statement of Social Minister Lars Engqvist, cited in Expressen 18/1-04.
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The Governance Gap incentives in order to reverse municipalities’ low prioritisation of mental health following the 1980 Social Services Act. The government used stimulus finance; providing financial incentives to fund the transition and ‘pump prime’ the reform’s first three implementation years. The finance was for projects to start up services such as inventories of local need. In total almost 1,000 million crowns of stimulus finance was allocated for three years. In order to receive stimulus finance, municipalities were required to meet three qualifying pre-conditions: a financial agreement between county and municipality specifying transitional arrangements to transfer patients, services and funding; a service development plan; and project descriptions for stimulus finance usage.302 It was up to municipalities whether or not to apply for project finance, and not all applied.303 Therefore, unlike the situation in Britain, considerable flexibility existed for municipalities to decide how to use stimulus finance. Stimulus finance was also used to steer the reform’s staffing, with stimulus finance available for training projects and working method development. However, the steering was loose as there was freedom for municipalities to determine the content of projects.304 There were criticisms that some municipalities used finance to fund pre-existing services.305 Therefore, the project finance can be considered a financial incentive and thus soft steering. The availability of finance was positive with only generalised guidance as to how it should be used. Financial steering: the later years In Sweden there were few specific reform steering instruments applied in the later years. The government assumed that municipalities would continue to fund and run the projects when stimulus finance ended, yet exerted no steering to ensure this occurred despite warnings about the reform’s long-term stability from the National Board of Health and Welfare.306 The National Board of Health and Welfare concluded that “the most powerful steering mechanism was the state’s stimulus finance”.307 In a review a decade after the reform’s implementation, the Mental Health Tsar urged the government 302
The following categories were available for project finance: collaboration, organizational change; education and training; supervision and method development; rehabilitation; healthcare; and social services, housing, activities and support. Socialstyrelsen 1998 pp. 56-60. 303 In 1998 the National Board of Health and Welfare reported only 67% of finance was used; some projects did not start; finance for housing services and inter-agency collaboration remained unused. There were major regional variations: some areas used over 80% of stimulus finance, whereas others used less than 30%. The reasons for the dramatic variations and poor utilisation of project finance were unclear and not explained: Socialstyrelsen 1998 p. 54-82. 304 See for example Regeringens Proposition 1993/94:218 p. 92. 305 Funding criticisms regarding Stockholm in Dagens Nyheter 3/12-98a; 3/12-98b; 13/12-98. 306 See for example National Board of Health and Welfare warnings over the problems created by government stimulus steering. Socialstyrelsen 1996a p. 52; Socialstyrelsen 1997b pp. 24-25; Socialstyrelsen 1998 p. 150; Socialstyrelsen 2003 pp. 124-125. 307 Socialstyrelsen 2003 p. 18 (my translation).
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Reform & Policy Background
to make future financial steering conditional of achieving service and quality goals.308 As with regulatory steering, the Swedish Local Government Association also had a significant indirect role in financial steering through involvement in negotiations with the government relating to priorities for grants and finance among other issues. The Association issued circulars containing financial guidance for municipalities.309 Summary: financial steering The Swedish financial steering focussed on facilitating service establishment. Instead of rigid rules and controls, the financial steering in Sweden gave municipalities freedoms to formulate their own priorities and projects within government designated categories. Therefore, the financial steering in Sweden was positive and based on incentives rather than negative penalties: thus it can be considered as softer steering.
Information steering There were three major types of information steering for the reform, plus some minor types. As some of these steering types spanned the entire period, therefore, this section of the book has not been split between early and later years, but instead divided thematically. Central evaluation as a norm giving exercise One major form of information steering was a series of evaluation reports produced by state agencies, especially The National Board of Health and Welfare.310 The Board had primary responsibility for producing information and guidance for the reform’s interpretation and implementation. However, as previously discussed, there was no specific mental health implementation guidance although there was general guidance relating to the Social Services and Disability Acts.311 At county and local levels the County Administrative Boards, which are state agencies located at county level, were responsible for reporting and producing information on municipal implementation and investigating user-complaints.312 The main type of information steering by 308
See SOU 2006:100 pp. 507-510. See Petersson 2001; Gustafsson 1999; Sveriges Kommuner & Landsting Cirkulär 1999:59. 310 The National Board of Health and Welfare, the County Administrative Boards (Länsstyrelserna) and the National Audi Office (Riksrevision) produced reports on the financial effects of the reform. The Mental Health Tsar also investigated mental health and produced reports. 311 See e-mail A Printz (National Board of Health & Welfare mental health unit) 12/6-09. 312 A sample of eight county implementation reports were reviewed: Länsstyrelsen i Dalarnas län 2003; Jönköpings län 2003; Kalmar län 2006; Stockholms län 2003; Uppsala län 2003; Värmland län 2003; Västmanlands län 2003; Östergötland län 2003a. The studies were chosen to give a balance between territorial area (North, South and Central Sweden), major cities, smaller towns and rural areas: Östermalm in central Stockholm, ca. 36,000 inhabitants; the northern town of Piteå in Norrbotten county ca. 41,000 inhabitants; Motala in central Sweden 309
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The Governance Gap
the National Board of Health and Welfare was a series of implementation evaluation reports. However, the type of reports produced fell into two main categories. There were national level evaluation reports where problem areas were identified in a general manner with implicit expectations of change. The first set annual implementation reports between 1996 and 1999, and focussed on compliance and with the reform’s loose legislative requirements, while discussing effects of financial steering given that the reform’s design allowed municipalities to formulate their own policies, services and working methods. The reports outlined general recommendations.313 The later reports in 2003 and 2005 produced a different type of information. Instead of a legalistic focus on legislation, the reports became holistic and focussed specifically on how municipalities had structured and organised the reform at political, administrative and professional levels. The reports contained information that conveyed the Board’s expectations, although these were not binding. For example, the Board had developed a specific methodology for user inventories; however, unlike the controls on data production in Britain, the Board’s methodology was not binding on Swedish municipalities.314 The 2005 report was based on a joint project between the National Board of Health and Welfare and the County Administrative Boards, based on municipal evaluations by the County Boards, using 10 implementation variables relating to implementation policies, organisation and documentation.315 The evaluation reports were non-binding and appeared mild in comparison with British steering. The County Board’s reports contained normative statements: “It is quite likely very complicated to steer and evaluate an activity that lacks objectives”.316 The choice of evaluation indicators represented strong normative information regarding how evaluation agencies expected municipalities to work with framework legislation, although municipalities were critical that concrete municipal requirements were not produced until several years later.317 Thus there were implicit statements of state exca. 30,000 inhabitants; Malmö City in southern Sweden ca. 290,000 inhabitants; and the semirural town of Smedjebacken in central Sweden ca. 11,000 inhabitants. The content and scope varied; Östermalm’s report was 98 text pages and Malmö’s 6, with 30-60 pages the average. 313 Socialstyrelsen 1996a; Socialstyrelsen 1997b; Socialstyrelsen 1998; Socialstyrelsen 1999a; Socialstyrelsen & Länsstyrelserna 2003; Socialstyrelsen & Länsstyrelserna 2005a. 314 By 2003, 45% of municipalities had a satisfactory user inventory, 15% were rated as good, and 30% used unreliable or poor methods: See Socialstyrelsen 2003 pp. 43-45. 315 The 10 variables were: 1. Knowledge of user groups; 2. Inventory of needs; 3. Political objectives; 4. Operational service plan; 5. Joint objectives and routines for inter-agency collaboration; 6. Agreed joint collaboration forms; 7. Variety and choice of user activities; 8. Service variety and choice; 9. Quality control system; 10. Staff development/ training plan. Only 40% of municipalities were rated satisfactory by achieving six or more variables; 13% of municipalities achieved two or less. Socialstyrelsen & Länsstyrelserna 2003 pp. 118-119. 316 Länsstyrelsen i Kalmar Län 2006 p. 5 (my translation). 317 The reports revealed that many municipalities had interpreted the reform’s minimum requirements contained in the framework legislation in considerably less generous terms than the County Administrative Board’s inspectors. Yet Grums municipality argued that the evaluation set the standards too high and did not have “any reasonable correlation to our financial
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pectations of municipalities, although in soft form of an advisory nature rather than in a mandatory form. It also demonstrated that although municipalities frequently demanded more steering, there was also opposition when the state requirements were detailed and concrete. However, the reports produced by central agencies and commissions cannot be regarded purely as government steering. There was also upward information steering by agencies and commissions who reported back from municipal perspectives on problem issues and areas where government action was required. In this respect the evaluations were also attempting to influence government behaviour upwards. For example, both the National Board of Health and Welfare and the Mental Health Tsar reported the need for greater central steering.318 The National Audit Office (Riksrevisionen) report made recommendations to government on future financial incentives and training issues.319 Therefore, the reports were also a form of knowledge based steering aimed at providing information upwards and downwards. Information steering & stimulus finance Government stimulus finance projects can also be considered as a form of information and knowledge steering, with projects representing financial steering. The government established general categories and priorities for projects, but the detailed content was neither stated nor steered by the government, as each municipality had freedom to formulate its own projects according to local priorities.320 Markström’s study revealed wide variations in ambition and content in staff training projects financed by stimulus finance including single training days, external consultants, and university courses. One municipality purchased the Boston model using trainers flown in from the USA, although some municipal staff did not consider that the Boston model adapted well to the Swedish welfare state.321 Thus although stimulus finance had an information steering role in the development of reform knowledge, the forms were fluid and flexible, allowing considerable variations among municipalities. Therefore, Sweden’s information steering was not prescriptive or centrally steered. Information steering & professional development In contrast to the strong steering of social work training in Britain, the Swedish government did not regulate social work degrees and there was no reality”. Comment by Grums Municipal Council cited in Länsstyrelsen Värmland 2003 (my translation). 318 See SOU 2006:100 pp. 489-514. Socialstyrelsen 2005 pp. 192-195. 319 Riksrevision 2009. 320 See for example Socialstyrelsen 1996b pp. 19 & 51-52. In year one, 35,000 staff received training of which 25,000 were from social services. In year two staff training reduced but projects still trained 15,000-20,000 staff: See Socialstyrelsen 1999a p. 70. 321 See Markström 2003 pp. 255-258; see also Socialstyrelsen 1999a pp. 15-16 & 76.
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The Governance Gap
standard content. In 2006 the Mental Health Tsar found huge variations in ambitions and content for social work degrees. Mental health courses were not compulsory for social work degree students, existing only as elective short-courses with fewer than 20 hours of education. 322 Thus there was loose steering of professional knowledge, with mental health expertise considered optional for social workers. There was no Swedish equivalent to the specialist, postgraduate mental health qualification in Britain. Therefore, there was little dissemination of information and knowledge to social workers. Informal information steering There were also other informal information and knowledge steering forms such as conferences and seminars arranged by the National Board of Health and Welfare, Swedish Local Government Association, and National Audit Office. These were important for creating values and norms for the reform. There was also informal information steering and advice to municipalities from the Swedish Local Government Association that published a number of newsletters and booklets relating to the reform as well as organising projects. The information took the form of information on implementation and method developments and comparative financial statistics. In particular, in 2001 the Association produced guidance on applying disability legislation to the psychiatrically disabled.323 Thus actors such as National Board of Health and Welfare and the Local Government Association were important sources of informal information steering, even if these mechanisms were non-binding, they had significant norm-giving components. Summary: information steering In Sweden there was a low level of formal information steering of municipalities. The information was usually unconditional and non-binding. There was nothing to correspond to the coercive steering via performance information, league tables and homicide inquiries that occurred in Britain. The information provided was general and the tone of the reports informative, with mild criticisms rather than naming and shaming. It was not until the 10 evaluation variables that municipalities received concrete information on the implicit assumptions of how the reform should be implemented. However, some municipalities were aggrieved that specifying these variables changed the ‘rules of the game’, despite many having demanded greater steering. Unlike Britain the information steering was soft, and without coercion and 322
Mental health was not a compulsory subject in social work (socionom) degrees. Mental health courses were short optional electives; typically 9-15 hours of teaching: See SOU 2006:100 pp. 455-470. 323 See for example Svenska Kommunförbundet circulars 1993:85; 1994:110; 1995:47; 1995:100; 1998:188; 2000:141; 2004:61; 2005:34; Svenska Kommunförbundet 2000; Svenska Kommunförbundet 2001; Svenska Kommunförbundet 2004; Sveriges Kommuner & Landsting 2008; SKL Newsletters; SKL website.
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obligatory norms or strings attached. However, it is important to recognise that information steering was indirect in Sweden and there was no direct steering by politicians as the evaluation and information are produced by independent agencies. The general tone in Sweden was that information and reports were ‘educational’ and focussed on advice for improvement. In Sweden the reports did not any of the ‘naming and shaming’ or the threats of government intervention that occurred in Britain.
Conclusions: steering strategies in Britain & Sweden In this chapter I analysed the premise that the governments of Britain and Sweden chose different governance strategies for steering the municipalities implementing the mental health reforms. In order to classify the steering strategies selected by the two countries, I first developed a new theoretical model based on the idea that harder and softer steering choices exist within each of the main categories of policy steering instruments: regulation, incentive and information steering. In my analytical model I developed indicators for hard and soft steering choices within each of the three categories which are summarised in Table 3.1. Therefore, my model links the discourses of policy steering instruments with that of hard and soft steering. I believe that this contributes a new perspective to policy steering instrument research through the identification and formulation of a typology where the categories are not mutually exclusive when it comes to hard and soft steering. I argued that these instruments do not exist as static measures but instead constitute a scale where harder and softer choices exist within each category. The model governance strategy as hard or soft steering was then used to categorise that instruments selected for the mental health reforms in Britain and Sweden. My findings and conclusions are summarised below. Regulatory steering At the start of this chapter I analysed soft and hard mechanisms of regulatory steering. While regulatory steering is always formally binding, I identified that even here there are harder ad softer forms. Hard steering is based on high levels of obligation and compliance through legislation and directives. Soft regulatory steering however, is based on greater flexibility, such as framework legislation, where despite a biding obligation there are freedoms to interpret the law and formulate services. My findings are that there were substantial differences in the regulatory steering of the mental health reforms. In Britain there was a chaotic legislative environment with a constant stream of legislative and rule changes. The government adopted reactive and coercive strategies, constantly issuing new directive and rules to clarify the reform and deflect perceived criticisms. There were numerous mandatory initiatives relating to structure, inspection, audits and procedures. Thus the 95
The Governance Gap
governance strategy was based on central control over the reform, including its organisation and staffing, with regulatory powers concentrated at the centre. In Sweden, in contrast, the reform had low regulatory intensity. The legislative base was stable with the four main Acts and little change. Regulatory steering used soft mechanisms; the government provided framework legislation and broad objectives only, and each municipality decided its own interpretation and operationalisation of the reform. There were no obligatory or compliance directives or interventions from the government even when central agencies recommended increased central steering. Unlike the British reform the government emphasised that implementation was a municipal responsibility, adopting an ‘arm’s length’ stance. Incentive & financial steering The conditions for hard and soft steering using finance were also considered earlier in the chapter: hard steering characterised by negative and binding instruments based on compliance often with threat of financial penalties. Soft financial steering was based on incentives with few preconditions. There were also clear differences in how incentive and financial steering instruments were utilised. Britain adopted hard steering strategies of central financial rules and controls, exacerbated by the dependence of municipalities on central funding. There were often conditionalities whereby municipalities had to comply with government conditions to obtain reform finance such as; markets and contracting; resource and service rationing; and cost controls. In Sweden the low level of financial dependence of municipalities meant that there were limited steering mechanisms available. However, this also meant that the national reform was dependent on prioritisation by local politicians. One area of more concrete steering in Sweden was the use of stimulus finance as a flexible incentive to develop services. However, this finance also had some negative long-term reform consequences as it encouraged a shortterm focus without guaranteeing the long-term financial viability of services. Information steering Information steering, the sermon, was the final steering type considered. The steering strategies could range from hard steering strategies, which were theoretically voluntary but where the conditions and threats gave a more coercive appearance, to soft steering based on general information instruments whereby the state aims to persuade or educate addressees to comply with government intentions. Information steering demonstrated different types of regulatory instruments. In Britain there was an emphasis on information being used in coercive ways, using the threat of direct intervention to enforce compliance. The government required the production of certain types of information for comparative league tables. In Sweden the general tone of information measures from the government was softer with emphasis on education and information rather than coercion. The most specific form 96
Reform & Policy Background
used were the 10 indicators used as the basis of the National Board of Health and Welfare’s 2005 report, yet this occurred a decade after the reform. Conclusions: governance strategy - hard & soft steering It is clear that the selected governance and steering strategies were different for the British and Swedish reforms despite the similarities of the reform goals and contents. Despite both reforms emphasising a municipality’s responsibility for the reform, in Britain the relationship between state and municipality was characterised by a recentralisation through steering mechanisms involving compulsion and coercion with a strong preference for harder steering types. Thus despite the reform aim of local services, the government retained significant control. In Sweden, however, the government employed loose and flexible steering allowing municipalities to determine their own responses to the reform, but also creating significant service variations. Thus the two worlds of outcomes and results discussed in Chapter 1 are also reflected in the governance and steering strategies selected. Britain demonstrated a preference for hard steering with high levels of obligations, conditionality and compliance mechanisms focussed on central government priorities. Sweden on the other hand selected soft steering strategies whereby the government was responsible for a general framework of aims and values, but where detailed reform decisions were made at lower levels, and focussed on local priorities. Therefore, this chapter has identified that Britain and Sweden selected divergent governance strategies for steering the mental health reforms.
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[Type text]
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Constructing the Invisible Frame
Chapter 4
Constructing the invisible frame: A Triad of Influences Governments have a wide variety of governance and steering strategies at their disposal, yet the evidence of the previous chapter is that there may be national preferences for certain types of strategies. The previous chapter demonstrated that despite similar policy reform objectives and contents, that the governments of Britain and Sweden choose very different combinations of regulatory, incentive and informational steering instruments. This resulted in harder governance strategies in Britain and softer choices in Sweden. However, the concepts of steering choices and policy styles are an underresearched area of public administration, with no commonality or consistency among prior research concerning the dimensions and perspectives to be included in a national policy style model. It is also unclear as to what extent tat a single fixed national policy style exists in the policy implementation phase, or whether issues relating to the particular policy sector may be of importance to governance and steering issues. In this chapter I argue that policy styles are not rigid and fixed; instead, the policy style that determines reform steering consists of national institutions and preferences, combined with influences relating to specific sectors. Thus policy styles and dimensions of influence over governance and steering choices are not static, but are part of a dynamic process. In Chapter 1 I identified three dimensions that may influence steering strategy: firstly national influences of administrative traditions and the historical legacies that create national preferences for certain steering types; secondly the influence of the implementing professions as expert actors and the way in which government steering is influenced by professional roles; and finally the influence of policy framing and how the government frames the need for state action. Therefore, I argue that these three national and sectoral dimensions combine to
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form an invisible frame324 that influences governance and steering strategy decisions. I call these three dimensions a Triad of Influences that influence the government’s choice of governance and steering strategies. My research question lies on the boundaries of several areas of research literature. These discourses are relevant to studying modes of governance and the steering of the mental health reforms, including governance; steering strategy; policy instruments; policy styles; public management reforms; administrative traditions; professions; and policy framing. These bodies of literature are entwined with the research question, and I must analyse the relevance and contribution that these research discourses can make to my study. As the theoretical basis of my study is drawn from several discourses, it is not possible to produce an exhaustive review of all of these discourses; selections have been necessary. I focus on key elements of particular relevance to my research question regarding why Britain chose hard governance and steering strategies while Sweden chose soft for the mental health reform.
Influencing governance: public reforms & policy styles The focus of this book is to determine what influences governments to choose particular governance and steering strategies. As I discussed in Chapter 3, while there is significant prior research into the identification and categorisation of steering instruments,325 there is little prior research that links steering strategy selection to hard or soft governance, making this an under researched area. Recent public administration literature often focuses on reform discourses such as NPM where rational and business-management inspired strategies influence steering choices. Other research, however, points to policy styles influencing steering strategies as governments are influenced by national preferences for certain types of decision-making, relationships and instruments. Thus these discourses must be reviewed in order to determine whether they can aid the theoretical development aims of this study to understand the selection of governance and steering strategies.
Public management reform & policy instruments Public management reforms in the 1980s and 1990s also led to a reevaluation of steering and instrument choices. The reforms reflected economic and social changes and a move away from the “high quality standard-
324
Feick 1992. See for example Vedung’s extensive review of the literature on identification and categorisation of policy tools, Vedung 1998 together with Salamon’s analysis of tool categories and classifications in Salamon 2002a. See also Lowi 1972; Schnieder & Ingram 1990; May 2002; May 2003; Van der Dolen 1998; Bememans-Videc 1998; Hood 2006; Linder & Peters 1989. 325
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ized solution”326 model for public services. The rationale of reform advocated a decrease in central steering, more citizen participation: non-state actors producing services; as well as efficiency and flexibility. There was a shift in perceptions of government-implementer relationships, which introduced the idea that steering instruments were rational, apolitical tools for governments to achieve policy objectives.327 New Public Management (NPM) & policy instruments Public management reforms changed the steering relationship between state and lower-level agencies. Reform ideas such as New Public Management (NPM) emphasised new steering relationships and efficiency. NPM is not an integrated theoretical model, but refers to a “shopping basket”328 of empirical reform ideas derived from business practice. I define NPM as “the adoption of business-oriented strategies and mechanisms aimed to increase the efficiency of public services”. NPM was closely related to steering based on Osborne and Gaebler’s analogy that leaders should steer not row,329 which was the idea that public agencies should direct implementation, yet without necessarily ‘rowing the boat’ as service by producing services in-house. Hood contends that NPM was a collective term for reforms based on neoliberal economic models and business management practice.330 NPM emphasised a package of ‘corporate’ steering instruments including cost control, decentralisation, performance measures, management by objectives, market, contracts, deregulation, disaggregation and divesting non ‘core business’ activities.331 It was assumed that a public service management was no different from a profit-maximising business; thus hospitals could be run like supermarkets. NPM was an instrumental discourse: the idea of utilising an apolitical ‘toolbox’ of policy instruments to achieve rational implementation. The NPM discourse led to a decline in research interest in policy steering and implementation studies, owing to assumptions that rational decisionmakers would choose similar strategies and instruments. Rist argues that NPM-inspired policy process literature portrayed policy steering and instrument decision as a series of four rational and linear steps of problem identification; policy response formulation; instrument selection; and problem resolution.332 In addition, Barrett contends that the NPM literature did not con-
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Rothstein 1994 cited in Blomqvist 2004 p. 144. See May 2003 p. 225; Linder & Peters 1989 p. 38; Hood 2006 pp. 472-473. 328 Pollitt & Summa 1997 p. 7. 329 Osborne and Gaebler’s analogy refers to a leadership role of charting the course of public services rather than rowing the ‘boat’ of routine service production: 1992/93 pp. 41-59. 330 Hood 1991 argues that NPM is based on neo-liberal economic models emphasising market mechanisms to maximise efficiency, business management emphasising leadership and service managers “free to manage” unencumbered by bureaucratic ‘red-tape’. 331 See Hood 1991; Osborne & Gaebler 1992/1993; Dunleavy & Hood 1994. 332 See discussion in Rist 1998 p. 149. 327
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sider how the complexities of the political environment would influence implementation and steering decisions.333 The mental health reforms that I analyse in this book contained some NPM inspired reform ideas: health services divesting non-medical social care tasks (disaggregation); coordination across sector boundaries (joined-up services); local decision-making for social care (decentralisation, municipalisation); using private and voluntary actors (market mechanisms); and ideas that local domiciliary care was more efficient than centralised asylums (efficiency, and cost control). However, despite similar reform ideas, Britain’s and Sweden’s steering choices failed to converge; my analysis in Chapter 3 found, that similar reform ideas and content did not result in similar governance and steering instrument choices. Therefore, instead of the single rational path assumed by NPM, governments have various options at each of the four stages. At stage one, problem identification, governments can have different problem perceptions and Vedung argues that states must decide whether to act at all; or whether it is for the individual or market to resolve.334 Stage two, response formulation, involves decisions and judgements that may depend on which sources of advice the government chooses to consult. Pollitt and Bouckaert outline the range at a government’s disposal including civil servants, academics, think-tanks, businesses, unions, political parties, consultants, experts and voluntary groups, which may result in different ideas for policy programmes and responses.335 For the third stage, instrument choice, Bemelmans-Videc argues there are many types of regulatory, incentive and information instruments.336 In the final stage, implementation, decisions are made concerning who receives services (such as how much service, how long for) and whether problems are resolved. Thus this book focuses on the third stage, the government choice of instruments to steer and implement policy. However, the above discussion shows that this process is not technical where a single rational path exists; options exist at each stage. Thus my PhD thesis also refutes some of the central ideas of NPM and management reform models that there is a single, uncontested rational path and choice of instruments. Instead I argue that there remain significant national differences in governance and steering choices, and I aim to understand what influences governments’ strategy selections. Governance & policy instruments Public management reforms created new steering environments as a consequence of new relationships between state and non-state actors. As outlined in Chapter 1, a looser and more diffuse concept of governance was intro333
See discussion of implementation and NPM in Barrett 2004 p. 257-259. Vedung asserts that the first choice for governments is whether the issue is regarded as an area for government action at all: See Vedung 1998 pp. 22-23. 335 See Pollitt & Bouckaert on sources of policy advice 2004 pp. 42 & 57-58. 336 Bemelmans-Videc et al 1998. 334
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duced in public administration literature which has numerous definitions and approaches. However, in this study I focus on a steering perspective, using Pierre’s idea that governance is the “extent the state has the political and institutional capacity to ‘steer’”.337 Governance is linked to public management reforms as the dispersal of power created by public management reforms required reappraisals of steering relationships where relationships cut across “traditional jurisdictional boundaries”.338 These relationships are referred to as multi-level governance to reflect coordination of different levels:339 territorial levels such as state, regions and municipalities; coordination between policy sectors; and non-state actors such as private companies, voluntary agencies and civil society. According to Smith, multi-level governance presents two main challenges for public administration. Firstly for nationally elected, policy-makers, there is the steering challenge of how they can ensure that reforms are implemented by lower levels and whether vetopoints reduce national steering capacity. Secondly multi-level governance is a complex management problem as it is difficult for national levels coordinate policy to ensure uniform implementation at lower levels.340 These issues are of utmost relevance for my study as I identified issues of steering, variability and accountability in my overview of reform outcomes in Chapter 1. As decision-making powers are disseminated within and outside of the public sector, the state requires new strategies and instruments. Yet the governance as a concept is contested; it is unclear whether it is a new phenomenon or a variation on previous steering forms.341 In this PhD thesis I assume that despite power dispersal, the state remains a central actor, with a strong interest in ensuring that national reforms are implemented in accordance with state intentions. Thus governance and steering strategies are the central mechanisms by which the state exerts influence on lower-level agencies when it no longer has direct control. Governance research has also led to a new body of research relating to steering and regulatory relationships. Although much focuses on privatised industries,342 some is relevant to my study, in particular Knill and 337
Pierre 2000 p. 3. See Smith 2003 p. 619. See also Peters & Pierre 2000 pp. 2-7 & 15-24; Pierre 2000 pp. 3-6; Ling 2000 pp. 87-89; King 2007 p. 19; Moran 2002 pp. 404-409; Power 1997 pp. 134-140; Bevir & Rhodes 2003; Hall & Löfgren 2006 pp. 33 & 89. 339 See Smith 2003 p. 619. See also Painter 2003 p. 592. 340 See discussion in Smith 2003 p. 626. 341 According to Smith, 2003 researchers are divided over whether governance is a new phenomenon or whether it builds on historical and cultural traditions: pp. 20-21. 342 Regulatory state and governance literature was developed by law and economics researchers in response to monopolistic utility privatisation, which led to a corresponding loss of government control over central aspects of the economy and daily life such as water, energy, transport and communications. The literature covers the strategies and instruments of steering, control and influence that states use to persuade or coerce compliance: See Scott 2000; Scott 2004; Mosedale 2004; Majone 1997; Christensen & Lægreid 2005 (accessed 16/0-07); Jordana & Levi-Faur 2004; Moran 2002; Knill & Lenschow 2004; Rhodes 1997. 338
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Lenschow’s four approaches to governance, steering and regulation. Two approaches relate to centralised, harder steering forms: Regulatory standards based on hierarchical, coercive, legally binding steering instruments; and New Instruments, where decentralised implementation is combined with re-centralisation using incentive and sanction instruments. Two models relate to softer steering: Self-regulation, where lower levels regulate themselves;343 and the Open Method of Coordination (OMC) with soft consensus steering and non-binding instruments such as best-practice guidance and peer review.344 The governance strategies reflect the hard and soft steering instruments discussed in Chapter 3, yet do not help us understand what influences governments to select a hard or soft steering strategy in the first place. There is a correlation between the types of concepts and ideas of the mental health reform and NPM and governance literature. My findings in Chapter 3, however, refute assumptions of NPM research that there would be a convergence of reform design and outcomes; far from a convergence, Britain and Sweden chose very different steering and governance strategies.345 Thus although public management reform literature in many ways inspired the mental health reforms, it does not help identify what influenced Britain and Sweden to choose separate paths. Thus I must use other literature with which to develop my theoretical arguments.
National policy styles & steering choice Some of the prior research on policy instruments contained general suggestions that different instrument selections might be explained by the existence of different national policy styles. The literature on national policy styles is based on ideas that countries have national preferences for certain policy process decision-making procedures or interactions that form identifiable patterns or styles. Thus policy-makers choose strategies that conform to these preferred national styles. However, despite references to possible connections between policy styles and instrument choice in the policy-steering instrument literature, the idea of policy styles is rarely operationalised or analysed using in-depth empirical or comparative studies. Instead, references to policy styles in the literature are usually presented as brief and general suggestions as a useful direction for future researchers to study yet have been researched theoretically, empirically or comparatively in a structured 343
Self-regulation may under the shadow of the state, contingent on certain conditions being fullfilled and failure to abide by these will result in state intervention. 344 See Knill & Lenschow 2004 pp. 219-223. See also for example Christensen & Lægreid 2005 pp. 4-5; Scott 2004 pp. 145-50; Moran 2002; Lee & Woodward 2002; King 2007 p. 67. 345 Although not specifically related to steering, other literature has also pointed to the lack of policy formulation and implementation convergence: See Pollitt & Summa 1997; Pollitt & Bouckaert 2004; Peters & Painter 2010; Bevir et al 2003; Bevir & Rhodes 2003.
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and focussed manner.346 Therefore, this research the concept of policy styles appears to be a promising starting point for understanding the puzzle of the mental health reforms, and Britain and Sweden’s choice of hard and respectively soft steering. Prior research on national policy styles The literature on national policy styles focused on identifying country specific trajectories and patterns of policy-making and implementation styles.347 However, research does not provide a ready-made typology owing to the lack of agreed definitions or commonality of approaches in previous research where the term has been used in numerous different ways. The idea of national policy styles peaked in the 1970s and 1980s among comparative public administration researchers. The classic 1982 book by Richardson et al defined policy styles as “standard operating procedures” of national decision-making patterns and norms.348 Thus a policy style is perceived as an “invisible frame”349 underpinning and influencing government decisions, which would include soft or hard steering preferences. However, among the prior research there was no common approach; some research focussed on actor’s interactions only, whereas other studies included institutional dimensions.350 The NPM era reduced interest in policy styles research owing to the underlying discourse, previously discussed, that applying logical and rational NPM business tools would make national decision-making styles obsolete. Yet convergence failed to materialise and national variations remained despite similar sounding reform policies. In addition, new literature has also identified that national policy styles continue to exist; Bevir et al argued that the standard NPM business terms obscured national differences of interpretation.351 In the 1990s there was a revival of policy styles research as a means to explain different reform results and resulted in some recent single country studies352 and discussion of theoretical approaches.353 At first glance it appears that the policy styles research may be a ‘readymade’ discourse that could be utilised for my study. However, after reviewing these texts, I conclude that although there are elements of the existing literature that are relevant and ideas that are useable to my study for explain346
Bemelmans-Videc 1998 pp. 5-6; Linder & Peters 1989 pp. 49-50; Howlett 1991. See Howlett & Ramesh 1993; John & Cole 2000; Van Thiel 2006; Lian 2003. 348 See model developed in Richardson et al 1982a. See also discussion Richardson 1982b. 349 Feick 1992 p. 262. 350 See Anton 1969; Heclo 1974; Freeman 1985; Premfors 1981; Kelman 1981; Howlett and Ramesh 1993; John and Cole 2000; Lian 2003; Van Thiel 2006; Rose 1990. In particular see the Richardson et al 1982 anthology of European countries by different authors. 351 Bevir et al 2003 argue that states used the same terms to describe different reforms; decentralisation was interpreted differently in Britain and France. See also Bevir and Rhodes 2003. 352 Single case studies include Dorey’s (2004) study of Britain and influences of Thatcher and Blair; Bergh & Erlingsson’s (2009) study of policy actor behaviour in Sweden; Van Thiel’s study of institutional reform in Holland 2006; Hinnfors’ study of Sweden 1997. 353 Lian 2003; Howlett & Ramesh 1993; Bevir et al 2003; Bevir & Rhodes 2003; Feick 1992. 347
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ing the different steering choices in the community mental care reforms in Britain and Sweden, none can be used in their current form. There are definitions differences among previous research and no agreement as to which elements should be included in the policy style, which would assist future research. In addition, policy implementation and steering issues were poorly covered as most models focus on policy-making variables, rendering them less relevant and useful to my study.354 A particular problem was the lack of fully comparative studies; most research was single country case studies or anthologies lacking consistent approaches to indicator evaluation. In some cases it was unclear whether like-with-like was compared.355 As I also found with steering instruments, the research often was theoretical, tending to focus on categorisation lacking empirical studies; studies often produced long lists of elements, illustrated with selected empirical examples but not structured comparative case studies where the elements were analysed.356 The issue of operationalisation was unclear in some literature; the models produced broad and general indicators, but it was unclear how subsequent researchers should proceed.357 Thus the broad-brush approaches did not always aid the identification of key national characteristics. Some research needs updating as many studies date from the 1980s; even recent studies do not always include post-NPM empirical data. This is a particular problem for the steering and implementation where reforms had considerable impact.358 Thus models need to be updated to reflect the governance changes that resulted from public management reform era. However, despite the problems of theoretical research, there were several relevant studies that approached similar research questions to mine and that were relevant to my study. Kelman 1981 for example examined a puzzle of why the adoption of similar occupational health and safety regulations in the USA and Sweden created differences in implementation instruments, although this study was not solely focussed on implementation steering as it also studied policy-making differences.359 Despite conventional wisdom of
354
For example the main focus of Richardson et al 1982 and Premfors 1981 is policy-making. For example single case studies include Dorey 2005; Bergh & Erlingsson 2009; and in the Richardson et al anthology 1982 the chapters did not follow a common structure. 356 See for example Linder & Peters 1989; Freeman 1985; Feick 1992. 357 The classic anthology by Richardson et al used broad categories based on government approach to policy-making, as anticipatory or reactive, and government-actor relationships as consensus or imposition. However, an analysis of 21 case studies placed all but four European states in the same category thus did not help differentiate national policy styles: 1982a p. 13. 358 For example Dorey’s study of the British policy process includes updates for the impact of public management reforms: 2005 pp. 263-284. However, Bergh and Erlingsson claim Sweden’s policy style is unchanged since Anton’s research in 1969: Bergh & Erlingsson 2009; see also Anton 1969. However, both of these texts focussed primarily on policy-making rather than implementation and steering, which are the focus of my study. 359 Kelman 1981 US implementation involved regulation and was more rigid and rule based, whereas Sweden’s approach involved information instruments such as education and advice. 355
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Constructing the Invisible Frame Sweden as ‘pro-regulation’ and the USA as ‘anti-regulation’, Kelman’s findings contradicted this conventional these views: the US steering was more regulatory, whereas Sweden tended to use information instruments. Thus Sweden’s policy style was cooperative and consensus-based, in contrast to bureaucratic ideals of monitoring and control in the US. Kelman traced a number of influencing factors relating to historical and institutional traditions;360 although it was more a wide-ranging discussion rather than a structured theoretically guided model. However, what is relevant to my study is his conclusions that national policy styles emanate from historical factors and traditions of the state-building process. Arentsen also conducted a similar study to Kelman’s, regarding occupational protection policy in the Netherlands, England and Belgium. In a similar research question to mine, the countries chose similar policies, but steering instrument choices diverged.361 Arentsen argues that despite the similarities of the policy formulation, different national policy styles led divergent steering styles and instruments. However, it is unclear from the text how this analysis was constructed and conclusions drawn as a structured comparative model was not developed in the text. The conclusions were rather vague and fuzzy statements. These were most developed in the case of Belgium where Arentsen asserts that federalism and language divisions influenced the policy style. However, the assertions regarding England and Holland were more nebulous: in the case of England he argues merely that the pragmatic approach reflects England’s policy style without further explanation; and for Holland he contends that a learning-based instrument “suits the morality-preaching Dutch administrative culture.”362 Thus although Arentsen has a similar research question, linking national policy styles and preferences to instrument choices, the lack of a model or structure to support the assertion and conclusions means that his approach is impossible to replicate. The idea of national policy styles seems to have a strong connection to the choice of steering and policy instruments. However, the existing literature is problematic, because it either consists of lists of elements with little operationalisation or relates to empirically derived discussions without a structured theoretical focus. In addition, the research often focuses on policy-making rather than the implementation and steering issues of my study. However, the prior research has shown that steering choices are not solely technocratic or mechanical; different combinations of influences shape steerIn addition, policy-making negotiations in the US were adversarial, court-like proceedings, whereas Sweden’s were deliberative, based on trust and consensus. 360 Kelman’s discussion covered a wide range of influences relating to institutional, social and philosophical issues relating to attitudes to class, collectivism, corporatism and individualism. 361 The three countries chose different strategies: The Netherlands adopted educational instruments based on informing and educating addressees; England’s approach was ‘functional’ based on formal relationships and sanctions; in Belgium there were observed differences between the formal state regulations and passive provincial enforcement: Arentsen 1998. 362 See discussion in Arentsen 1998 p. 224-225.
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ing and choice. Thus the idea that the policy style influences the implementation and steering systems is very relevant to this study, but fails to provide an expedient model for this book. However, I regard a policy style to be broader concept than institutional definitions. My interpretation is that for welfare policy implementation, policy styles may contain dynamic aspects relating to the ideology and relative actor power. Therefore, using existing research as a starting point, I develop my own theoretically guided categories from a steering perspective that can be used to compare and analyse the steering and instrument choices for the reforms in Britain and Sweden.
Developing a typology: A Triad of Influences In the previous section it was demonstrated that despite public management reform, there is still evidence of differing government preferences that result in different steering strategies and instruments. Therefore, it is important to identify which dimensions may be relevant to my study. Previous research contains suggestions for dimensions that may form the policy style, and thus influence steering and instrument choice. In many cases these also reflect my interpretation of combinations of legacies and dynamic aspects. Peters concludes that there are five broad *i*s of influences: interests, ideas, individuals, institutions and international environment. Although Peters’ five ‘i’s are fairly general, these dimensions neatly summarise many of the elements taken up in other research regarding the influences of institutional structures and interests; political dimensions of politicians and underlying ideology; key policy process actors including administrators and professions; as well as general influences of the international environment and spread of administrative reform ideas and trends.363 In addition, policy steering and instrument literature identified influences over steering choices that mirrored Peters’ five *i*s. These dimensions can be summarised as follows: historical state-building factors relate to the cleavages and settlements regarding religious, ethnic, language, social class and territorial factors. Institutional factors relate to institutional capacities and preferences regarding political, legal and administrative systems. Ideological context underpin political norms, values and ideologies, where tool selection reflects policy-makers’ beliefs and preferences. Professional factors, relating to the professional context of roles, norms and powers of professions involved.364 Peters’ five i’s are: interests including political, professional and other interests; ideas, and ideological values and beliefs of policy-makers; individuals, regarding individual actors’ roles as ‘policy entrepreneurs’; institutions, and historical traditions and structures; and the international environment and the spread of ideas relating to public administration and management, for example the international spread of NPM concepts: see Peters 2002 pp. 553-558. 364 See for example Bemelmans-Videc 1998; Salamon 2002a; Salamon 2002b; Vedung 1998; Rist 1998; May 2002; Ringeling 2002; Feick 1992; Linder & Peters 1989. 363
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Thus a significant degree of commonality and overlap exists in the proposed influences identified by national policy styles and policy steering instruments literature; indeed some researchers, including Peters, are active in both genres. Peters also summarised several influences on government choices, which may provide the basis for developing my own model.365 Although Peters’ focus is external steering and my study focussed on internal steering, these dimensions can be reformulated and adapted to my research question related to internal governance and steering strategy in order to aid understanding of what influences government choices. I assert that three of Peters’ key influences are especially relevant to the selection of internal governance and steering strategies and are therefore, worthy of further study: government and institutions and the legacies shape instrument choice; individual and implementing staff, and the scope for staff, both professional and administrative, to influence policy and implementation decisions with professional norms and culture; social regulation and ideas, based on underlying political visions or framing that acts as the rationale for policy instrument decisions; for example an ideological preference for the market or publicly produced services.366 Yet most of these influences identified in the policy instrument research have not been theoretically developed, operationalised or analysed in structured comparative empirical studies. However, the commonality of the proposed influences gives a starting point for the development of my own theoretical instrument. Three dimensions of influence The first dimension that I identified was the influence of administrative and institutional traditions. A common research theme was the influence of historical legacies on policy styles. This dimension includes governing traditions of the state-building context, including political, legal and administrative systems and institutions as important influence, which determine what types of decisions and steering are deemed appropriate.367 Some research identified administrative traditions as the only influence on government, implementation and steering decision. However, based on Peters’ and Painters’ recent conclusions that administrative traditions may not alone be a complete explanation, and in accordance with my own wider policy style definition, I also cast my net wider to analyse the influences of dynamic 365
Peters identified several important influences. The ones that will be taken up in this book are the nature of government institutions, policy ideas and individual bureaucratic discretion. Peters also takes up a fourth element of individual interests and types of tax expenditures which relate to the personal/self interests and attitudes to types of tax instruments. This is considered less relevant to this study of the community mental health reform policy reform as an internal steering mechanism. See Peters 2002 pp. 561-562. 366 See Peters 2002 p. 561-562. 367 See the discussion of institutional influences on the administrative system in BemelmansVidec 1998 pp. 2 & 13; Vedung 1998 p. 39; Rist 1998 pp. 159-160; Linder & Peters 1989 p. 50; Ringeling 2002 pp. 593-597.
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aspects of policy steering relating to the roles of political and professional actors which are discussed below. The second dimension relates to the influence of professions and professionals on steering strategies. Some prior research mentions the possibility of professional influence, such as professional norms and values influencing steering instruments choice.368 This occurs in several ways, either through classic bureau-professional model where the state grants power and authority to professions to make decisions, as well as freedoms from. There are also state-regulated mechanisms where the professional influence is mediated by the state and the state utilises professions to legitimise state strategy. However, the influence of profession is under-researched with few theoretical or empirical studies that link professions to governance and steering choices. The third influence in my triad is the influence of policy framing, which relates to the way that the political values and beliefs of policy-makers can affect decision-making. This relates to the discussion in prior research that the power of ideas and underlying ideology can be influential in determining implementation and steering strategies. Therefore, governments may be committed to specific values or state roles, which influence preferences for certain instruments and strategies; for example some governments may have underlying ideological commitments to public or private providers which influences selected the instruments.369 Thus the way that the government’s underlying values and ideology frames a particular policy problem, its users or the need for state action may influence which steering mechanisms are considered appropriate. Thus the state may frame a problem as an private or individual issue that would require little state steering, or the problem might be framed as a central issue where the state must act and steer. Discussion The review of prior research on policy-steering instruments and national policy styles revealed many similarities in the ideas regarding the types of dimensions that influence the government selection of governance and steering strategy. This commonality can be summarised as three dimensions of influence relating to institutions and administrative traditions, implementing professions and actors, and ideological and policy-framing. However, these dimensions need to be developed and adapted to the research question of this book and its focus on government steering of lower-level agencies. 370 There368
Linder & Peters argue that professional background may influence instruments; for example where the dominant professional group is lawyers, legal tools and instruments; 1989 p. 53. See also Bemelmans-Videc 1998 p. 13; Linder & Peters 1989 pp. 37-50; Rist 1998 p. 150. 369 See discussion of policy framing and instrument choice in Bemelmans-Videc 1998 pp. 2 & 13; Vedung 1998 p. 38; Rist 1998 pp. 150-155; Salamon 2002a p. 24; Salamon 2002b pp. 171-2; Peters 2002 p. 555; Ringeling 2002 pp. 594-597; Schneider & Ingram 1990 pp. 522-523; Lowi 1972; Linder & Peters 1989 pp. 50-52; May 2003 p. 226. 370 Research by Peters 2002 and the Bemelmans-Videc 1998 anthology discussed different research questions relating to external steering rather than internal steering of this study.
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fore,. in this study I will analyse the three dimensions of the triad of influence, developing them theoretically and then using the models constructed to conduct a theoretically-guided analysis of the empirical information relating to the mental health reforms. This will enable me to determine the extent to which these dimensions help us understand why governments choose certain governance and steering strategies. In the theoretical analysis of this chapter and the three following empirical chapters I consider the dimensions separately in order to analyse the extent to which each dimension offers a stand-alone explanation for governance and steering choice. However, this does not mean that I consider these dimensions to be mutually exclusive. There are areas where these dimensions may combine and act in synergy, hence my depiction as a triad of influences rather than three separate models. Issues relating to interaction effects will be discussed in more detail in Chapter 8, where I conduct withincase analysis to assess the relative strength of each dimension for Britain and Sweden as individual cases. Thus having identified a triad of influences of three dimensions that may determine a policy style, the following sections operationalise and analyse the three elements theoretically to develop indicators that can be applied to the empirical material of the mental health reforms and to determine the influence on choices of hard steering in Britain and soft steering in Sweden.
Administrative & institutional traditions influences It is not possible properly to understand the present without at least some appreciation of how that present came about, of how it developed out of and differs from the past.371
The idea of administrative and institutional traditions is a relatively new discourse based on old ideas, with roots in the 1980s policy styles research. However, administrative traditions research focuses more specifically on institutional and historical legacies in contrast to the somewhat vague actorcentred approach of the national policy styles research. Therefore, in this PhD thesis I regard administrative traditions as a potential constituent part of a policy style. Administrative traditions literature developed as a response to the puzzle whereby NPM’s expected convergence of reform and instrumenttypes failed to materialise in reality. Thus researchers looked at ideas that a country’s policy preferences are shaped by the historical, legal and bureaucratic legacies. This underlying framework filters and shapes reform ideas, thus creating norms for governance and steering. As we saw for the community mental care reforms, Britain and Sweden adopted similar reforms, yet 371
Wilson & Game 2006 p. 49.
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chose different steering strategies and instruments. Thus in this section I will examine to what extent the concept of administrative traditions can help us understand the observed differences.
What is an administrative tradition? Administrative tradition is more specific than the broad term policy styles. It is based on ideas that decision-making is influenced by path dependencies of historical and institutional legacies, and that these in turn influence modern policy processes. Peters defines administrative traditions as follows: By administrative traditions we mean a historically based set of values, structures and relationships with other institutions that defines the nature 372 of appropriate public administration within a society.
Administrative traditions are based on ideas of historical institutionalism, whereby historical legacies create path dependencies that influence current decision-making, thus forming stable patterns that shape policy interpretation and implementation. Current decisions broadly conform to predictable patterns of these inherited characteristics, often relating to constitutional, political, administrative and legal institutions and these dimensions influence decision-making styles and relationships between actors, agencies, sectors or territorial levels.373 The idea is that countries tend to act in accordance with the traditions. Therefore, in this section I define administrative traditions as a country’s historical, institutional and bureaucratic traditions, which create specific modes of decision-making, communication and relationships. It is however, important to note that the path dependencies are not deterministic. Dynamic forces, shocks and crises as well the values, norms ideologies or decisions of individual actors can create deviations from the tradition.374 Therefore, I believe that the idea of administrative traditions is to act as an outer framework through which reform ideas are interpreted. The traditions become a filtration mechanism that sifts new public management reform ideas to determine which are accepted, rejected or modified in accordance with the underlying framework of legacies. Thus they may assist in understanding the choices of soft and hard steering mechanisms for implementing the mental health reforms in Britain and Sweden, as the existence of differing administrative traditions could have influenced the choice of steering instrument. 372
Peters 2005 p. 2. See for example the discussion in Pollitt and Summa 1997; Peters 2001; Peters 2005; Bevir et al 2003; Bevir & Rhodes 2003. 374 The path dependencies are not fixed as the policy process may be influenced by international trends or the ideology of actors which can result in changes to the tradition; however, the administrative traditions will act as a framework: See discussion in Knill 2001 pp. 21-23; Thoenig 2003 pp. 128-129; Pollitt and Bouckaert 2004 p. 23. See also Immergut 2006. 373
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Prior research: administrative traditions In the previous section, I identified how administrative traditions may aid understanding of the different steering strategies and instrument choices for the mental health reforms. Administrative traditions research gained prominence in the 1990s as a consequence of the puzzling results of the NPM reforms in Western countries. As discussed earlier the architects of NPM thought that adopting similar business-inspired reform models would result in an international convergence of implementation styles and steering instruments. Yet by the late-1990s many researchers, including Rhodes, Peters and Pollitt, concluded that significant national differences remained.375 However, the pre-existing, rather fuzzy, national policy styles discourse did not fully explain the differences observed. In many instances governments articulated similar reform aims yet the concrete reform and implementation choices often diverged. Thus administrative traditions discourse sought to understand this by studying underlying historical and institutional mechanisms. The idea was that new reform trends are interpreted through the preexisting institutional framework. In the case of the mental health reforms, despite having reforms based on similar ideas of municipalisation, disaggregation and a transfer of resources, there were differences in reform results. These differences may have resulted from the underlying administrative traditions forming an ‘invisible frame’.376 Thus the prior research on administrative traditions may assist in the understanding of Britain’s and Sweden’s differing steering choices. In order to be able to utilise the previous administrative traditions research, the discourse needs to be operationalised and broken down into elements and indictors. However, the prior research often focussed on broad categorisation and national-level modelling, yet was often not operationalised. Therefore, lists of elements were produced aimed at categorising a number of states into broad categories as models or ideal types, however, few systematic comparative studies were produced using the typologies with empirical data and focussing on detailed mechanisms. Thus there is little concrete guidance for future researchers conducting empirical studies. A considerable amount of administrative traditions research focuses on classification by sorting countries into various categories, families and traditions. In many cases the focus was on abstract concepts at the national level and categorisation at state level; it was for example unclear how abstract concepts and broad-brush elements such as the ‘state and society’ could be applied to individual reforms as in the case of my specific research question concerning the detailed mechanisms of steering strategies and instrument choice. Peters has been an active contributor to the classification of adminis375
See for example Peters 2001; Peters 2005; Pollitt & Summa 1997; Pollitt & Bouckaert 2004; Knill 2001; Bevir et al 2003; Bevir & Rhodes 2003. 376 Term ‘invisible frame’ developed by Feick 1992.
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trative traditions, In addition, to research on policy instruments and national policy styles. His model sorts western countries into four traditions: AngloAmerican, Napoleonic, Germanic and Scandinavian.377 Research by Castles identifies a ‘families of nations’ based on quantitative patterns of welfare expenditure inputs;378 or Pollitt and Summa’s analysis of reform choices by Westminster and Nordic model countries.379 However, my findings are that the wide-ranging, broad-brush categories are not always a good fit for my comparative case study. Britain is usually categorised as an Anglo-American or liberal market-state. Peters classified Britain as an Anglo-American tradition state, characterised by contractual perceptions of the state-society relationship, yet with strong Ministerial control of the civil service. However, these national level characterisations are difficult to apply to my research question. In addition, the Anglo-American group of states is fairly heterogeneous; considerable differences exist between the federal traditions of the USA and Britain as a unitary state.380 Castles categorises Britain as belonging to the English Speaking Family based on welfare expenditure. This ‘family’ is characterised by low levels of state services and welfare expenditure focussed on poverty relief.381 Pollitt and Summa analysed reform choices, identifying Britain as a Westminster model state. Some findings mirror my own: Westminster countries favoured privatisation, market strategies and intensive, individualised reforms, often using the political system to impose reforms.382 However, while in some sectors Britain was a leading advocate of market reforms, the model images of limited privatised welfare does not fully fit with the extensive availability of publicly funded welfare services such as free education, health and social services. Sweden on the other hand 377
Peters identifies the following dimensions: state and society; management or law; civil service traditions; level of uniformity; recognition of non-state interests; and accountability systems. See Peters 2005; Peters 2000. 378 Castles four ‘families’ are an English speaking family (Britain, USA, Canada, Australia, Ireland, & New Zealand), with common language, legal and political traditions, welfare spending patterns focused on poverty reduction with low state service levels; Nordic family, (Sweden, Denmark, Finland, Norway) shares historical, legal and language traditions (except Finnish), with high state service expenditure; a Continental European family, with common historical and cultural legacies; high income replacement but low service levels; a Southern European family with cultural ties, Catholic Church influence, late economic and political development; high income replacement levels and the lowest service levels: See Castles 2004 pp. 64 & 67; see also Cousins 2005 pp. 113-114. 379 Pollitt & Summa 1997 studied Britain, Sweden, Finland & New Zealand. The Westminster and Nordic models are adapted from Lijphart’s classifications. See also Lijphart 1999. The reform strategies chosen were privatisation, marketisation, decentralisation, output orientation, traditional restructuring and reform “intensity”. 380 Differences that emerge in this group. Britain’s tradition is career and apolitical civil service whereas the USA has a spoils system. Britain is unitary and rather centralised, whereas the USA is a federation with dispersed powers. There are also differences in how lobbying and outside interests are perceived. Peters 2005 pp. 13-15. 381 See Castles 2004. 382 Pollitt & Summa 1997. See also a similar approach by Pollitt and Bouckaert 2004 which used differences in reforms to classify countries: Britain was categorised as a ‘marketizer’.
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is usually characterised as a Scandinavian or Nordic model based on statedetermined, publicly produced welfare services. Peters classifies Sweden as a Scandinavian model country; however, this is also a heterogeneous group where Germanic legalism and Anglo-American managerialism coexist.383 According to Pollitt and Summa Nordic countries chose state-oriented reorganisations and lower intensity reforms and emphasise reform programmes based on negotiated solutions and corporatism.384 In addition, my findings for Sweden do not entirely fit the some of the models that focus on elements of state-dominated services. This issue was also discussed in Kelman385who found considerable local flexibility, as opposed to the common view of Sweden as having strong state regulation. There are however, several findings of the administrative traditions research that mirror my own and will be a useful starting place for development. Painter and Peters characterise the Anglo-American countries as strongly centralised, whereas within the Scandinavian model considerable decentralisation exists within unitary states.386 Pollitt and Summa’s article refuted ideas that there was a single, convergent trajectory of public management reforms. Instead they found pervasive differences in reform choices which reflect my findings on steering choices: Westminster countries favoured privatisation, market strategies and intensive, individualised reforms, whereas Nordic countries opted for restructuring, decentralisation and participatory reforms.387 Even though these issues were not analysed in detail in the short article by Pollitt and Summa, they are areas that could be developed in my study. However, there is still a focus on policy-making and reform choice, whereas my study aims to understand the choice of steering and governance differences where reform choices were similar. Therefore, although some aspects may be useful, these models are not a ready-made model for my research question. Many of the existing models as well as focussing on the national level are dominated by policy-making elements but lack a steering or implementation focus. Knill’s study of EU policy implementation by Britain and Germany is an exception. Although the supranational-national level focus is not always instantly applicable to my research question pertaining to multi-level governance within states, Knill also concludes that there have been few empirical implementation studies and focuses on structural elements relating to national state institutions including similar headings as some other adminis383
The main characteristic of the Scandinavian model is an extensive welfare state although the scope and provision vary. In addition, there are formalised links by the legitimisation and inclusion of other actors through corporatism: See Peters 2005 pp. 13-15; Peters 2000. 384 Pollitt & Summa 1997. See also Pollitt and Bouckaert 2004 where Sweden was categorised as a ‘modernizer’: pp. 96-102. 385 Kelman 1981 analysed work place protection policy in the USA and Sweden and found Sweden’s implementation culture was characterised by local flexibility and decision-making. 386 See table in Painter & Peters 2010 p. 20. 387 Pollitt & Summa 1997.
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trative traditions models.388 Knill uses elements to evaluate the capacity of states to comply with EU legislation including issues of power concentration, institutional entrenchment and administrators’ roles. Some of the elements appear to be very relevant to my research question. However, some of Knill’s conclusions do not appear to fit with my results in Chapter 3; for example he claims that Britain’s implementation style is based on pragmatic and informal relationships between the state, civil service, local government and civil society.389 This statement does not reflect my findings, although these statements are based on sources from 20 years ago and may need updating, or it could be a result of the different and supranational focus of Knills study relating to environmental legislation, which is often concerned about regulating private companies rather than public agencies and welfare services. In addition, Knill uses administrative traditions as the dependent variable to be explained, whereas my approach is to analyse administrative traditions as a potential explanation. Thus it appears that some aspects of Knill’s approach are useful, but these must be adapted to take account of the governance and steering focus of my own research question. Therefore, I reviewed the prior administrative traditions research to see whether there were ready-made and pre-existing models that could help me operationalise the administrative traditions concept. However, my general findings are that while the theoretical frameworks provide a useful starting point, none of the models are suitable in their existing form without adaptation to my research question. Some research is too abstract for my purposes and focuses on conceptual ideas such as state and society or national level administration, whereas my study is focussed on the delivery of local welfare reform. Therefore, the somewhat abstract concepts and broad-brush approach which are useful for examining overarching national level trends and sorting multiple states are less useful for my study which is to understand the specific reform mechanisms. In addition, the recent conclusions of Peters and Painter 2010 show no clear evidence that administrative traditions are the sole explanation for reform choice differences.390 Thus means that it could be a timely moment for a detailed empirical study to identify whether the influence of administrative traditions aids understanding of reform mechanisms. Prior research often focussed on models, thus there is a dearth of systematic, comparative studies. It appears that “nations matter” and that administrative traditions may influence hard and soft steering choice.
388
The dimensions evaluated by Knill include the power concentration and government capacity; the level of institutional entrenchment; and the ways in which the bureaucracy can formulate policy. Knill studies state and society; the legal system; structure and functions of the Civil Service; administrative organisations; level of power centralisation; and roles of the executive, agencies and local government: See Knill 2001 pp. 9-115. 389 See Knill 2001 pp. 82-83. 390 Peters & Painter 2010 pp. 234-237.
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Studying the influence of administrative traditions on steering The review of administrative traditions literature found that many models focused on the administrative structures of the state relating to constitutional, political, administrative and legal systems. However, in many cases these are not directly linked to steering and instrument choices. Instead they are focused more on the policy-making systems. In the case of the mental health reforms in Britain and Sweden, the reforms related to two national governments, both unitary states, which passed similar reforms, with similar implementation arrangements based on municipal social services departments. Thus administrative traditions may have influenced the choice of governance and steering strategies. Using the prior research, I have identified three elements that relate specifically to national policy implementation: the territorial degree of centralisation, the level of executive control and the ability to impose sanctions. These are discussed in greater detail below. Territorial degree of centralisation It is important to examine the historical and constitutional traditions relating to the territorial dispersal of power, and the relative power and discretion of central and local government over the implementation phase. The mental health reforms were national policies, which were implemented by lower government levels and external actors. Therefore, traditions relating to the power dispersal are of central importance to the choice of hard or soft steering instruments. This element relates to the degree of centralisation and the manner of power dispersal. It relates to relationships between government and local implementers: whether power is centralised with uniform administrative and decision-making systems, or whether power is decentralised with flexible and variable local decision-making and policy powers. Many administrative traditions models391 that I reviewed in the previous sections examined traditions relating to these constitutional arrangements; the dispersal of power between different levels of government and how the central-regional-local relationships influence reform processes. Some models focussed on the constitutional position of lower levels in federal systems. However, this distinction is less important in my study of two unitary states as there is often no specific constitutional division of power. What is important however, is the degree of centralisation: the relative power of the different actors in a reform process and the underlying level of centralisation. Therefore, the degree of centralisation can be a crucial factor in the state’s capacity to steer reform implementation at lower levels. The mental health reforms involved the transfer of responsibilities to local government therefore, the institutional divisions of power between central and local government may be an important factor determining the choice of government 391
See Pollitt & Summa 1997; Pollitt & Bouckaert 2004; Knill 2001; Peters 2005.
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steering strategies. Thus this element will examine whether there is strong centralisation assisting hard steering strategies, or whether there is low centralisation which would benefit soft steering. Level of executive control over the administrative system The traditions relating to executive power are important to governance, especially the opportunities for the executive to steer the implementation process. This element involves studying whether the executive can steer directly and control the administrative process, or whether administrative agencies have discretion. For the mental health reforms it is important to determine whether the government could exert strong levels of hard steering instruments over the administrative system, or whether the traditions required a softer, less direct approach. The role of executive power was a common element in the administrative models reviewed in this chapter. However, many models focus on the executive’s roles in policy-making relating to electoral and political systems, or contrasting national civil service systems.392 In order to study the implementation phase, a change of focus is required to examine relationships between the executive and administrative system in the implementation for the reform. This relationship is important as it is often departments and agencies that interpret reforms and communicate directly with the frontline local implementing agencies. Therefore, there is a question of whether the government has a direct, harder ‘chain of command’ steering of these contacts, or whether it is based on softer ‘arm’s length’ relationships where administrators determine their own interpretations and administrative policies. There are several key issues involved; is there strong Ministerial steering or a separation between executive and administration? Is the executive involved in the detailed implementation arrangements at central and local levels? Can the government direct implementation from the centre or do administrative actors have independence requiring negotiation and consensus? This element will consider whether there is a tradition of high levels of executive control which facilitates hard steering or whether the tradition is for low levels of steering resulting in soft steering strategies. The level of formal sanctions A final type of administrative tradition relevant to my study of implementation steering focused on traditions relating to the ability of the centre to impose legal and administrative sanctions. According to Pierre and Peters, the underlying influence of the legal systems is reflected in the extent of the 392
The models such as Pollitt & Bouckaert 1997, Peters 2005 and Knill 2001 examined the role of; electoral systems, for example contrasting the capacity of majoritarian election systems, “macho” majority governments who are in a strong position to exert control and dominate the reform process with weaker, either fragmented or more consensual governments based on proportional electoral systems and coalition governments; such governments may be unable to implement their reform agenda without the support of other parties.
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state’s legal powers of authority and coercion.393 The literature focussed on the role of administrative law in influencing the capacity for reform and implementation. However, these elements were often narrowly defined as a dichotomy between the Rechtstaat and Public interest models.394 However, as well as the narrow issue of precise legal compliance, the legal structures of governance may be an explanatory factor regarding whether the administrative culture allows harder, coercive compliance mechanisms, or whether there are few or restricted legal mechanisms whereby governments can impose sanctions on territorial or administrative agencies. This will enable an assessment of how the underlying sanction culture influenced the opportunities for the centre to enforce the reforms. Thus this element will consider in what ways the underlying legal arrangements assisted hard and soft steering strategies and what sanctions the government can impose for noncompliance, such as whether there are strong legalistic, contractual and judicial mechanisms, or whether the options for enforcement and sanctions are weaker and flexible. Thus a system that allows legal and administrative instruments will facilitate harder steering mechanisms, whereas a lack of legal enforcement powers and sanctions may result in softer steering strategies. Discussion: operationalising administrative traditions The literature review outlined the ways in which the administrative and institutional traditions may assist in explaining the differences in governance and steering for the community mental care reforms. However, most of the prior research on administrative traditions was more genera, and nationally focussed and was thus difficult to apply to a specific case involving implementation, steering and instrument choice; therefore, the choice of indicators must be tailored to the research question of this book. Three elements of particular importance to the case of the mental health reforms were identified as potential influences on steering strategy choice: level of centralisation; the level of executive power; and the level of formal sanctions. Therefore, I have used the prior research on Administrative Traditions to develop elements relevant to my study of governance and steering strategy. These three elements are summarised in table 4.1:
393
See Pierre and Peters 2000 p. 37. The Rechtstaat model is based on a concept of a state role of preparing, interpreting and implementing the constitution and laws, with aculture of legal correctness, control and equality before the law. The Public interest model has a contractual perception of the state as an artificial creation based on limited public consent where government and state should be limited to preserve individual freedoms The role of administration and law is to balance competing interests. See Knill 2001; Peters 2005 pp. 4-5; Pollitt and Bouckaert 2004 pp. 52-3. 394
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Table 4.1: Summary administrative tradition elements & steering strategy Administrative tradition
Hard steering
Soft steering
Level of centralisation
High
Low
Level of executive control
High
Low
Level of formal sanctions
High
Low
The administrative traditions appear to form the outer layer or “invisible frame” that influences implementation and steering; the influence of administrative traditions is one piece of the puzzle. In Chapter 5 these three elements will be analysed using material from the mental health reforms in order to determine to what extent the administrative traditions contributed to the differing governance and steering strategies. However, despite administrative traditions being a tried and trusted explanation, I believe that that the dimension may not be a stand-alone explanation. There is evidence that governments do not adopt the same steering approach to all sectors; for many governments adopt soft steering of the economy, yet hard steering in other sectors. Thus despite the similar administrative and institutional traditions, government steering does not always converge between sectors. In addition, Peters and Painters’ recent conclusions, relating to an anthology of 14 case studies, reveal that administrative traditions do not appear to influence all policy decisions.395 Therefore, my aim is to reappraise administrative traditions in a detailed, structured comparative study that focussed on mechanisms. It is possible that administrative traditions may be one piece of the puzzle, thus I must consider other alternative or complimentary explanations that can explain the differences between sectors. Administrative traditions may be one influence but not necessarily the only influence on governance and steering strategy choices.
Professions The relationship between state and lower level agencies implementing welfare reforms is often dependent on the role and expertise of professions: the welfare state professions that occupy the key mediating roles between state policy and reform users giving them central roles and potential for influence over governance and steering decisions depending on relationships between state and profession. Policy-makers are often dependent on professional expertise, and Markström argues that “professions have a strong influence over
395
Peters and Painter 2010 pp. 234-237.
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the deliberations that occur in a policy process”;396 these deliberations and considerations include governance and steering strategies. However, public sector professions find themselves in pivotal positions; while some may have lower levels of traditional autonomy and self-regulation than 19th century “free-professions”, the location of professions within the policy process gives them a potential access to the policy process and influence on state decisions. Professions often occupy positions of unique access and influence over the policy process. Pollitt argues that public sector managers often prefer to define difficult and controversial decisions as issues for professionals, granting considerable flexibility and low levels of steering.397 Therefore, professions are significant implementation actors that link policy-makers, local government and users, and that may influence government steering strategies for reform implementation. The issue focuses on Winblad Spångberg’s question of “who makes the choices?” of the steering relationship and strategies between state and profession.398 Thus the central role of professions in the implementation of reforms may be a dimension that assists understanding of hard and soft steering choices.
What is a profession? The issue of defining professions is an area that has been a matter of debate among researchers for well over half a century. There is a substantial body of traditional professions literature, usually modelled on the 19th century ‘free professions’ of self-regulating, private-practising professions such as medicine and law. A considerable amount of the literature focuses on defining and categorisation of the term profession: devising methods to determine which occupations ‘make the cut’ to be considered professions.399 There were two main approaches traits and process. Traits research, often based on Wilensky’s classic model,400 attempted to identify specific characteristics of professions;401 whereas process research, such as Abbott, regarded professionalisation as a set of pre-determined steps required to achieve occupation-
396
Markström 2003 p. 225 (my translation). Pollitt argues that health managers often leave difficult decisions to doctors: 1990 p. 441. 398 See Winblad Spångberg’s discussion of the relationship between doctors and politicians in the healthcare choice reforms in Stockholm: Winblad Spångberg 2003 pp. 9-21. 399 Free professions research focuses on traditional 19th century ‘gentleman’s professions’ of independent, private practicing, high-status professions: See Evetts 2006b pp. 515-516. 400 Wilensky argues that the main traits are Exclusive jurisdiction; Long university education: combining theory and competence; Technical basis of knowledge applying scientific or moral knowledge; Organisation through a professional body; Professional codes of conduct: ethical codes governing external relationships and internal collegial relationships; Professional autonomy and discretion: 1964 pp. 138-141. See also Hall 1968 pp. 92-93. 401 See for example the research by Evetts 2006b p. 519; Wilensky 1964 pp. 138-141. See also discussion Hall 1968 p. 93; Beckman 1989; Torstendahl 1989; Brante 1989; Wingfors 2004. 397
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al jurisdiction over a particular field.402 The result was copious classification literature, including attempts to subdivide the term further into full and semi, or strong and weak professions. However, none of this research activity resulted in an agreed definition of the term profession; typologies were often complex, inconsistent and difficult to adapt to either the public sector or the changing field of occupations. Thus some researchers started to question categorisation research; Bringselius argues that the professional sphere is not static; new professions emerge and old ones change, making definitive lists hard to maintain.403 Increasingly researchers, such as Evetts, argue that simplified approaches are needed in place of the “time wasting diversion” of categorisation, advocating simplified definitions of professions as knowledge-based service occupations based on higher education, vocational training and experience to deal with the uncertainties of modern life.404 In this study I intend to use a simplified approach to defining professions, therefore, I define a profession as: a graduate level occupation, involving common problem perceptions, with trust based relationships as well as discretionary decision-making authority and flexibility in problem-solving roles. Social work: is it a profession? The mental health reform based on the idea of transferring social care services from health authorities to municipal social services departments where the main profession is social work. Therefore, I focus on social work when analysing the professions dimension, as social work was the main profession within municipal social services at the time of the reform. When I discuss social work in this study, I am referring to professional social work carried out by municipally-employed social work graduates. However, social work has been controversial among professions researchers, resulting in a variety of different classifications as a profession, semi-profession or weak profession.405 Social work lacks a distinct scientific knowledge base and lacks opportunities for private practice in many countries. As Hugman argues, professions based on perceived gender roles are often accorded lower status by professions research; caring occupations are regarded as common sense or
402
The two phases include a pre-professional phase of university-level education and skills development, and secondly the professionalisation phase of entry standards, professional codes and monopoly: See Abbott 1988; Evetts 2006b pp. 519-520; Wingfors 2004. 403 See Bringselius 2008 p. 58. 404 Evetts refers to issues of birth, health and well-being, dispute resolution, law and order, finance, education, socialisation, security, arts and leisure and religion: 2006a p. 134-135. 405 Social work has been categorised in a number of different categories. Brante calls it a state profession, 1989 p. 46; Svensson 1999 & Kirkpatrick et al. 2005 p. 28 categorise social work as a weak profession; Wilensky 1964 categorises social work as a marginal or semi-profession under a professionalisation process p. 143; yet Hall argues that some social workers are ‘strongly professionalised’ 1968 p. 97.
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extensions of traditional female roles. This results in lower status for professions such as social work, nursing and teaching: Caring for is seen as less expert, it is women’s’ work, it is work done by black people, it is work that ‘anybody can do’ (but which not everybody does or wants to), it can be done by volunteers as well as people who are paid, by people who are less highly trained or even untrained. So the circularity of low status is reinforced: the task is low status, so the people who perform it are low status ad infinitum.406
Hugman argues that tasks are often regarded as low status when carried out by women, working classes or ethnic minorities yet become somehow higher-status and more ‘professional’ when carried out by white, middle class men. Social work had higher status when predominantly carried out by male priests and linked to the church’s moral and theological teachings.407 In addition, Abbott argues that traditional trait models are open to research bias and manipulation: “If one disliked social work, one easily found some trait excluding social work from the prestigious category of ‘professions’”.408 Thus prior research was uneven: some literature used very broad definitions that included unqualified and volunteer ‘social workers’;409 whereas in other research some restricted social work to defined qualifications; and some used sub-categories such as strong-weak, and full-semi professions but the basis was not always clearly defined. However, many definitions identify certain common elements of a profession: professional association, work organisation and knowledge development.410 Social work in Britain and Sweden demonstrates many of the requirements to be considered a profession:411 i. Professional organisation & ethics: in both countries social work has a professional associations which developed ethical codes; ii. Organisation & recruitment: in both countries social workers are recruited for professional welfare state activities in problem-solving roles requiring decision-making trust, flexibility and discretion; iii. Education & training: in both countries social work is a graduate profession and exists as an academic research-based subject. Therefore, social work is a graduate occupation focussed on solving community social problems. The nature of these problems means that they cannot be prescribed from the centre or in detailed rules, and require flexibility and discretion. I would also add the caveat that just because I consider social work to be a profession, this does not mean that all professions have equal 406
See Hugman 1991a p. 12. See discussions on origins of social work in Hugman 1991a pp. 86-90. 408 Abbott 1988 p. 4. 409 For example home-care staff, youth workers and care assistants. 410 See for example Evetts 2006a; Wilensky 1964; Hall 1968; Abbott 1988. 411 See Jones 1996; Jones 1999; Kirkpatrick et al 2005; Langan 2000; Lymberry 1998; Lymberry 2000; Pettersson 2001; Wingfors 1999; Wingfors 2003. 407
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power and status; professions have a variety of characteristics that combine in different ways. However, based on my definition of professions, I consider that social work fulfils my criteria to be a profession.
Prior research: professions & the state This book focuses on the influences on steering choices, and the professions dimension is based on ideas that professions and professional culture are influential when it comes to steering strategy choices. Thus the municipal professions implementing the mental health reform in Britain and Sweden may have influenced steering choices and policy steering instruments.412 However, links between professional influence and policy instrument steering strategy choice appear not to have been operationalised or studied empirically; therefore, there is no pre-existing approach to follow. However, there is prior research on state-profession relationships often based on mutual dependence. States require professional expertise, knowledge and skills for the implementation of welfare programmes, whereas professions obtain status, and access and influence within the policy process through state recognition. According to Price, professions occupy a pivotal space between science and politics, whereby professions influence and mediate the application of scientific knowledge to concrete situations, thus occupying a central position of influence within policy processes.413 Freidson argues that professions are a balance between three central interests: practitioners, administrators and teachers/researchers.414 However, these relationships within the policy process may influence steering strategy choices. Much of the traditional professions research was focussed on 19th century ‘free professions’, making it problematic to apply to public sector occupations that exist within political environments. Scholars such as Evetts argue that the assumptions of the 19th century “golden age” of professional working practices, where free professions worked autonomously and free from regulation, may be invalid.415 Abbott asserts that modern working organisation means that traditional definitions are not always applicable even to the professions of medicine and law; these days most lawyers and doctors are not ‘sole-trader’ practitioners, but employees of organisations.416 Thus professions are a central element of many public sector activities, but as such most are regulated in some form by political decisions, but also with access
412
See for example Linder & Peters 1989 pp. 50 & 54; Bemelmans-Videc 1998 pp. 2 & 13. Price argues that there are ‘four estates from truth to power’: science, professions, administration and politics. Professions and administration act as bridges between science and politics; administration lies closer to politics, and professions closer to science: 1965 pp. 122-137. 414 Freidson 1986, cited in Lymberry 1998 p. 864. 415 Evetts 2002 p. 342. 416 Abbott argues that lawyers are often corporate employees doing routine work: 1988 p. 8. 413
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to the policy process as public employees, thereby creating different ways to influence government decisions. Traditional models & “Bureau-Professionalism” Traditional models of public professionals are based on perceptions of professions as positive aid to state steering, especially in welfare policy where Brante argues professions contributed to the expert implementation of welfare services after 1945.417 Professionals were perceived as positive contributors to the public interest, and were granted power and influence as trusted state partners. Clarke and Newman call this relationship the bureauprofessional model: combining bureaucratic implementation of using standardised and impartial welfare programmes and apparatus with professional expertise of frontline professions, such as doctors, teachers and social workers, to solve welfare problems.418 Professions literature emphasises that incorporating professions into state activities changed the dynamic between state, profession and users. Instead of the 19th century client-profession relationship, the problems and tasks were mediated by the state, and the state became a key employer of professionals.419 Therefore, professions obtained state-sanctioned power and status through implementation roles. Evetts argues that bureau-professional roles were characterised by high trust; professions were perceived as working impartially and in the long-term public interest, in contrast to short time horizons of politicians and business.420 Thus it was a mutually beneficial relationship for state and profession as the state obtained access to expertise and skills under general democratic control and professions obtained influence in terms of decision-making discretion and freedoms from steering owing to the trust-based relationship with the state. Evetts calls this bureau-professional relationship occupational professionalism,421 arguing that it gives professions significant influence. There is often freedom from steering and regulation, as the state allows professions to create jurisdiction over policy sectors. The state thus confers powers and discretion to resolve problems: firstly decision-making authority is transferred away from politicians to professions; secondly the profession obtains influence and flexibility to decide work tasks and content; thirdly the profession retains authority over its professional identity, culture and organisation,422 which also pervade the policy sector; fourthly monitoring and con417
Brante discusses the state and professions relating to the welfare state in 1999 pp. 67-68. See the discussion in Clarke and Newman 1997 pp. 1-12. 419 Hugman’s argument, based on Johnsson’s typology of professional power, is that traditional relationships were based on direct relationships between the instructing client and professional; however, the state played a mediating role with welfare professions: See Hugman 1991a pp. 3-4 & 18-19. See also Kirkpatrick et al 2005 pp. 31-33. 420 See discussion of professions and trust in Evetts 2006b pp. 515-517. 421 See Evetts 2006a pp. 140-141. See also Evetts 2006b; Evetts 2002. 422 Elements relating to professional identity, culture and organisation include relating to socialisation, shared values, common education, and internally determined ethical codes. 418
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trols are conducted by either professional associations or professionally dominated public bodies. The profession obtains power and influence over the policy process and these strategies allow professions to establish an “autonomous form of governance”, whereby the state consents to the profession’s jurisdictional influence within the policy process.423 Therefore, traditional research results in the state conferring authority and influence to selected professions based on the level of trust in the profession, as well as the state’s dependence on professional expertise. The model tends to favour soft governance strategies reflecting the state granting power, discretion and freedom from steering based on trust in the profession. State-regulated professional influence & “New Professionalism” The concept of state-regulated or new professionalism occurs where the state has a similar need for professional knowledge and expertise as under the previous bureau-professional model. However, under this model the state retains democratic control by the use of regulatory mechanisms. Therefore, the state is influenced by the perceived need for professional knowledge, skills or legitimacy, and professions retain a central role. Yet the influence of the profession is not formulated through freedoms from steering; instead, it is kept under democratic control through harder steering strategies. The idea of tempering professional power with state steering has roots in a debate from the 1970s onwards regarding democratic and expert power. The debate focussed on the risk for goal divergence between government policy objectives and professional norms, values and power: he problem was summarised by Hutton and Massey: “can professionals serve two masters?”424 Although states remained influenced by the need for professional expertise, there was pressure for the state to define the nature of professional power and bring it under democratic control. At this time there was a body of literature whereby professions were regarded as undemocratic elites rather than positive forces supporting public interests; the literature emphasised that the authority and influence of professions should be steered more actively by the state.425 There was also a strong focus on implementation “failure” where a common theme was that professions subverted democratic decisions.426 Classic implementation studies focused on the democratic deficit of frontline professions and implementation such as Lipsky’s Street Level Bureaucrats and Pressman and Wildavsky’s classic study of implementation.427 The public management reform literature of the late 1980s emphasised new
423
See discussion in Evetts 2002; Evetts 2006a; Evetts 2006b. See discussion in Hutton & Massey 2006 pp. 23-24. 425 See Rothstein 2002 pp. 125-128; Brante 1989 pp. 37-38; Evetts 2006b p. 521. 426 See discussion of implementation research in Winter 2003; Barrett 2004; Winblad Spånberg 2003 pp. 49-51. 427 See Lipsky 1980; Pressman & Wildavsky 1984. 424
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Constructing the Invisible Frame professional roles, such as Osborne and Gaebler’s ideas of ‘steering not rowing’.428 However, the state remained influenced by the need for professions and was reliant on professional expertise to implement reform. The debate led to ideas that the state should steer these roles more actively and increase the level of democratic control over the professional influence. The literature focussed on the new regulatory approaches to professional influence and the need for governments to change the state-profession relationship and enhance democratic power. There was often an emphasis on state organisational objectives such as devolved budgeting, financial gatekeeping, collaborative working and market mechanisms. 429 These types of state-determined roles could potentially create conflicts between organisational and professional values and norms.430 However, the research literature is divided in this point. Some professions literature focuses on the increased steering as deprofessionalisation or proletarianisation for professions, whereby increased standardisation, regulation and routinisation leads to a decline in trust-based discretionary roles.431 Svensson argued that the balance of policy implementation shifted from professionally determined decisionmaking to state directed management and political objectives.432 Thus the increased state involvement meant a decline in the traditional professional influence based on loose and soft arrangements of trust-based steering. However, other literature refuted the negative perceptions arguing that and increase in management and decision-making does not preclude professional influence. Laffin and Entwistle argue that opportunities for professions to influence public policy and steering remain; many professions are themselves senior managers. In addition, consultation procedures give professions a voice. However, they argue that one issue is the blurring of traditional boundaries and the increased number of professions means that there is crowding and competition within the professional sphere; there are few outright monopolies and more professions compete to influence government.433 Farrell and Morris argue that the idea of ‘persecuted professions’ is overstated, ignoring the fact that managers are often experienced professionals such as head teachers and local doctors who do not reject professional norms 428
Osborne & Gaebler argued that implementation should be steered actively by policy entrepreneurs; see Osborne & Gaebler 1993/94. 429 See discussion of new professionalism in Hargreaves 1994. 430 This potential conflict of interest between professional interests and state reform policy was discussed in theoretical terms by Rein 2006 pp. 401-402; Hutton & Massey 2006 pp. 23-27. See empirical studies such as Castro’s analysis of a Stockholm hospital conflict: Castro 1999 pp. 43-44. Winblad Spångberg’s 2003 study of user-choice healthcare reforms. 431 See for example Exworthy & Halford 1999a p. 15; Menter and Muschamp’s study of bureaucratisation in teaching and emphasis on regulation and audit: 1999 pp. 75-78. Harrisson discusses proletarisation and corporatisation of medicine 1999 pp. 53-54; Kirkpatrick et al 2005 identified working relationships and proletarianisation: 2005 pp. 33. 432 Svensson argues that market and choice reforms changed relationships between professionals and clients as management controls replaced trust: See Svensson 2006 pp. 581-583. 433 See discussion in Laffin & Entwistle 2000.
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when they become managers. However, reforms have winners and losers as professions lack homogeneity.434 Evetts calls this state-regulated model the organisational professional model, and argues that it differs from the bureau-professional model. While the state is also influenced by professions, in this model professional power is harnessed and controlled by the state. Thus professions’ roles and influence occur under state direction, and are focussed on organisational goals.435 This model is also sometimes called ‘new professionalism’, and research by Hargreaves contends that this model is less focussed on individualistic professional authority; instead, there is a synergy between the professional and institutional development where professional roles remain.436 Thus multi-disciplinary working and joined up government have created demands for new forms of professional working. Organisational professionalism or new professionalism is a state-directed professional development whereby professionals are incorporated into administrative and organisational structures rather than existing as separate and individualistic sources of expertise. According to Evetts, this professionalism is based on utilising professions to achieve state-defined organisational priorities and goals. The profession’s role and in some cases identity is constructed externally by politicians; however, the profession achieves state legitimacy and a guaranteed policy process position. However, in the traditional relationships based on mutualtrust, and professional discretion, are replaced by state control through rules, regulations and sometimes the creation of regulatory agencies. Evetts argues that these relationships focus on state-constructed identities; professions that refuse to conform or defend their traditional professional norms may be labelled as ‘unprofessional’ by state agencies.437 Therefore, professions remain influential but in government sanctioned roles with discretion bounded by the state. Relationships are regulation-based rather than trust-based as state controls prioritise government objectives. Thus government steering utilises harder regulatory steering mechanisms. No professional influence: the concept of pretermitted professionalism There is also a third concept, which is not a model of professional influence, but which is instead based on professions having no influence owing to the state ignoring or failing to consider professions at all. I call this concept of non-influence as pretermitted professionalism.438 This category is not mentioned in professions literature; however, I have derived this form of non434
Farell & Morris 2003 argue that decentralisation and budgetary reforms have meant new spheres of professional influence for professionals such as head teachers and GPs. 435 See Evetts 2006a. 436 See discussion of new professionalism in Hargreaves 1994. 437 See Evetts 2006a & 2006b. 438 The word pretermitted means to overlook, disregard, omit or neglect to perform a function: See for example Oxford English Dictionary & Collins English Dictionary: pretermit.
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steering influence from some of the professions literature as it may help differentiate between active state strategies of deliberate and formalised influence and inactive strategies where influence occurs unintentionally, as the result of the state’s neglect or omission of professions in the policy process. Sometimes at first sight this model may appear similar to traditional models; there is considerable scope for professional influence. However, the state fails to legitimise professions or professional roles, which results in a lack of legitimacy. Therefore, unlike the active state strategies of previous models, the policy process influence of this model is unplanned and inadvertent. The model is based on challenging Lipsky’s ideas of Street Level Bureaucracy. Lipsky argues that governments cannot control frontline client-processing professionals, such as doctors, nurses, teachers, police and social workers, and that these professionals may subvert government policy and priorities. The nature of frontline professional work requires flexibility and discretion; thus Street Level Bureaucrats develop their own procedures and priorities, but not in accordance with state intentions.439 Thus a steering problem develops; the state needs expertise, but professions seize power away from elected government.440 However, Winblad Spångberg argues that Lipsky ignores the political reality of street level bureaucrats. The frontline professionals operate within the organisational and political structures created by policymakers; thus the scope for professional power and influence is determined by policy-makers and the space for professional freedoms created. Therefore, state-profession relationships are more complex than Lipsky’s assumptions of generic professions usurping power from elected leaders.441 Winblad Spångberg asserts this is a political and steering problem where politicians have ignored the influence and centrality of professions within the policy process. Often this occurred as a result of a focus on user outcomes and is connected to processes and mechanisms becoming unfashionable.442 The debate raises some interesting points for this study. Winblad Spångberg points out that professional power is bound by state-determined freedoms; it is ultimately the state that determines the framework of hard or soft steering, and thus the space available for professional influence or action. My argument is that the influence and role of professions may not be based on active government choices to use strategies of occupational or organisational professionalism, but operate in a vacuum created by policy-makers’ 439
See discussion in Lipsky 1980 pp. 3-25. See Winblad Spångberg 2003; Vinzant & Crothers 1998; Exworthy & Halford 1999a. 441 Although Winblad Spångberg’s study focuses on implementation, I believe that the ideas can be applied to a wider policy process influence: Winblad Spångberg 2003 pp. 60-62. 442 Winblad Spångberg’s 2003 study found that the official policy of user choice in healthcare conflicted with clinicians’ professional perceptions that decisions should be an issue of professional judgement and expertise. She describes in her study of doctors and of the implementation of the choice reforms in Sweden that health authorities failed to give clear directives on how implementation should occur, leaving the policy to be decided by doctors themselves. See discussion pp. 207-212. 440
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informal, loose and vague formulation of reform objectives and nondefinition of staff roles. Thus in some situations professional influence may be based on non-steering and government neglect of professions. Summary: professions & steering Prior research approached professional influence from differing perspectives as supporting the public interest, or as self interests that governments should control. Traditional professional models focus on professional influence through the norms of the bureau-professional system whereby governments are strongly influenced by professions and grant trust-based powers and discretion, as well as freedom from steering. On the other hand in stateregulated professional models the government is also influenced by the need for professional expertise, yet under stricter, state-sanctioned, democratic control focussed on the state’s organisational objectives. In recent years there has been a tendency in professions’ literature to focus on professional influence as a steering problem by emphasising street level bureaucrats’ ability to disobey or rebel against government steering.443 However, Winblad Spångberg argues that there must be state complicity or tacit-consent for professional influence, as professions operate within legislative and regulatory frameworks determined by government. Therefore, I formulated a final pretermitted professional model where the government neglects and fails to consider professions; thus the influence or lack of influence of professions is the unintended consequence of government neglect.
Studying the influence of professions on steering choice The professions dimension is a different type of dimension of influence compared with the other two categories. There is a duality in the ways that professions can be used. Firstly professions can influence government steering in the traditional bureau-professional manner of a government granting freedoms and discretion in return for soft steering. However, professions may exert influence on government strategy as a result of their suitability as a steering instrument. The government may need professional legitimacy and expertise to achieve policy and organisational goals, yet wants to retain political control and formulate its role by using hard steering strategies. Thus the previous sections have shown that the relationship between state and professions can influence the choice of steering strategies, both relating to traditional and state-regulated perspectives of the state-professional relationship. Professional culture and influence are suggested as influencing steering strategy choices in the policy steering instrument literature; this was not
443
See for example Lipsky 1980; Winblad Spångberg 2003.
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supported with detailed theoretical or empirical research. 444 Therefore, approaches must be developed to determine how this state-professional relationship forms an influence on governance and steering strategy choices. In the previous sections, two main models were identified that may assist in the study of the influences on the government choices of steering strategies for the mental health reforms: a professions regulated model of influence based on concepts of influence inspired by bureau-professionalism; and a stateregulated model of influence whereby the need for the profession is recognised, but where the state retains control. The professions regulated model of influence This traditional model of professions regulated model of influence is based on ideas of professional influencing governance and steering strategies based on concepts of bureau-professionalism and the occupational professionalism model. According to this model the basis of the influence exerted is the state’s trust in the profession and the profession’s status based on knowledge and expertise. Therefore, the control of work is devolved to the frontline profession, and the profession influences steering choices as the freedoms and flexibilities granted to the profession require soft steering approaches from government. It is common that under this model the profession becomes a policy process “insider” exerting direct influence into the policy process through formalised positions in state agencies etc. In addition, the profession is granted considerable self-regulation powers to control its own professional organisation, such as registration, authorisation, education and training. Thus this model involves soft steering strategies from the government as much of the decision-making and professional organisation relies on internal professional decisions without the input of government. The state-regulated model of influence The basis of this model is a state-centred and regulated form of professional influence. While the state is influenced by the need for professional knowledge and expertise, under this model the state retains democratic control over professional influence and uses harder steering strategies. Therefore, the state does not hand over control to the profession so that the influence of the profession is also mediated by policy-makers’ priorities to fulfil organisational and operational objectives. Thus although professions may have extensive roles, there is less freedom as the state-professional relationship is more tightly controlled through standardised procedures, administrative controls and higher levels of regulation and control. In addition, the individual profession may have a guaranteed occupational jurisdiction as 444
For example there is mention of professions and the context and/or culture of frontline professions influencing policy instrument choice in Bemelmans-Videc 1998 p. 13; Linder & Peters 1989 pp. 37-50; Rist 1998 p. 150.
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there may be blurred boundaries between professional, administrative and managerial norms, and in some cases more than one profession operating within the policy sphere. There may also be a higher level of state control of the profession though state controlled registration, training and certification requirements, in order to ensure the profession is focussed on state policy objectives and priorities. Thus this model is instrumental. The influence of the profession is a means of achieving government objectives and the state does not relinquish control. Thus the influence of the profession according to this model is less related to freedoms and autonomy, and more to do with the profession being utilised as an effective tool to achieve state objectives. I summarise the two main models in the table below. Pretermitted professionalism is not constructed as a model as it is not a model of professional influence; however, it may be used in Chapter 6 for comparative purposes. Table 4.2: Models of professional influence Professions regulated influence
State-regulated influence
Basis of influence
Trust & acceptance of status.
Professions under democratic control.
Control of work
Devolved decision-making: professionally determined priorities
Central control: statedetermined professional priorities
Direct influence
Professional jurisdiction
Shared jurisdiction
Basis of professional control
Discretion & self-regulation: internal values.
State-regulation & authorisation: external values
Discussion: professions & steering strategies The role and influence of professions appear to be a central issue for determining the actor-related roles of the policy style; inter-relationships between professions and politicians are an important influence on the choice of steering instruments, and in particular the relationship relating to the professionally regulated or state-regulated influence. The influence of professions can occur through ‘autonomous governance’ influence where the profession is a trusted partner of the state, or it can be a state mediated role where the profession’s influence as a result of usefulness to providing knowledge and skills needed to achieve government objectives. Therefore, existence of an organised and identifiable profession can also influence the choice of instrument and strategy in several ways, not only through traditional professionalisation concepts. In Chapter 6 conceptions of professional influence as either professions regulated or state-regulated influences will be evaluated using empirical data in order to determine the extent to which professional 132
Constructing the Invisible Frame influences contributed to Britain’s choice of hard steering and Sweden’s choice of soft steering in the mental health reforms.
Policy framing The final dimension of the triad of influence is the idea that governance and steering are influenced by the underlying discourse relating to the nature of the problem to be solved, the government’s perceptions of users, and the government action required and that the way in which governments “frame” the discourse influences policy-decisions. Thus policy framing is a dynamic dimension, which creates rationales and preferences for certain types of policy action, interventions and instruments.
What is policy framing? Policy framing refers to the way that policy-makers perceive and construct policy problems, which influences policy programmes and ultimately steering strategy choices. Stone calls policy framing causal stories, where policymakers construct a narrative through “deliberate use of language and of symbols” to “deliberately portray” policy issues and problems in a certain way to gain support for their preferred course of action.445 Any given policy problem has a number of potential policy responses, without one single ‘correct’ response; thus government framing can alter perceptions of the policy issue. In this respect policy framing rejects business models assertion of ‘standard tools,’446 where choices are purely rational and technocratic processes; instead, policy framing focuses on steering decisions as a political process. Government perceptions of policy problem and need for action are influenced by underlying ideological beliefs and preferred steering styles.447 This view is emphasised by Peters: “instruments are selected in conformity with the prevailing political values”.448 Therefore, a policy framing dimension may increase understanding of why hard and soft steering was chosen for the mental health reforms as the framing influences what is considered an appropriate state response. According to Stone governments
445
See Stone 1989 p. 282. See discussion in Rein 2006 p. 389; see also Schön & Rein 1994 pp. 13-14. 447 There is political science research that rejects the arguments developed in economics and rational choice literature. According to this literature, policy and steering decision are not a technical, rational and linear process based on dispassionate technical analysis. The choice of steering strategy and instrument choice is very much linked to political and ideological convictions: See for example Stone 1989; Salamon 2002a p. 24; Salamon 2002b p. 601; Vedung 198 p 39; May 2002 p. 172; Peters 2002 p. 552; Rist 1998 p. 152. Bemelmans-Videc 1998 p. 2; Schneider & Ingram 1990 pp. 519-520. 448 Peters 2002 p. 563. 446
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Thus similar policy issues can be framed as requiring completely different state interventions and steering depending on the political framing: for example, gun control and ownership as a policy issue: in many European countries it is framed as a public safety/law and order issue, thus policy responses focus on regulatory steering mechanisms, whereas in certain states of the USA it is framed as a constitutional civil-right where state intervention should be minimised, using soft steering. The choice of whether to use hard or soft steering instruments is therefore, a political decision, reflecting underlying policy sector philosophy, norms and values regarding the need for and types of steering deemed appropriate. Therefore, steering choices cannot be divorced from politics; it reflects policy-makers’ ideological convictions rather than a rational choice of appropriate instruments. The policy framing represents a dynamic and evolutionary element of the policy process.
Prior research: policy framing The policy framing dimension as an influence on steering instruments choice is taken up by Peter’s previously mentioned five ‘I’s as the influence of: ideas and ideological beliefs; and political interests as the elite perceptions and values that steer the policy instruments selection.450 The issue of ideological influences has also been linked to national policy styles in policy style and instrument literature. Scholars such as Kelman and Ringeling assert that underlying ideological preferences, beliefs and norms influence perceptions of problems, government action and the steering strategies needed to solve the problems of society.451 However, I argue that policy frames are not merely a deterministic ideological ‘tradition’ as some authors suggest, but that policy framing is a dynamic moment where shifting values in society and new philosophical trends converge to change the perceptions of policy issues and alter the underlying steering philosophy. This also corresponds with Peters and Painter’s lack of clear evidence relating to administrative traditions. I argue that this is because the traditions alone miss the dynamic as-
449
Stone 1989 p. 282. See discussion for example in Peters 2002 pp. 553-556. See also Hood 2006 p. 470. 451 See for example Kelman’s 1981 study of policy implementation in Sweden and the USA that linked underlying ideological and cultural preferences and influences to steering choices. See also Ringeling’s analysis linking European ideological influence to steering instrument choice. Ringeling argues: Christian Democracy framed social policies in terms of state and church with preferred steering instruments incentives where state funding was channelled to independent religious service providers. Liberalism defined the extent and limits of state power, preferring regulatory and legal instruments to identify the scope of state power. Social Democracy favoured state instruments such as direct service provision: 2002 pp. 594-595. 450
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pects of new discourses and framing; thus policy process choices are a political, dynamic, evolving and ultimately changeable dimension. Policy framing & governance strategy According to research by Stone as well as Schön and Rein, policy framing is used at two levels of the policy process: firstly policy framing has a rhetorical function in the selection of facts and their normative presentation to justify and build support for the government’s viewpoint; secondly is the action function that builds on rhetorical frames to underpin government proposals for certain types of action as the ‘logical’ response to the problem identified.452 Therefore, the framing process is used by governments to select a discourse that corresponds to its ideological beliefs and values, which helps the government to organise the presentation of empirical ‘facts’ to support its prescription for government action. Governments combine the processes of rhetorical and action framing in order to create an underpinning political argument to win support for their policy process decisions. The first stage is problem definition and user identification to define the new policy. As in all policy sectors there are competing discourses regarding the nature of the policy problem, and as Bacchi argues, policy problems do not just “exist ‘out there’ in the community”: they are constructed and shaped by policy-makers.453 Policy-makers must decide which discourses to align themselves to, and which to ignore. Thus the government constructs narratives, described by Stone as causal stories, which appear as factual descriptions yet are based on carefully selected empirical material that supports government beliefs and norms.454 The “story” includes a causal programme theory of what/who has caused the situation, and what action the state should take and includes a number of implicit decision points: whether the problem is an issue for state action; political costs and benefits; a decision to act or not act; allocation of responsibility or ‘blame’; and choice of instruments.455 Clarke and Newman discuss re-framing of welfare under the new right, arguing that the framing discourse shifted from universalism and support of the disadvantaged, to re-framing as tax burdens and lazy, welfare cheats.456 Policy framing may influence institutions; Dorey asserts that agencies have a ‘dominant ethos’ of underlying values and culture that shape “policy perspective and approaches to problems, including how problems are defined -
452
Schön and Rein discuss rhetorical and action frames in 1994 pp. xiii & 32-34. See also Stone’s discussion of empirical and normative phases of causal stories: 1989 pp. 282-283. 453 See discussion and literature review in Bacchi 2000 p. 48. 454 See Stone 1989 pp. 282-283. 455 For political context analysis: see Rist 1998 pp. 154-155; Linder and Peters 1989 p. 47. 456 See Clarke & Newman 1997 pp. 1-17. See also Fischer’s argument that the Thatcher/ Reagan use of economic language formed a political frame for the state’s role and purpose, thus limiting strategy choice, despite purporting to be rational and technical: See 2003 p. 25.
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or denied”.457 The framing narrative defines a need for government responses and also influences governance and steering strategy. The problem definition enables policy-makers to define users and the reform’s target recipients, sometimes placing restrictions on ‘undesirables’ by shifting them to other actors or to excluding them from programmes.458 However, the norms, beliefs and values of policy-makers are dynamic and evolutionary processes: problem definitions and classifications are not permanent and static The second stage is the need for action and the steering mechanism. Researchers including Stone and Salamon emphasise a link between steering strategies and policy framing; the causal story constructed by government also determines steering choices. For example the frame determines if problems are regarded as state, market or private responsibilities, creating preferences for certain instrument types: tax breaks, direct services or vouchers etc.459 In addition, the literature reveals that often powerful and favoured groups are more likely to be chosen for ‘carrot’ incentives, whereas poorer or ‘deviant’ groups are more likely to receive the ‘sticks’ of sanctions and coercion.460 Linder and Peters argue that ideological and value preferences create different perceptions of governance and steering strategies, even if they have very similar overall consequences. Thus for the state a tax credit, welfare benefit, government grant or social insurance may have similar net financial effects, yet the choice reveals underlying ideological preferences.461 Thus policy framing and instrument choice send specific political messages. Policy framing & mental health There is some prior research that links policy framing with mental health, and several scholars have investigated mental health from a policy framing perspective. According to Rein, the way in which governments define and frame problems and users influences the types of policies adopted, including perceptions of the need for hard or soft steering, and instruments selection. Rein’s study of mental health in Boston demonstrates how policy-makers’ framing constructs the problem in a particular way, linking it to one of the competing mental health discourses. Therefore, framing of mental health varies depending on which characteristics were emphasised. In Boston at Dorey contends that the underlying frames can shift; the Department of Social Security’s shifted from universalism to selectivity, targeting and fraud detection: 2005 pp. 93-94. 458 Rein discusses how actors engage in creaming (cherry picking) to restrict ‘target groups’ and offload undesirable clients to other institutions: 2006 pp. 397-400. See also Schneider Ingram 1990 relating to problem analysis framing users and choosing instruments based on users’ social acceptance and political power. 459 Stone argues that the causal story creates different choices of instrument such as regulation/sanctions, taxes/benefits or information campaigns/education are available to government: 1989 p. 282. Salamon links instrument choice and political values: 2002b pp. 601-602. 460 See discussion regarding the use of coercive tools with unfavoured groups and incentives with favoured groups based on the way that the policy analysis frames the target group in Schneider & Ingram 1990 pp. 519-523; May 2003 p. 227. 461 See Linder and Peters 1989 p. 43. 457
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different times, mental health was framed as a healthcare problem with arguments focussing on medical and treatment needs; social problem emphasising homelessness and social deprivation; or finally a criminal justice problem with the narrative focussed on criminality, risk and danger.462 Each of the frames suggested a different set of policy interventions, actors, programmes and steering approaches. Thus the underlying policy framing constructed the problem and users in different ways and created a rationale for very different government policy responses and steering. Wolff’s analysis of mental health policy found that mental health is a particular challenge for government framing. Drawing on empirical analyses of the USA and Britain, Wolff contends that mental health policy represents a dilemma for governments; while psychiatric treatments are no more complex than for somatic illnesses, mental health is not only framed as a medicosocial problem, but also normatively as a political and judicial problem. Thus Wolff argues “[t]he conundrums of mental health policy arise as much from political and legal complexities as from clinical challenges”.463 There are competing frames for mental health as medical; social, user rights; risk; and law and order issues.464 Therefore, the way in which policy-makers define and frame the problem influences the types of policy responses and steering strategies selected. Summary: policy framing & instrument choice The discussion above demonstrated that the selection governance and steering strategies are not a technocratic process but an active political process, shaped by arguments constructed by governments in accordance with underlying political beliefs and values. I identified how the government framing of policy problems and users also shapes government action and steering strategy choices. Thus the framing of mental health creates underpinning arguments for the types of interventions and steering among the competing mental health discourses such as medical, social or criminal justice framing.
Studying policy framing & steering choice The review of prior research above has established a link between policy framing and governance; interventions, steering strategies and instruments are framed in accordance with the policy-makers’ perceptions of policy problems and users. I discussed in Chapter 2 how the basic mental health reform idea and content were similar, shifting away from the medical model discourse towards a normalisation discourse of community living. However, it is unclear whether the policy framing in Britain and Sweden was similar or 462
See the discussion relating to framing and mental health policies in Rein 2006 pp. 397-402. Wolff 2002 p. 802. 464 See discussion of mental health policy dilemmas in Wolff 2002 pp. 801-802. 463
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whether policy-makers aligned themselves to divergent discourses requiring differing interventions; thus steering differences may result from different political arguments. Research by Wolff and Rein identified that mental health may be perceived in differing terms as medical, user rights or criminal justice issues. Thus the different frames create different expectations and ideas of which types of government interventions and instruments are necessary for mental health policy. Using the literature on framing and mental health analysed in the sections above, and following the approaches of Wolff and Rein, I have developed three mental health care ideologies that represent different elements of policy framing. By care ideology I mean the underpinning norms and values of mental health as a policy issue, perceptions of the psychiatrically disabled and the type of government interventions and programmes required. I have chosen to focus on care ideology only in order to avoid overlap and duplication with administrative models. It is recognised that the three frames are not an exhaustive typology, but focus on three major mental health discourses to be used in Chapter 7 to analyse how policy framing may have contributed to shaping the steering choices of the mental health reforms. The three models are the medical model; the disability model; and the risk model. The medical model The traditional model for constructing and framing mental healthcare from the 19th century onwards was the medical model, emphasising mental health as an illness problem requiring treatment, and as discussed in Chapter 2, the medical model was the dominant discourse of the asylum. According to Rogers and Pilgrim, medical models emphasise mental illness as a disease or sickness with biological and/or chemical causes, and the role of doctors skilled in diagnosis and treatment. Policy and service organisation is based on hospitals, drug-based treatments and psychological therapies. The medical model’s hegemony as the traditional care ideology resulted in medical specialism and terminology dominating user care and the entire care chain; thus the term ‘psychiatry’ is often used as a collective term, not only to denote the doctor and medical speciality, but also to describe the organisation of services including social care.465 Other authors argue that the medical model focuses on mental illness classifications, based on approved psychiatric diagnoses, clinical definitions and judgements, thereby legitimising doctors as key decision-makers.466 The main focus is to provide therapy and treatment to ‘correct’ the brain’s biological and chemical imbalances. However, the medical and psychiatric terminology also frames service users in terms of their diagnosed mental illness, referring to users as a ‘schizophrenic’ or ‘psychotic’, so the user identity is constructed in terms of the individu465 466
Rogers and Pilgrim discuss the role of psychiatry in mental health: 2001 pp. 20-21. See medical model discussed in Lindqvist et al 2010 pp. 10-11; Golightley 2008 pp. 25-26.
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Constructing the Invisible Frame al’s diagnosis and illness. The medical model also accords users a subservient status; users are classified as ‘patients’467, emphasising passivity and a person who is calm, accepting and submissive. Therefore, according to this model, service users are constructed as sick, but are assigned passive roles as patients while needs and services are determined on their behalf by a dominant, and some might argue paternalistic, medical profession. The disability model The disability model is a social model based on the normalisation concepts and user rights discussed in Chapter 2. According to this model, users were perceived as citizens, albeit with special support needs, with rights to live as ordinary citizens and to make their own decisions. According to Sharkey, this model views the psychiatrically disabled as an oppressed group: disabled by society’s attitudes and failure to make adjustments for their needs. Thus the model emphasises enforcing citizenship rights and reducing limitations.468 Kemshall argues that the disability model is the opposite of the risk model, involving risk-taking rather than risk aversion: challenging the medical model’s paternalism, and oppression of risk models by arguing for user empowerment, autonomy and citizenship rights.469 Thus this model is based on the psychiatrically disabled as ordinary citizens with equal rights to participate in society. In the disability model the problem is identified as empowering the psychiatrically disabled and overcoming barriers to facilitate access to normal living. The basis of state interventions is to provide services and a support network according to users’ individual needs and priorities. The model is individualised and tailored with a coordinated support network of public, voluntary and private actors in different combinations to meet users’ individual priorities and preferences.470 The determining factors of this model are user-centred and user-generated support and services rather than support and services determined by professional and/or organisational considerations. Thus according to this model, users are constructed as individuals and ordinary citizens with the right to live normal lives in the community. The state’s interventions are therefore, individual. Risk-management model The risk-management model focuses on problem definitions and perceptions of users as a danger and a threat to public safety. This argument builds on Beck’s idea of a Risk Society and an increasing preoccupation in some countries in debating, preventing and managing risks.471 The model focuses on 467
The Oxford English Dictionary defines patient not only in healthcare terms but also as a derivative of patience meaning “calm endurance of hardship, provocation, pain, delay”. 468 Sharkey 2000 pp. 110-111. 469 See Kemshall 2002 p. 93. 470 See Walmsley 1997; Bachrach 1997 pp. 23-5; Lindqvist el al 2010 p. 11. 471 Beck 2006 p 4.
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perceptions of social problems in terms of risk and reduced solidarity. The political discourse focuses on the “endemic” risk culture in society created by low levels of public trust and reduced public acceptance for political risktaking. The risk discourse presents itself as prudent, using risk-management strategies as mechanisms for dealing with uncertainty for both citizens and policy-makers.472 According to Zinn and Taylor-Gooby, risk-management “promised a systematic way of coping with the irreducible uncertainties of decision-making and thereby providing legitimation for policy”.473 The risk discourse is built on zero tolerance for risks, creating a perception that all risks can be managed. Research by authors such as Kemshall, Stone and Power argue that the risk discourse represents a shift away from the traditional welfare concepts of risk-pooling and solidarity and ideas that “accidents happen”; instead it focuses on ideas that risks are caused, and failure to control them means someone is to blame.474 Thus the risk model is inextricably linked with the blame culture that individualises risk-management; failure to manage risk means individual culpability. Risk framing emphasises steering strategies to reduce uncertainty, a reduction in trust and judgement based on services and increased control strategies. However, increased control mechanisms have consequences for the service legitimacy. Mental health is one area of welfare policy where the risk model has been discussed, and arguments of potential danger and unpredictability of service users form a pervasive discourse. Wolff argues that the risk discourse is often built by media framing of scandals; mental health coverage tends to be focussed on moral panics or based on ‘crazed killers’; thus framing perceptions of psychiatric disability in risk terms. There are two main issues of the risk model in mental health: the perceived unpredictability of the mentally ill, and avoidability and blame culture arguments. Despite the somewhat contradictory nature of being able to avoid an unpredictable risk, the risk model presents facts based on ideas that improved controls and procedures eradicate risks. Policy framing focuses on a high-risk minority while ignoring the low risk majority. The model prioritises public perceptions and alleviates fears at the expense of user rights and freedoms. Government intervention focuses on controlling risks by coercive means.475 Wolff argues: Mental health policy can be framed in terms of mental illness as an illness or mental illness as a risk factor. Currently it is framed in terms of a risk factor, … But this approach alters the balance between security and care in the management of the illness and in ways that internalize the public’s stereotypical views of persons with mental illness.476
472
See Hutter 2006; Hood et al 2001 p. 5; Zinn & Taylor Gooby 2006 pp. 54-58 &70. Zinn and Taylor Gooby 2006 p. 56. 474 Kemshall 2002 pp. 8-9 & 19-21; Stone 1989 p. 283; Power 1997 p. 138-139. 475 Wolff 2002 pp. 801-807. 476 Wolff 2002 p. 824. 473
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According to Taylor-Gooby and Zinn, the risk model replaces the traditional needs-based culture for community mental health services, with a “risk” group focus.477 Although services are organised through welfare agencies, it borrows from the criminal justice discourse; users are framed as criminals rather than citizens or patients. The services focus on criminal justice strategies and organisations such as police and probation services, by applying strategies developed for controlling former prisoners in the community to the psychiatrically disabled. Services are based on surveillance, controls and coercion and focus on the duty of the service user to comply with the state’s requirements, rather than the duty of the state meet users’ needs.478 My review of the risk model shows that certain risks are unacceptable, in particular risks relating to marginalised or undesirable groups; for example mental health is constructed as an unacceptable risk based on a small number of violent events, yet the level of crime attributable to the psychiatrically disabled is far less than for example alcohol or car related crimes, yet these are not perceived as unacceptable in the same way. Discussion: operationalising the policy framing dimension The previous discussion reviewed three care ideologies and how these may be utilised by governments in order to frame policy and influence governance and steering strategies for the mental health reforms. To summarise, the medical model identifies the problem in terms of illness and diagnosis with the psychiatrically disabled constructed in passive roles as patients while decisions are taken on their behalf by doctors. This model frames state action in terms of providing treatment, with the service ideal based on hospitals and clinics that provide treatments in the form of therapies and medications. However, treatment provision is often on the basis of professionally driven local organisations such as hospitals and clinics where the basis of decisionmaking is medical knowledge and skills. The disability model on the other hand frames the problem in terms of disability and the way that society limits the psychiatrically disabled from leading lives as ordinary citizens in the community. Thus the focus is enforcement of legal rights, and state action is focussed on supporting users own decision-making and reducing structural obstacles in accordance with users’ own preferences. Finally, the risk model frames the policy problem using a discourse of danger and public safety and the unpredictability of mental illness. As in Rein’s analysis users are framed in criminal justice terms; as criminal risks or threats to law and order. Thus the logical state policy action is framed in terms of risk-management with the service ideal based on the criminal justice system and probation service whereby users are kept under surveillance in the community so that the risks 477
Taylor-Gooby and Zinn 2006 p. 274. See for example Maycraft Kall 2008; Wolff 2002; Kemshall pp. 8-9 & 19-21; Zinn & Taylor Gooby 2006 pp. 54-58; Taylor Gooby 2006 pp. 271-280. 478
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can be controlled and contained with coercion if necessary. I have summarised the four models into the following table: Table: 4.3: Summary – Three models of care ideology Characteristic
Medical model
Disability model
Risk model
Problem identification
Mental illness & diagnosis
Disability & need for normal living
Public protection
Construction of user
Patient
Citizen
Criminal danger
Action required
Treatment
Support for user decisions
Risk-management
Therefore, I identify three care ideology discourses for mental health, which policy-makers might utilise in order to frame mental health services. By analysing the way in which policy-makers framed and constructed their arguments will provide insight into the way in which policy-framing influences steering strategy and instrument selections. Thus the models will be operationalised and discussed in Chapter 7. Therefore, the final dimension of policy framing focuses on the dynamic influences of politics, values and ideology on governance and steering choices, an element often neglected by institutional arguments. Thus the policy framing dimension is the final piece of the puzzle. In Chapter 7 this dimension will be analysed using empirical documents relating to mental health reform in Britain and Sweden in order to determine to what extent policy framing discourse(s) contributed to the different steering strategies and instrument choices observed in the mental health reforms.
Constructing the Triad of Influences: conclusions This chapter has reviewed the theoretical literature relating to governance and steering in order to ascertain whether previous research can assist in the understanding of the governance gap of why Britain chose hard steering strategies, while Sweden chose soft for implementing the mental health reforms. The choice of steering strategies is constructed as a Triad of Influences of national and sectoral influences relating to institutions, actors and political framing that form underlying preferences for certain types of steering and instruments for implementing public policy. Thus the policy style can be influenced by an alliance between three dimensions: administrative traditions, professions and ideological discourse. Research into national policy styles and steering choices declined during the NPM era of the 1980s and 142
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1990s when the expected convergence of business-inspired steering strategies failed to occur. This resulted in increased research interest that there may be perspectives that influence the policy style that favoured certain types of steering mechanisms. Thus the results of many public management reforms demonstrated that despite similar reform policies, there were often differences in the implementation and steering strategies chosen by national governments. The literature pointed to the possibility that governance and steering decisions are influenced by the three dimensions of administrative traditions, professions and policy framing. Therefore, in order to understand the different steering and instrument choices of government, the three dimensions that form a triad of influence must be analysed in terms of the mental health reforms.
1. Administrative & institutional traditions This first dimension relates to the influence of institutional legacies, and traditions on current policy-making, implementation and steering strategies, creating path dependencies. They consist of political, administrative and legal institutions and traditions that influence the policy-making and implementation systems. The administrative traditions act as a framework for decision-making, steering, communications and relationships between actors, agencies, sectors or territorial levels, thereby creating differences in the programmes implemented by governments despite similar reform policies. Thus the implementation of public policy is assumed to conform to a predictable pattern and to act as a mechanism for filtering and interpreting new reform ideas. There are a number of elements that influence the policy process: constitutional, political, legal and administrative systems; relationships between state and other actors and cultural legacies. I identified three elements for analysis that were relevant to the mental health reforms. I have summarised steering and administrative traditions relationship in the table below: Table 4.4: Summary administrative tradition elements & steering strategy Administrative tradition
Hard steering
Soft steering
Level of centralisation
High
Low
Level of executive control
High
Low
Level of formal sanctions
High
Low
2. Professions The second dimension relates to the professional influence over governance and steering strategies. The relationship between state and professions can 143
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influence the steering strategies chosen. I developed two main models of professional influence. The first is profession-regulated professional influence, based on the traditions of the bureau-professional model where the profession obtains substantial influence based on status and trust in the knowledge and expertise of the profession. This confers extensive policy process roles with freedoms, discretion and decision-making powers in policy formulation and implementation based on the state devolving authority to the profession. The profession is often incorporated into professional structures and granted particular powers through occupational jurisdiction. The profession also has substantial control over professional activity. This model has a strong association with soft steering and professional independence as the state grants powers to the profession as an extension of state power, with the profession obtaining influence and freedoms from steering. The second model is state-regulated professional influence where the profession remains influential as the state regards professional knowledge as a mechanism for achieving state objectives. However, the state attempts to maintain professional influence under democratic control. The trust and freedoms of the occupational professionalism model are replaced by a framework of government controlled by managerial procedures and state regulation. There is often blurred jurisdiction owing to the non-closure of the professional sphere owing to the influence of state and management perspectives. In addition, the state actively constructs professional roles using powers of central regulation and authorisation. Thus the knowledge and expertise are needed by the state to legitimise state policies and programmes; however, the professional influence is mediated by the state to achieve government policy objectives and organisational aims. Thus this form of professionalism is associated with harder steering and governance. Finally I identified how in some instances there is no influence according to the idea of pretermitted professionalism whereby governments neglect or ignore the role of professions in the policy process. Thus I summarise the two main models in the table below: Table 4.5: Summary – Professions & steering strategies Professional influence
Hard steering
Professional regulation State regulation
Soft steering X
X
3. Policy framing The final dimension of the triad of influence is policy framing, which relates to the way that politicians’ underlying discourse influences the choice steering strategies. This dimension is based on the notion that policy sector deci144
Constructing the Invisible Frame sions are influenced by the government’s underlying care ideologies, consisting of norms, values and beliefs in relation to mental health that creates preferences for specific types of interventions and instruments. The concept of the policy frame’s influence refutes arguments from business economics that steering and instrument choices are mechanical, rational and purely technical choices. Policy framing demonstrates that policy and steering strategies are influenced by politicians’ values and beliefs; thus no single correct decision exists. Instead, policy-makers construct causal stories based on how the perceive the problem, the users and the need for the state to take action. The way in which these underlying discourses of care-ideology are framed, influences the type of governance and steering strategies used by the state and thus the use of hard or soft steering approaches. Utilising prior research on mental health, I developed three models of care ideology relating to mental health framing. These models will be operationalised in Chapter 7, but an overview of the three care ideologies is included here. The first is a medical model, where the government frames the policy in terms of medical problems and medical responsibility. The government shifts responsibility from the state to local healthcare actors such as health authorities, hospitals, clinics, doctors and other medically trained staff. Decisions are based on the individual’s medical needs and require flexibility and freedom of action for local medical actors. The medical model dominates healthcare services; however, it can also exist in other settings. For example, even where users are transferred to municipal social care services, the medical model may still dominate if municipalities find themselves in subordinate positions where they are subjected to the priorities and decisions of external healthcare actors, or in services where a significant proportion of staff are medically-trained and focus on medical and treatment perspectives. The medical model influences soft steering as decision-making is individual and based on medical priorities. The government cannot steer medical decision making in detail and the steering approach is soft. The second is the disability model that emphasised citizenship, disability and support for users’ own decisions. This model can be approached from two perspectives based on hard or soft steering approaches depending on which perspective the government policy frame adopted. From the stateperspective, the disability model can be viewed as a top-down hard steering approach as the state is concerned with establishing formal and binding rights through disability legislation, regulations and rules. When the disability model is based on the perspective of the state’s regulatory framework, municipalities are subjected to hard-steering as the framing emphasises a binding and uniform regulatory framework, and possibly include sanctions for municipal non-compliance. Therefore, this approach is based on hard steering strategies. However, disability models may also focus on a bottomup, user-perspective and the frame may instead emphasise freedom of choice or the person’s right to individually tailored services based on their individu145
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al preferences. Thus this approach would result in soft and flexible steering as decisions are steered by users own preferences and choices and cannot be steered in detail from the centre, thus steering may be based on general aims, non-binding guidance and the provision of general information. The final model is the risk model whereby the government emphasises the control of danger and the need for instruments and strategies aimed at controlling the threat of criminal behaviour and increasing public safety and protection. The need to control dangers and risk would require policing and control strategies based on hard steering approaches and instruments. Table 4.6: Summary – Policy framing, care ideology & steering strategies Model
Hard steering
Medical
Soft steering X
Disability
X
Risk
X
X
Concluding remark There is a broad agreement among researchers that a link between the concept of policy styles and the choices governments make in relation to governance and steering strategies, and the choice of instruments. I have identified a flexible model of a triad of influence based on national and sectoral policy styles and relationships. However, few structured comparative studies have examined why the adoption of similar policy instruments resulted in different forms of governance and steering choices in the implementation phase. In the three chapters that follow, each of these dimensions of influence will be analysed in detail as comparative and empirical studies. The dimensions will be used to study the mental health reforms.
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Chapter 5
Administrative Traditions In this chapter I consider the influence of administrative traditions as the first of the three dimensions of the Triad of Influence identified in Chapter 4. The aim is to analyse the extent that this dimension increases understanding of steering strategy choice and in particular, why Britain chose hard steering while Sweden chose soft for the mental health reforms. My main conclusion is that the steering choices of both countries were strongly influenced by the institutional and administrative traditions of each country, but that administrative traditions may not be the only influence. In Britain I found that administrative traditions displayed strong central powers and executive domination, which link to the choice of harder steering instruments. However, I also found that Britain’s hard steering strategies intensified in the later reform period, which is not altogether explained by this dimension. In Sweden the softer steering strategies appeared connected to doctrine of local selfgovernment as well as traditions of low executive steering. However, it also appeared that these constitutional doctrines were not fixed and binding on government, but instead functioned more as a form of administrative cultural convention that was open to interpretation by the government of the day. I found, therefore, that both countries chose steering and governance strategies that broadly corresponded to the underlying administrative traditions, but I also found that there may be other influencing forces and explanations. However, overall administrative traditions do appear to have influenced Britain’s preference for hard steering, in contrast to Sweden’s use of soft steering strategies and instruments.
What is an Administrative Tradition? In the previous chapter I discussed the way that a country’s historical and institutional legacies, conventions and norms create invisible frames that influence and structure future decisions. These underlying administrative traditions influence the way that new ideologies, reform ideas and international policy transfers are perceived, interpreted and filtered. However, the path dependencies of administrative traditions are not rigidly deterministic in 147
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conforming to past patterns. Instead they constitute what Peters and Painter refer to as ‘administrative DNA’:479 in the same way as genetic legacies where siblings have the same biological legacy but different physical characteristics, administrative legacies influence future actors but future decisions are not pre-determined. In Chapter 4, I identified three key administrative traditions that may influence steering choices: territorial centralisation, executive control and formal sanctions. These three elements will now be analysed in greater detail in order to determine whether they are linked to the choice of hard and soft steering.
Administrative Traditions in Britain: general conditions General conditions relating to administrative traditions may influence the choice of governance and steering strategies. These are considered using two approaches. The first is based on the underlying doctrines, concepts and conventions that together form an underpinning framework of government in Britain. The second is focussed on analysing central historical events of the state building process, which may affect modern decision-making. These two approaches will then be analysed in terms of the three critical administrative elements identified in Chapter 4, which are the level of territorial centralisation, the level of executive control and the level of sanctions.
General conditions: institutions, doctrines & conventions In Britain I identified how several underpinning doctrines and conventions influence the governments’ relationships with lower territorial levels. These concepts include: the unwritten constitution; the concept of ultra vires; ministerialism and Ministerial responsibility; and the Common Law. The unwritten constitution Britain is famous for its unwritten constitution, a slightly misleading term, which suggests no written documents. In fact there are a number of written sources, but no single written constitution. Knill argues there are several effects, in particular, for local government and democracy: Britain knows no constitutionally entrenched guarantee of local selfgovernment or regional autonomy, local authorities and regions can at any time have their powers rescinded by a simple Parliamentary statute. 480
Therefore, constitution consists of multiple of sources dating back to the Magna Carta in 1215. There are Laws and Acts of Parliament, such as the 479 480
Peters & Painter 2010 p. 235. Knill 2001 p. 101.
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Act of Settlement in 1701 which sets out the Royal succession and relationships between monarch and Parliament. In addition, the Common Law is part of the constitution through court decisions and precedents. There are also a number of conventions including government collective responsibility and the Prime Minister being an elected Member of Parliament (MP) in the House of Commons. In recent years international sources including European and international law have been included. As there is no single constitutional document, Britain has no special machinery for constitutional amendments and no special constitutional courts.481 There is also no specified constitutional dispersal of territorial power or task allocation. The unwritten constitution is based on the concept Parliamentary Sovereignty, whereby Parliament can change the constitutional arrangements by a simple majority vote. The majoritarian electoral system favours two-party systems, giving large majorities and concentrating power in executive hands. The government can amend or withdraw constitutional power allocations by legislation.482 Wilson and Game assert argue that this is a major source of executive power that governments can “create, abolish, restructure, and amend the powers of local authorities as and when they determine”.483 Bevir and Rhodes argue that the unwritten constitution means that executive power has few formal constraints.484 Therefore, Britain’s unwritten constitution is very flexible, allowing for rapid changes and amendments. The executive dominates and can easily change the constitutional balance of power between central and local legislating. The concept of ultra vires In addition, to the weak constitutional protection for municipalities in Britain, Wilson and Game argue that there is a long history of tension between central and local government concerning the extent of local self-government. The doctrine of ultra vires means to act beyond the powers. Municipalities and administration are subordinate to government power, and only allowed to incur expenditure and conduct functions authorised by government. The use of finance for other purposes is illegal.485 This doctrine is not static owing to the executive’s powers to prescribe or change department, agency or municipal functions through legislation. The unwritten constitution makes the doctrine of ultra vires important: there is no strict separation of powers or constitutional courts to constrain executive power or declare government actions unconstitutional. The courts can only determine whether public administration is acting beyond its current powers (ultra vires). However, the powers of administration and lower government levels are not fixed: there is 481
See Punnet 1976 pp. 159-162. See Knill 2001 pp. 77, 84 & 101. See also discussion in Coulson 2004; Cochrane 2000. 483 Wilson & Game 2006 p. 158. 484 See Bevir & Rhode 2003 p. 94. 485 See Wilson & Game 2006 pp. 26-27. 482
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nothing to stop the government of the day merely passing new legislation that would declare actions illegal. Ministerialism & the doctrine of Ministerial responsibility In Britain, Ministers have traditionally been held accountable for the actions of their departments according to the doctrine of Ministerial responsibility. Punnet argues that the doctrine regards Ministers as having direct line responsibility and accountability to Parliament for their Department’s actions. Thus Ministers have general duties to inform and to provide information. However, Ministers are also individually responsible for their Department’s actions.486 Although the doctrine is an important convention, its importance has declined in recent years. Peters refers to it as a “convenient myth” as modern Ministers are no longer the only identifiable departmental representative of information source: these days civil servants are public figures and appear before committees, and executive agencies have their own leaders. Punnet argues that even historically few Ministers actually resigned.487 However, it demonstrates an expectation that Ministers are individually responsible to Parliament and also public opinion. In Britain, Ministers and the Cabinet have central roles in initiating and managing the policy process. There are traditions of exerting chain-ofcommand steering over departments and implementing agencies. However, executive agencies created in the 1980s were based on separating policy from implementation: Ministers retained rights to intervene in policy issues, but implementation was meant to occur at arm’s length. Yet despite structural changes, many Ministers often invoked Ministerial responsibility to justify direct interventions.488 Several high level Minister-agency disputes revealed differing interpretations of what constituted a policy issue. A particular conflict that resulted in the Director of the Prisons Agency being fired revealed that the policy and implementation boundary was never clarified. Ministers used a somewhat circular argument to justify intervention: that the minister’s decision to intervene by design makes an issue a policy matter: [I]t had been made clear: the home secretary sets policy, the head of the prison service runs operations ... But no one ... bothered to define the distinction properly. 'I heard an MP give one definition,' ... 'He said the home secretary must have the right to intervene when he wants to. By the act of intervening that thing becomes a policy matter.489 486
See Punnet 1976 pp. 179-182. Punnet 1976 states that only 20 ministerial resignations were based on the doctrine in the period 1855-1955: pp. 183 & 318-327. See Peters 2001 pp. 139 & 315-316. 488 See Peters 2001 pp. 139 & 315-316; Punnet 1976 pp. 318-327; Mellon 1993. 489 In the 1990s a dispute between the Prisons Agency Director, Derek Lewis, and the Home Secretary, Michael Howard, resulted in Lewis being fired for opposing direct Ministerial interference in day-to-day operations. It revealed difficulties in determining the Agency Director’s freedom to manage: See Interview with Lewis: Management Today 1/1-96. 487
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Administrative Traditions Thus Britain contrasts with Sweden’s tradition of independent executive agencies. Knill argues that administration in Britain lacks autonomy from Ministerial control.490 Thus in Britain the long traditions of direct Ministerial intervention are hard to break despite reforms and formal role separations. The Common Law The British legal tradition is based on the medieval Common Law tradition, with law created by judicial case decisions. Therefore, the law constantly evolves with the individual court decisions, and there are no separate administrative courts and no constitutionally binding competences or allocations of powers.491 Therefore, the legal system in Britain has not been a central aspect of public administration for the interpretation and enforcement of administrative law. Thus legal sanctions are often dependent on government legislation or court decisions rather than fixed constitutional law. In addition, the legal basis of public administration and civil servants are not strictly defined by law. The lack of a fixed constitution and separate body of administrative law meant reforms were easy to implement, with few legal or constitutional constraints against radicalism. Dunleavy and Hood argue that the radical reforms in Britain resulted in little reflection of the legal consequences or discussion concerning which areas of competence ought to be retained under direct political and legal control.492 Summary – General conditions: institutions, doctrines & conventions This review of underlying constitutional concepts and doctrines demonstrate that most favour central and executive power. There is no formal separation of powers; indeed until 2005 it was possible for the Lord Chancellor to sit in all three branches of power: legislative, executive and judiciary. In addition, local government lacks constitutionally guaranteed independence and powers. Thus the dispersal of tasks and allocation of powers depends on the government and can be removed or altered at any time by a simple majority vote in Parliament. Therefore, the underlying constitutional concepts reinforce central and executive power.
General conditions: historical legacies & state building493 Britain has a complex system of local government as a result of incremental development and ad-hoc reforms. My review of the historical legacies in this section found that there was a strong legacy that emphasises the develop490
See Knill 2001 p. 115. Pollitt and Bouckaert 2004 p. 53; Page 1992 pp. 132 & 138; Knill 2001 pp. 74-77 & 84. 492 See Dunleavy & Hood 1994 pp. 15-16. 493 The section relating to the general conditions for administrative traditions is based on Wilson & Game 2006; Page 1992; Punnet 1976; Mackintosh 1977; Bevir & Rhodes 2003; Hill 2005; English History & Heritage guide; British History online. 491
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ment of central control and authority. In Britain municipal government is responsible for the provision of local services and has a major role in welfare policy implementation; in particular, education and social services account for over 50% of municipal budgets.494 According to Wilson & Game, there is a historical tradition of incremental and haphazard municipal organisation and structures: the modern structures coexist with the old such as AngloSaxon Shires,495 and 12th century ‘Charter’ towns.496 Early government & administration – establishing central control Local government in Britain dates back over 1000 years to the selfgoverning Saxon Shires (700-1000 A.D.). However, since this time a recurring theme has been establishing and maintaining central authority and control. The Norman invasion of 1066 introduced centralised and rigid administrative systems based on French feudal traditions. Paid sheriffs were appointed to represent and maintain the King’s central authority in the regions, and conduct judicial and administrative functions.497 Thus the main emphasis was establishing central authority over conquered territory. This process of continued centralisation of administration and taxation powers continued throughout the medieval era.498 Further administrative reform occurred in the late medieval period as feudalism declined and was replaced by increased central intervention in local implementation. The main central mechanism was the creation of Crown appointed Justices of the Peace (JPs) to conduct administrative and judicial functions.499 The JP system existed for over 500 years as a centralising administrative system of appointed local judiciary and administrators: JPs remain today as lay-magistrates in lower criminal courts. Therefore, establishing central authority and power in local areas was a key legacy with low levels of local power or representation for those outside elite groups. There was also a preference for unelected bodies with patronage and appointed officials in central administrative and judicial roles.
494
Wilson & Game argue that the main tasks of municipalities are education, social services, community safety, infrastructure, planning and development, environmental and public health, economic development, housing, consumer protection etc: 2006 pp. 123-140. 495 The areas of councils such as Oxfordshire, Cambridgeshire, Bedfordshire, Hampshire, etc are based on the Anglo-Saxon Shire territories. 496 Wilson & Game 2006 p. 49. 497 Sheriffs developed from a Saxon tradition of Shire-reeves, and were paid by the King as instruments of central control in the counties. Steering instruments such as the Doomsday book were used as a census to register inhabitants and wealth as the basis for administrative and taxation systems. Sheriffs represented the struggle between central and local power. In the tale of Robin Hood, the Sheriff of Nottingham is depicted as an autocratic despot burdening citizens with central taxes, whereas Robin Hood represents the local community. 498 For example some towns were awarded limited local administrative freedoms through Royal Charters, sold by the King to raise revenue, and the role of parliament increased. 499 JP’s were regional aristocrats, appointed by the King to conduct functions, such as presiding at court cases, administrative functions related to infrastructure and parish oversight.
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The period between 1500 and 1700 included certain key political and institutional reforms. The consolidation of central power continued under Tudor monarchs and Henry VII reformed administrative, financial and legal systems. The JP system continued as the Crown’s long arm in the regions, and by the 1700s JPs had extensive regional administrative functions, including responsibility for constructing the early asylums. In addition, parishes played a greater role in local administration, especially poor relief. The 1601 Poor Law gave parishes certain powers to levy a local property tax (Rates) to fund poor relief and the Rates became the main form of local finance for several centuries. The 17th century was dominated by conflicts between Crown and Parliament, which resulted in a civil war, and the execution of Charles I. However, even after the settlement and restoration of the monarchy that saw Parliament’s powers increase, the Crown still controlled patronage and thus effectively controlled the administrative system. Attempts by Parliament wrest control of patronage powers from the Crown, fragmented and dispersed appointments, and created chaotic, inefficient administration: by the 18th century JP and administrative posts were purchased or owned by MPs and filled by family and friends. Page calls the administrative system “an unelected county squirearchy”, based on arbitrary decisionmaking and implementation.500 Thus this period was as a time of political reform at national and local levels. Local parish councils became responsible for early welfare services.501 However, appointments and administration were not carried out on the basis of impartiality or merit. 19th century administrative reform: the Golden Age of local government In the 19th century, central-local relationships were fragmented. Local administration was provided by 150,000 Parish Councils, JPs and a myriad of state-appointed officials and single-purpose boards. There were pressures to reform electoral systems and patronage in the 1830s.502 The 1835 Municipal Corporations Act created councils elected by local rate-paying property owners. In 1834 the Poor Law Amendment Act also reformed welfare administration by transferring services from parish councils to elected boards, with strong central controls through the inspections by Poor Law Commissioners. However, the reform was short-lived; scandals led to the transfer of poor relief to a central board under Ministerial control in 1847. Central administrative reform also occurred in the mid-19th century. The need to reform public administration had become acute after the disastrous administration of the Crimean War and public positions had tripled as a result of patronage from 16,000 officials in 1800, to 40,000 by 1850. There 500
See Page 1992 pp. 23-25. This section is based on Silberman 1993 pp. 294-309; Page 1992 pp. 22-24; English History and Heritage website (accessed 28/5-10). 502 The Great Reform Act of 1832 abolished the ‘rotten boroughs’ used as a source of patronage; Old Sarum borough had two seats in parliament yet only seven eligible voters. 501
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was a need for improved administration. The 1854 Northcote-Trevelyan report recommended a centralised and standardised approach to administration based on the talented amateur model.503 In contrast to other European states, administrative and legal training was not emphasised: instead the ‘gentleman all-rounder’ was the ideal. Initially local government was excluded and remained the domain of unelected local gentry. However, administrative reform was controversial as many politicians opposed merit recruitment. Punnet asserts that politicians feared “a Civil Service based on academic talent would become too efficient and too powerful, and would consequently be a threat to the authority of Ministers”.504 Thus Page argues there were inbuilt preferences for “government by Gentlemen” rather than a technocratic Weberian bureaucracy.505 As previously discussed, an administrative tradition is not deterministic and there can be periods where traditions change and adapt. One period in Britain was the “Golden Age” of local government between the 1870s and 1930s where some decentralisation occurred. In the late 19th century, reforms abolished JP’s powers and created municipal councils. However, despite these reforms, the system remained unwieldy with numerous unelected boards. Thus after 50 years new municipal reforms established a two-tier system that also made limited provision for central grants.506 In 1929 a Local Government Act transferred responsibility for health and poor relief to municipal government, funded by central grants increasing the municipal role in welfare. In 1931 municipal government also became responsible for Unemployment Benefit payments. This was a golden age of municipal administration, yet centralisation also remained; universal suffrage strengthened the two-party system, thus increasing executive power. In 1918 the Haldane Committee concluded that the executive was the driving force for policy and implementation. 1930s onwards – recentralisation The 1930s and 1940s saw a change in direction and a gradual recentralisation of local administration. Unemployment benefits were removed from municipal control and transferred to a state board after only three years Silberman refers to civil service reform as “The efficient secret” 1993 p. 363, as reform was based on colonial administration systems after the Crimean War’s administrative failures created reform pressures: Silberman 1993 pp. 363-369. Recommendations included a Civil Service Commission to remove patronage; entry via competitive examination; a neutral career civil service; upper class generalist, from elite “Oxbridge” Universities with Classics or humanities degrees, civil servants posted anywhere in the country every few years: See Silberman 1993 chapter 12; Page 1992 pp. 24-25; Peters 2001 pp. 141-142; Punnet 1976 p. 307. 504 See Punnet 1976 p. 308. 505 Page 1992 p. 29. 506 For example the 1888 Local Government Act and 1894 Local Government Act. The 1888 Act also saw provisions for central grants to be paid by the Exchequer to local government ‘in aid of local rates’: See Wilson & Game 2006 pp. 51-58; Punnet 1976; Page 1992. 503
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in 1934. After 1945, municipal utilities were also transferred to unelected, government-appointed bodies.507 In addition, health services transferred from municipalities to the unelected National Health Service (NHS). Generally municipal roles became more limited and were often prescribed by government legislation. The golden age of local services gave way to recentralisation and reduced local decision-making. In addition, to centralising municipal functions, the government also demonstrated a proclivity to use legal powers against municipalities, with fines or bans from office for local councillors who refused to comply with government policies or exceeded their powers.508 The government also used administrative tribunals often combining jurists and lay members with quasi-judicial powers to recommend change and impose sanctions; Knill argues there are now over 2000 tribunals with varying types of sanctioning powers.509 Therefore, there was an increased willingness to use legal mechanisms and statute law in order to impose sanctions on non-compliant implementers. There were also financial reforms. The traditional system of local taxes, known as rates, had existed since the 1600s, but these were insufficient to fund local welfare services, thus municipalities relied on central grants.510 In 1958 legislation consolidated previous ad-hoc grants into a general government Rate Support Grant, increasing municipalities’ financial dependence on government. There was a brief change to a Poll Tax in the 1990s, where all residents paid the same charge regardless of income. However, the Poll Tax was rapidly scrapped following riots and replaced in 1993 by the Community Charge, a property tax. However, in Britain less than a quarter of municipal finance is determined locally. In addition, the government has increased the use of earmarked grants to direct municipal expenditure, thus increasing opportunities for central steering.511 There were also a number of local government organisational reforms after 1945. In 1974 the government attempted to create a uniform two-tier local government system to remove inconsistencies, yet many of the historic and traditional authorities remained unchanged. The system lasted only 12 507
Utilities such as electricity, gas, water and telephone services were transferred from local authority control to unelected boards and agencies appointed by central government. 508 The most famous cases were the Clay Cross case in 1974 where councillors refused to raise rents and were fined and barred from elections. The 1985 rate-capping rebellion involved 15 councils that refused to comply with new government powers to limit budgets. 78 Labour councillors were personally surcharged with some forced to declare bankruptcy. 509 See Knill 2001 p. 77. 510 Municipalities in Britain have no income taxation powers. Taxation is centralised with national, unified marginal rates of income tax regardless of where people live. The government then disperses the finance collected to municipalities as grants. 511 The Community Charge accounts for only 22-25% of municipal income. Business Rates where levels are determined account for 20-30%. Central grants account for 50-60% of income and the use of earmarked central grants has increased from 14% in 1976 to 31% by 2006. Statistics in Wilson & Game show that the level of locally determined income has declined from 35% in 1976 to 22% in 2006: See Wilson and Game 2006 p. 218.
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years, as the Thatcher government regarded municipalities as potential policy veto points that obstructed its reform agenda. In 1986 the government abolished the upper tier of (mostly Labour controlled) Metropolitan Authorities, responsible for policy coordination and implementation in major cities. Some functions passed to Borough Councils, but many were transferred to an unelected and fragmented “range of joint boards, joint committees, ad hoc agencies and central government departments”.512 These reforms were taken up in much of the literature from the perspective of local government’s lack of constitutional safeguards in Britain. In many countries it would be unconstitutional for the government of the day to use its Parliamentary majority to abolish tiers of local government. Hebbert comments that the decision was: “very much a personal decision of Mrs. Thatcher, widely regarded as an act of political spite … right off the normal political agenda in almost any other European country.513 In Sweden it would be astounding for the government to use its parliamentary majority to abolish Stockholm City Council. Yet Britain, concentrated central power and executive domination meant that a parliamentary vote was sufficient to leave London without an elected city government for the first time since the 19th century.514 Summary: historical legacies & state building The historical review of the state-building and administrative development revealed a number of reoccurring patterns in British administration. The lack of a clear constitutional separation of powers and constitutional guarantees for local government has repeatedly demonstrated a strong tendency for the central structures and actors to dominate. In addition, there appears to be a recurring preference for unelected boards controlled by the state.
General conditions: Administrative Traditions in Britain I have identified several historical legacies that may help us understand why Britain chose hard governance and steering strategies. I discuss the administrative legacies identified using the three element of level of territorial centralisation, level of executive control and level of formal sanctions in order to isolate the crucial and essential traditions in the British system that might have influenced the steering of the mental health reforms. The level of territorial centralisation The overview of administrative legacies shows a strong tradition of central control over local government, and the weak constitutional position of local government allows central government to dominate. Central government has 512
Wilson & Game 2006 p. 61. Hebbert 1998, cited in Wilson & Game 2006 p. 61. 514 Wilson & Game 2006 p. 61. 513
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extensive powers to impose reform; declare functions to be ultra vires; or abolish local government functions and structures. Therefore, the centre can enforce rapid constitutional change with little formal protection for the local level. There was also a tradition removing responsibilities when lower tiers opposed the government. Wilson and Game refer to central-local relationships as “hyper-centralised”.515 This pattern was also evident in the historical review; since medieval times there is a tendency for the state to extend central power. There was a frequent use of centrally appointed officials to extend central power over local administration such as Sheriffs, JPs, appointed boards and guardians. Since the late 1800s the state’s decision that local government should play an increased role of in welfare service provision also brought an increased dependence on central finance. There was a brief interlude of stronger local government in the late 19th century and early 20th century, yet from the 1930s onwards recentralisation occurred, with many welfare functions and public utilities transferred to the state or unelected bodies. Thus the long arm of the state was a reoccurring theme of centrallocal relationships and frequently extended into the lower territorial levels with little constitutional protection. I have identified three main traditions relating to the level of centralisation in Britain that may influence steering and instrument choices. Power imbalance between central and local government: local levels have no constitutionally guaranteed independence as they are reliant on central decision-making where powers and authority can be changed or rescinded without warning. Unelected authorities: there is a tradition of appointing unelected authorities and officials for policy implementation. Thus many implementation decisions are not under local democratic control. Local government’s financial dependence: municipalities are dependent on central grants and lack independent income taxation powers. Thus the British administrative traditions that I have identified show a high level of centralisation. There are many opportunities for the central government to intervene and steer the actions of lower levels through its constitutionally and financially dominant position. Level of executive control of administration The review of administrative traditions demonstrates that the executive dominates both central and local administration. The unwritten constitution gives the executive strong powers to implement radical reforms and to use legislative powers to control lower levels. The Doctrine of Ministerial Responsibility emphasises individual Ministerial administrative power and control through departmental management. Punnet argued that the doctrine includes 515
Wilson & Game 2006 p. 157.
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a Ministerial responsibility to be responsive to public opinion, as well as a strict responsibility to Parliament. Strong executive power was also a recurrent theme with legacies of increasing executive power in policy implementation. There was also a specific expectation that Ministers should dominate central administration; for example fears were expressed that an educated administrative corps might develop as a counter power516 to Ministerial authority. Thus in Britain there was no tradition of a strong, independent legally-trained administration to balance executive power. In addition, the executive exerted administrative control through inspection powers. Therefore, there are strong administrative traditions of administrative centralisation, executive power and Ministerial intervention in administrative matters. Although the MPM reforms of the 1980s and 1990s aimed to disperse power, for example by creating executive agencies and devolving responsibilities to municipalities, there was often a re-centralisation through regulatory powers and inspection powers. Thus my review identified two main administrative traditions relating to levels of executive and Ministerial control over administration in Britain: Ministerial steering: there is a tradition that Ministers intervene directly to direct and control policy implementation at central and local levels. Executive control through inspection: there is a tradition of inspection and oversight agencies that influence administrative operations. Thus there are traditions of strong executive controls over the central and local administration with low levels of administrative autonomy. Level of formal sanctions The review of administrative traditions in Britain shows a mixed pattern of possibilities to exert pressure and sanctions. The unwritten constitution means that sanctioning powers and decisions rest with the government as other levels of government are not guaranteed functions or independence. The concept of ultra vires means that governments can legislate to restrict municipal actions or functions. In addition, parliamentary sovereignty and the common law mean that the law is flexible and easily changed. There is no fixed system of administrative courts that restrain central government. Therefore, sanctions depend on the government’s will to impose them. Since 1945, there has been an increasing use of courts and quasi legal tribunals as a source of sanctioning power, as well as a tendency for legislation to have strings attached in the form of sanctions for non-compliance. Therefore, my review has revealed two main administrative traditions when it comes to the government’s opportunity to impose sanctions: Executive imposed sanctions: there is a tradition of including sanctions for non-compliance; Use of courts: to declare activities and actions as ultra vires. 516
See use of the term counter power in Wockelberg 2003.
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Thus I have identified several key administrative traditions relevant to the implementation focus of my study. These are summarised in the table below: Table 5.1: Summary of Administrative Traditions in Britain
Tradition type
Administrative tradition in Britain
Level of territorial centralisation
Power imbalance between central and local government Unelected authorities Local government financially dependent
Level of executive control of administration
Ministerial steering Executive control through inspection
Level of formal sanctions
Executive imposed sanctions Use of courts
Administrative Traditions & mental health reform Having established the general conditions for administrative traditions in Britain, I must determine how these manifested themselves in the mental health reforms by analysing key decision-making points. I have selected points when the government chose the reform’s steering and instruments, or where a window of opportunity existed for the government to make different steering choices by studying documents produced as critical points of the reform. I will determine to what extent the government’s decisions broadly correspond to the administrative traditions outlined above. The first document to be analysed is the independent review by Griffiths commissioned prior to the reform, which formed the baseline reform recommendations, that government chose to accept or reject. The second document is the government policy White Paper Caring for People, which set out the reform proposals, and choice of steering strategies. The third documents to be analysed relate to the 1995 Community Care (Patients in the Community) Act. The fourth and fifth documents relate to 1998 Labour government policy statements: Modernising Mental Health and Modernising Social Services, resulting in several legislative changes in the 2000s. These decision points during the reform’s short- and long-term implementation will be analysed to determine the level of accordance with administrative traditions.
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1988 Community Care: Agenda for action (Griffiths report) The Griffiths report was commissioned by the government in order to make recommendations for increasing community care based on government policy at the time of involving private sector managers in public reform policy.517 The recommendations produced in 1988 Community Care: Agenda for Action recommended community care reforms for the elderly disabled and mental healthcare and came to be known as the ‘Griffiths Report’ The report’s recommendations relating to regulatory steering and instruments focussed on the need to balance central steering and local discretion making. Griffiths argued that the government should provide a regulatory framework of values, structures and resources, implemented by creating a new post, Minister of Community Care.518 The government would also be required to produce legislation for structural and organisational reforms. 519 However, Griffiths argued for low detailed regulation. The government should create framework with low levels of coercion: “the minimum consistent with there being a national policy”.520 Reform decisions should be local and made by elected municipalities as they “cannot be managed in detail from Whitehall.”521 Therefore, Griffiths’ contention was that community care must avoid central administrative “prescription”;522 he envisaged substantial local discretion and key decision-making roles located in municipalities: Elected local authorities are best placed in my judgement to assess local needs, set local priorities, and monitor local performance.523
Therefore, Griffiths recommended clarifying and separating roles with a clear division between central policy and local implementation. In contrast to Britain’s administrative traditions, his recommendations emphasised softer central steering and greater local implementation discretion. Financial and incentive steering was clearly emphasised as the government’s terms of reference to Griffiths focussed on financial steering instruments: To review the way in which public funds are used to support community care policy and ... for action that would improve the use of these funds as a contribution to more effective community care. 524 517
Griffiths came from retail management as a Director of the supermarket chain Sainsbury’s. See Griffiths 1988 pp. iv & 1. 519 Griffiths argued that government should be responsible for legislation for transforming structures and clarifying responsibilities; legislation to determine grant allocations; legislation to enable independent providers and transfer NHS staff to municipalities: 1988 p. 23. 520 See Griffiths 1988 p. viii. 521 Griffiths 1988 p. viii. 522 Griffiths mentioned in four places that the government must avoid prescription, 1988 pp. iv, vii, viii, 11. 523 Griffiths 1988 p. 11. 518
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Administrative Traditions Community care had been an ‘official’ policy for 30 years. However, the financial issues had never been resolved and there were few incentives for municipalities to develop community services.525 Griffiths recommended abolishing existing financially patchy and fragmented systems, which favoured residential care rather than domiciliary services. Instead, he urged government to adopt clear financial incentives for municipalities and voluntary agencies.526 New systems were necessary to provide certainty and continuity for implementing actors. However, he did not envisage grants as a coercive instrument, instead finance “will provide an instrument of central control, but it should not be seen as an instrument of constraint.”527 Griffiths argued that while government must create community care incentives, but rejected the idea that it was ‘a cheap option’.528 He recommended a policy of balanced responsibilities where the government should fund a fixed percentage of community care expenditure.529 However, Griffiths viewed the financial arrangements as an important factor for stimulating independent care providers, regarding municipalities as ‘enablers’ of independent services rather than monopolistic providers.530 Therefore, once again, Griffiths argued for a softer government approach based on a framework of financial incentives and local decision-making, although one area that the government should steer was the mixed economy of care and independent provision. Griffiths’ approach regarding information steering instruments involved a specific recommendation that the government should provide implementation information and good practice guidance to municipalities. This information would prevent waste and duplication among municipalities, and he emphasised that guidance should not be prescriptive or hard: This role should support rather than constrain the development of imaginative and entrepreneurial solutions at the local level. 531
However, there was also information steering in the way that the reform was presented as a management problem in the format of a corporate business plan, possibly linked to Griffiths’ own retail background. Thus the report’s emphasis on management systems development was also a form of information steering relating to the values that the government would expect municipalities to adopt such as information systems; cost-effective care packages for consumers; better financial allocation systems and ‘corporate think524
Griffiths 1988 p. iii. The problems of community care finance are discussed in Chapter 2. 526 Griffiths 1988 citation p. iii, see also pp. iv & 9. 527 Griffiths 1988 p. viii. 528 See Griffiths 1988 pp. viii-ix. 529 In the text Griffiths recommended that the central government should finance 45% or 50% of the estimated community care costs as a fixed proportion: See Griffiths 1988 pp. 16-17. 530 Griffiths 1988 p. 20. 531 See Griffiths 1988 p. 23. 525
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532
See Griffiths 1988 pp. vii-viii, ix, 1 & 24.
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The Community Care reform proposals & 1990 Act The government produced a White Paper Caring for People in 1989, which was the basis of the 1990 National Health Service and Community Care Act. Although the government proposals built on the Griffiths Report, there were also major differences in emphasis. In particular the government’s policy response was more centralised and prescriptive. The government’s choice of regulatory steering strategies and instruments rested strongly on legislation and central regulation. The policy proposals included legislation to require municipalities to produce and publish community care plans and to create the mixed economy of care. There were also extensive Ministerial powers to demand information and issue directives. There were also detailed financial and grant regulations.533 The government also chose a central role for inspection and monitoring of implementation with the government, creating inspection roles for the Social Services Inspectorate and Audit Commission.534 The 1990 NHS and Community Care Act emphasised central government’s powers to direct and intervene in the reform’s implementation: [E]very local authority shall exercise their social services function in accordance with such direction as may be given to them ... by the Secretary of State.535
In contrast to Griffiths, the government emphasised centralised, top-down regulation based on legislation, central directives and an active Ministerial steering role. The government does not refer to the reform as a decentralisation of power and authority, but uses the term “delegating” responsibility to municipalities.536 This suggests that real power remained located at the centre, and that municipal authority was conditional. The government advocated harder, top-down and centrally directed regulation compared with Griffiths’ ideas of a looser government framework and local discretion. The government’s choice of financial steering strategies and instruments was far more prescriptive strategies and instruments, as financial control was a major government reform objective.537 The government focussed on managerial reforms directed by the centre that required value for money, consumer choice, budget control, the mixed economy of care, and care packages.538 Municipalities were required to meet government priorities such as “securing delivery within available resources” and to “promote the development of
See Her Majesty’s Government 1989 p. 41 & 1990 National Health Service & Community Care Act, part III. 534 Her Majesty’s Government 1989 p. 45. 535 1990 National Health Service & Community Care Act, part III, paragraph 50. 536 Her Majesty’s Government 1989 p. 4. 537 Her Majesty’s Government 1989 p. 9. 538 Her Majesty’s Government 1989. 533
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a flourishing independent sector”.539 The government directly rejected Griffiths’ recommendations of earmarked and fixed community care finance and instead chose to include community care funding in general municipal grants (Rate-Support Grant). There was no guarantee that community care finance would be spent on services.540 The 1990 Act included detailed financial regulations on the use of residential care and welfare benefit payments, and gave Ministers powers to issue directions on almost any issue involving community care.541 Ministers utilised these powers to issue a number of financial steering directives, which emphasised that municipalities were required to purchase services from independent providers,542 directing that 85% of transitional grants were used on private and voluntary contract services.543 The financial steering emphasis was clearly stated in a directive relating to the psychiatrically disabled sent by the government to municipalities, which underlined municipal responsibility for “ [A]assessing and within available resources making arrangements for meeting the social needs of people with learning disabilities within a mixed economy of care.544
Thus the government’s directive to municipalities was that user needs were subordinate to financial steering objectives of resource availability and promotion of private and voluntary providers. In contrast to Griffiths’ ideas of local decision-making, the government chose harder steering instruments to direct the reform in detail from Whitehall. The government’s choices of information steering instruments were more detailed and prescriptive that the ‘supportive’ guidelines envisaged by Griffiths. Information instruments included detailed implementation and planning guidelines, with the White Paper containing detailed rules and regulations for municipal social care services including the planning system, timetable, and contents of municipal community care plans; there were detailed descriptions of plan contents, including 13 government specified areas.545 This guidance also contained the threat of intervention for non-compliance: “the government will not hesitate to intervene in order to stimulate improvements”.546 In addition, there was specific guidance for mental health Her Majesty’s Government 1989 pp. 5-6 & 13. Her Majesty’s Government 1989 pp. 57 & 66. 541 1990 National Health Service & Community Care Act, part III. 542 See for example LAC(91)12. 543 See LAC(93)4. 544 See LAC(92)15 paragraph 2. 545 The government created detailed planning regulations including 13 areas to be covered in municipal plans: demographics; national community care objectives; the way need was to be identified and met; assessment arrangements; purchasing arrangements; improvements planned for domiciliary services; coordination with health services and housing; case management; arrangements to inform users and carers; training; stimulation of independent services; inspection and quality assurance: Her Majesty’s Government 1989 pp. 41-43. 546 Her Majesty’s Government 1989 p. 43. 539 540
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relating to admissions and risk-management; for inspection agencies to disseminate results information and training advice; and also for mental health guidance was spread through conferences and commissioned research.547 Analysis: 1989 Caring for People & Administrative Traditions It is clear that the government reform policy is embedded in central perceptions of power with the government proposing merely to delegate decisionmaking to the local level without a full decentralisation or devolution of power and responsibility. In place of the balanced and complementary central-local responsibilities proposed by Griffiths, the government policy emphasised central controls and the threat of intervention. Government reform policy & the level of territorial centralisation In contrast to Griffiths’ localism, the government proposals emphasised strong territorial centralisation with government dominance. These were underlined through regulations, directives and financial steering mechanisms requiring municipalities to interpret the reform in terms of central financial and market objectives. Information and guidance occurred under the shadow of the state, with threats of intervention and withholding of finance for noncompliance. In addition, the government’s preference for non-state services was emphasised; municipalities were required to promote a mixed economy of care involving the private and voluntary sectors. The government increased municipal financial dependence by making some grants conditional on services being organised in accordance with government market objectives. Therefore, the tradition of territorial centralisation is very apparent in the government proposals in contrast to the division of powers advocated by Griffiths. Thus the level of centralisation corresponded to the administrative traditions and was reflected in hard steering strategies and instruments such as legislation and directives to steer lower territorial levels. Early government reform policy & level of executive control The government ignored Griffiths’ recommendation for local steering, and reverted instead to the administrative tradition of strong executive steering and control. There were a large number of Ministerial directives containing detailed requirements for the administrative implementation of the reform. In addition, the government chose also to extend executive control by means of increased monitoring and inspection, using agencies such as the Social Services Inspectorate and Audit Commission. The government chose to ignore the recommendations of the Griffiths Report advocating softer executive steering by advocating detailed executive control not only through strong administrative steering by departments and Ministers, but also detailed administrative prescription of planning documents’ content. Thus there appears 547
Her Majesty’s Government 1989 pp. 57-58 & 66.
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to be a strong correlation between the choice of hard steering strategies and the administrative tradition of strong executive control. Early government reform policy & level of formal sanctions The government’s policy proposal contains a ‘carrot and stick’ approach whereby there are rewards such as grants for compliance, but a clear threat of government intervention and penalties for non-compliant municipalities. However, there was no specific reference to the administrative tradition of legal sanctions. Thus in this the impact of this element was weaker as there was no strong use of sanctions, yet the reform was built on detailed regulation linked to financial instruments. Therefore, the government used the veiled threat of sanctions rather than specified sanctions.
The 1995 Mental Health (Patients in the Community) Act A crucial decision point occurred within a few months of the final implementation of the mental health reform in 1993, when government decided to amend and clarify certain reform responsibilities in response to mental health scandals. The full reform implementation was delayed from 1991 until 1993 over concerns for the financial consequences of the reform’s implementation at the same time as the controversial Poll Tax. However, in this intervening period of delay and partial implementation, the asylums continued to discharge patients into the community, resulting in major scandals in 1992 relating to patients discharged with poor levels of support.548 A report in to these scandals in July 1993 found failings in the care these former patients had received. In particular, communications and collaboration between health and municipal social services were poor.549 The report created pressures for Ministers to act and intervene, and the Health Minister promised an ‘urgent solution’.550 Within weeks the government announced new mental health initiatives to amend community care. There was an internal review within the Department of Health, and a Ministerial announcement known as ‘Mrs Bottomley’s ten point plan’. Some points required a new statutory basis which was introduced as the 1995 Community Care (Patients in the Community) Act. There was no White Paper produced for this Act as it was chiefly a revision to the 1983 Mental Health Act, and aimed to clarify issues relating to care and supervision in the community. The regulatory steering strategies and instruments emphasised legal and administrative procedures to increase supervision. There is a focus on legal and administrative procedural arrangements including criteria, conditions, 548
In December 1992 psychiatrically disabled Christopher Clunis murdered Jonathan Zito at a London underground station and Ben Silcock climbed into the lion enclosure at London Zoo. 549 See Independent 19/7-93. 550 See Hampson & Davison 1994; Independent 10/1-93.
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procedures, duration; and arrangements for non-compliance, recall to hospital and patient appeal rights.551 The Ten Point Plan announced by the Health Minister contained two main regulatory sticks: firstly relating to new supervision powers, and secondly a requirement that municipalities compile ‘at risk’ registers to identify people who might pose a threat in the community. The codifying 1995 Act introduced new powers to supervise community living including statutory supervision requirements for agencies. There were powers to require users to live at specified addresses, to demand attendance at specified medical and social work appointments, to access users’ homes for medical staff and social workers, and duties to compile and maintain risk registers of the psychiatrically disabled in the municipality.552 There were new Codes of Practice for existing legislation detailing compulsory admission criteria. This Act reduced scope for local decision-making flexibility as supervision requirements were detailed in the legislation. The use of legislation also created sanctions, although these focussed on individuals, not local government, and the psychiatrically disabled’s civil rights were eroded by the new powers as discussed in Chapter 1. Some mental health voluntary groups called for legally binding quality standards for community mental care; however, this was rejected by Ministers.553 When it came to financial and incentive steering instruments, there were no ‘carrots’ for municipalities as there was no new finance to meet the costs of implementing supervision legislation. In a letter to the Association of Directors of Social Services (ADSS), the Department of Health revealed that it was considering legislation to allow municipalities to charge users for the costs of the new, more rigorous statutory aftercare and supervision: The department’s lawyers have confirmed that charges cannot be made for services provided under section 117 of the Mental Health Act. I realise that this is very unwelcome news for local authorities, and we are urgently considering ways in which the position might be rectified. 554
However, charging the psychiatrically disabled for coercive supervision that reduced their civil rights was controversial and politically sensitive. When the proposal was leaked to the media, the Department of Health issued a statement that the “letter is an official point of view, not Ministerial”.555 Thus for municipalities the new Act meant that they were required to assume significant and costly supervision tasks; these were not linked to incentives or new finance. The only financial mechanism under consideration was charging users for their own supervision. However, there is no evidence that 551
Department of Health 1993b pp. 17 & 29-34. See 1995 Community Care Act paragraph 25 A-E; Department of Health 1993b. 553 See The Independent 13/1-94 & 10/10-94. 554 Tom Luce, senior official in the Department of Health, in a letter to the ADSS cited in the Independent 17/2-95. 555 See The Independent 17/2-95. 552
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charging was implemented and municipalities had to absorb supervision costs. The choice of information steering instruments in the documents relating to the new 1995 Mental Health Act included many information instruments to improve the dissemination of mental health knowledge and methods. Reviews conducted by the Department of Health and the Royal College of Psychiatrists would be published and developed into guidance aimed at preventing inappropriate discharges. There were recommendations for better information systems and planning. A new training initiative was planned whereby staff would review cases that went wrong. In addition, executive agencies would be involved in distributing best practice advice.556 Thus there were many new sources of information, although mostly based on a top-down perspective of disseminating and training staff in the government’s legislation and codes rather than a mutual interchange of ideas. Analysis: 1995 Mental Health Act & Administrative Traditions The 1995 Act was a key decision point owing to pressures on the government to respond to public opinion and criticisms of the community care policy following the scandals of 1992. The government’s coercive response was criticised by voluntary groups and implementing staff owing to the lack of new resources and the civil liberties implications.557 One union official referred to the new measures as a ‘panic response’ by Ministers.558 The 1995 Mental Health Act & the level of centralisation The government’s decision to amend and clarify reform responsibilities within a few months of full implementation demonstrates that implementation was perceived as a central and national responsibility. The increased emphasis on a centralised interpretation of legislation, and detailed description of responsibilities moved away from any idea of the reform being a local responsibility. The government used legislative powers to override and alter the powers of local government. There was also an increasing tendency to use executive agencies to issue ‘best practice’ guidance. Therefore, implementation decisions were removed from the local sphere and transferred to unelected, centrally appointed bodies. For municipalities the new Act meant substantial new responsibilities without new resources. Thus the reform corresponded very closely to the administrative traditions of strong central power where local government was subordinate to central decisions.
556
There were a number of bodies involved such as the Clinical Standards Advisory Group, the London Implementation Group and a Government Mental Health Task Force: See Department of Health 1993b. 557 Independent 28/12-93. 558 Abberley, Unison, cited in Independent 28/12-93.
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The 1995 Mental Health Act & the level of executive control The decision to intervene was strongly associated with the personal power of the Minister who announced reform with a ten point plan informally named after the Minister. The Minister reacted and intervened personally in response to criticism and new coercive measures, and legislation were proposed within several weeks of a critical report. There was also an increased emphasis on ‘auditability’559 with increased standardisation of the community care requirements by use of codes of practice, detailed procedural requirements, best practice guidelines, registers and even suggested standard letters to be sent to users. This also links with strong executive control of the administration: the introduction of standard procedures, reduced the scope for discretion and flexibility for implementers. Thus administrative implementation strategies were increasingly controlled from the centre and the government showed strong adherence to the executive control. The 1995 Mental Health Act & the level of formal sanctions The new legislation did contain some sanctions; however, these were not aimed at municipalities but at the service users. In contrast to the aims of ‘normal living’ in the original reform, the new proposals increased coercion and reduced the civil rights of users. The dominance of state agencies was emphasised with low levels of user choice to determine their own living conditions and for thousands of people that would be placed on risk registers, their right to choose would be removed. The sanctions contained in the 1995 legislation were individual and included the loss of liberty. Service users who were non-compliant could be returned to mental hospitals even if no crime or incident had occurred. Thus the coercive mechanisms and sanctions introduced a policing and criminal justice culture to community care with a custodial approach where freedoms were conditional on cooperating with central agencies. Therefore, the government’s implementation adjustments demonstrate a new and more coercive policy culture, although the sanctions were aimed at users rather than implementing authorities.
Modernising mental health services: safe sound & supportive The next major decision-making moment occurred when the new Labour government came to power in with a manifesto commitment to improving mental healthcare.560 At first it appeared that the community mental care reform would be abandoned. The Health Secretary, Frank Dobson, declared in an interview that “Care in the community has failed” and would be dis559
By auditability I am referring to the standardisation of procedures that makes services easier to inspect and audit as implementing agencies are working from a common set of instructions and procedures, thus reducing local variation. 560 Labour Party manifesto pp. 64-65.
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mantled.561 However, the new policy document Modernising Mental Health in 1998 was much less dramatic and did not repeal the reform. Care in the community continued to be emphasised: “The government will ensure that Health and Local Authorities can deliver effective community treatment”.562 However, the government chose new steering strategies and instruments, with the focus of steering evident in the title: there was emphasis on services being ‘safe’, while ‘support’ was last on the list. Government policy aims appeared somewhat contradictory; on the one hand government argued that mental illness was common and there was a need to reduce stigma, on the other hand the government heavily emphasised public safety such as the risk and danger of mental health, thus focussing on negative aspects. The proposals emphasised three areas: resources and systems, legislative powers; and the care process.563 Thus these new proposals did not rescind the community mental health reform but changed certain aspects of governance and steering. The new proposals strongly emphasised regulatory instruments for steering community care; recommending changes to the existing regulatory framework. The government argued that a ‘modern legislative framework’ was needed to reflect the fact that most psychiatrically disabled persons were treated in the community not in hospital. Thus legislation was required to reduce risk, increase compliance and facilitate forced treatment in the community with programmes such as assertive outreach. Legislation was also proposed to detain indefinitely persons with personality disorders who were regarded as a ‘genuine risk’ even if they had never committed a crime; the government argued that “the safety of the public is of prime concern”.564 There were also organisational and regulatory frameworks planned such as the National Service Framework, the National Institute for Clinical Excellence and new Care Trusts whereby the government “will spell out ‘service blueprints’ and the standards that services will have to meet”.565 The government also proposed to steer mental health services through new nationally determined performance standards and targets to create “evidence-based and outcome-driven”566 mental health services. There would be Regional Commissions for care standards to regulate social care with “tough new powers and national standards”,567 and other initiatives such as Best Value; a longterm care Charter; and new monitoring and inspection roles for the Depart-
561
BBC News Online 17/1-98. Department of Health 1998a paragraph 4.21. 563 Department of Health 1998a executive summary and paragraphs 2.22 & 2.23. 564 Department of Health 1998a paragraph 4.21-4.33. 565 Department of Health 1998a paragraphs 2.9-2.10. 566 Department of Health 1998a paragraph 2.20. 567 Department of Health 1998a paragraph 2.11. 562
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ment of Health and the Social Services Inspectorate.568 The government argued there was a need for standardised targets and regulations to provide: [R]igorous and systematic approach to improving local authority performance. This will enable local authorities to demonstrate to their electorate and to central Government that they are achieving best value. 569
The government proposed intervening directly in the organisation of local social services. Municipalities would be required to adopt a standardised Care Programme Approach and produce “robust” care plans.570 In addition, there were changes to welfare benefit regulations administered by the Employment and Benefits Agencies to increase the numbers of psychiatrically disabled in employment “we are committed to making work pay”.571 Thus the new regulatory proposals represented significant centralisation and standardisation and a further reduction in local decision-making freedoms. The government announced financial and incentive-based instruments, totalling £700 million consistently referred to as ‘investment’ suggesting that they were expecting a yield or returns. The financial incentives were conditional, with strings attached. Municipalities must comply and achieve targets performance, cost-efficiency and effectiveness.572 The government expressed strict central aims: “The requirement of services to make good use of this investment will be demanding”.573 Thus the ‘carrots’ of financial incentives were linked to central aims and performance outcomes. The government also announced some specific incentives and grants linked to municipalities implementing measures to spread and adapt their organisation, procedure and services to ‘best practice’, such as staff training.574 Thus unlike previous Conservative governments, Labour offered financial incentives, however, these were strongly linked to the municipalities achieving objectives and goals determined at the centre. The Labour government also used information steering instruments to promote its policies. There was an information campaign aimed at reducing the stigma of mental illness, although it appeared to conflict with the general risk message of the policy document. In addition, there were staff training initiatives and strategies related to the production of standardised information by municipalities that should produce a ‘Minimum data set’ of local social care indicators as the basis of service planning. In addition, the government announced the publication of a ‘leadership pack’ aimed at persuading professionals to take up mental health careers, which also contained ad568
Department of Health 1998a paragraphs 2.10-2.20 & 5.22. Department of Health 1998a paragraph 2.12. 570 Department of Health 1998a paragraph 4.46. 571 Department of Health 1998a paragraph 4.53. 572 Department of Health 1998a paragraphs 4.68-4.69. 573 Department of Health 1998a paragraph 5.7. 574 Department of Health 1998a paragraphs 5.10 & 5.20. 569
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vice and information for existing staff. Thus there was central intervention in detailed aspects of providing information for municipalities and users. Analysis: Modernising Mental Health & Administrative Traditions My analysis shows that there was radical rhetoric when the Labour government came to power relating to the failure of the community mental care reform, and Ministerial intentions to reverse the reform. However, when the proposals appeared a year later, they did not amount to change of the original community care reform idea; patients would remain in the community with support services. However, there was a change of steering philosophy with a more rigidly steered centralisation and standardisation. Modernising mental health & the level of centralisation There was a strong emphasis on central control and government taking control of municipal powers. The government not only stated that municipalities were accountable to their local electorate, but also declared a duty of accountability to central government. There was reduced local power and discretion with an enhanced role for unelected commissions and institutes which would determine the guidelines and regulations that municipalities were expected to follow. The financial dependence of municipalities was also underlined by the proposals. Although finance was available, this was not linked to local decision-making but was dependent on achieving central goals; thus emphasising municipalities subordinate roles. Mental health became more individualised and rigid; mental health was linked to criminality and risk. The policy involved depriving certain psychiatrically disabled persons of their liberty, through powers of detention, even where no crime had been committed in the name of public protection. Thus there was a strong emphasis on central powers with little self-determination for municipalities relating to implementation. The centre dominated and municipalities were forced into subsidiary roles. Therefore, this decision-making moment appears to represent escalating centralisation, even compared to the previous traditions of strong centralisation. The power imbalance and government domination is more obvious. The fact that many implementation details were to be determined by unelected bodies and that only compliant municipalities would receive funding accentuated central power. Although the highly centralised central-local relationship does correspond with the administrative tradition, what the tradition does not explain is why the relationship appears to be changing and becoming even more centralised than under the Conservative government. It appears that although there is a strong match with the administrative tradition, there in also an intensification of central control which is not entirely explained by administrative traditions alone.
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Modernising mental health & the level of executive control There was increased executive steering whereby the government specified in detail the outcomes to be achieved, using targets and standardised objectives. The administrative arrangements were dictated from the centre by using instruments to create an administrative ‘blueprint’ that municipalities were required to follow. The government determined objectives and specified performance standards with less scope for local decision-making. There was increased executive intervention in administrative issues with controls exerted; ‘robust’ community care plans demanded compliance with government objectives. Government financial incentives required compliance with government priorities by reducing local freedoms to determine needs and priorities. The executive would have increased powers to determine administrative practices by using ‘best practice’ guidance and ‘evidence-based’ methods. The research based methods were used less as a support for local decisionmaking, but more in a deterministic manner to control implementation. The government steering decisions are in accordance with the administrative tradition that emphasises Ministerial steering of administration and control through inspections. The proposals also represent a major intensification of administrative control, reducing scope for municipalities to tailor services to local conditions. However, as discussed in the previous section, it is unclear why the levels of centralisation were increasing, which suggests the possibility of other influences In addition, to administrative traditions. Modernising mental health & the level of sanctions The policy proposals did not announce strong sanctions for municipalities, although the strong administrative controls meant municipalities would be penalised for non-compliance. There were, however, penalties for individuals based on the tough zero tolerance policy including forced medication through ‘assertive outreach’ policies, and indefinite detention without trial or crime for certain groups. Therefore, the toughest sanctions were aimed at users rather than the municipalities implementing the reform. However, the lack of sanctions may be a result of the emphasis on power concentration and central administrative controls through standardised procedures and central targets as discussed in the previous elements.
Modernising Social Services: promoting improving protection and raising standards
independence,
In 1998, the same year as Modernising Mental Health, the government also produced Modernising Social Services outlining new governance arrangements for municipal social services, including mental health. The government accused municipalities of being ‘inflexible’ in their social services provision, yet the government’s recipe for change, somewhat contradictorily, 173
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was greater central control and increased centralisation and standardisation in order to clarify and meet national objectives and targets. As in the previous document, Modernising Mental Health, there was also a strong emphasis on risk and public protection; protection is again mentioned in the title. The government emphasised regulatory steering and instruments; it was a ‘stick-heavy’ document as the Minister argued that there was insufficient central control of municipal social services. Thus there was a need for government to intervene directly, and steer in detail to define central standards and targets for municipalities to achieve. The Minister stated: One big trouble that social services have suffered from is that up to now no Government has spelled out exactly what people can expect and what staff are expected to do. Nor have any clear standards of performance been laid down. This Government is to change all that. 575
The government saw the problems in terms of steering and control, and a need to standardise and control by means of central performance targets. Thus municipalities were required to achieve the following: government aims and national objectives; National Priorities guidance; resource and budget targets; and cooperate with new monitoring and inspection systems designed to “drive up standards”.576 The following years saw substantial new legislation based on this document.577 There was a significant increase in numbers of inspection and regulatory agencies,578 as well as the use of ‘enforceable standards’579. A tribunal was created to resolve disputes. A new regulatory body for social care staff, the General Social Care Council, was created;580 which aimed to “strengthen the regulatory framework and public protection”.581 There were also new roles for the Audit Commission and Social Services Inspectorate to monitor, inspect and evaluate compliance with national standards and targets.582 The government stated an intention to monitor social services organisation and management; there were detailed requirements relating to how local political structures should be organised; the roles of politicians, accountability arrangements, mental health liaison and management information.583 In addition, the government announced strong central interventions and sanctions for municipalities failing to achieve central standards and targets. Municipalities would be forced to ac575
Department of Health 1998b: Foreword by the Secretary of State. Department of Health 1998b: paragraphs 7.3-7.4 & 7.17. 577 Department of Health 1998b: paragraph 4.60. 578 A new Commission for Care Standards monitored adherence to national standards. Powers to inspect independent providers transferred from municipalities to the Commission, along with powers to deregister failing providers: Department of Health 1998b: Chapter 4. 579 Department of Health 1998b: paragraph 5.16. 580 Department of Health 1998b: The roles of the GSCC will be discussed in more detail in Chapter 6 of this book. 581 Department of Health 1998b: paragraph 5.40. 582 Department of Health 1998b: Foreword by the Secretary of State. 583 Department of Health 1998b: paragraphs 7.32-7.34. 576
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cept government appointed consultants and advisors, with the ultimate sanction that the Minister could remove responsibilities and even whole social services departments from municipal control.584 These powers will be available to the Secretary of State for Health to enable him to intervene where local Social Services authorities are failing to deliver best value.585
Thus there was an extreme and radical hard steering approach with strong roles for central government and Ministers in directing local municipal social services, with a corresponding loss of municipal discretion, and the threat of a loss of democratic control. The proposals contained several financial and incentive-based instruments and strategies. However, the incentives were linked to compliance with government objectives. There was short-term financing of £3 billion to finance initial organisational changes required, although the government expected long term cost savings. The Minister stated: “Doing things properly doesn’t necessarily cost more than doing things badly. Sometimes it can even be cheaper.”586 There were also financial incentives to encourage partnership working between municipal social services and other actors.587 The government also announced that municipal social services departments judged by the government to be excellent could apply for “Beacon status”, an award with extra funding and a commitment to share its knowledge with other municipalities.588 Thus the government linked incentives to municipalities’ compliance with central objectives and standards. The information steering strategies and instruments contained in this document came mainly from multiple case studies of best practice achieved by various authorities and projects; there was a strong message that the municipalities should aspire to replicating this type of performance. Beacon status was a form of aspirational information steering whereby municipalities who achieved government objectives and targets would be recognised and rewarded, and encouraged to inspire other municipalities by sharing their best practice advice. There were also harder forms of information steering through publication of municipal performance reports based on standardised, national targets; there would be increased freedoms for those judged excellent, but increased state intervention for poor performers.589 The government believed that these “naming and shaming” steering strategies would drive up local performance. 584
Department of Health 1998b: paragraphs 7.21-7.22. See also BBC online 26/11-99a & 26/11-99b for discussion of municipalities losing service powers (accessed 19/5-10). 585 Department of Health 1998b: paragraph 7.22. 586 Department of Health 1998b: Foreword by the Secretary of State. 587 Department of Health 1998b: Chapter 2. 588 Department of Health 1998b: paragraphs 7.19-7.20, see also Beacons Archive online. 589 Department of Health 1998b: Foreword by the Secretary of State.
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Analysis: Modernising Social Services & Administrative Traditions The Modernising Social Services White Paper had a tough centralising emphasis, with strong and increased central control of local social services. In accordance with Modernising Mental Health, there was a strong public protection and risk-management focus as well as centrally determined and defined performance measures and targets. It was clear that Ministers would play central roles and there would be direct government intervention through inspection and regulation, with increased options for the imposition of sanction on poor performers. Modernising Social Services & the level of centralisation This White Paper represented a strong increase in central control and state dominance of local social services. There was little that would be entirely within the remit of elected local politicians owing to the government’s emphasis on standardisation and centralisation. The national and central regulatory focus extended to local political organisation and management. The centre would determine the local political structures and publish performance statistics against central standards. The state would also pronounce whether services had ‘failed’. In addition, to roles for the Social Services Inspectorate and Audit Commission, the proposals recommended expanded roles for unelected central regulatory agencies; social work would be regulated by a central council and an unelected commission took over municipal validation and inspection tasks for public and private care provision, with powers to deregister ‘poor’ performers. In addition, the municipal dependence on state finance was underlined with the financing of change and restructuring dependent on compliance with central objectives and standards. The government’s proposals demonstrated an extremely centralised concept of accountability; it was accountability to state definitions of good performance that were of critical importance. Thus accountability was viewed from a state perspective, with little reference to the role of local politicians and service users in formulating their own priorities and preferences for services; the government regarded ‘successful’ services as those that complied with central priorities and performance standards with little scope for local decision-making. Thus while the government proposals correspond to the administrative tradition of central control, under Labour there was also a shift to hyper-centralisation, whereby centralisation intensified to a much greater level of central control than either the historical legacy suggested, or indeed the Thatcher government had implemented. Modernising Social Services & the level of executive control There was an emphasis on new Ministerial powers to determine which municipalities would be classified as ‘successes’ or ‘failures’. This was backed with very tough new Ministerial powers to control municipal social services 176
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departments judged to be failing. The Minister could either force local politicians to accept external managers, or in serious cases, could remove municipal social services from local democratic control and run municipal functions directly from Whitehall, via the administrative on the basis of a Ministerial decision and based on executive agency and audit reports. Thus these proposals granted strong and personal powers to Ministers. In addition, there was emphasis on the use of centrally appointed executive agencies to exert executive control over local government. There was a strong audit and inspection emphasis through the Audit Commission and Social Services Inspectorate obtaining new powers to determine compliance with standard performance targets and standards. These audits were used as the basis for central performance reforms and Star Ratings that named and shamed municipalities; the targets and standards were produced centrally by a Commission appointed by Ministers. In addition, the powers to regulate and control the social work profession were taken over by state and placed in the hands of a state-appointed council. Therefore, the proposals represented a strong and intensifying concentration of power in the executive. Modernising Social Services & the level of formal sanctions This document also placed strong emphasis on sanctions. Some were of a judicial nature, such as powers of a new quasi-judicial tribunal system to resolve disputes and confirm deregistration of care providers. However, the strongest sanction powers were in the hands of the executive with Ministerial powers to remove social services functions and even the entire department from local democratic control and appoint their own managers to run the social services of the municipality. This demonstrates the power of the centre to impose its will and punish non-compliance.
Discussion: Administrative Traditions in Britain The dimension of administrative traditions relates to whether the customs, conventions and historical state building legacies assist in the understanding of the hard steering governance and steering strategies for the mental health reforms in Britain. In these conclusions I will draw together the patterns of traditions for each element identified in Chapter 4 and analyse them against the empirical findings of the mental health reforms in order to draw conclusions regarding the overall influence of administrative and institutional traditions on steering and governance choices. My findings are that in general terms the government decisions appeared influenced by the administrative traditions, with strong influences of territorial centralisation and executive administrative control. However, there is a puzzling intensification when Labour came to power after 1997 that appears to be unexplained by traditions. Therefore, my conclusions are that adminis177
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trative traditions matter, but that there may be other forces that influence the choice of governance and steering strategy and instruments.
The level of territorial centralisation in Britain The overall conclusion on the level of territorial centralisation is that Britain displayed strong centralisation in its choice of governance and steering strategies that conformed to the tradition of central domination and control of lower territorial levels. The role of local government in care provision and decision-making reduced; many functions previously played by municipalities were removed and placed with private and voluntary sectors, or with newly created central executive agencies. However, one aspect that remains unexplained is why centralisation increased after Labour came to power. The reform started with the independent Griffiths Reports in 1988 which if implemented would have diverged significantly from the administrative tradition. Griffiths argued against strong centralisation and advocated a central-local power balance, albeit without questioning state financial dominance. The recommendations emphasised flexibility: a government framework coupled with local decision freedoms. The government proposals for the reform, however, reverted to the tradition of territorial centralisation, with the government involved in local implementation details. However, it was post-implementation that the ‘hyper-centralisation’ occurred with strong government interventions in local implementation with the 1995 Mental Health (Patients in the Community) Act which gave detailed instructions to municipalities. The new Labour government from 1997 onwards significantly increased levels of central control and government intervention in local implementation. The document Modernising Mental Health emphasised municipal responsibility to central government as well as their electorate. Thus government perceptions of accountability focussed on compliance with central standards; reduced municipal discretion; and earmarked finance, conditional on meeting government standards and objectives. There was also a criminalisation of mental health with emphasis on the central control of national risk. The document Modernising Social Services continued this perspective with increased central powers to determine local political organisation, increased standardisation and powers to unelected audit, inspection and standard setting agencies. Thus national policy priorities and central state powers were the dominant emphasis. Therefore, steering choices appear to be influenced by the administrative tradition of central control. This demonstrates the lack of constitutional safeguards for local government in Britain. However, centralisation increased substantially during the period analysed; the Blair administration was significantly more centralised than the Thatcher and Major government. Thus, while the administrative traditions appear to explain the hard and centralised steering choices, other dimensions must be considered in Chapters 6 and 7. 178
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The level of executive control in Britain The general conclusion of this section is that there were strong executive controls, emphasising Ministerial intervention and a rapid expansion of inspection agencies. Thus the overall conclusion is that the community mental care reform corresponded to the administrative tradition of executive administrative control. Fragmentation at central level was also identified as a problem with criticisms that departments followed their own objectives: “Whitehall fiefdoms fail the mentally ill”.590 However, as in the previous category on the level of centralisation, there is an unexplained intensification and increase of executive controls during the long term implementation. The initial report produced by Griffiths contrasts with the administrative tradition by recommending a restricted executive and Ministerial role and a balance of decision-making powers between central and local levels. However, Griffiths did not fully advocate local decision-making as he also recommended a reduced municipal role in direct service provision where municipalities would be enablers of private and voluntary services. The Government rejected Griffiths’ ideas that Whitehall should reduce administrative control and should create a more limited role for Ministers. The 1990 Community Care Act generated a plethora of central steering directives relating to reform administration and implementation, as well as enhanced inspection with the Audit Commission and Social Services Inspectorate expanding their social care regulation roles. The final decision point of a Conservative government was the 1995 Mental Health (Patients in the Community) Act, which shows the Health Minister’s personal involvement, and a government reactive to criticisms and public opinion. There was increased standardisation and specific central and detailed administrative steering; the government response demonstrated that both central and local administration was under government control. The Labour decision point outlined in Modernising Mental Health intensified executive control, with centralised performance management, standardised central targets and substantially reduced local flexibility and discretion. A similar approach can be seen in Modernising Social Services where executive power intensified. Ministers would determine if municipalities were ‘failing’ and could force administrative change or take control of municipal departments. Thus there was strong and direct intervention from Ministers.591 There were major role of inspection agencies to produce standardised targets for municipalities, and, as a result of inspections performed, to collate inspection information as the basis of performance league tables. A plethora of both new agencies, and new roles for existing agencies were created including Social Services Inspectorate, Audit Commission, Care Standards Commission, National Institute for Mental 590
See Independent 9/9-94. For example evidence of frequent and direct ministerial intervention in social services: See The Times 24/4-10. 591
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Health, National Institute of Clinical Excellence the General Social Care Council, and Performance Action Teams. Therefore, there is a pattern of a strong influence of the tradition of central administrative controls in the reform steering. However, there is no clear explanation of why this control intensified when Labour came to power.
The level of formal sanctions in Britain As I discussed at the start of the chapter, it was more difficult to determine a definite pattern in relation to sanctions. While there were powers to impose sanctions, these depended on the inclination of the government of the day. There is no clear pattern discernable relating to sanctions other than sanctions against municipalities became a stronger and expanding feature of central-local relations since the Labour government took power in 1997. At the reform’s outset, there was little mention of formal legal or administrative sanctions by either Griffiths or the 1990 NHS and Community Care Act. However, the revised 1995 Mental Health Act introduced the idea of individual sanctions such as returning the psychiatrically disabled to hospital and generally treating service users as prisoners on probation. However, these sanctions were against individuals rather than the administrative system. However, this changed after 1997 when the Labour government introduced tougher sanctions for both individuals and organisations. The 1998 Modernising Mental Health White Paper replaced ‘care’ in the community with a policy based on ‘coercion’ in the community, with measures such as assertive outreach, forced treatment and indefinite detention. Modernising Social Services introduced strong sanctions for non-compliant municipalities in the form of centrally imposed managers or Ministerial decisions to remove social services departments’ democratic municipal control to manage local services from Whitehall or the use of government appointed contractors. Thus the traditions and patterns when relating to sanctions appear to mirror the previous two traditions; the lack of constitutional safeguards for local government powers means that the level and type of sanction depend on government decisions. However, the pattern is similar to what was observed in previous sections with increased central control under Labour.
Summary: Administrative Traditions & steering in Britain My analysis of administrative traditions and the mental health reforms demonstrates strong centralisation and control, especially relating to the levels of territorial control and executive power. The high levels of territorial and executive control would certainly assist in the understanding of the British government’s preference for hard steering strategies that are determined by the centre. There is a tradition of the centre dominating local government, 180
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and of ministers and the executive strongly steering administration. The traditions relating to sanctions are somewhat less clear. However, it is clear that centralisation intensified during the period, which is not fully explained by the concept of a stable institutional influence of traditions. Thus my conclusion is that administrative and institutional traditions appear to be a dimension that is very useful to understanding the choice of hard steering strategies; however, the intensification of centralisation suggests that other dimensions may also have influenced the steering and governance choices.
Administrative Traditions in Sweden In Sweden I followed the same process as used for analysing Britain, firstly reviewing the general conditions for administrative traditions, and secondly analysing the traditions identified using the empirical material from the mental health reform. My findings are that, in sharp contrast to Britain, Sweden’s system of government system has traditions and conventions that limit direct government steering. Therefore, the centralising tendencies and opportunities for the government to exert sanctions in Sweden are generally low and facilitate the soft steering forms observed in the analysis of instruments used in the reform in Chapter 3.
General conditions: institutions, doctrines & conventions The general conditions for administrative traditions consist of the underpinning theories and history of state building. I follow the same pattern as I did in Britain by discussing doctrines, concepts and conventions that form an underlying framework of government in Sweden and then the historical state building process. These legacies and traditions are then analysed according to the three key administrative traditions identified in Chapter 4: territorial centralisation; executive control of administration; and sanctions. Local self-government Sweden is a unitary state, yet there is also a strong historical legacy of local power.592 A cornerstone of Swedish governance is the principle of local selfgovernment (kommunal självstyrelse) whereby local government has extensive freedoms to manage its own affairs.593 In contrast to Britain’s unwritten constitution and local government’s low level of constitutional protection, Sweden’s written constitution enshrines municipal independence. The 1974 Instrument of Government (Regeringsform) states:
592 593
For detailed discussion of the historical state building process in Sweden see Herlitz 1960. See for example Montin 2004 p. 23; Gustafsson 1999 pp. 75-78.
181
The Governance Gap All public power in Sweden proceeds from the people, Swedish democracy is founded on the free formation of opinion and on universal and equal suffrage. It shall be realised through a representative and parliamentary polity and through local self-government.594
Swedish local government is organised in two elected tiers in County Councils (Landsting) and Municipal Councils (Kommuner). However, despite local government’s organisation in two tiers, the relationship is not hierarchical and municipalities are not accountable to counties.595 Swedish municipalities also have considerable financial independence from the state. In contrast to Britain where municipalities control only a quarter of their income; in Sweden the figure is over 80%. According to statistics produced by the Swedish Association of Local Authorities and Regions (Sveriges Kommuner & Landsting) in 2005, less than 15% of municipal income comes from central government grants.596 Unlike Britain, Sweden does not have a national income tax system with standardised tax rates. Instead each Swedish municipality sets its own income tax rate.597 Some literature, such as Strandberg, contends that municipalities’ relative power has declined in recent years as a result of legislation requiring new functions; laws restricting decisions, and tax redistribution policies.598 However, Lidström argues that by international comparison, Swedish municipalities have substantial powers and income taxation is a unique source of power which exists in few European municipalities.599 Therefore, municipalities also have relative financial independence from the state and can determine local income taxes. Local government in Sweden also has a central role in welfare policy implementation, as legislation is primarily implemented at county and municipal levels. Ahlbäck Öberg argues the degree of centralisation is an important issue as Sweden’s tradition of decentralised decision-making powers gave local agencies freedoms to formulate welfare services’ aims and content: Seen historically, it must be stated that the decentralising tendencies in Sweden have been strong, and this means that it is difficult for central agencies to steer local government activities; for example education, health and social care.600
594
The Swedish Constitution: The Instrument of Government (Regeringsform RF 1974:152) 1§ - English version Riksdagen’s homepage. 595 See discussion in Petersson 2007 p. 79. 596 Statistics from Sveriges Kommuner och Landsting, The Economy Report 2005 p. 12. 597 Municipalities must develop services yet balance expectations (taxpayers, users, partners, other actors) creating complexity and conflict potential: See Maycraft Kall 2008 pp. 140-141. 598 Strandberg 2003 argues that municipal power is limited by legislation that determines municipal functions, direct interventions in the 1990s e.g. ‘Stopplag’ to prevent public hospital sales, and ‘Robin Hood taxes’ reallocating tax income from wealthy to poor municipalities. 599 Lidström 2003. 600 Ahlbäck Öberg 2008 p. 181.
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Administrative Traditions Gustavsson argues that the development of the 20th century welfare state was based primarily on local decision-making rather than central state activity.601 This created a principle of local freedom of action (handlingsutrymme). Therefore, local levels have freedoms and flexibility to formulate and influence local services, which created strong local government in Sweden in comparison with other European countries.602 However, the constitutional guarantees of local self-government are also ambiguous. The constitution guarantees local self-government, but fails to specify precise divisions of power and in other articles, also proclaims the right of central government to steer Sweden.603 Larsson and Bäck argue that local self-government powers are not universal, but that local government has broad freedoms to determine its own policies and roles.604 The Local Government Act states: Municipalities and county councils may themselves attend to matters of general concern which are connected with the area of the municipality or county council or with their members and which are not to be attended to solely by the state, another municipality, another county council or some other body.605
Therefore, local self-government can be limited by the government’s inclinations to legislate, but contrasts with Britain where municipalities are prohibited from activities not specifically allowed by Parliament in accordance with the ultra vires principle. In Sweden municipalities have extensive freedoms in areas not prohibited by Parliament. Thus the extent and scope of local power are contested and tensions relating to central-local relationships are not fully resolved. Seen historically some scholars argue that municipal power has declined, whereas comparative literature asserts the relatively strong position of Sweden’s decentralised system of local government with taxation powers.606 However, Sweden is a unitary state without formal divisions of central and local powers that exist in federal systems, yet compared with Britain, Sweden’s municipalities have considerable independence with decision-making and taxation powers.
601
See Gustavsson 2005 pp. 4-5. Gustavsson 2005 p. 6. 603 Government powers are specified in the Instrument of Government – RF 1974:152 6§. 604 For example the Local Government Act (Kommunallagen) states that municipalities may not assume powers or competences specially allocated to other territorial levels, e.g. municipalities are prohibited from assuming foreign policy roles: Larsson & Bäck 2008 pp. 212-213. 605 The Local Government Act – cited in Larsson & Bäck 2008 p. 213. 606 Compare for example Strandberg 2003 who asserts that Sweden’s local self-government is undermined by the ability and inclination of the state to regulate and control local issues, with Lidström’s (2003) international perspective that Swedish local government is strong and independent compared with other European unitary states. See also Pollitt and Summa (1997) who assert that decentralised power is a key feature of Sweden’s public administration. 602
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Administrative independence & low Ministerialism Sweden has a unique and dualistic public administration model based on a formal separation between the political and administrative systems; the government is responsible for policy-making while the administrative agencies make decisions concerning implementation. The central departments and ministries responsible for policy formulation are small. They employ few staff and do not exert a chain of command influence over specific administrative agencies. Instead there is an arm’s length relationship between Ministers and administration. Although the government and Parliament can give general instructions to executive agencies,607 they cannot intervene in the way that agencies interpret laws and instructions or decide individual cases. Therefore, in Sweden the types of detailed steering directives and interventions seen in Britain are absent; steering is looser and more general. The concept of separating politics and administration dates back several centuries and is enshrined in the constitutional Instrument of Government (Regeringsform) stating that central politicians may not intervene in municipal decisions relating to the interpretation of legislation and individual cases: No public authority, including the Riksdag and the decision-making bodies of local authorities, may determine how an administrative authority shall decide in a particular case relating to the exercise of public authority vis-à-vis a private subject or a local authority, or relating to the application of law.608
Therefore, government rests on a principle of collective decision-making by the whole government rather than individual Ministers. There is lower scope for direct intervention as executive and local agencies are independent and not under the direct control of a particular Minister or ministry. Traditionally direct Ministerial steering is perceived as undesirable. However, the steering issue has become more contested in recent years. There is also evidence that informal contacts do occur. Yet the adoption framework legislation and budgeting in recent decades has meant that instructions to agencies have become more general and flexible, although the government may exert general influence thorough powers to appoint Agency Chief Executives. However, Ministers and MPs cannot formally direct and steer the administrative system.609 In contrast to Ministerialism in Britain, executive agencies in Sweden have considerable freedoms in formulating and implementing public policy. Wockelberg argues that the extensive administrative independence is not something that administrators have wrestled from democratic
607
Parliament exerts general steering through legislation. The government issues general instructions through annual appropriation directions (Regleringsbrev) to executive agencies. 608 Instrument of government (English version) RF 1974 Chapter 11, paragraph 7. 609 See for example Ahlbäck Öberg 2008; Kelman 1981 p. 16; Petersson 2007 pp. 72 & 77; Wockelberg 2003 pp.18-27; Larsson & Bäck 2008 pp. 190-191.
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control, but has been freely granted by politicians.610 The issue of agency steering has been controversial in recent years with government Commissions questioning the low levels of political steering. However, on the other hand, Ministers may also exploit the system as a blame avoidance strategy.611 Thus it is important to note that the arm’s length relationship between Ministers and administration is something that politicians have chosen to maintain over the centuries. There are some similarities between the traditional Swedish administrative model and NPM’s idea of separating policy and implementation popularised in public management reforms centuries later. Corporatism The Swedish administrative model has traditionally involved corporatism, which according to Rothstein is based on ideas of including certain special interests into a decision-making structure in return for shared responsibility.612 Petersson defines corporatism as: [C]ollaboration between the state and organisations, which means that the state institutionalises its contact with certain representatives for organised interests and gives them position as established participants in the political decision-making process.613
Corporatist systems allow non-elected interest groups to be incorporated into decision-making structures and obtain influence over policy-making and implementation, yet sit outside the normal legislative and constitutional requirements that govern public agencies such as freedom of information. According to earlier research, Swedish tradition of voluntary intervention outside of the formal state structures dates back to medieval times. 614 However, Sweden also operated a formal system of corporatism by incorporating employers and unions into labour market policy.615 Therefore, the idea of corporatism is based on negotiation and representation of a wide range of interests in contrast to the competition of pluralist systems. According to Rothstein, even though formal corporatism has declined since 1991, it remains important in certain areas, especially relating to employment.616 Of relevance to my study are corporatist relationships between 610
Wockelberg 2003 p. 17. Politicians may exploit the divided system to deny responsibility and reject culpability for deficiencies and problems: See Ahlbäck Öberg 2008; Larsson & Bäck 2008 p.191. 612 See discussion in Rothstein 2008 pp. 222-226. 613 Petersson 2007 p. 90. 614 The literature contains arguments regarding the development of corporatism; Petersson contends it dates back to medieval traditions of the King being influenced by local issues and interests: 2007 p. 92; Larsson and Bäck state its roots lie in 16th century voluntary interests and the development of the parliamentary and party systems: 2008 pp. 97-104. 615 For example a formal labour market corporatist agreement resulted from the Saltsjöbad agreement: See discussion in Elder et al. 1982 p. 181; Premfors et al 2003 pp. 72-76; Larsson & Bäck 2008 pp. 73 & 107; Petersson 2007 pp. 90-92. 616 See Rothstein 2008 pp. 229-230. 611
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central government and municipalities mediated by the Swedish Association of Local Government and Regions (Sveriges Kommuner & Landsting).617 Petersson contends that the Local Government Association has close relationships with the government and represents its members’ views both as a lobby group and as an employer organisation. Although the association is not a public authority, the association represents democratically elected municipal councils, which gives it what Petersson terms a ‘semi-official position’ in Swedish administration.618 Thus in Sweden there is a longstanding tradition of granting selected groups access to, and influence over, the policy process, which confers a semi-official status in consultations and negotiations. Thus there are contacts and influences that occur outside the official administrative channels and structures. Summary - general conditions: institutions, doctrines & conventions The central concepts of Swedish administration emphasise power dispersal, with decentralised structures and traditions of local and administrative freedoms. However, there is also a corporatist tradition of access to power being granted for state-sanctioned interests that allows ‘semi-official’ influences outside of state structures.
General conditions: historical legacies & state building619 In addition, to the underlying doctrines and concept, there are also historical traditions and legacies that may help understand the selection of soft governance and steering strategies in Sweden for the mental health reforms. My main findings are that the historical legacies in Sweden give considerable power to local and administrative agencies, whereas there are reduced roles for government and Ministerial steering of the implementation process. Early local administration & state building Sweden has a long tradition of decentralized structures and local government freedoms and government. In the 13th century, Sweden was not a fully consolidated state; key decision-making powers were located in regions (Lanskapsting) consisting of the ‘free men’. The Crown was not a hereditary institution; the King was elected by an assembly of regional noblemen (Stormän). Thus the arrangements for central administration were somewhat
617
The Swedish Association of Local Government and Regions (Sveriges Kommuner & Landsting) was formed in 2007 by the merger of The Swedish Local Government Association (Svenska Kommunförbundet) and the Association of County Councils (Landstingsförbundet). 618 See Petersson 2007 pp. 249-250. 619 This section is based on Herlitz 1960; Petersson 2007; Petersson 2001; Gustafsson 1999; Montin 2004; Larsson & Bäck 2008; Elder et al 1982; Nyström 1983; Gustavsson 2005.
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loose and without a strict differentiation between central and local issues.620 During this time, there was also an increasing role for parish councils; responsibilities were initially related to local church administration such as priest recruitment, church land management and property maintenance. The period 1400–1600 saw a state building process which laid the foundations of the modern Swedish state. In the 1400s a Four Estate Parliament (Ståndsriksdagen) was established based on representative ideals for the time, with a chamber for each of the the four property owning classes of Aristocracy, Clergy, Bourgeoisie and Farmers. In the 1500s; Gustav Vasa established a hereditary monarchy as well as administrative and legal reforms to establish the central authority of government power. Thus this early period was characterised by a tradition of local power and a state building process to establish a national government with administrative and legal powers. The 17th and 18th centuries saw the development of many of the structures that remain even today as the central pillars of Swedish administration. Public administration expanded rapidly during the “Great Power” period where Sweden was a leading European military power. However, the costs maintaining the military machinery required new administration and finance structures. Many of the structures of the Swedish administrative model date back to the major administrative reforms of Gustav II Adolf and Chancellor Axel Oxenstierna, who created a strong state power and national administrative machinery. A central system of administration was developed based on the Crown and a Governing Council (Rådet) consisting of five councils.621 There were reforms to extend the rule of law and improve regional and local implementation of laws and taxation. As with JPs in Britain, the Swedish state extended its influence into the regions by the appointment of County Governors (Landshövding), to maintain order and oversee policy implementation and tax collection. In addition, new national administration and regulatory structures were established for: education; post-services infrastructure and state involvement in trade and the iron industry. According to Petersson, this strong period centralisation did not make local decision-making unimportant; instead, there was mutual dependence between the state and local levels. Local interests such as farmers and cities were represented as estates in Parliament.622 In the 1600s parish councils obtained new welfare and administrative functions for poor relief, public health, road maintenance and, 620
The elected monarchy meant that if agreement could not be reached, there were several regional Kings. A small Crown advisory council of bishops and noblemen was established for public administration and in 1296 the Upplands Law (Upplandslagen) introduced the concept of the legal basis for the exercise of power. 621 There was a Secretariat (Kanslikollegium), a Legal, Financial and Administrative Council (Kammarkollegium), The Court of Appeal (Svea Hovrätt), The War Council (Krigskollegium) and the Admiralty Council (Amiralitetskollegium). 622 See Petersson 2001 p. 47.
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eventually, education. Administrative reforms also meant parish records became population registers; all inhabitants were registered (mantalskriven) for administrative and tax purposes. The 18th century also saw major political and administrative reforms, many of which continue to characterise Swedish public administration today and many of which, were discussed in the previous doctrines section. In 1720 a new constitutional Instrument of Government (Regeringsform) formally separated policy-making from implementation to create independent executive agencies and low direct Ministerial steering. In addition, a system of jurists and ombudsman was established for individual appeals and complaints about maladministration by other administrative bodies. In 1713 the Chancellor of Justice (Justitiekanslern) was established as a state jurist with powers to investigate the decision-making errors of public authorities and in 1809 the office of Parliamentary Ombudsman (Justitieombudsmannen) was created with powers to investigate individual complaints against public authorities. This was a important period for Swedish administration as it established a national apparatus, yet maintained localism such as welfare roles. In addition, independent central administration was created, which remained a central element to the Swedish model of public administration. 19th century & local government expansion The 19th Century saw both increased powers and self-government to local levels. The 1862 Local Government Act (Kommunallagen) established a system of local government which remained in place for a century. Based on ideas from the French Revolution, Sweden was divided into counties, cities, rural communes and parishes. The county councils became responsible primarily for healthcare but also for infrastructure, communications, agriculture and law and order. The primary councils of cities and rural communes (municipalities), obtained increased responsibilities for developing social policies including poor relief and education. Local government independence was enhanced by financial independence as the 1862 Act granted rights to levy local taxes. By the late 1800s, municipalities had developed administrative structures to carry out their expanding number of tasks and many appointed administrative directors. The 1847 Poor Relief Directive (fattigvårdförordningen) required municipalities to appoint boards to administer poor relief, which included mental health. During the period between 1875 and 1913 municipal welfare functions expanded significantly and in 1920 the government established a Department for Social Policy and Healthcare. At the central level, there was a gradual shift to power-sharing that eventually resulted in the establishment of parliamentarianism in the early 20th century. In 1809 there was a constitutional power division between the Crown, Parliament and judiciary where the King retained executive power, but was required to consult the executive council, which took collective responsibility for their advice to the King. In the 1840s government functions 188
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had expanded to such an extent that Ministers required departmental reforms to administer and prepare policies. Thus there were important administrative reforms at both central and local levels during this period. The 20th century welfare state & modern local government structures In the 20th century the principles of the welfare state started a gradual shift from residualism to universalism and citizenship rights. Herlitz argues that the development of the welfare state was a defining moment in Swedish government history.623 In the 1920s the ideological debate relating to welfare changed as a consequence of the increasing Social Democratic influence in politics. Traditional ideas of poverty based on charity, alms and means testing were rejected as feudal and instead the debate shifted to social justice and citizenship principles. Social policy was perceived as a means to improve the living conditions of ordinary workers including factory safety, employment, child welfare, social and housing conditions. New social policies were coordinated by local government, replacing the fragmented system of charities and agencies, and required new systems of administration.624 In 1924 the Social Affairs Minister preferred a new local apparatus based on municipal responsibility welfare service infrastructure over traditional state bureaucracy. According to Nyström it was for this reason that “[t]he welfare state’s administration came, to the greatest extent, to lie outside the old central administrative organs”.625 After 1945, there was strong faith in central planning for state welfare benefits and services.626 Many welfare services were developed as municipal responsibilities, and local taxes rose successively to finance welfare services from around 10% in 1950 to over 30% by 2000. Many functions concerned with the implementation and administration of welfare are carried out at arm’s length from government, either by executive agencies, or self-governing municipalities. Thus Swedish local government fulfilled new roles as implementer and financier of welfare policy. In 1974 a new Instrument of Government reinforced many constitutional principles of importance to administration including parliamentary sovereignty, local self-government, collective government decision-making, weak judicial roles in legislative interpretation and approval, and administrative independence from direct political steering. In addition, in the early 20th century rapid urbanisation and demographic change also created the need for local government reorganisation as many municipalities were too small to 623
See Herlitz 1960 p. 318. See Herlitz 1960 pp. 315-318; Nyström 1983 pp. 223-229; Gustavsson 2005 pp. 4-6. In the early 1900s there was increased state involvement in welfare with insurance schemes and state grants to social insurance 1891 (sjukkassa); old age pensions 1913 (folkpension); poor relief and elder care 1918 (fattigvårdsreform); and care of orphans (barnvård). 625 Nyström 1983 p. 231 (my translation). 626 For example there were state-financed social insurance benefits such as child benefits 1947 (barnbidrag), and compulsory health insurance 1955 (sjukförsäkring). 624
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organise efficient services.627 In 1971 a new uniform system of county and municipal authorities was introduced that reduced the number of municipalities from over 2500 to 280. Most welfare services are delivered locally by the elected; 78% of municipal budgets are used for welfare services such as personal social services, education, childcare and elder care, whereas healthcare accounts for 90% of county council budgets. The government’s role is mostly legislation and monitoring, and sometimes earmarked grants.628 Summary: historical legacies I have identified several historical legacies of relevance to my study. There is a tradition of local government, and in the past century the welfare service provision developed as a local municipal function. There is also a legacy of separating policy and administration which limits the executive role. Unlike most unitary states, there is no tradition in Sweden of direct Ministerial steering. Both local government and administrations have their roles enshrined in the constitution, yet in imprecise terms. In addition, there is no tradition of the executive imposing formal sanctions on municipalities in Sweden.
General conditions: Administrative Traditions in Sweden The Swedish historical and administrative legacies will be analysed using the three elements in order to isolate relevant Swedish administrative traditions for use in my empirical analysis of the mental health reforms. The level of territorial centralisation My review of the Swedish administrative traditions found a low level of centralisation as a result of constitutional traditions of local self-government. In contrast to Britain’s central government dominance there is a relatively high degree of decentralisation for a unitary state. The traditions of local municipal decision-making powers are based on historical legacies that saw service development at local levels. Wollman argues that the local selfgovernment tradition remains strong compared with other European states, and was further enhanced by decentralised public management reforms in recent decades.629 Thus Sweden demonstrates a high degree of local decision-making freedoms in relationships between state and municipality. Like Britain, Sweden is a unitary state where municipalities must abide by state legislation without a formal division of power as in federal states. However, 627
After 1945 there were around 500 municipalities with fewer than 500 inhabitants. A reorganisation in 1952 meant that no municipality had less than 2000 inhabitants. 628 Budget statistics used information from Sveriges Kommuner & Landsting website. 629 Wollmann 2004 p. 650.
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Administrative Traditions in sharp contrast to Britain’s ‘hyper-centralisation’ Sweden confers local decision-making freedoms and flexibilities based on two main traditions: Local self-government: a tradition of local independence to interpret legislation to determine its own structures and service aims/content. Financial independence from the state: that results from income taxation powers and low dependence on state grants. Thus I conclude is that Sweden has a low level of territorial centralisation. Level of executive control of administration Sweden displays a low level of executive control over the administrative system. There is a long historical legacy of separating politics and administration dating back to the 18th century. This means that the type of direct Ministerial steering and intervention in operational issues is not a feature of Swedish administrative models. Unlike other unitary states, including Britain, Swedish Ministers do not exert a ‘chain of command’ influence over the legislative interpretation and implementation in individual cases. Indeed, this type of ‘Ministerial steering’, considered the norm in many countries, is not acceptable in the Swedish model of public administration. Sweden’s executive agencies have a formally independent status and are not under direct Ministerial control and they also have a tradition of separating policy and administration, similar to NPM, only in Sweden it was a centuries old historical legacy rather than a modern public management trend. Another tradition is the involvement of external corporatist interests outside from the government and administrative systems. There is a long tradition of recognising particular interests within the decision-making process; from the Four Estate Parliament, and to the inclusion of corporatist actors such as employers and trade unions. Corporatist actors are often given a semi-official status and may achieve a position similar to public agencies where they participate in decision-making and are consulted on specific issues. Therefore, they often play a central mediating role between state policy and local implementation, yet are not bound by the same rules of the game as the formal public agencies such as transparency requirements or freedom of information laws. The corporatist actors may play a bridging role between Ministers and implementers yet without the appearance of direct steering. Thus my review has identified two main traditions of the Swedish administrative model: Lack of Ministerial steering: Ministers cannot steer agencies’ legislative interpretation and of individual case implementation, which limits Ministers’ reform roles. Roles for external/corporatist actors: the semi-formal mediating roles for selected actors and interests creates access to government decisionmaking and act as a bridge to disseminate state information to members.
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Level of formal sanctions In Sweden there is a tradition of a low level of formal sanctions applied by the state on lower territorial levels owing to the tradition of local selfgovernment and a reticence among Ministers to intervene in local decisionmaking. My review of the administrative tradition of sanctions reveals while there are mechanisms for the individual through the systems of ombudsmen or administrative courts, there are few direct sanctions. The results are often criticisms or exhortations from the ombudsman to the municipality to change their procedures; concrete fines or penalties are rare. Thus there are few sanctions that are available to government to sanction agencies or municipalities other than clarifying legislation. Thus I have identified that for Sweden the tradition was low for levels of administrative and legal sanctions. Therefore, the administrative traditions in Sweden can be summarised into the following table: Table 5.2: Summary of Administrative Traditions in Sweden
Tradition type
Administrative tradition in Sweden
Level of territorial centralisation
Local self-government Local government financial independence
Level of executive control of administration
No Ministerial steering Roles for external and/or corporatist actors
Level of formal sanctions
Low level of legal and executive sanctions over the administrative system
Administrative traditions & mental health reform I have established several administrative traditions derived from constitutional and historical legacies, so the next step is to analyse to what extent these were present in the mental health reforms by analysing key decisionmaking points by analysing critical texts. The empirical analysis starts with the 1992 Mental Health Inquiry (Psykiatriutredning) as a baseline for reform ideas. The second text is the government’s Mental Health Reform Proposition: the Conditions of the Mentally Disordered (Proposition 1993/94:218 Psykiskt stördas villkor) which introduced the government’s proposals. Although there were few substantive changes to the reform after this, I have identified several decision-making windows. The new Social Services Act (Socialtjänstlagen) in 2001 could have introduced change. In addition, in a 192
Administrative Traditions
Parliamentary Debate in 2003 the government was under pressure to rescind the reform as a result of mental health scandals. The final document is the 2006 Report of the Mental Health Tsar Inquiry (Psykiatrisamordnaren) commissioned as a government response to the mental health scandals, two reports are analysed: a stage report focussed on steering, Long-term, Coordination and Engagement (Långsiktighet, samordning och engagemang), and the final report, Ambition and Responsibility (Ambition och ansvar).630 The government response occurred after the end of the study period; however, I have included a brief footnote.
1992 The Mental Health Inquiry: Welfare & freedom of choice The Mental Health Inquiry (Psykiatriutredning) in its final report in 1992631 recommended radical reforms. As with Britain’s Griffiths Report, the Swedish Inquiry discussed how local mental health services were hindered by structural obstacles, yet argued strongly from a disability rights perspective that users should have the same civil rights and duties as other citizens, with support services tailored to individual needs and preferences. Therefore, a stronger social perspective was required for mental health services, which should occur in ‘open and normal’ forms in the community and which should be formulated to support users’ independence and integration.632 The inquiry emphasised a reform based on new enforceable rights and a social perspective of equal importance as medical perspectives. The report emphasised regulatory steering instruments and favoured legislative action to create enforceable rights. It argued that previous reforms using framework legislation had failed to guarantee user rights as the division of responsibilities was unclear and the implementation had been poor. The inquiry argued for specific legislation with enforceable rights that was needed to guarantee the psychiatrically disabled similar living standards to the rest of the community. Some user-groups also wanted enforceable sanctions against municipal legislative breaches. However, the inquiry determined that guaranteed legal rights that specified the roles and duties of public agencies would be sufficient to resolve problems. The report recommended also a right to a Personal Representative to support individual needs.633 According to the report, municipalities would have primary responsibility, and the previous voluntary agreements between health and social services
630
The Tsar-inquiry was commissioned in 2003 but did not report until 2006 at the end of the period of this study. However, I cover it as there are several interesting steering issues raised in relation to administrative traditions. 631 The final report was entitled Welfare and Freedom of Choice (Välfärd och valfrihet). 632 See SOU 1992:73 pp. 20-22. 633 See SOU 1992:73 pp. 21-25, 37& 147.
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would be replaced with statutory responsibilities.634 Thus the report recommended legally-binding disability rights that users could enforce in the courts rather than being dependent on the priorities of local decision-makers’ interpretations. The inquiry argued that such measures were necessary as a result of divergent and poor implementation of legislation to create proper mental health care. The report stated that financial and incentive instruments were needed to encourage the development of services for the psychiatrically disabled and argued that the state should provide financial incentives. The inquiry recommended a number of specific state grants for service development including adapted housing, rehabilitation, wage subsidies, education and training. In addition, voluntary and user groups should be funded to provide peer support services (kamratstöd). It was recommended that the state should provide financial incentives to develop municipal social methods and mental health services, as well as developing new structures.635 The report argued that prior reform attempts had failed as a result of the financial disincentives for municipalities to create mental health services; therefore, the government needed to act and create incentives through earmarked grants that would steer the development of essential services for the psychiatrically disabled. The inquiry report also recommended information steering instruments, such as the state providing information to assist the development of municipal mental health competence and knowledge. In addition, the state should aid the dissemination of international experience and knowledge through research, education, assessment projects as well as state staff-training initiatives.636 Thus the inquiry envisaged that the state would play a central role in steering and coordinating the development and spread of knowledge and methods needed to implement the reform. Analysis: the Mental Health Inquiry & Administrative Traditions It is clear that the 1992 Mental Health Inquiry represented a radical departure from the norms and conventions of Swedish administrative traditions. According to the inquiry team there were too few legal rights and safeguards for users as a result of local discretion and flexibility at municipal level. The inquiry advocated government regulatory steering of mental health. The Mental Health Inquiry & the level of territorial centralisation The mental health inquiry promoted a strong disability perspective, arguing for tough and enforceable users rights. In contrast to the traditions of extensive local freedoms and self-government, the inquiry team advocated greater 634
For example a requirement to provide care, support, suitable housing and daily activities: See SOU 1992:73 pp. 31-40. 635 See SOU 1992:73 pp. 32-42. 636 See SOU 1992:73 pp. 35-36, 42 & 53.
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state roles based on rights-based legislation which users could use to enforce municipal compliance. There were also recommendations that the government should centralise the production and dispersal of information to create greater standardisation and central control. In contrast to the tradition of municipal financial independence, the inquiry also argued for increased government steering through earmarked grants. Therefore, the inquiry report represented a departure from Swedish administrative traditions: the recommendations focussed on standardisation, centralisation, binding rights and targeted finance. This contrasts with the local decision-making and financial independence and discretion that characterises Swedish traditions. The Mental Health Inquiry & the level of administrative control A similar pattern is also discernable for the level of administrative control. While the inquiry did not recommend direct Ministerial intervention, it did recommend stronger regulation of administrative systems in accordance with centrally determined objectives. Instead of traditional independence and low steering levels, the inquiry argued for government direction of administrative mechanisms with specific standardised rules, grants, concrete staff education and training around centrally developed information. Thus the inquiry envisaged increased central direction of the administrative apparatus with lower discretion for both executive agencies and local agencies. The inquiry also emphasised the input of user groups, which represented an involvement of corporatist or interest groups in service provision. Thus while the recommendations contrasted with concepts of administrative independence, there was adherence to the idea of special interests and corporatist actors. In this case user groups representing the psychiatrically disabled were preferred. The Mental Health Inquiry & the level of formal sanctions There was little discussion of formal sanctions as the strong legislation was thought to be sufficient. However, some voluntary groups favoured sanctions for legislative breaches. Thus the inquiry team’s recommendation corresponds to the administrative tradition in the case of sanctions.
1994 Government reform proposition The government reform proposition built on the ideas of the Mental Health Inquiry, be it in a less radical form. There was less emphasis on enforceable disability rights and legislation, instead, a ‘softly softly’ approach emphasised that the reform was needed to solve local coordination: patients capable of community living remained in asylums as local agencies “had not yet found the most effective forms for this way of working”.637 Thus the government regarded the reform as an issue of local administration. 637
See Proposition 1993/94:218 p. 10 (citation – my translation). See also pp. 11 & 19.
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The regulatory steering approach advocated by the government diverged markedly from the inquiry. Instead of focussing on new legislation with tough, detailed and enforceable provisions, the government chose minor adjustment to the existing framework laws that gave discretion and flexibility to implementers. Unlike the detained directives and steering in Britain, in Sweden the reform regulation was based on locally negotiated and flexible agreements rather than central regulation.638 In place of detailed statutory responsibilities, the government argued that the division of tasks between county and municipality would be achieved with local agreements:639 The government assumes that county councils and municipalities can reach agreement locally on which services ought to be transferred from the county council to municipality. 640
The strongest legislative change related to creating a requirement for municipalities to pay for fully medically treated patients who remained in hospitals.641 In sharp contrast to the inquiry’s proposal for enforceable rights, the government did not propose specific new rights, arguing that improvements ought to occur as a result of the reform. The government approach was cautious, stating that both the mental health reform effects and the new Disability Act would need to be implemented and reviewed before new legislation was considered. The idea of Personal Representatives was implemented, yet instead of a legal right it was a three-year pilot project as the role was opposed by municipalities on the ground that it was a pre-existing municipal function. The government followed the compromise recommendation of the Local Government Association (Svenska Kommunförbundet) to avoid creating a legally binding right and to develop the role as pilot projects.642 Therefore, the government’s proposals were appreciably weaker and looser that the strict legal rights and specific municipal duties advocated by the inquiry. The government proposed several financial incentive steering strategies in order to stimulate services development and organisational changes needed for the reform. The main instrument was Stimulus Finance (stimulanspengar), available for three years, for restructuring and collaborative projects. The finance was contingent on negotiated agreements between municipalities and county health services for transferring services and finance,643 as well as specific short-term incentive grants.644 Thus the govern-
638
For example inventories, planning, living conditions, outreach, suitable activity and employment services. 639 Proposition 1993/94:218 p. 23 & 26. 640 Proposition 1993/94:218 p. 26 (my translation). 641 Proposition 1993/94:218 pp. 41-42. 642 Proposition 1993/94:218 pp. 29-31. 643 Proposition 1993/94:218 p. 92. 644 For example: housing, personal representatives, psychotherapy, staff development; and user peer support services: Proposition 1993/94:218 pp. 29, 80, 87-89, 92 & 94.
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ment proposed service development incentives, but these planned as shortterm ‘pump-priming’ methods, and not long term financial commitments. The government proposed a number of information steering instruments, based on informational and educational ideas. A series of reports by The National Board of Health and Welfare would evaluate the reform’s implementation and provide best-practice information.645 Information was also dispersed through training and education projects where municipalities could formulate their own projects with stimulus grants funding. Analysis: government reform proposition & Administrative Traditions The Mental Health Inquiry had been radical in its approach, yet the government proposition represented a reversion to the conventions of the administrative traditions. In place of the inquiry’s strong steering and detailed, legally binding rights, the government’s proposal was based on framework legislation, management by objectives and local decision-making. The government reform proposition & the level of territorial centralisation The government rejected the inquiry’s recommendations to introduce detailed new legislation with legally enforceable rights. The reform proposition was based on minor amendment to existing legislation, in many cases merely adding clarifying words relating to mental health to existing paragraphs. The main regulatory reform was to clarify a pre-existing municipal payment responsibility. However, the main thrust of the reform was local negotiation, agreement, and low central enforcement, while the main central contribution was short term stimulus finance. Therefore, the government rejected the inquiry’s ideas of increased central steering and reverted to traditions of local freedoms. Although the reform finance meant a degree of central steering, in practice it was formulated to give local agencies freedoms to develop their own projects, and as such it was not a coercive form of steering. The government reform proposition & the level executive control There were no specific, executive control-mechanisms mentioned, other than some general and flexible instructions to the central agencies for health, employment and social insurance to play a greater role in mental health. There is some evidence that corporatist actors were influential; the inquiry recommended a legal right to Personal Representatives for the users; however, the Local Government Association opposed permanent, rights-based services, arguing for pilot projects to assess the idea. The government chose to follow the association’s advice rather than the inquiry. Thus policy reflected the administrative traditions of low levels of executive steering and control, with evidence that corporatist actors influence executive policy.
645
Proposition 1993/94:218 pp. 27-29 & 48-50.
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The government reform proposition & the level of formal sanctions There was no discussion of central sanctions in the government’s proposal. Thus this follows the tradition of low levels of formal sanctions.
2001 The New Social Services Act The new 2001 Social Services Act will be considered very briefly, however, as it was not a specific mental health Act, a detailed analysis has not been carried out. The Act related to general social services provision; yet it was a potential window of change, when harder state-steering strategies could have used to clarify and steer mental health more concretely. There were several new elements that introduced a degree of regulatory steering. For welfare benefit payments (socialbidrag) there was more precise guidance of what cost the term ‘reasonable living standards’ included and a suggested, but not binding, national level (riksnormen). There was a new right to appeal municipal decisions in the courts as prior to this Act municipal welfare decisions could not be appealed. However, the proposals were controversial and some municipalities argued that they restricted local self-government.646 However, the government retained the Social Services Act as framework legislation; arguing that adaptability to local conditions was crucial, even if it resulted in wide variations of interpretation among municipalities. The inquiry report prior to the new Act had argued that these variations could be overcome with improved national monitoring and reporting.647 Framework legislation for social services that gives general ambitions and goals for certain activities within social services and support to certain groups in society is thus, according to the Social Services Inquiry, preferred over detailed regulation.648
Therefore, the greatest emphasis was on issues of regulatory steering, underlining local decision-making powers and self-government. The Act did not contain detailed regulations or central intervention, and instead focussed on general norms and objectives. Analysis: Social Service Act & administrative traditions The changes of the new Social Services Acts were small in relation to mental health, thus have been analysed briefly in terms of administrative traditions. The 2001 Social Services Act & the level of territorial centralisation The Act emphasised the concept of local self-government with little detailed regulation, despite the problems identified in the National Board of Health 646
See Proposition 2000/01:90 pp. 87-97. See SOU 1999:97 pp. 14-16. 648 SOU 1999:97 p. 15 (my translation). 647
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and Welfare’s reform report-series that had identified municipalities’ lack of direction and understanding in applying social services legislation to mental health. The administrative tradition of low territorial centralisation was evident: the framework legislation was retained to facilitate municipal decisionmaking discretion and flexibility. Some amendments created more steering through national guidelines, but many were advisory rather than binding. The right of appeal increased user power; however, generally the Act did little to clarify specific issues relating to the mental health reform. Therefore, the framework legislation maintained municipal freedoms, generally reinforcing administrative traditions of low levels of centralisation. The 2001 Social Services Act & the level of administrative control There was very little emphasis on government intervention of central controls, and the tradition of a low level of administrative control was retained. Despite critical evaluations of the reform by the National Board of Health and Welfare, the agency was not given stronger powers to enforce change. The 2001 Social Services Act & the level of formal sanctions The inclusion of appeal rights and the power of the administrative courts to impose finance for non-compliance with court orders was a major change to the Social Services Act. The previous 1980 Social Services Act had been based on trust relationships between government, municipality and users, and had not given users the right of appeal. Therefore, the 2001 Act represented a departure from the tradition of low levels of sanctions by creating judicial sanctions, such as fines, that the Administrative Courts could impose on municipalities that flouted the law. For the first time, the government included sanctions to prevent municipalities evading their responsibilities to provide services. This represented a tougher approach to ensure legislative compliance; however, the sanctions were for appeals of individual cases and not a general mechanism for central government to sanction municipalities.
2003 Parliamentary Mental Health Debate The parliamentary Mental Health Debate in 2003 was a potential decisionmaking moment where the government could have chosen new strategies for mental health services.649 It represented a moment of huge political and public pressure for changes to mental health policy and regulation, yet the government refused to divert from its chosen course. There were no new initiatives other than the appointment of a Mental Health Tsar (Psykiatrisamordnaren) to conduct an inquiry into mental health services.
As previously mentioned the debate’s background was several violent crimes committed by the mentally ill in 2003; including the Foreign Minister’s murder in September 2003. 649
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The debate occurred at a time where there were strong pressures for the government to introduce new regulatory approaches to mental health as a result of mental health scandals. The debate was high-profile; the main opposition party-leaders had prominent debate roles and demanded increased regulation, guarantees, finance and coercion.650 The Minister blamed local municipal care failures for the scandals. He argued “[w]hat is needed is harder work in order to realise the intentions that lie behind Parliament’s decision so that we get mental healthcare that works”.651 Thus he stated that the problems were local and rejected the notion that it was the government’s responsibility to play a greater role in reform regulation.652 The Social Affairs Minister did not concede the need for greater regulatory steering and instead argued that the reform was a local responsibility. His contention was that doctrines such as local self-government precluded Ministerial steering and that Ministers were constitutionally unable to steer: County councils have full responsibility for medical and healthcare, municipalities have full responsibility for social services, and we have repeatedly been in agreement that the Swedish constitution should look like this. The government and Parliament are responsible for legislation and monitoring.653
The Minister also asserted that the reform’s regulatory arrangements were a Parliamentary responsibility. He argued that the reform had been a shared, cross-party decision and that the current opposition had been the party in power that had formulated the reform legislation: “In 1994 a united parliament stood behind the community mental care reform that the right-wing government had presented.”654 Therefore, at this critical decision point, the Minister argued the government had a low level of responsibility for regulatory steering owing to the constitution: local self-government meant local agencies were responsible for frontline services and parliamentarianism meant there was a collective political responsibility. Thus the Minister argued that the government had no sole areas of responsibility and little power to act; therefore, no change of direction was necessary. However, opposition MPs and party leaders found the Minister’s approach illegitimate and evasive and did not accept the constitutional arguments. The leader of the Christian Democrat Party (Svensson) criticised the government’s evasion of responsibility and central-local ‘blame-game’: “[T]he Social Affairs Minister blames municipalities and municipalities blame the Social Affairs Minister”.655 In the same vein the Conservative Par650
See Riksdagens protokoll 6/10-03 statements 21-25. Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20 (my translation). 652 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 36. 653 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 27 (my translation). 654 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20 (my translation). 655 Alf Svensson, Riksdagen’s protokoll 6/10-03 statement 21 (my translation). 651
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Administrative Traditions ty (Moderaterna) leader (Reinfeldt) criticised the government’s approach to mental health and the government’s failure to steer or to take responsibility. In particular, he questioned the Social Affairs Minister’s strategy of asking Parliament questions rather than providing the answers: Lars Engqvist ought instead to give answers ... I have tried to decipher who Lars Engqvist blames. It never sounds as though this has anything to do with Lars Engqvist ... It is almost impossible to get anyone to take responsibility for the exercise of power ... nevertheless Lars Engqvist points to municipalities and says they did not fulfil their role.656
The minister’s response was to re-emphasise the constitutional issues and his own inability to intervene. Therefore, the minister was strongly in favour of retaining the status quo. Despite the crisis representing a key decision moment, it did not appear that government steering would change. Analysis: 2003 Mental Health Debate This debate represented a key decision-making moment when there was political and public opinion pressure on the government to change direction in light of the mental health scandals of the previous six months. In particular, there were pressures to change both the mental health policy and steering strategies, with some MPs demanding the centralisation of mental health. 2003 Mental Health Debate & the level of territorial centralisation The Minister emphasised the territorial administrative traditions in his statements in the chamber; in particular, he emphasised the constitutional divisions of power and he rejected pressure for Ministerial action. He based his arguments on the concept of local self-government and blamed implementation deficiencies on municipalities: the government role was restricted to legislation, monitoring and limited incentives. Thus the Minister strongly resisted greater governance and steering of the central local relationships. 2003 Mental Health Debate & the level of executive control Despite pressures for increased central steering, the Minister rejected increased steering and emphasised the government’s limited role. He appeared to deny a Ministerial role in reform steering and implementation. Instead, he focussed on the collective responsibility of Parliament to act, stating that executive agencies such as the National Board of Health and Welfare had reported the reform’s successes and failures to Parliament. The government thus distanced itself from an active responsibility for steering the reform. The main action proposed was a new administrative inquiry with the appointment of a Mental Health Tsar to investigate mental health.
656
Fredrik Reinfeldt, Riksdagen’s protokoll 6/10-03 statement 22. (my translation).
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2003 Mental Health Debate & the level of formal sanction The Minister made no reference to the imposition of formal sanctions on municipalities, despite criticising their role.
2006 Mental Health Tsar Reports The inquiry by the Mental Health Tsar took three years to complete. The final report argued that the reform’s problems lay in the lack of clarity in the central-local steering relationships and the low levels of government steering. The Tsar concluded that he was unable “to determine any clear state steering strategy”.657 The Tsar identified regulatory steering as a major problem. He identified many of the reform’s problems as issues of administrative culture. The government’s preference for framework legislation created low levels of direction and regulation, and, in addition, the executive agencies’ constitutional independence reduced steering opportunities. The different government levels and agency cultures had also contributed to the problem: executive agencies had different expert and administrative cultures; county psychiatric services were professionally steered; and municipalities were politically steered in committee-based organisations.658 The executive agencies’ independence meant that central interventions to municipalities were uncoordinated and that central steering appeared “in different ships” where lower territorial agencies received multiple inputs from executive agencies with uncoordinated and conflicting agendas.659 The Tsar asserted that the government needed to take an active steering role and to establish a permanent steering committee at national level.660 Therefore, the government steering arrangements were part of the problem; current arrangements sent contradictory and confused messages to municipalities who were unsure of what they were expected to do: [G]overnance shall express involvement and political desire, ... governance shall clarify the joint responsibility of responsible authorities, governance shall help achieve a clear distribution of roles, governance shall jointly bridge traditional boundaries, governance shall be long-term.661
However, the idea of increased steering appeared to be an issue of conflict between government and the Tsar. In 2004 the Mental Health Tsar published an article in a national newspaper, seemingly critical of government unwillingness to use those steering instruments that it did have at its disposal to steer mental health. He listed cases from other policy areas where the government had used harder steering strategies and contrasted these interven657
See SOU 2006:3 p. 58 (my translation). SOU 2006:3 pp. 20-33. 659 See SOU 2006:3 pp. 58-59 (citation – my translation). 660 SOU 2006:100 (English edition) pp. 17-18. 661 SOU 2006:100 (English edition) p.19. 658
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Ander Miltons, debate article in Dagens Nyheter 2/6-04 (my translation). SOU 2006:100 (English edition) p. 20. 664 SOU 2006:100 (English edition) pp. 20-30. 663
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agencies to ensure goal congruence. Although this was a marginal increase in steering, the main focus was better coordination of the instructions given to agencies. Therefore, the Tsar’s report did not represent a significant departure from the administrative traditions of lower levels of central steering. 2006 Mental Health Tsar Reports & the level of formal sanctions Sanctions were not a focus of the Tsar’s report, which accords with administrative traditions. There remained a strong emphasis on traditional soft knowledge and educational steering mechanisms. Footnote: the Mental Health Tsar & the new government’s policy response The Mental Health Tsar report took three years to complete and was submitted in November 2006; this is at the end of the period studied in this book and the report was submitted to a different government that the one that had commissioned the Tsar’s inquiry.665 The government’s response did not occur until May 2009 and falls well outside the period studied. However, I comment briefly on issues of interest for administrative traditions. The Mental Health Tsar had argued for a stricter regulatory and financial steering approach with legislative rights and earmarked grants. However, as with the previous government, the new government did not adopt new legislation or major changes of direction. Once again, the disability rights perspective recommended by a government commissioned inquiry was ignored. The regulatory changes amounted to three small legislative adjustments to clarify existing legislation.666 Therefore, the original reform appeared to have come full circle with minor adjustments to existing framework legislation. The new government did, however, implement a new financial steering system of earmarked grants between 2007 and 2009 for a number of special projects. These projects were mostly focussed on central administration and health services, although there were several funding areas for municipal services including method development, knowledge, education and finance for new service types.667 It is notable that the new government did not find harder financial steering through earmarked finance to be unconstitutional as claimed by the previous government, and used earmarked and conditional allocations for specific purposes. Although this steering did not represent hard steering, it was a move to a medium steering form. This suggests that the previous government’s administrative traditions arguments may have 665
The report was received by the Reinfeldt Right-Wing Conservative coalition in 2006, not the Social Democratic Persson government that commissioned the report in 2003. 666 The legislative changes were implemented in January 2010. The three changes were the right for children of the mentally ill to receive information and support; a requirement for counties and municipalities to formulate cooperative agreements for mental health services; and the requirement for municipalities to identify the psychiatrically disabled and develop individual plans: See Proposition 2008/09:193. 667 See government website: psykiatrisatsning 2007, 2008 & 2009.
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Discussion: administrative traditions in Sweden The previous sections have analysed Sweden’s administrative traditions to determine to what extent they aid understanding of why Sweden chose soft governance and steering strategies for the mental health reforms. My conclusion is that Sweden’s chosen course of action to a large extent corresponded with its institutional and administrative traditions. Despite several inquiries that recommended a shift away from traditional patterns, the government selected steering strategies that largely corresponded to the administrative traditions. Despite criticisms, scandals and the murder of a Ministerial colleague, the government did not diverge from these choices during the decade of my study. My findings correspond with Pierre’s recent conclusions that Swedish administrative traditions are resilient and patterns are enduring with high institutional autonomy at central and local levels. Therefore, Swedish institutions are less vulnerable to rapid and radical reforms.668 Thus in the case of Sweden, administrative traditions appear to be a strong explanation. However, there was evidence at the end of the period studied and from government responses to the Mental Health Tsar that the influence of administrative traditions is to a large extent customs and conventions of governance that create a specific administrative culture. Sweden is a unitary state; therefore, governments can choose to use harder steering forms if they wish, even if by convention they usually do not. This was demonstrated by the government’s rejection of strong steering prior to 2006, yet the subsequent governments did increase the hardness of financial steering. Thus the scope of doctrines, such as local self-government, are not fixed, which suggests that In addition, to the administrative tradition, the interpretations made by central politicians of what constitutes “appropriate”669 action is also important. This suggests that administrative traditions alone may not be the sole influence, but that issues of policy framing that will be discussed in Chapter 7 may also be important. The administrative legacies are not constitutionally binding on decision-makers as a result of the loose way that the constitution is formulated on this point. However, the tradition forms as framework for decision-making.
668
Pierre 2010 p. 193. See for example Olsen & March 2004 and the discussion of the logic of appropriateness whereby political decision-makers feel bound by what they consider to be unwritten rules of appropriate behaviour based on ethos, practices and expectations of institutions. 669
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The level of territorial centralisation in Sweden The tradition of separating central policy from local implementation was strongly emphasised in this reform. Despite the Mental Health Inquiry recommending strong centralisation and enforceable rights, the government steering emphasised the administrative tradition of local self-government, focussing on loosely steered local implementation decision-making. Between 1995 and 2006 there were several opportunities to increase steering but the government chose not to. The 2001 Social Services Act represented an opportunity for intervention following three years of critical reports from the National Board of Health and Welfare regarding the poor local implementation of the reform. However, the government chose not to increase precision or binding legal requirements apart from minor changes; instead, the commitment to framework legislation and local discretion remained. In addition, the 2003 parliamentary debate was a crucial decision point when a change of strategy could have been announced. However, the Minister strongly defended the central-local division of tasks both in the Parliamentary Chamber and also against the Mental Health Tsar; Ministers argued the reform was a matter for municipalities and Parliament, not the government. The strategy was unchanged during the period and it appeared the government’s choice of soft steering between 1995 and 2006 was influenced by a preference for a division of tasks between central and local government, with low levels of central intervention, although the new government after 2006 did increase the level of financial steering to a certain degree through earmarked grants.
The level of executive control in Sweden The tradition of separating policy and implementation and low levels of executive control was also a key feature of the reform. The Mental Health Inquiry in 1992 argued for strong administrative controls; however, the government proposition rejected these ideas and instead advocated a hands-off approach from the executive. The National Board of Health and Welfare published critical reports each year between 1996 and 1999, yet these did not appear to influence government decision-making or to lead to steering strategy changes. New legislation, such as the 2001 Social Services Act, did not increase central steering. Despite criticisms of the low levels of administrative steering, the Minister consistently denied responsibility for the administrative implementation or for steering executive agencies. This may have been a “distancing and blaming”670 strategy, yet it was a consistent strategy that the government maintained for 10 years, even when announcing that stronger steering might have been an easier political option. Therefore, the tradition of low levels of executive control over the administration is an en670
Pollitt & Bouckaert 2004 p. 185.
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during feature of the reform; it appears to have been a strong factor that influenced soft steering as the division of tasks meant a lack of Ministerial involvement in administration of detailed implementation.
The level of formal sanctions in Sweden The tradition of a low level of formal sanctions was maintained, as sanctions against municipalities were not discussed in the original reform. However, the 2001 Social Services Act gave the administrative courts powers to impose sanctions in individual cases through appeal rights and fines on municipalities for non-compliance. The reform, therefore, accorded to the administrative tradition of low level of government sanctions.
Conclusions: Administrative Traditions & steering In this chapter I operationalised the concept of administrative traditions by reviewing the concepts and doctrines, as well as historical legacies of Britain and Sweden to identify core administrative traditions that might influence governance and steering strategy. The traditions were then analysed using reform texts produced at critical decision points. In both countries, state commissioned inquiries in the pre-reform phase diverged from the administrative traditions: the Griffiths Report in Britain advocated a greater balance between central and local government and increased local roles; whereas the Mental Health Inquiry in Sweden recommended strong regulatory steering to create enforceable user-rights. However, in both cases the governance and steering strategies chosen by government rejected the inquiry’s recommendations: Britain chose hard steering strategies while Sweden chose soft. Thus notwithstanding the recommendations to break with traditions, in both countries the government reverted to the patterns of their respective administrative legacies. In Britain hard steering strategies corresponded with traditions of strong central control over lower territorial levels and the domination of the executive over administrative system, whereas the government in Sweden emphasised local self-government and administrative independence as reasons for low levels of central government steering.
The level of territorial centralisation The level of territorial centralisation relates to the institutions and structure whereby the powers and responsibilities are divided, and whether the centre can exert steering and control over local government agencies. In Britain there was a high level of territorial control as the unwritten constitution and concept of ultra vires allowed the centre to dominate local levels. In addition, there were traditions of the use of unelected authorities and of munici207
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pal dependence on state finance. The steering of the community mental care reforms was strongly influenced by the tradition of territorial centralisation. The role and powers were determined by the centre, and municipal government lost powers to unelected bodies: direct provision was contracted to independent contractors, and local inspection roles were transferred to regulatory agencies. In addition, municipalities’ dependence on state finance tied them to central priorities: under the Conservatives these related to the market and under Labour these related to meeting centrally defined performance targets. Thus there was a strong link between the tradition of territorial centralisation and the hard steering strategies observed in the reform. Yet there was also a puzzling tendency for the level of centralisation to intensify under the Blair government in comparison with the Thatcher-Major years, such as Labour Ministers’ powers to remove services deemed “failing” from municipal control, which undermined the concept of local-democratic decisionmaking, which is not fully explained by the underlying tradition. Therefore, the other triad of influence dimensions may have been influential. The traditions in Sweden, however, emphasised low levels of territorial centralisation: the doctrine of local self-government and a high degree of financial independence favoured local decision-making and soft steering strategies. The traditions influenced the government’s strategy choices and key reform details and decisions were left to local negotiation with references to the concept of local self-government in government policy documents with only minor changes. The broad pattern was that Sweden’s reform strategy did not change course, between 1995 and 1996 even when there was political pressure to do so as a result of scandals. However, the low level of territorial centralisation may be based on government preference for noninterventions and the customs and conventions of governance. As the post2006 footnote shows, governments are not constitutionally prohibited from intervention. Steering can increase, yet the custom of local independence tends to be respected. There are major differences in the level of territorial centralisation that influence steering strategy. In Britain state domination of the territorial relationships creates a significant powerbase for government steering, while in Sweden customs and traditions of governance reflect the strong freedoms and flexibilities of local democratic levels. Thus I conclude that the choice of governance steering strategies appears to have been influenced by traditions relating to the level of territorial centralisation in both Britain and Sweden. However, in both countries the traditions do not appear to be the sole determining factor as political values and preferences also appear to influence governance and steering choices.
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The level of executive control over administration The level of executive control over administration relates to the extent to which the government and Ministers attempt to steer and influence the administrative implementation systems. In Britain there is a tradition of strong executive control through direct Ministerial steering and the use of executive regulatory agencies, which was reflected in the mental health reform. Ministers played a direct and interventionist role in steering the administrative system using detailed directives and regulations. Ministers were also reactive in response to scandals, announcing new administrative controls, and there was an expectation that Ministers should take personal charge of implementation problems. There was a rapid expansion in the number of regulatory agencies for standard setting aimed at increased central steering, audit and inspection. As seen in the previous category, although executive steering was always strong, the level of intensity increased appreciably under the Labour government, which is not fully explained by the tradition. In Sweden I found that soft steering corresponded to the tradition of low levels of executive steering. There was little visible Ministerial steering of executive agencies which played independent and sometimes conflicting roles, with strong, semi-official roles for corporatist actors such as local government associations. Ministers maintained an arm’s length distance from the reform, emphasising instead that responsibility for reform implementation rested with administrative agencies and self-governing municipalities. As in Britain, there were mental health scandals in Sweden, yet the Ministerial reactiveness observed in Britain was absent in Sweden; Ministers did not take charge, issue new directives or increase controls. Instead Ministers stressed constitutional role limitations on executive Ministerial power. It was only after the end of the period studied in this book that steering levels increased slightly such as linking financial incentives to stated aims. However, the softer information and education executive steering was also maintained. My findings are that in both Britain and Sweden steering decisions were strongly influenced by administrative traditions. However, there is also evidence that other factors may also be influential: in Britain there was a pattern of intensifying executive control, whereas in Sweden the doctrine of local self-government appeared more flexible and open to executive interpretation.
The level of formal sanctions The level of formal sanctions relates to the opportunities available to central government to enforce reforms on reluctant municipalities using judicial or executive sanctions or penalties. Britain has a mixed tradition of sanctions, and sanctions are often linked to central government dominance of the territorial and executive spheres. The government preferences for formal sanctions displayed mixed reform patterns. Sanctions and coercive compliance 209
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mechanisms increased under Labour, and there were tough Ministerial powers to remove social services departments from municipal control. Sweden, however, broadly followed traditions of few sanctions, although in a break with tradition there were court powers to impose fines on municipalities in individual cases after 2001. The level of sanctions was the element where there was least empirical material; however, my findings show that although there were broad tendencies that conform with the traditions, the sanctions element gave more mixed results than the previous elements.
Conclusion: administrative tradition & steering choice My analysis shows a link between administrative traditions results in different patterns of steering relationships. In Britain power is centralised so that when problems arose there was an expectation that Ministers should act and take charge of the situation, which created an automatic centralising tendency. The governance strategy for correcting problems was control through increased regulation. The state attempted to increase the precision and efficiency of steering mechanisms by creating new mechanisms. The result was an expanding apparatus of separate specialist ‘single purpose’ agencies to control particular tasks such as standard setting, regulation, audit and evaluation. These institutions were responsible for small yet specialised sections of the system. Thus it appeared that centralising tendencies created a momentum for spiralling centralisation and specialisation. However, paradoxically the drive to centralise and standardise also created fragmentation and complexity as each agency developed rules, standards and policies. Therefore, the drive for steering efficiency and control resulted in municipalities being bombarded with multiple directives, guidance and regulations. In Sweden, however, power is more dispersed. Ministers were not expected to control and respond, Instead Ministers utilised the strategy referred to by Lewin as “denial of competence” by claiming not to have decisionmaking rights. Thus when problems occurred, the decentralised traditions and mechanisms meant that Ministers could choose whether to respond, Intervention strategies could have been chosen as the development of earmarked grants after 2006 demonstrated; yet there were strong conventions of non-intervention and arm’s length relationships. The dispersed nature of the administrative power meant that there was much less need for Ministers to formulate regulations and specify risks as the executive agencies’ roles were to interpret law and to formulate implementation. Therefore, my overall findings for administrative traditions are that they do appear to exert a strong influence on steering choice. In particular the two elements relating to the level of territorial centralisation and the level of administrative control were influential, although element-relating sanctions gave mixed results. Therefore, despite adopting reforms with similar aims and content, the centralised executive controlled traditions of Britain correspond well to the 210
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choice of hard steering instruments, whereas the traditions of decentralised structures in Sweden are reflected in the preference for soft steering. However, the analysis also leads me to conclude that administrative traditions may not be the sole influence; in both countries there is some evidence that political preferences matter. This suggests that other dimensions, may also influence governance and steering choices.
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Chapter 6
Professions The professions dimension, to be studied in this chapter, is how professions may influence the choice of governance and steering strategies. As discussed in Chapter 4, the state’s reliance on professional knowledge, expertise and skill can influence both the formulation of welfare reforms and the state’s selection of steering strategies. Therefore, analysing the power and influence of professions would appear to be important for a welfare service such as municipal mental healthcare. In this chapter I analyse how the influence of professions may help understand why Britain chose hard steering whereas Sweden chose soft for the mental health reforms. According to the professions literature, professions are interested in expanding the professional jurisdiction and in establishing new areas of professional influence. The mental health reforms thus represented a potential new area of professional jurisdiction, expertise and responsibility for social workers as the main profession in the social care domain: there would be a possibility to expand their occupational jurisdiction through the psychiatrically disabled. Thus the reform can be perceived as a professional opportunity for social workers to claim jurisdiction and influence over social care services for the psychiatrically disabled. Therefore, the possibility of the profession exerting its influence over the government’s choice of steering strategies may increase understanding of the difference observed in steering mechanisms.
Operationalisation: influence of professions on steering choices In Chapter 4 I developed two models of professional influence. The first was the professions regulated influence based on traditional bureau-professional concepts of state-professional relationships where the state delegates freedoms-, authority- and discretion to act to professions. The model is based on mutual trust and requires only soft steering approaches from the state. The second model is state-regulated where the state requires professional expertise, and creates significant professional roles, but defines and steers these in detail. The profession operates within state-sanctioned limits and under democratic controls in order to achieve specific and state-determined objec213
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tives. Thus this model requires hard steering strategies. Therefore, the interrelation between profession and state influences the choice of hard and soft steering strategies. I formulated in Chapter 4 the key influences in a model which I reproduce below: Table 6.1: Models of professional influence671 Professions regulated influence
State-regulated influence
Basis of influence
Trust & acceptance of status
Professions under democratic control
Control of work
Devolved decision-making: professionally determined priorities
Central control: statedetermined professional priorities
Direct influence
Professional jurisdiction
Shared jurisdiction
Basis of profession control
Discretion & self-regulation: internal values
State-regulation & authorisation: external values
I will use this model in the discussion in part two of this chapter relating to the type of influence exerted by professions over the government’s choice of steering and instrument strategies. The chapter will examine the influence of professions on the community mental care reforms. This will be achieved by analysing the influence of professions in two stages: 1. Historical state profession relationships and influences: the first stage considers whether there were historical reasons for the differing levels of influence already at the time of the reform, based on different aspects of the state-profession relationship. For example, the professions in the countries may have been on differing trajectories and linked to different models at the start of the reform, thus these historical conditions may have continued to influence the state-profession relationship. Therefore, historical analyses will ascertain the level and type of professional influence at the time of the reform for Britain and Sweden which help us understand the influence of professions on governance and steering strategies. This section is based on the historical research literature produced by social work researchers which I analyse in accordance with the elements of professional influence developed in Chapter 4 (summarised in the table above). 2. Professional influence & the mental health reforms: The second stage is to analyse the influence of the professions specifically relating to the mental health reforms in using a short- and long-term time horizon to 671
This is identical to table 4.2 in Chapter 4.
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determine whether the influence level at the start of the reform identified in the previous section remained unchanged or evolved into a different form of influence during the reform’s implementation. The information is triangulated from a variety of sources672 in order to evaluate the professional influences from two elements: a) Government attitude to the profession: the issue of how the government regarded the profession is an important factor to whether the profession was in a position of influence. The element relates to whether the state legitimised the profession’s status and influence or whether the state rejected the profession as an influential actor? b) Attempts and forms of professional reform influence: this relates to the strategies used by the profession and the attempts to obtain influence over the reform; was social work a policy process “insider” or was the profession forced to lobby as a policy process “outsider”. In addition, was mental health considered a central area for professional jurisdiction and influence, or was mental health an area of secondary importance for the social work profession? In each case study section, firstly I evaluate the government reform documents relating to the governments view of the social work profession: How was social work perceived? Were specific occupational jurisdictions reserved for social workers? Was the profession influential in steering strategy? The second section will evaluate the attempts by the professions themselves to influence government steering; the types of strategies employed; and the level of success. This analysis will enable me to draw conclusions relating to the level of influence that the professions exerted over steering strategy choice.
Historical influences: the state & social work In Chapter 4 I identified social work as the main profession within the municipal social services field at the time of the community mental care reforms; thus following the norm for implementation of welfare reforms, social workers could be expected to have played a central role in influencing the development at the reforms, including steering relationships. However, it is important to consider the impact of the historical development of statesocial work relationships and the relative position at the start of the reforms; for example was social work already in a position of influence or not? 672
These will be discussed in each section but include government documents; professional consultation papers and reports; meeting minutes and protocols; newsletters; professional press and journals.
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Historical influences: the state & social work in Britain British social work originated in 19th century Victorian philanthropy. Charitable organisations formed to campaign for social reform and, through poor relief, to improve the poor social conditions caused by industrialisation and urbanisation. Prior to 1945, the Poor Law was the main social legislation, providing basic relief though Parish Councils and non-state boards. Hugman argues there was limited support for the ‘deserving’ and ‘respectable’ poor, whereas the ‘undeserving’ and ‘disorderly poor’ were subjected to harsh workhouse conditions.673 Social work was performed by volunteers, often with strong moral and religious overtones, emphasising self-help. Incorporation into state structures In Britain, early social services were provided by charities such as the Charitable Organisation Society (COS) founded in 1869674 where social work was conducted by volunteers. However, the COS established some professional training and methods such as the casework675 method.676 Thus until the early 20th century there was little state involvement in social policy, apart from harsh Poor Laws and stigmatised workhouses.677 Philanthropic social work was divided on class and gender lines with middle-class volunteers in supervisory and inspection roles678 and working-class staff in paid, but less desirable jobs.679 Hugman argues that there was little immediate pressure for professional authorisation as the charities’ own structures achieved a degree of occupational closure on class lines by separating the tasks of middle-class caseworkers’ and working-class staff.680 In the early 20th century, several professional associations were created for hospital social workers, but also mental health. The Association of Psychiatric Social Workers was created in 1929 and later a Society of Mental Welfare Officers in 1954.681 Social work 673
See Hugman 1991a p. 20. There were several main charities: Charitable Organisation Society emphasised practical help: Family Action website (accessed 13/7-10); Settlement Movement, where poor and middle classes lived together: British Association of Settlement and Social Action Centres website; Toynbee Hall website (accessed 13/7-10); Police Court Missions working with prisoners: Guardian 29/1-07; Almoners, priests and chaplains distributed alms (money) to the poor. 675 Casework was an integrated method of case investigation; application, interviews, evidence collection and recommendations regarding whether, and type, of support to be offered. 676 See Hopkins 1996 pp. 22-24. 677 Hugman 1991a p. 18 & 20; Symonds 1998 p. 20. In the early 20th century there was limited funding for social insurance, health and housing schemes: See Symonds 1998 pp. 23-25. 678 Male volunteers used social work as a stepping stone to church careers where charitable experience in deprived urban conditions was considered a merit for the priesthood. For women charity work was a rare type of acceptable female activity outside of the home. 679 Working-class social workers were employed in workhouses or to work with criminals. The COS employed ‘respectable’ working-class men for claim investigation and debt collection: See Hugman 1991a pp. 54-55 & 87-88; Hopkins 1996 pp. 23-24; Symonds 1998 p. 20. 680 See Hugman 1991a pp. 88-89. 681 In the early 20th century several social work associations existed: Institute of Hospital Almoners 1907; Association of Psychiatric Social Workers 1929; British Federation of Social 674
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was specialised and developed as a number of expert organisations, each representing a particular branch of social work. After 1945 the specialised organisation of social work continued with several specialist associations formed, to develop professional and clinical roles, based on psychotherapy and casework methods. The new welfare state organisations recognised specialist social work, creating expert organisations and roles within welfare state structures. Social workers were often autonomous with professional roles such as Mental Welfare Officers and Children’s Officers. This created additional legitimacy for social work’s role in the welfare state.682 Thus by the 1950s social work had developed as a collection of specialist associations each with expertise and skills in a specific area of social work. Social work’s intellectual and professional development as a specialist profession continued after 1945. Social work became an accepted bureauprofession with strong state-profession links with social workers being granted high levels of freedoms and discretion. However, this changed in the late 1960s when the 1968 Seebohm Committee recommended social work’s incorporation into municipal structure, and created generalist Social Services Departments.683 Integration into municipal administrative structures created conflicts between employers and profession: social workers were used to roles as autonomous, professional experts in small agencies, whereas municipalities wanted loyal employees to work in bureaucratic structures. The transition from small specialist agencies to incorporation into municipal administration had a significant impact on social work shifting from a specialist service to a ‘subordinate agency’.684 According to Jones, municipalisation also undermined key social work professional methods that had legitimised the profession’s post-war bureau-professional development. Social services departments were administrative rather than professional organisations, leaving little time for long-term psychotherapy or casework counselling.685 Therefore, the municipalisation of social work represented a strong shift from its roots in small specialist associations to generalist, municipal workers. Thus incorporation into municipal organisations undermined social workers’ traditional influence based on specialisation and expertise. A divided profession At the same time as the municipalisation of social work, the profession reorganised from separate organisations to a single professional body through the creation in 1970 of the British Association of Social Work (BASW)
Workers 1930s; and Society of Mental Welfare Officers in 1954: See Rolph 2003 pp. 340 & 354; Modern Records Centre website. 682 See discussion in Jones 1996 pp. 193-197; Hopkins 1996 pp. 25-26; Rolph et al 2003. 683 See Hopkins 1996 pp. 26-29. 684 See Jones 1999 p. 44; see also Jones 1996. 685 See Jones 1996 pp. 196-198; Jones 1999 pp. 38-46.
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through the merger of six specialist associations.686 However, social workers were divided regarding BASW’s future direction between groups advocating professional, trade union and community activism roles.687 In addition, the BASW limited its role to professional issues; social workers’ pay and conditions were negotiated by municipal trade unions. The 1960s and 1970s were a turbulent time of student activism and radicalism which also extended to social work causing BASW membership to decline; only a third of social workers were BASW members.688 Some social work students focussed on community activist roles, perceiving users as victims of society’s structural oppression and rejecting traditional social work as elitist and paternalistic. Some social workers also defined themselves as municipal workers rather than professionals, rejecting what they perceived as BASW’s ‘elitism’ and focussing on trade union activities to further their interests. In addition, social work education became more political, and less clinical and professional. In the 1970s the state established a training body and national social work qualification,689 although universities and colleges could develop their own courses. Some colleges and students focussed on sociological and Marxist models whereby social problems were deemed to be caused by society and structural oppression of the poor.690 However, by the late 1970s employers demanded a “pro-training and anti education” shift.691 They wanted more practical training and less theoretical, social science course content, which employers regarded as irrelevant to social work. Thus employers had formulated a narrower social work role based on the efficient administration of services and benefits. The conflicts between profession, unions, state and employers became more pronounced in the 1970s, culminating in a national social worker’s strike between 1978 and 1979. Thus Jones argues that the 1970s was a turning point for social work. The profession began the decade with strong bureau-professional influence with recognised expertise and state contacts, yet by the end was demoralised, on strike, forced into narrower state-defined bureaucratic roles.692 The 1980s saw declining professional independence and influence and increased state control. BASW continued its professionalisation agenda, 686
The British Association of Social Workers was formed by the merger of Association of Child Care Officers, Association of Family Case Workers, Association of Psychiatric Social Workers, Association of Social Workers, Institute of Medical Social Workers, Society of Mental Welfare Officers and the Moral Welfare Workers’ Association. 687 Payne asserts three groups existed within BASW who advocated differing direction: a professionalisation group; community activist groups advocating social campaigning; and a trade union group demanding BASW fight on pay and conditions issues: 2002 p. 972. 688 BASW membership varied between 11,029 in 1973 and a low of 7,845 in 1982. In 1993 there were 11,000 members representing only one third of social workers: Payne 2002 p. 973. 689 The Central Council for the Education and Training of Social Workers was established in 1972, and introduced the Certificate of Qualification in Social Work (CQSW) in 1975. 690 See Jones 1996 pp. 199-203; Webb 1996 pp. 179-181. 691 Jones 1999 p. 47. 692 See Jones 1999 pp. 43-47; Jones 1996 pp. 196-205; Webb 1996 pp. 178-179;Payne 2002.
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producing codes of ethics; and establishing research and journals.693 In addition, BASW favoured a state social work authorisation scheme; however, authorisation was rejected by the Barclay Committee in 1982, although the Barclay report did specify social work’s role and tasks in detail, which resulted in more bureaucratisation and less professional influence.694 However, the profession remained divided between social workers wanting professional expertise and influence and those who rejected this approach as elitist, defining their role as municipal trade unionists and/or social activists. In addition, the strike damaged perceptions of social work as a trust bureauprofession. Therefore, the profession remained organisationally divided between the BASW’s professionalisation strategies and the municipal trade unions’ focus on pay and conditions’ negotiations. This split was problematic as social work did not speak with a single voice in its dealings with government. Instead the profession was represented by organisations with conflicting objectives and strategies. Professional mental health specialism In Britain mental health was an early area of social work development and expertise. There were statutory roles in the 1890 Lunacy Act, although these were mainly administrative to ensure efficient hospital admissions.695 Mental health social work was early to develop professional associations: the Institute of Hospital Almoners formed in 1907 and included asylum work; in 1929 a specialist Association of Psychiatric Social Workers was established; and the Society of Mental Welfare Officers was founded in 1954. Thus mental health social workers were organised, and their specialism was recognised in welfare roles.696 The Association of Psychiatric Social Workers in particular was prestigious, with a university course created at the London School of Economics as early as the 1930s for its members.697 After 1945 social workers developed specific mental health knowledge as well as expertise and specialist skills in psychotherapy, counselling and casework.698 The welfare state increased the need for trained social workers; however, staff shortages also led to a certain dilution of expertise.699 The 1959 Mental Health Act enshrined the role of social workers to monitor pa693
Codes of Ethics were produced in 1975 & 1986: See British Association of Social Workers 1990 p. 24; see discussion of research and publications in Payne 2002 pp. 982-986. 694 See for example discussion in Guy 1994; Glasby 2005 pp. 64-66. 695 The Duly Authorised Relieving Officer was created by the 1890 Lunacy Act and the Duly Authorised Officer by the 1930 Mental Treatment Act: See Prior 1992 pp. 105 & 110. 696 See Rolph 2003 pp. 340 & 354; Modern Records Centre website. 697 According to Rolph 2003, it was originally envisaged that mental health roles would be undertaken by female graduates, yet social pressures meant that few women took up posts. 698 The Curtis report in 1946 recommended that Children’s Officers should be graduates with social science diplomas. See discussion of social work education in Hopkins 1996 pp. 25-26. 699 Training became more professional and courses included social science, ethics, psychology, social administration and economics.
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tients released from psychiatric hospitals. However, few community services were available, so the role was often related to social control, monitoring and re-admission.700 As a result of pervasive shortages of psychiatric social workers, a new social work role was created, Mental Welfare Officers, unqualified men, recruited from asylums or demobilised from armed services. Few had formal qualifications, and staff induction relied on a range of ad hoc arrangements; one Mental Welfare Officer recounted that his ‘training’ consisted of advice to buy “stout shoes and an umbrella” and directions to the bus stop.701 The different recruitment and training resulted in occupational culture conflicts between the graduate Psychiatric Social Workers, and unqualified Mental Health Officers. Some Mental Welfare Officers interpreted the role as “psychiatric police”, “going out and rounding people up” and capturing “mad” people on the loose,702 while graduate Psychiatric Social Workers were frustrated by a “sectioning service” emphasis and the lack of resources for their professional training.703 Thus Britain has a long history of strong mental health social work function; however, around two-thirds had no formal qualifications.704 Thus although mental health work was a recognised social work specialism, training was variable and until the 1980s ranged from the highly qualified to the completely unqualified. Mental health remained a special area of social work even after the transition to generalism. BASW lobbied for specialist social work roles in the 1983 Mental Health Act.705 The Act introduced a unified and regulated system to mental health social work, requiring municipalities to appoint trained and specialist Approved Social Workers (ASW),706 for specific tasks.707 However, the ASW role reignited conflicts between BASW and municipal trade unions. BASW strongly supported the development of ASW roles as a professionalisation mechanism that could provide higher status for members. Yet the trade unions regarded the new requirements for social workers to undergo assessments and tests as a condition of the ASW approval process as an illegitimate change of members’ working conditions. Thus the main union banned its members from cooperating or participating with the ASW authorisation scheme. Therefore, the government was forced to compromise, and in 1986 a directive set out the education and competence requirements
700
1959 Mental Health Act. See also Rolph et al. 2003. Trainee Mental Health Officer cited by Rolph et al. 2003 p. 350. 702 Dorothy Atkinson, a Mental Health Officer, interviewed by Rolph et al criticises the way that male colleagues enjoyed the thrill and drama of compulsory admission: pp. 354-355. 703 See discussion in Rolph et al. 2003; Hopkins 1996 p. 25-26. 704 In 1970 there were 1,808 Mental Welfare Social Workers; 197 were graduate psychiatric social workers; and 1,443 were members of the Society of Mental Health Officers, of whom only 365 had social work certificates: See Rolph et al. 2003 p. 351. 705 BASW 1977: Mental Health Crisis Services paragraph 3 – cited in Prior 1992 p. 116. 706 Approved Social Workers are social workers with post-graduate mental health training. 707 See discussion in Jones 1999 p. 48; Rogers & Pilgrim 2001 p. 97; Prior 1992 pp. 111-113. 701
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for mental health approval.708 Municipalities were required to appoint approved social workers for statutory tasks such as compulsory hospital admissions, guardianship and supervision.709 In addition, the Act contained general social work duties for non-specialist social workers such as social reporting and aftercare services.710 Therefore, at the time of the reform there was a specific and specialist mental health social work role: it was a state-regulated activity, controlled by legislation. The government issued central directives and state agencies were involved. Thus there were guaranteed roles for social expertise and perspectives in mental health: yet social work’s role was legitimised through regulatory steering associated with hard governance. Summary: the state & social Work – historical influences The pattern that emerges from the previous discussion of the history of statesocial work relationships in Britain gives somewhat mixed results. The early developments appear to reflect a professionally regulated influence model, with the early decades of the 20th century following a bureau-professional development based on specialist expertise. After 1970 though, this influence declined in favour of generalism, and social workers became divided over how to pursue their occupational interests between professional and trade union strategies. However, the concept of mental health as a social work area of expertise remained strong during the 20th century, and was retained even after the shift to generalism through the creation of ASW posts.
Historical influences: the state & social work in Sweden711 There are differences in Britain’s and Sweden’s economic development with Sweden’s industrialisation coming in the late 1800s, around a century after Britain’s, yet despite these differences, there are similarities in social work’s development. As in Britain, social work in Sweden can be traced to 19th century charitable activities, with little state involvement other than basic and harsh Poor Law (fattigvård) interventions.712 Pettersson argues that charitable activity was based on paternalistic supervision of the poor by the upper- and middle-classes, usually women. As in Britain, in Sweden the poor and needy were sorted into ‘deserving’ and ‘undeserving’ categories. Poor relief was often organised by voluntary associations funded by lotteries and craft sales, 708
Applicants must be qualified social workers; hold a specialist post graduate mental health diploma; meet competence standards; and be re-approved every five years: See LAC (86)15. 709 Sections 11 and 13 of Mental Health Act 1983. See also Rogers & Pilgrim 2001 pp. 97 ff. 710 See for example Community Care website: careers in adult services (downloaded 15/1-07); Institute of Mental Health Practitioners: Guide to the Mental Health Acts. 711 This section is based on historical research on the social work profession in Sweden such as Pettersson 2001, Wingfors 2004, Lundenmark 2008, as well as other relevant sources. 712 Parish Poor Law interventions (fattigvård) were harsh. For example until 1918 parishes auctioned unwanted children and orphans to the lowest bidder who would accept least money for their upkeep: See Nationalencyklopedin; Wingfors 2004 p. 22.
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The Governance Gap staffed by middle class volunteers, such as ‘Ladies’ Associations’ (Fruntimmersföreningar), which aimed to improve social conditions, and provided links between state poor relief and local charities. However, in the early 20th century philanthropy declined and state social policy activity increase.713 Therefore, the origins of social work as a middle-class and parish activity in Sweden are similar to social work’s development in Britain. In the same way as for Britain, I reviewed social work’s historical development in Sweden to identify whether certain legacies of social work’s professional development may have influenced the profession-state steering relationship for the mental health reform. My review has identified three central historical legacies of relevance to my study: the evolution of a single professional organisation; the strong emphasis on administrative roles; and the relatively late development of professional methods. Single professional association As in Britain, early social work organisation in Sweden was based on philanthropy. In 1903 several charities merged to become the Central Organisation of Social Work (Centralförbundet för Socialt Arbete, CSA), which aimed to improve poor relief coordination and lobbied for better social conditions through information campaigns. It operated in a similar way to the COS in Britain and developed close contacts with policy-makers, described once as a “shadow department for liberal social policy”.714 In the early 20th century, the CSA lobbied for social reform on issues including poor relief, child welfare, alcohol laws, worker protection, housing standards and public health. However, the CSA was internally divided between those favouring liberal policies and those who supported biological theories. In addition, there were conflicts regarding whether the CSA should focus on practical assistance, or develop as a campaigning body and lobby for legislative change.715 The period between the 1940s and 1960s was important for organisational development. In 1944 the Hospital Counsellors and Welfare Workers Association (Svensk Kuratorsförening) formed a professional association for hospital social work and psycho-social perspectives.716 In 1958 a major development was the breakaway of 300 social workers from the trade union representing administrative staff717 to form the Swedish Association of Social Workers (SASW), (Akademikerförbundet SSR) as a branch in the Swedish Confederation of Academic and Professional Employees (Sveriges Akade713
See Pettersson 2001 pp. 23-24. Cited in Pettersson 2001 p. 58 (my translation). 715 See discussion in Wingfors 2004 pp. 22-24; Pettersson 2001 pp. 24 & 59-62; Meeuwisse & Swärd 2007 pp. 29-30. 716 See Svensk Kuratorförening website – historia (accessed 23/7-10). The association was instrumental in developing methods for hospital social work. 717 The Swedish Confederation of Professional Employees (Tjänstemännens Centralorganisation, TCO), a collection of unions representing administrative staff. 714
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mikers Centralorganisation). The reason for the breakaway was dissatisfaction over salaries, and recognition of qualifications; the group was critical that they were treated as a marginalised subgroup of municipal administrators. The new SASW was formed in a crucial period of welfare state expansion and focussed on the negotiation of pay and conditions; education, training and professionalisation issues; and social policy debates.718 Yet in contrast to Britain where professional association and union activities developed separately, in Sweden SASW aimed to satisfy both professional and tradeunion agendas positioned in the union organisation for graduates. As in Britain, one particular area for SASW was the state’s recognition of the profession through a professional authorisation scheme as self-regulation options were regarded as less desirable. SASW lobbied a government commission actively for social work to become a licensed profession, only to be rejected in 1983.719 Proposals for a USA style two-tier regulation scheme created internal division and were deferred. In the 1990s, a new government commission on professional licensing considered and again rejected social work licenses.720 The SASW argued that groups with similar responsibilities are state-authorisedised.721 However, despite wide responsibilities and authority, in Sweden anyone can call themselves a social worker. There were however, some successes. In 1980 SASW mounted a successful campaign to improve social work’s status by changing the job title from social assistants to social workers.722 (socialsekretare). SASW developed an ethical code based on the International Federation of Social Work’s Code of Ethics, although some social workers perceived difficulties applying the code to Sweden’s statutory social work function compared with the clinical roles in other countries.723 SASW lobbied to increase social work’s recognition as a profession and to increase the academic content of training. However, Wingfors argues that there were some contradictions between professional and trade union activities.724 Thus in Sweden SASW as a single asso718
Lundenmark 2008 pp. 24-30; Akademikerförbundet SSR website (accessed 23/7-10). The committee recommendations in 1983 took a restrictive approach to licensing professions, recommending that only those involved with patient safety should be licensed. 720 In the 1980s SASW considered a two-tier, US inspired self-regulation scheme, with basic and advanced certification. However, some SASW members were ambivalent to professionalisation and self-regulation at all, whereas others were hostile to the two-tier proposal. The ensuing conflict resulted in the proposal being put on hold. For details of the attempts by the Association to achieve state licensing: See Wingfors 2004 pp. 149-162. 721 Licensed professions include doctors, nurses, dentists, pharmacists; physiotherapists, occupational therapists, speech therapists, chiropractors, psychotherapists, psychologists – even estate agents: See discussion in Wingfors 2004 pp. 61-84. 722 I use social worker rather than a literal translation to avoid confusion. In English ‘social secretary’ refers to a correspondence secretary or a person who organises social events. 723 See for example the discussion on social work’s development strategies in Lundenmark 2008; Wingfors 2004 pp. 127-131; Wingfors 1999 pp. 349 & 353. 724 Wingfors argued that on the one hand, the association adopted traditional professional strategies such as opposing the training of too many social workers and supporting new areas 719
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ciation combined the roles carried out by the BASW and municipal unions in Britain. Although there were some inherent role contradictions, in comparison to the professional divisions in Britain, Swedish social work was more united and spoke with a single voice. The SASW campaigned on both union and professional issues, focussing on professionalisation and education. Late professional development & strong administrative focus One of the differences between Swedish and British social work was that Swedish social work found it harder to establish a separate professional identity. In Sweden the term social work was used in a much wider sense than in other countries. In early 20th century social work was used as a broad collective term to describe any work in the public interest, ranging from doctors to administrators. There were many different strands of social work development. In the 19th century social work had been associated with being a religious or moral ‘call’ rather than an occupation. Thus much of the early social work was carried out by church welfare workers (diakon) or volunteer charity workers.725 In addition, research by Pettersson726 shows that other occupations dominated the social policy debate, in particular doctors with no social work voice.727 Therefore, in contrast to the early method developments and organisation of social workers in Britain, in Sweden social workers struggled to establish a separate identity. In the early 20th century, social work as a paid occupation developed in Sweden in response to legislative reforms. In the early decades new social legislation created paid social work roles in factory welfare work, public health, care homes, and poor relief administration.728 In 1910 the CSA developed a one-year social work course for the expanding social work roles and in 1920 the Institute of Social Policy and Municipal Education and Research729 was established, which was the only non-religious social work education until 1944. Therefore, social work was often defined in narrow administrative and legal terms rather than areas of specialist clinical and professional expertise. Pettersson argues that social work was an administrative function, where “social workers functioned as an integrated part of the state apparatus”.730 Thus the professional development in Sweden demonstrated a duality; part professional, part bureaucratic function; however, social work’s organisation in Sweden limited the introduction of professional methods such as casework and psychodynamics which were popular in Britain. of monopoly. Yet on the other, the Association focused on traditional union strategies of salary negotiation and membership drives to enhance negotiation power: 2004 pp. 116-124. 725 See Meeuwisse &.Swärd 2007 pp. 31-32. 726 Pettersson evaluated journals including Svensk Fattigvårds och Barnavårds Tidning, Socialmedicinsk Tidskrift & Tidsskrift för Barnavård och Ungdomsskydd. 727 See discussion in Pettersson 2001 pp. 126-142. 728 See Meeuwisse & Swärd 2007 pp. 31-32, 42 & 70; Wingfors 2004 p. 24. 729 Institutet för socialpolitisk och kommunal utbildning och forskning. 730 See Pettersson 2001 p. 126 (my translation).
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After 1945 social work continued to develop as a municipal administrative function although the role was defined in legalistic and administrative terms,731 which Wingfors argues “reflected a professional role which placed social work close to a classic bureaucracy”732 The 1940s also established social work education systems that remained the basis for professional training for 40 years; creating Social Institutes in Stockholm, Gothenburg and Lund. In the 1950s courses training and increased in academic content, introducing the degree title ‘socionom’. Yet social work education in Sweden emphasised basic courses that were practical and administrative. The professional methods of casework and psychology were restricted to optional electives for hospital staff. Thus few municipal social workers were trained in these professional methods.733 Therefore, the increase in professional training, did not give all access to theory and methods education; mental health courses were limited to hospital social workers. From the 1960s there was greater debate on social work’s role compared with the limited previous debates.734 Methods such as casework were originally regarded with scepticism; casework was first accepted in Sweden 50-100 years after its development in Britain and USA. It was not until the method was re-formulated into a Swedish organisational context and taught as a course on socionom degrees as “Social Welfare Methodology” (socialvårdsmetodik) that it obtained a broader acceptance in Sweden.735 Thus the development until the 1950s saw social work in Sweden develop as a part of municipal machinery rather than independent or clinical roles. This legal and administrative focus of social work in Sweden resulted in a slower pace of professional development as the clinical and psychotherapeutic counselling methods used in other countries were less applicable to the Swedish context. There were key developments in social work education between 1960 and 1980. As previously discussed, the traditionally broad social work definitions meant that Sweden followed a different trajectory compared with Britain and the USA. This was also reflected in education where the Swedish Social Institute’s ‘socionom’ courses developed as a general public sector administration qualification, not limited to social work. There were three different ‘lines’ (specialisms) such as social work; public administration and finance; and theory. Students studied a common introduction course and took electives from their chosen line; yet all were awarded the socionom title. However, the administrative and financial line tended to dominate, 731
See Pettersson 2001 p. 126-127 & 192-201. See discussion in Wingfors 1999 pp. 347-348. 733 See discussion in Meeuwisse & Swärd 2007 pp. 31-32 & 42-43; Wingfors 2004 pp. 24-25; Pettersson 2001 pp. 24-62, &191-204. 734 Social workers debated issues related to power, democracy, user participation, selfunderstanding and social structures. In addition, new academic journals, such as a mental health journal (Pyskisk hälsa), focussed on social perspectives: Pettersson 2001 p. 213. 735 Pettersson 2001 pp. 218 & 230-232. 732
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while mainstream social work method and theory were under-developed.736 Pettersson and Wingfors argue that the degree content and breadth became contested. Social workers campaigned to establish social work as a separate academic discipline based on professional methods and theories, and rejected the administrative emphasis. However, it was not until after the University reforms of 1977 that the social work and administrative lines separated. Social Institutes were integrated into university structures and courses developed into pure social work degrees.737 Thus it is clear that social work education was late to develop a separate professional identity, regarded by degree courses as a branch of public administration until the 1980s. In the 1980s there was a strong emphasis on professionalising social work education from SASW.738 In addition, Pettersson argued that several scandals revealed deficiencies in social work training, which resulted in improved methods and theory education, including an increased interest among social workers for psycho-social and therapeutic methods.739 Thus Britain and Sweden appeared to be on opposing trajectories. According to Lymberry et al, British social work was increasingly centralised and based on central directives for narrow, work-based competences, whereas Swedish universities had significant flexibility and freedom to develop degree courses’ structure and content within a broad framework.740 Thus for Swedish social work, the 1980s was a time of strong focus on professionalisation; education and training expanded rapidly from a form of public administration to a separate academic subject with increased focus on method and research development. There were also major changes to municipal structures after the late 1970s that changed the nature of social work. There were general decentralisation and sectorisation reforms in healthcare and the process of mental healthcare de-institutionalisation commenced. Unlike Britain there was considerable flexibility to formulate roles and functions at local level.741 Thus there was increasing flexibility owing to organisational change. A key reform was the 1980 Social Services Act introducing changes to social work, and mental health. The Act was formulated as framework legislation with general aims and flexibility for municipalities and social workers to interpret and formulate service aims and contents.742 In addition, the Act created municipal responsibility for the psychiatrically disabled living in the community, including benefits, services and support, although the generic framework legislation approach conflicted with the specialist knowledge needed for
736
Pettersson 2001 pp. 277-278. Pettersson 2001 pp. 278-281; Wingfors 2004 p. 116. 738 See Lundenmark 2008 pp. 119-127. 739 Pettersson 2001 pp. 288-289. 740 Lymberry et al 2000 pp. 269-271. 741 See Pettersson 2001 pp. 240 & 285-286; Lindqvist et al 2010 p. 31. 742 See discussion in Hollander 2007 p. 111; Börjeson et al 2007 pp. 373-374. 737
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mental health.743 Wingfors argues that framework legislation of recent decade gave social workers more discretion to determine interventions, yet often there was little statutory guidance on the role and scope of social work.744 Lindqvist et al argue that the new Act had a limited mental health impact: it created few services and social work interventions as the exact nature of responsibilities was unclear.745 In the early 1990s structural reforms gave municipalities freedom to determine their own organisations, which led to wide structural variations.746 Therefore, at the time of the reform social work in Sweden and Britain was going in opposite directions: in Sweden regulation was reducing with increased professional and organisational flexibility, whereas Britain adopted a stricter regulatory approach including defined professional roles in the 1983 Mental Health Act. Summary: the state & social work – historical influences The pattern that emerges in Sweden also gives somewhat mixed results, although Sweden appears to be following the opposite trajectory compared with Britain. In Sweden social work developed as an administrative function focussed on the implementation of social legislation. Unlike Britain, the development of professional methods and skills came relatively late, and it was not until the 1980s that social work developed as a separate academic university subject. However, historically there was no specialist mental health social work expert qualification to correspond to the ASW in Britain.
Analysis: the state and social work – historical influences It is clear that there were certain similarities in the very early 19th century development of social work. In both countries the origins of social work developed from philanthropic and religious origins; these were based on charitable activities organised by middle-class volunteers and through poor relief carried out by churches. However, in order to analyse the 20th century development of social work as a profession and the influence on state decision-making, I use the four categories of the model constructed in Chapter 4. Basis of influence The first element, the basis of influence, relates to the extent of trust based relationships, of whether professional activity is controlled by the state. Britain demonstrated mixed results in this respect. The early decades of the 20 th century followed the professionally regulated model with Britain following a bureau-professional development. The profession developed strong levels of 743
See Lindqvist et al 2010 p. 31; Börjeson et al 2007 pp. 374-375. See Wingfors 1999 pp. 347-348. 745 See Lindqvist et al 2010 p. 31. 746 See Pettersson 2001 p. 286. 744
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expertise and methods, and the state allowed them to work in small specialist agencies with discretionary working and extensive freedoms. Mental health was an early area of specialism and granted specialist roles in social legislation. Specialist social workers, such as Psychiatric Social Workers and Children’s Officers, were granted freedoms from strong steering based on their knowledge and expertise. However, the high levels of discretionary influence declined from the 1970s following the incorporation of social work into municipal administration, where generalist roles under municipal line management were emphasised, thus shifting to a more state-regulated model. In Sweden on the other hand the early years were state-regulated with early social work functions strongly embedded in roles as agents of the state with low levels of professional discretion, yet the adoption of framework legislation, such as the 1980 Social Services Act, created opportunities for social work to develop greater freedom and discretion. However, there was little evidence that social work ever had strong bureau-professional roles. Control of work The second element, the control of work, also displayed differences. In Britain there were high levels of discretion and freedom from steering until the 1970s in accordance with the professional model of influence. The creation of small specialist agencies and the organisation of social work in expert associations gave social workers high levels of control and autonomy based on trust in their expertise. However, this position reversed following the incorporation of social workers into municipal administration; their roles became re-defined in terms of municipal priorities for generalist administrators rather than experts. This development accords with the state-regulated model, and resulted in a decline in traditional expert methods such as casework and psychotherapies as a result of increased state control and direction of work. In Sweden the early social work role was more state-controlled and defined more narrowly in terms of social workers interpreting and implementing social legislation. Social work was defined as a subdivision of municipal administration: method development occurred late as social work did not exist as a separate academic subject prior to the 1980s. However, the change to framework legislation increased the freedoms and flexibility of social workers. In addition, the new social work focussed university courses gave increased emphasis to professional rather than bureaucratic methods. Direct influence The category of direct influence relates to the level of occupational jurisdiction and incorporation of profession into decision-making structures. The historical research relating to social work in Britain emphasised the contacts and influence of the profession on the state prior to the 1970s. Social workers had access to state power and were granted specialist jurisdiction over areas of social policy development. There were however, changes; the mu228
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nicipalisation and bureaucratisation that occurred in the 1970s emphasised generalism and a loss of expert jurisdiction for the profession. However, mental health social work was an exception to this trend and the specialist roles of ASWs were recognised by the state, although even this area they became more regulated during the 1980s to resolve conflicts between professional and trade union associations. In Sweden, on the other hand, there were low levels of specialist occupational jurisdiction in municipal social work as the profession was administratively focussed: social work roles appeared to be an extension of municipal administration and even the job-title ‘social assistant’ reflected the subordinate role. In addition, there did not appear to be a formalised bureau-professional relationship between state and social work profession; however, the introduction of framework legislation with greater freedoms and discretion for implementers did create a potential opportunity for social workers to expand their occupational jurisdiction and create new spheres of expertise and influence. Professional control The final category is professional control. An interesting factor is that in both countries social work associations wanted state-authorisedisation and campaigned vigorously for this. Social work was a newer profession that was mainly active in the public sector. Therefore, state recognition of a professional monopoly for social workers would be important to their establishing social work’s occupational domain. In this respect, there is a certain difference between the modern public sector professions and traditional professions theories based on 19th century free-practicing professions. The public sector professions often see the benefit of state-authorisation and registration as a means to occupational closure whereby certain tasks and roles are restricted to members of the profession. Although this means a certain loss of professional influence over registration requirements and disciplinary issues, the benefits are that the profession is legitimised by the state. Social work in Britain developed strong professional control strategies at an early state with: organisational and method developments; education and research strategies; and ethical codes etc. However, after the 1970s the internal cohesion of social work declined. There were two main factors for the decline. Firstly was the external influence of the incorporation into municipal structures and the increased state role in controlling and organising work and education. Second was the internal split between BASW’s desire to follow the professionalisation strategies of a bureau-profession, and the municipal trade union’s rejection of these roles through an adversarial approach of workplace conflict and strike action. Thus the profession was divided; the conflicts between different factions undermined its professional status and reputation with government. In Sweden there was little state action or intervention in the profession. However, the profession consolidated its own position into a single organisation and developed professionalisation strategies. 229
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Discussion: historical influence of professions The results of the historical review demonstrate somewhat mixed results for Britain and Sweden. In Britain social work initially started to develop as a classic bureau-profession following the professional regulation model; there were strong independent methods developments; these were organised in expert associations; and most work was carried out in small, professions-led specialist agencies, although this changed from the 1970s as the level of state regulation increased. While social work retained central roles in welfare policy implementation, the results of municipalising the profession led to greater state control. In addition, the divisions within the professions with some social workers adopting anti-state and anti-professional strategies undermined some of the earlier bureau-professional status. However, mental health was an exception to the trend of generalism and remained a strong area of specialist social work expertise, although even this role became more regulated following the 1983 Mental Health Act and the legislative requirements for municipalities to employ ASWs. In Sweden social work’s history started from a position of state-regulated influence; however, the adoption of framework legislation from the 1980s created looser arrangements with greater freedoms and flexibility, and in addition, social work was undergoing a strong professionalisation process of education and method development. Despite these developments, in Sweden there had never been a strong municipal social work role in mental health; there were no qualification or roles that corresponded to the ASW and mental health roles in Britain. In addition, it was unclear whether Sweden was moving to a bureau-professional role, as despite the increased flexibility, social work had not had huge success in influencing government or obtaining occupational jurisdiction through professional authorisation. Thus in both countries the historical evidence is somewhat mixed. Social work in Britain appeared to be shifting to a stateregulated model; social work was accorded a central role in mental health through legislation, but there was increased state regulation of this role. In Sweden the background appears more contradictory, although the increased use of framework legislation meant potential scope for social workers in Sweden to take a lead in the mental health reform through their powers to interpret legislation and formulate services. Therefore, mental health was a potential new area where Swedish social workers could exert occupational jurisdiction by expanding its domain of professional expertise. At the time of the reform, there were differences in the relationship between profession and governments in Britain and Sweden. In Britain social work had a pre-existing expertise and role in mental health which could be utilised by the government in the reform. In Sweden, on the other hand, there was a general loosening of state steering with framework legislation, and little direct state intervention into professional, educational or organisational issues. Thus the mental health reform represented an opportunity for profes230
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sional social work to improve its occupational jurisdiction by establishing mental health social work as its professional domain. Thus the professional conditions within municipalities at the start of the reform were: In Britain social work appeared to be on a trajectory of increasing regulation and moving towards state-regulated influence model and was more higher regulated using harder steering forms; In Sweden social work appeared to be moving in the general direction of the professionally regulated influence model as a result of greater freedoms and flexibilities, based on soft steering forms. Did these separate professional conditions mean that there were different opportunities for professions to influence the governance and steering strategies for the reforms? In the following sections the roles of professional influence that specifically relates to the mental health reforms are studied.
Professions & the mental health reform in Britain In this section I analyse how social work may have influenced the government’s choice of steering strategies. This is carried using out a triangulation of information from different sources in order to develop a rounded perception. Firstly I appraise the government’s attitude to the social work profession and the way in which steering strategy choice may have been influenced by carrying out a text-analysis of government documents, including reports, circulars and letters. Secondly I analyse the strategies used by the main social work professional associations attempted to influence government steering policy. BASW has no archivist or research resources so I was unable to access association documents in the same way as for SASW via the TAMarchive.747 Thus I combined material from a number of different sources using published documents from government, agencies and the profession, as well as secondary sources and research studies, academic journals, professional press and general news media where social work’s influence and the role of BASW is discussed. By triangulating my results in this way from a number of authoritative sources and by attempting to confirm my results from several sources, I believe that my results are both valid and reliable.
The government attitude to the social work profession in Britain There is considerable literature on state-social work relationships in Britain. As we saw in the historical review, social work’s bureau-professional influence was initially present but dwindled after the 1970s as a result of internal divisions within the profession and the incorporation in to state bureaucracy. 747
The TAM-archive holds the archives of the trade unions and professional associations representing white-collar occupations and professions.
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In addition, the reform was developed by the Thatcher leadership, a government which was generally negatively inclined to social work as a profession. However, much of the long-term mental health reform implementation occurred under the Labour government of Blair, where the Labour party was generally considered to be supportive of social work. General state-social work relationships During the 1980s and 1990s there was a changed state-public sector relationship owing to the differing priorities for public services. This impacted on social work and also the reform, as the late 1980s was considered the period where Thatcherism’s radical reform agenda peaked.748 Unlike traditional post-war welfare developments, the Conservative governments of Thatcher and Major did not automatically accept the state’s role in solving society’s problems. Indeed Thatcher is famous for saying “[t]here is no such thing as society”.749 rejecting ideas that the state should assist citizens with social problems. There was a hostility towards social work and its role in social help; regarded by Conservatives as ideologically linked with ‘soft’ ‘liberal’ ideologies750 and Thatcher described social work as: [F]ashionable theories and progressive clap-trap ... in which the old virtues of discipline and self-restraint were denigrated.751
Although Major is usually considered less radical than Thatcher, he also reflected changed attitudes to welfare recipients: “Society needs to condemn a little more and understand a little less”.752 Thus the Conservative governments were hostile to the social approaches to problem-solving, and the role of social policies underpinned the reform’s formulation and implementation. Webb argues that this discourse led to a politically orchestrated discourse of ‘mockery, shaming and degradation’ of the competence, calibre and credibility of social workers.753 Lymberry argues that the Conservatives were influenced by new right values, with impacts on fundamental principles of social work. Ideas of universalism were rejected and replaced with concepts administration, financial management, and regulation.754 According to Harris, the 1990 NHS and Community Care Act reflected a new approach to social work practice, which he calls the “proceduralization and commodifi-
748
Clarke & Newman 1997 assert that during the late 1980s the emphasis shifted from efficiency measures to radical policies of privatisation, market mechanisms and contracting. 749 Margaret Thatcher cited in an interview article by Keays 1987 (accessed 9/4-10). 750 See Lymberry 1998 pp. 869-870; Harris 1998; Lymberry 2001 pp. 372-373; Ramon 2001. 751 Margaret Thatcher cited in Jones & Novak 1993 p. 198. 752 John Major commenting on juvenile crime: Independent 21/2-93. 753 See Webb 1996 p. 179. 754 See Lymberry 2001 pp. 373-375.
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cation”755 of social work based on market and business routines favouring managerial skills, gate-keeping and reduced discretion.756 Traditionally the profession and social services departments emphasised professionally driven norms of “good social work” such as reducing poverty, disadvantage and social exclusion; problem-solving; and having direct contacts with clients. In addition, social work provided access to state programmes and resources; encompassed community work such as outreach and advocacy; and included clinical roles including counselling and psychotherapy.757 Thus traditional social work focussed on professional, problemsolving tasks. However, Conservative governments emphasised rational and efficient business approaches. There was hostility to academic and theoretical knowledge, rejecting social science as ‘irrelevant’. Social work became re-focussed on a narrow range of practical responses, reminiscent of 19th century social work. There was a reduced emphasis on prevention and roles. and increased focus on administration and control.758 One Director of Social Services summed up the new approach with “I want doers not thinkers”.759 The Labour government that took office in 1997 was welcomed by the profession, yet appeared to have an ambivalent attitude toward social work. The Labour manifesto declared a policy of increased state involvement and reduced emphasis on business and market strategies. However, there were also extended managerial and risk controls over social work. Research by Jordan, Orme and Jones found a paradox that after 18 years of denigration under the Conservatives, professional social work appeared to fare worse under Labour. There were increased central regulation, controls and riskmanagement while municipal powers declined. There were also concerns that the term social work appeared to vanish from the government’s vocabulary, the government preferring the generic term social care that included unqualified and voluntary staff. In addition, municipal social services lost tasks to new multi-disciplinary agencies, often under medical control:760 New Labour, in all of its reformist rhetoric, seldom uses the term ‘social work’, and when it does, for activities that are largely narrow and negative, concerned with rationing and risk assessment; it prefers new words and new agencies for its ambitious, generous and expansionist initiatives.761
755
Harris 1998 p. 859. See Harris 1998 pp. 854-856. 757 See for example Jones 2001; Jones 1996; Ellis et al 1999; Pettersson 2001; Hopkins 1996. 758 See for example Jones 1999 pp. 46-48; Hopkins 1996 pp. 31-32; Jones 1996 pp. 206-209; Webb 1996 p. 187; Community Care Website: Diploma Social Work (accessed 15/7-10). 759 Comments made by a Director of Social Services at meeting to discuss future of social work training: Cited by Jones 1996 p. 209. 760 See Jordan 2001; Jones 2001; Orme 2001. 761 See Jordan 2001 p. 527. 756
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The reform & government approach to social work In Britain the government had formulated a social work role under the 1983 Mental Health Act, despite the government’s general scepticism of social work. This pre-existing professional role under the 1983 Mental Health Act was retained, requiring municipalities to appoint specialist mental health ASWs. The ASWs had strong legal powers in areas including compulsory admissions, guardianship and supervising discharge. In addition, there was a general role for non-specialist qualified social workers in compiling social reports and arranging statutory aftercare for psychiatrically disabled persons discharged following a period in hospital.762 The 1988 Griffiths Report also emphasised a social reform work role, although Griffiths defined the role as a management function including planning, budgeting, purchasing, contracting, reviewing and monitoring and the need for social workers to be trained as management. Thus Griffiths’ proposals represented a shift from traditional professional functions and methods of direct care and counselling.763 The Griffiths recommendations were endorsed by the reform bill in 1989, with the government arguing that social workers should be arrangers and purchasers of care but not providers, thereby emphasising management roles.764 Thus the reform re-formulated a social work role in managerial terms as administrative and procedural functions rather than a service based on professional trust. The government followed up these new roles with detailed guidance. Mental health services were required to follow the Care Programme Approach, with government directives, specifying assessment, planning, reviews and appointment of a key worker.765 The government also produced meticulous care management guidance for social workers in a handbook Care Management and Assessment: Practitioners’ Guide 1991. The guide was produced in management manual format detailing a seven-step administrative process for care management in minute detail, even including standard letters to be sent to users and suggesting “trigger questions” for social workers to use in user interviews.766 There was further specification of administrative regulations for social workers as a result of the riskmanagement procedures and controls introduced by the 1995 Mental Health (Patients in the Community) Act with specified systems and forms to be used for documenting supervised discharge and aftercare.767 The roles determined 762
Community Care website: careers in adult services (downloaded 15/1-07); Institute of Mental Health Practitioners website: Guide to the Mental Health Acts. 763 See Griffiths Reports 1988 para. 6.6, 7.8 & 8.1. 764 Her Majesty’s Government 1989, para. 3.13, 3.34, 8.39. 765 See Circular LASS(90)11. 766 The Care Management Guide included: implementation timetables; checklists with tick boxes; action plans; standardised documents and letters; and a list of “trigger questions” for social workers to use when interviewing clients: See Department of Health 1991. 767 See LAC (96)8.
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by the government were strongly associated with government efficiency aims and ideological commitments to a “mixed economy of care”. Government policy meant that Social Services were obliged to contract out much of their direct service provision role to the private and voluntary sectors. Therefore, the role of social services departments became focussed on contracting, policing and financial and contract monitoring as the traditional professional clinical and outreach roles disappeared. Services were coordinated by care managers. usually qualified social workers, responsible for assessing userneeds and developing care “packages” to meet the identified needs that would be implemented by independent contractors.768 In addition, ASWs had legal duties under the 1983 Mental Health Act such as providing statutory aftercare; supporting and monitoring; and arranging compulsory hospital readmission where necessary. The 1990 NHS and Community Care Act also created general municipal social work roles for dealing with the psychiatrically disabled including responsibility for planning and coordinating services with both users and other actors.769 Therefore, the reform created a shift in roles. In place of traditional social work roles such as direct contacts, therapies and counselling, the government emphasised social workers as managers and gatekeepers of services and resources. The main social work roles were tasks such as controlling access to services and finance, supervising contractors and surveillance over clients. The government also established a culture that focussed on riskmanagement and on individual, professional blame when things went wrong through directives on investigations and inquiries into homicides. The government introduced directives requiring professionals to manage risk, supervise the psychiatrically disabled in the community and ensure treatment compliance. Professionals were required to follow both the Care Management, and Care Programme Approach as well as the new Supervised Discharge arrangements, and where the psychiatrically disabled were not in compliance, to send them back to hospital. When things went wrong, there were new requirements to hold an investigative inquiry to identify failings and apportion blame.770 Although research evidence points to murders by the mentally-disordered being low and stable at around 5% of murders,771 government-professional relations became focussed on risk-management after the mid-1990s, and quasi-judicial inquiries held mental health professionals individually to account. The Department of Health lays down general admin768
The specific care management tasks includes assessing needs; coordination with other actors, consulting with users and carers; negotiating and communicating with service providers; monitoring service quality and costs. 769 See Her Majesty’s Government 1989; 1990 NHS and Community Care Act; Community Care website: Careers in adult services (downloaded 15/1-07). 770 See LASS (94)4. 771 The Sainsbury Centre for Mental Health states around 30-50 of 800 murders committed each year are committed by psychiatrically disabled persons. See BBC News Online 23/12-04; Independent 6/1-99; 7/5-99.
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istrative inquiry guidelines, but there is no standard format. Inquiries are arranged and financed by the county and municipal councils, and the format is determined by these actors and the inquiry team consisting of lawyers, medical and social care professionals. There are hearings with all involved, before conclusions are reached and blame apportioned. Each inquiry decides its own culpability thresholds; these can be of higher than applicable in court cases or professional misconduct hearings.772 Thus government riskmanagement aims were prioritised. Mental health professionals, including doctors, nurses and social workers, were held to a higher level of individual culpability through the inquiries than those working in other health or social work related disciplines, yet underlying political and administrative policies were not considered. Thus there was a reduced level of trust-based-steering; administrative procedures were specified in minute detail, with little scope for social worker discretion or professional judgement. Long-term developments in government-professions relationships The long term effects found that social work influence had declined, yet also that social work had become an unattractive career choice owing to its individual “blame culture”. In 2001, a Department of Health report into social work recruitment found declining numbers of students entering social work, and experienced social workers also leaving the profession; some municipalities reported over 30% of social work posts were vacant as a result of: [Y]ears of high profile harsh criticism in the media, low pay compared to other professions and increasing competition from more attractive careers and training opportunities.773
The mental health reforms, together with a plethora of other reforms had reduced the attractiveness of social work as a profession, as social work was considered high stress but low status and low trust.774 The profession was unattractive to university students owing to low status and lack of recognition. Experienced social workers were leaving as a result of excessive workloads, bureaucracy, poor management, high stress and in particular the blame culture where social workers are “stereotyped in a uniformly negative way, either as ‘ineffectual wimps’ or ‘interfering bullies’.”775 However, the government’s response was status-raising plans based on increased state intervention, control and regulation of social work.776 Thus the government was 772
The Department of Health guidelines include examination of health and social care planning; risk assessments; adequacy of treatments; care and supervision; the level and suitability of staff qualifications and training and the collaboration; communication and documentation of involved actors. The inquiry team can decide whether: to hold hearings in public or private sessions; witnesses are permitted legal representation: See Buchanan 1999 pp. 1089-1090. 773 Department of Health 2001 p. 7. 774 See Department of Health 2001. 775 Department of Health 2001 p. 10. 776 Department of Health 2003.
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focussed on state-regulated modes of professionalism; the government wanted to increase social work’s status, yet chose state-driven procedures and regulatory action as the main mechanisms, thus emphasising government priorities and controls. There was also evidence that the professional divisions between unions and BASW resulted in the profession losing status and influence over government, whereas the management-oriented Association of Directors of Social Services gained ground. For example for the hearings for the Parliamentary Select Committee Report in 2000, one session took oral evidence from representatives of mental health professions; there was no representative from BASW: instead social work was represented by the Association of Directors of Social Services.777 Social work was the only profession to be represented by a professional association focussed on managerial decisionmakers rather than the mainstream professional association. This suggested that BASW as the main social work professional association had reduced influence of over parliamentary and government decision-making. The most significant government intervention was the state ‘takeover’ of the social work profession by the creation of a General Social Care Council (GSCC) to regulate the profession. Social work became a state-regulated graduate profession with a protected job title and registration requirement for social workers.778 The government argued that the GSCC would be a ‘lean and effective’ regulatory agency that would protect the public, and that had powers to “strike-off” social workers from the register. 779 Thus the government emphasised the individual accountability and personal accountability of social workers. The government envisaged the GSCC more as a public protection agency than a professional body to further social workers’ professional interests. The council’s composition made lay members and service users the majority, with social work academics and practitioners a minority:780 the 10 government-appointed council members, only four have a social work background while the six ‘lay members’ have backgrounds in law, audit, state administration and private consultancy.781 Therefore, there is a strong emphasis on the government’s managerial, audit and business competence priorities over professional interests. Registration requirement mean social workers must meet the GSCC’s criteria regarding qualifications, health, character and ethics. In addition, universities are obliged to have the content and structure of social work degrees approved by the GSCC as con777
The attendance list for the professional hearing session included representatives from. The Royal College of Psychiatrists; The Royal College of Nursing; The British Psychological Society; The College of Occupational Therapists; and the Association of Directors of Social Services: See House of Commons 2000 List of Witnesses 11 May 2000. 778 The GSCC’s role was to develop a regulatory framework; to set standards of conduct and practice; and to set training standards and approve new social work degrees. 779 See Department of Health 1998b, Chapter 5. 780 See Department of Health 1998b paragraph 5.10. 781 Reflecting the composition of the GSCC on 9/4-10; GSCC website.
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forming to government requirements and the GSCC has powers to inspect and regulate Universities offering social work and social care qualifications.782 Thus under Labour social work become dominated by mechanisms of state-regulated professional influence; the profession became statecontrolled, influenced by managerial, bureaucratic and risk norms of stateregulators rather than traditional social work values. Despite the negative impact on the profession and recruitment, the Labour government also maintained the Homicide Inquiry system into murders committed by the psychiatrically disabled. The inquiry system was individualist; professionals involved were named in the published reports, with detailed accounts of each professional’s actions. A review of five randomly selected homicide inquiry reports783 under the Labour administration found that Inquiry reports are blamed-focussed, apportioning blame directly on individuals named and shamed for their professional conduct: “Mr EllisDears [social worker], in particular, was seriously deficient”.784 The underlying risk-management and procedural perspective of the Inquiries is that all homicides would be preventable if better professional controls and systems were used. Yet in the five homicide inquiry reports and numerous press reports reviewed for this section, there was no mention of the political or management decisions that created the framework for the individual professionals. Thus the inquiry system focussed on professional blame, reinforcing negative perceptions of mental health professionals: the social work newspaper Community Care commented that the constant criticism had created a “crisis of trust” in professions and a ‘culture of suspicion’785 of social work. The Labour government identified improving the status and attractiveness of social work as a profession as a key aim. However, in the 2004 draft Mental Health Act the government attacked social workers prestigious and guaranteed ASW role in mental health and proposed replacing it with an Approved Mental Health Professional (AMHP), which was not reserved for social workers. This opened the role to healthcare staff such as nurses, occupational therapists and psychologists who underwent the approval training. Thus the reserved place for social work and the social perspective was removed. The Minister took the unusual step of publishing an open letter to social workers in an attempt to placate social workers and persuade them that their role was valued:
782
See Maycraft Kall 2008 pp. 143 & 146-147. See also General Social Care Council website. See for example Homicide Inquiry: South West London Strategic Health Authority 2006; Homicide Inquiry Blackburn & Darwen Primary Care Trust 2003; Homicide Inquiry Bury Primary Care Trust 2003; Homicide Inquiry South West London & St George’s Mental Health Trust & Wandsworth Council 2000; Medway Primary Care Trust & Medway Council. Newspaper articles relating to other homicide inquiries: Independent 25/2-94; 26/2-94; 17/8-94; 17/1-95a; 17/1-95b; 17/1-95c; 27/7-95a; 27/7-95b. 784 Homicide Inquiry Blackburn & Darwen Primary Care Trust 2003. 785 See Community Care 28/3-02. 783
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Professions ASWs are highly valued, both within their own organisation and by other professions for their knowledge and skills in assessment and joint working across a range of professional interests. 786
The Act included the change to AMHP, despite widespread concerns of losing the social work expertise and social perspective. It was unclear whether other professions had sufficient training or interest in the role. Indeed, the government admitted in the short-term, AMHPs would be ASWs as social work was the only profession with sufficient training.787 The proposals also focussed on regulation and risk-management roles, emphasising coercive and compulsion mechanisms and the detention without crime or trial.788 Summary: government attitude to social work profession The government’s approaches to social work were strongly linked to stateregulated professional influence, based on ideas of organisational professionalism. Social work was accorded a central reform role, yet under both the Conservatives and Labour the roles were increasingly focussed on state priorities where mechanisms reduced the trust in professional decisionmaking. There was little scope for professional decision-making or traditional professional methods. Work was increasingly controlled by managerial systems with standardisation and directives. There was also an increasing focus on risk and blame for social workers and mental health professionals. Thus at the start of the reform time the profession was less state-regulated, although the government and employers exerted some influence over social work dominated education. However, the profession was brought under state control by Labour and the establishment of the GSCC.
Influence of the social work profession in Britain This section traces the way that the social work profession attempted to influence the mental health reforms using two approaches: firstly the specific attempts to influence government reform policy and steering by BASW; and secondly through the general attempts of social workers to influence the government through national debate and professional press and campaigns. The time around the mental health reforms was turbulent for social work in Britain. An editorial in the British Journal of Social Work argued that there had been changes impacting almost every aspect of social work: legislative reforms for almost every client group; organisational reform; changes to education and training; social policy and economic change; and government hostility to the social work profession.789 During the 1980s the power 786
Rosie Winterton, Minister of State for Health, Department of Health 2004. See Department of Health 2008. 788 See discussions relating to coercive mechanisms in Department of Health 1998a. 789 Editorial, British Journal of Social Work: 1996 pp. 151-152. 787
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The Governance Gap
and influence of the profession in general declined compared with previous influence in the welfare state’s development; the profession faced many internal and external challenges. Aldridge contends that the profession was disunited following the conflicts of the 1970s and 1980s; BASW only represented around a third of social workers, with many rejecting professionalisation as elitism. In addition, government and employer interests were increasingly dominant.790 Ramon argues that social work became increasingly marginalised by a government hostile to both municipalities, and social work perceived as representing ‘soft’, ‘liberal’ welfare policies.791 A survey by the Association of Directors of Social Services just prior to the reforms found that there was low morale among social workers who felt “undervalued and powerless to influence” as a result of professional values and goals being subordinated to government organisational and financial objectives.792 Thus the backdrop of the reform was a profession which feared it was on the downswing of influence over government policy. Influence of the British Association of Social Workers (BASW) The main organisation representing social workers in Britain was BASW, but its position had been eroded by the internal and external conflicts of the previous decade. Payne argues that BASW continued to operate as a lobbying and policy organisation that focussed on professional interests and that had alliances with other organisations, but that the influence was limited owing to it representing only a minority of social workers. BASW conducted little direct lobbying in connection with the community care reforms, apart from a 1990 policy statement arguing for social work roles based on professional values.793 According to Ramon social work had a more active voice in mental health and continued to lobby in alliances with other actors. However, there was an increasing focus on management roles and the Association of Directors of Social Services, representing senior managers, increased its visibility and influence at the expense of BASW.794 In addition, to the policy statement, BASW raised specific issues relating to professional role, care 790
See Aldridge 1996 pp. 178-180. Ramon 2001 (accessed 18/7-10). 792 Community Care 19/9-92. 793 See Payne 2002 pp. 972-973 & 989; Payne 1995 p. 219. It is unclear why BASW had so little involvement in lobbying in relation to the community care reforms. According to Alaszewski & Manthorpe 1990, the lack of lobbying might be due that the reforms were under discussion at the same time as the 1989 Children’s Act which was considered a more mainstream professional role and social work interest, or that social workers had not realised the full impacts of the organisational and professional interests. 794 See Ramon 2001 (accessed 19/7-10). There was an increased emphasis on the roles and influence of social work managers over practitioners. The 2000 House of Commons Select Committee on Mental Health held several days of hearings. One session was reserved for mental health professions where social work was represented by the Association of Directors of Social Services rather than BASW. Social work was the only profession to be represented by managers rather than the main professional association representing practitioners. 791
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management and specific mental health skills. Post-1997 BASW campaigned actively against the loss of ASW roles, but with little success. Professional role and ethical development BASW had always operated as a professional organisation owing to the historical split with the unions. In the 1990 policy statement BASW argued that the reform required social work’s specialist knowledge and that social work as a profession was most suited to reform implementation, emphasising knowledge, skills and competences of methods, services and clients necessary for the implementation of the reform. BASW emphasised professional knowledge and skills in indentifying and meeting long-term social care and support needs, and specific knowledge of social interventions:795 [T]he Association believes social workers should be key persons within social services and social work departments who understand tasks of identifying need and planning care.796
BASW emphasised direct user contacts through professional methods involving long-term professional-client relationships such as Casework methodology. The profession perceived itself in problem-solving roles rather than in routine, administrative-processing functions. In particular, BASW emphasised a user-participation and social worker’s ability to work in sensitive areas while protecting user integrity.797 Thus BASW arguments were built on profession-regulated influence concepts emphasising social work’s professional competence in areas involving methods, knowledge and skills. One major arguments put forward by BASW related to ethics and that BASW’s ethical development activities meant that social workers should be trusted reform professionals. In the 1990 document BASW emphasised its 1975 and 1986 codes of ethics that set out the professional standards and values needed to underpin reform services.798 Ethics were also stressed under the Labour government. However, there was a dual approach as both BASW and GSCC produced codes of ethics for professional social workers. Yet there are considerable differences in the scope and emphasis of the two ethical codes. The BASW code emphasised professional activities involving relationships, promoting social change and solving human problems.799 Thus BASW adopted a universal conception of social work roles and ethics in society. The GSCC Code of Practice was more restricted to social work as a state function, identifying central principles for social work practice. These 795
British Association of Social Workers 1990 p. 6 & 10-13. British Association of Social Workers 1990 p. 5. 797 British Association of Social Workers 1990 p. 13. 798 British Association of Social Workers 1990 p. 6. 799 The BASW Code of Ethics stated five key values and principles: human dignity and worth; social justice; service to humanity; integrity of social workers; and competence through knowledge and skills: British Association of Social Workers 2002. 796
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The Governance Gap principles emphasised more negative principles of social work’s responsibility for public protection, risk-management and individual accountability for their working situations.800 Thus there are currently two competing ethical codes in existence, which underlines that BASW’s influence declined in this central area of professional activity. The GSCC code binding on all registered social workers, yet represents the state’s priorities rather than the priorities of professional social workers. The code produced by BASW reflects the profession’s conception of professional practice and is binding on BASW members, yet as previously mentioned only around a third of social workers are BASW members. Therefore, profession was unable to influence the government’s negative and organisational perception of social work. Initial reform: BASW, ASW & care management The 1990 BASW policy statement attempted to influence the government in issues relating to the reform. One central issue was the term ‘care management’ introduced by the government as the main social work reform method. BASW argued that while the government implied that care management was a new method, professional social workers in Britain had always carried out casework and case management as part of their professional practice. However, BASW expressed reservations about the term ‘care management’, asserting the importance of the casework professional tradition, rather than managerial, administrative, financial or control functions. BASW emphasised that social workers must be given clear statements of priorities, and sufficient resources by government and employers. The Association believes qualified social workers should carry a key role in work with disabled people. This paper demonstrates why the values, knowledge and skills of social work are required in identifying need, planning care and supporting family and friends who daily give care. It suggests that organisations responsible for managing care must have clear policies in which care is given with certainty and clarity. 801
Therefore, although BASW was generally supportive of the creation of professional roles for social work, there were concerns of a shift from professionally defined roles to managerial functions. BASW also argued that social workers had mental health competence in the 1990 policy statement. BASW emphasised the long tradition of mental health work in British social work, arguing that the Association of Psychiatric Social Workers formed in the 1920s was a founder member of BASW 800
The GSCC Code of Practice identified with six principles for social work practice where social workers must protect and promote users’ interests; establish and maintain users’ trust and confidence; promote user independence and protect them from harm; respect users’ rights while ensuring that their behaviour does not harm themselves or others; uphold public confidence in services; and be accountable for work and responsible for maintaining and improving knowledge and skills: GSCC website – Code of Practice (accessed 29/7-10). 801 British Association of Social Workers 1990 p. 4.
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and contributed to the early development of psychiatric social work. BASW argued that social work’s specialist skills and competence were essential to the reform and that managers did not always prioritised disability and that it was important that those “disabled through physical or mental illness or intellectual impairment ... are given a service from people adequately trained and possessing the range of knowledge and skills required.”802 Thus social work presented itself as the established social profession in mental health by stressing its history, knowledge and skill. Later developments: BASW & Approved Mental Health Professional AMHP As previously mentioned social work and the social perspective had guaranteed roles under the 1983 Mental Health Act. The creation of a new Act was another moment where BASW chose to lobby and influence government policy to retain social work’s guaranteed and reserved role in mental health. The 1998 Modernising Mental Health policy document emphasised the government’s intention to legislate organisational change to create multidisciplinary working in Mental Health Trusts under NHS control. The proposals also included the removal of social work’s guaranteed role by altering mental health legislation; the term Approved Social Worker would be removed and replaced with Approved Mental Health Professional, creating roles for other professions including nurses, occupational therapists and psychologists. This was regarded as a deprofessionalisation and reduction in status by BASW who lobbied against the change. In addition, a network of Approved Social Workers, (the ASW Leads Network) was formed to organise and coordinate ASWs’ professional opposition to the change. BASW and the ASW Network engaged in a variety of influencing strategies including direct lobbying of the Department of Health and Parliament through contacts and briefings.803 Several central arguments were used: firstly, was the need for a professionally independent voice in mental health decision-making. The change was perceived as removing a guaranteed nonmedical perspective in mental health decision-making; using staff trained in the medical model to conduct this function was seen as returning to medicalised mental health. Secondly was concern that the change would lack organisational independence; ASWs were municipal employees even when working in the NHS thus ensuring independence. There were fears that if all staff were NHS employees, there might be collusion or pressure within teams where junior medical staff, such as nurses, would in a weaker position to oppose psychiatrists. Finally the increased emphasis on coercive and custodial functions, were likened to the 1890 Lunacy Act.804 Therefore, the argu802
British Association of Social Workers 1990 p. 4. See British Association of Social Work 2006c; ASW Leads Network 2006a. 804 See lobbying papers and arguments in British Association of Social Work 2006a, 2006b, 2006c; ASW Leads Network 2006a; ASW Leads Network 2006b. 803
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ments were based on professional roles and ethics. However, the claim to professional jurisdiction in mental health was controversial in the profession owing to the divisions between groups favouring pro- and anti-professional strategies. In a BASW handbook produced to guide members on mental health social work at the time of the reform, the author is almost apologetic for recommending professional methods and theory: It is acknowledged from the outset that what has been written sounds prescriptive at times smacking of the professionalism which many people might condemn as elitist.805
Thus professional jurisdiction was contested within the profession and hindered BASW’s attempt to influence government. Alternative forms of professional influence & debate There was also the possibility for pressure through the public and professional debate. In this section I reviewed previous studies in social work policy literature all copies of the British Journal of Social Work between 1990 and 2006, as well as the social work publications, focussed on practitioners and news reports such as Practice and Community Care. Profession & government: the general debate There was considerable debate in the professional press and academic journals regarding the hostility of the Conservative governments to social work. Jones and Novak argue that Thatcher regarded social workers as 1960s hippies, dealing with the ‘undeserving’, thus weakening social discipline and family authority.806 In 1997 there were great expectations that the Labour government would restore social work’s professional influence. Jones’ 2001 interview study found that social workers assumed that Labour would repair the profession’s position: many Labour MPs had social work backgrounds, and the party traditionally emphasised social democracy and welfare. However, there was disappointment that ‘New Labour’ was equally negative to social work as the Conservatives. Social workers were demoralised by government criticisms that were increasing authoritarian and demonstrating a reduced trust in social work.807 Butler and Drakeford argue Labour’s that professions policies were based on low-levels of trust, adopting a “scolding tone” to the poor, while social work became marginalised and fragmented:808 [S]ocial work becomes, at best, a sort of pull-yourself-together profession, charged with imposing a sense of responsibility where none existed
805
Tilbury 1993 p. 2. See discussion of social work and the Conservatives in Jones & Novak 1993 pp. 198-199. 807 See Jones 2001. 808 Butler & Drakeford 2005. 806
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Professions before. At worst, it becomes a fairly straightforward agent of social enforcement.809
I summarise the main issues of professional debate and influence during the decade of my study below: Poor professional influence? A central issue was criticism within the professions of the poor professional influence of social work, especially in relation to the reform. The internal divisions within the profession between BASW and trade unions undermined social work’s opportunities to influence government.810 Thus in part the profession undermined its own position by failing to present itself as a trusted partner. There was recognition that the combination of a hostile government and internal divisions had damaged professional influence in social policy: [S]ocial work has shown little evidence of being able to resist or control its own transformation. Many in practice seem too demoralised, exhausted and overwhelmed by the constant changes to resist ... The occupation is not only on the defensive, but it is weak, demoralised and in retreat. 811
There was criticism that BASW was too passive in its relationships with the government and that the association was not proactive in defending social workers’ interests. An editorial in the professional press claimed that social work risked being “defined into – or out of – existence by others”.812 Surveys found that social work was less active than other professions in defending and expanding territory. In particular nurses had expanded into community care, taking over some areas of social work’s occupational jurisdiction. There was also debate and criticisms that the BASW did not support its members in times of trouble and that the profession needed to stand up for itself:813 The issue of BASW’s relationship with government, and in particular BASW’s lack of influence on government policy, was a recurrent theme; with a common perception that the BASW’s influence declined in the 1990s. There was agreement that BASW had exerted little influence over the 1990 community care reform. Other research and interview studies reached similar conclusions, those being that BASW needed to be more proactive as it had become invisible in lobbying and campaigning, losing ground to management and the Association of Directors of Social Services.814 Public management reform had also undermined the traditional social work identity; independent contractors and multidisciplinary working through health-led NHS Care Trusts blurred professional boundaries.815 Surveys also found that 809
Butler & Drakeford 2005 p. 649. See Aldridge 1996 p.180; Ramon 2001. See also Community Care 17/6-04; 8/7-04. 811 Jones & Novak 1993 p. 210. 812 Editorial Practice 1998a. 813 See Care Services Improvement Partnership 2006; Community Care 13/2-03; 9/10-03. 814 Community Care 5/12-02. 815 See for example Community Care 17/6-04; 8/7-04. 810
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social work had lost ground to other professions, and specialist expertise and skills had been lost. Therefore, there were strong internal criticisms regarding the profession’s lack of influence over the government; social work appeared less able and willing to defend its territory and members from other professions and government. Mental health social work: The profession’s specialist mental health status was also debated and was an issue of professional division. Many social workers were positive to ASWs as an important source of professional status and occupational jurisdiction. The ASW role guaranteed a social perspective in mental health and the enhanced status of ASWs created professional opportunities for social work to further its professional interests in alliances with other actors. The ASWs developed as an elite group in social work, with increased prestige, pay and power against other professions:816 It enables social workers and autonomous position vis a vis other assessors, notably psychiatrists and GPs.817
However, some social workers and unions felt that professional status was elitist and undesirable. Thus the profession was divided, which reduced effective influence of social workers.818 The profession fared worse under Labour, with considerable opposition to the new Mental Health Bill; especially plans to remove the guaranteed social work role, regarded as a ‘kick in the teeth’ by social workers.819 Many policy papers were produced by social work and mental health partnership networks820 that warned of the risks of losing holistic and non-medical perspectives in mental health. They regarded the creation of AMHP roles as a regression of mental health policy to the pre-reform medical model.821 It seems to us that in recent years the status of the profession has been eroded; the proposed change from ASW to AMHP could be seen as further evidence of this erosion. 822
There were also criticisms of the risk and public safety emphasis under Labour, which emphasised social controls by administrative procedures.823 Wolff asserts that the government’s focus on risk and formal homicide inquiries “vilifies” staff by the individualistic concept of professional account816
See Prior 1992; Ramon 2001. Ramon 2001. 818 See Prior 1992 pp. 111-116. 819 Community Care 12/1-06. 820 These networks included the Northern Centre for Mental Health and the Social Perspectives Network which combined professions and users; and the Care Services Improvement Partnership 2006 including management perspectives in consultations and discussions. 821 The Care Services Improvement Partnership 2006 pp. 3-4; Northern Centre for Mental Health 2004; Social Perspectives Network, Mental Health website (accessed 29/7-10). 822 The Care Services Improvement Partnership 2006 p. 53. 823 See for example Preston-Shoot 2001; McLaughlin 2001. 817
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ability.824 The homicide inquiries were criticised as legally and procedurally unfair to mental health professionals. The professionals who were forced to defend their actions had no legal rights: there was no presumption of innocence; no right to cross-examine or challenge witnesses; secrecy; no standard judicial procedures; no culpability thresholds and no right of appeal.825 One psychiatrist argued that professionals are: “dealing with a highly irrational, quasi-legal form of local audit”.826 The underlying assumption was that homicides committed by the mentally ill must result from professional failures.827 Salter developed a professional “survival kit” on how to approach the ‘irrationalities’ of a homicide inquiry; he advised: Expect to be involved in a process that has more to do with drama than with common sense and expect your efforts to be judged by a standard far higher than that expected of most other professions (with the exception of social work). Anticipate the finding of files, records and opinions unknown to your team and expect their content to be explored in Proustian detail.828
Thus the homicide inquiry system represents a government-directed and individual form of professional accountability. The reports are closely scrutinised by politicians and the media, yet responsibility for policy, resources and working conditions are not addressed in the homicide inquiries, as the professionals’ employers set the terms of reference. Professional methods – care management: The government’s introduction of care management with the reform was controversial. It was originally welcomed when the Griffiths report mentioned case-management, a longstanding professional social work method.829 However, the government used the term care-management in the reform proposals: some social workers felt care-management sounded passive and medical, like the managed care in US hospitals as a cost-cutting mechanism; there were also concerns from BASW and social workers that the definition and professional implications were not explicit.830 Payne argues that while social work had a specific reform role, it was not the professionally-driven case-management but instead organisationally-led, efficiency focussed care-management.831 Research by Jones found that social workers opposed “mundane and routinised relationships with clients” based on bureaucracy; for social workers, direct user contacts
824
Wolff 2002 p. 818. See for example Eastman 1996; Salter 2003; Buchanan 1999. 826 Salter 2003. 827 See for example Eastman 1996; Salter 2003; Buchanan 1999. 828 Salter 2003. 829 See Lymberry 1998; Hugman 1991b. 830 See debate in Alaszewski & Manthorpe 1990 p. 246; Huxley 1993; Lewis et al 1997; Cambridge et al 2005. See also British Journal of Social work editorial 1993 pp. 319-328. 831 See discussion in Payne 1995 pp. 52-73. 825
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Labour introduced state-authorisation by creating the GSCC. The development was not universally supported by BASW members. The GSCC was not perceived as a professional body, but as a bureaucratic, disciplinary agency that intruded into social workers’ private lives.840 In addition, the GSCC focussed on management and regulation rather than professional values.841 832
Jones 2001 pp. 552-553. Community Care 24/10-02; see also Huxley et al 2005 that found that bureaucracy, workload and stress were endemic in mental health social work. Many ASWs had high enough stress levels to meet mental illness criteria. 834 See Payne 1995 pp. 224-230. For discussion of the reform process for social work training see discussion in Hopkins 1996; Webb 1996; Jones 1996; Jones 1999. 835 See for discussion Jones and Novak 1993; Dominelli 1996; Editorial Practice 1998b. See also discussion in the hostility to social work academics and research in Hopkins 1996; Webb 1996; Jones 1996; Jones 1999. See also Practice, editorial 1998a pp. 3-4. 836 See Dominelli 1996. 837 For example the government-appointed Chairman of the social work training agency denounced theoretical perspectives on gender and racial equality as “nonsense” to be “rooted out” of social work education: See Independent 24/8-93. 838 See Hugman 1991b pp. 212-213; Guy 1994; Community Care 11/7-02; 10/10-02; 14/4-04. 839 Denise Platt Commission for Social Care Inspection, cited in Community Care 9/10-03. 840 See Community Care 25/11-04. The GSCC Code of Practice required social workers to be ‘physically and mentally fit’. In one case a man with bi-polar disorder was refused registration: see Community Care 3/11-03. There were also concerns that the GSCC had a very broad 833
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Professions The government has put community care in the dock, tried it and found it guilty of failing mentally ill people. The answer, it says, is to usher in a new era of management driven practice.842
However, the BASW appeared not to want strong influence in all areas: in 2005 the BASW Director stated that the BASW rejected self-regulation for social work arguing that “professional development” should be independent of discipline and regulation tasks.843 Therefore, the social work itself appeared divided regarding the future direction of professional organisation. Summary – influence of the social work profession The influence of social work is not easy to determine; however, in general terms the government appeared to formulate the role of professions in terms of state-regulated professional influence whereby the influence of professions was instrumental; there was a pre-existing mental health role through the ASWs with a recognised mental health tradition and role. In addition, despite the government’s general scepticism regarding social work, clear social work reform roles were created, although they were not necessarily professionally driven roles that social workers envisaged or wanted, nor were they based on social work values. The profession attempted to influence the government using strategies of professionally regulated influence where BASW emphasised social work’s values, ethics, experience, knowledge and skills. However, the government’s response was increased state-regulated influence based on increased administrative and managerial procedures, routines and steering. There were additional difficulties created by organisational and structural changes; the decline in universal welfare undermined social work values; structural change reduced the municipality’s power, with multidisciplinary working benefitting health professions; in addition, the focus on risk in social work and mental health practice undermined traditional values such as discretion and flexible decision-making. Thus there was an underlying clash of culture between government and profession which made it difficult for social work to assert its professional status. However, the lack of professional influence is not only in relation to the state-professional relationship, there were internal reasons why social work lacked influence. The divisions among social workers regarding the professions direction between professional and union organisations meant that social work failed to speak with a single, clear voice; it was also problematic that BASW represented only one third of social workers. In addition, social workers and BASW failed to argue for their own position and were often invisible in the public and media debate resulting in a loss of jurisdiction to interpretation of misconduct with social workers disciplined for non-practice issues relating to their personal lives involving drinking, e-mailing and tax issues: Community Care 27/7-07. 841 Gordon Jones new Chairman of BASW: Community Care 2/6-05. 842 Community Care 15/5-00. 843 Editorial British Journal of Social Work 2005.
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healthcare professions and the more managerially oriented Association of Directors of Social Services.
Professions & mental health reform As in the previous section for Britain, I analyse the influence of professions in the mental health reform in Sweden. I examined the government’s attitude to social work through s review of policy documents produced by the government in order to determine what type of influence existed and how the government viewed the profession. In order to examine the professions influence in Sweden, I have used several sources. In Sweden, there was greater access to direct sources such as the SASW archive materials but fewer general sources such as the various types of social work press. Therefore, I have reviewed SASW’s governing board minutes (Förbundsstyrelsen, protokoll) for two periods that I identified as crucial reform periods for formulation and implementation.844 In addition, I examined documents relating to consultation processes on reform legislation, and reviewed a decade covering the reform in the main social work magazine Socionomen. I believe that this provides me with access to material that gives a well-rounded picture of the level of influence of the profession.
The government attitude to the social work profession in Sweden The initial government Mental Health Inquiry in 1992 advocated ambitious reforms to increase social perspectives in mental health. The inquiry recommended that social care needs and social theories and methods should be given greater emphasis, and the psychiatrically disabled should have legal rights to Personal Representatives, or caseworkers, working from usercentred perspectives to aid inter-agency coordination.845 Thus it appeared that the reform would develop guaranteed roles for non-medical perspectives in mental health through the creation of specific roles for municipal social services based on social theories and methods as well as social work skills. The reform & government approach to social work The government’s reform proposition in 1994 was much less specific about the social perspective and social work role in the reform. There was no specific social work role or tasks created for the reform. As previously mentioned, government strategy was that reform details, including the recruit844
The first period was 1993-1995 where the reform decision was formally taken and implemented, and the second period 1999-2000, which coincided with critical reports by the National Board of Health and Welfare in 1999 on implementation and staffing. 845 See SOU 1992:73.
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ment of professional competence, were to be negotiated locally. However, there were concerns from the outset that municipalities lacked mental health knowledge.846 The government did create one significant social work role, the Personal Representative (Personligt Ombud).847 Yet this role was created outside of mainstream social work agencies and was not reserved for social workers; thus the professional social work role was unclear. One of the government’s stated aims was to clarify boundaries between medical and social services, yet the government policy proposals blurred the issue by emphasising that municipal social services departments should recruit medically trained healthcare staff to retain the knowledge and expertise of medical services. It was recommended that whole units or care homes could be transferred complete with staff from county or municipality, or that contractual arrangements could allow county health services to run services as contracted ‘entrepreneurs’.848 In a pragmatically negotiated solution between the government and employers’ associations, the Swedish Local Government Association (Svenska Kommunförbundet) and County Council Association (Landstingsförbundet), it was recommended that municipalities ‘buy in’ reform expertise by employing medically trained staff from closing services in locally negotiated transfers between county and municipality: [I]n our judgement certain staff resources are freed-up within psychiatry. This concerns primarily staff working with the care of the long-term and seriously mentally disordered. The Government believes – after consultation with the Swedish Local Government Association and County Council Association – that an essential part of the competence improvement in the new municipal services ought to be achievable through the transfer of nurses and mental health assistants from county to municipal services.849
While this appears a pragmatic solution for the employers’ associations to minimise reform costs, the government proposal also emphasised the medical model. It was unclear how a new social perspective for mental health would be developed when services were dominated by former asylum staff; thus the boundaries remained blurred. Despite the mental health reform being a major social reform, the government appeared ambivalent as to the social and professional content of the reform: the social work role was unclear, and professional and staff recruitment was left to pragmatic local negotiation. Despite social services being the lead organisation for mental health services, the main social work role of Personal Representatives was organisationally separate; the government advocated medically trained staff for social care services; and psychiatrists held most power through sole discharge authority. Thus from the outset the government did not create a spe846
Proposition 1993/94: 218 p. 23 & 92. See discussion of Personal Representatives in Proposition 1993/94: 218 p. 29-32. 848 See Regeringens Proposition 1993/94: 218 p. 26. 849 Regeringens Proposition 1993/94: 218 p. 92 (my translation). 847
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cific reform role for professional social work nor a guaranteed place for nonmedical perspectives. Subsequent developments in government-professions policy The issue of specific social roles, competence and perspectives was one issue that the government never clarified during the decade examined despite it being identified as a continuing reform problem with reports recommending the development of social competence in mental health. The National Board of Health and Welfare reported in 1999 that the need for increased competence in social services was required in classic professional areas including ethics, theory, method and analysis, in particular relating to social perspectives. The Board pointed out that the mental health reform had resulted in a medicalisation of municipal social services departments; 4,000 mental health assistants transferred from county psychiatry as a result of the mental health reform.850 Thus, the traditional municipal social care perspective declined with the influx of medically trained staff. The National Board of Health and Welfare reported again in 2005 that most of the mental health knowledge in municipalities rested in direct care functions carried out by former health service staff, and that there was a need to develop a wider role of social work in mental health. Over half of social workers lacked mental health training, and most training that did exist was medical, concerning diagnosis and treatments.851 Unlike Britain, social workers in Sweden lacked defined mental health roles; municipalities often restricted social workers to traditional administrative functions of assessment and authorisation.852 The Mental Health Tsar in 2006 criticised social work degrees for lacking mental health content; in most degrees mental health study was an optional short course.853 Thus the issue of the social work role and professional social work training and social methods/perspectives in mental health was a recurring theme of the reform and one that the government chose not to resolve. Summary: Government attitudes to the social work profession The government appeared not to have been influenced by professional considerations when formulating the reform; in particular no role was created for social work as social services’ main profession. The influence of professions appeared to be minimal with staffing arrangements mostly left for local decision-makers to determine, often influenced by the expediency of solving two agencies’ staffing problems by a simple staff transfers. Staffing issues and need for professional social work inputs to the reform were identified in 850
In addition, the Ädel reform for elder and disability care had increased medical staff in municipalities from 700 to 11,000: See Socialstyrelsen 1999a pp. 215-219. 851 Socialstyrelsen 2005 pp. 142-146. 852 Socialstyrelsen 2005 pp. 177-180. 853 There was no compulsory mental health content on Socionom degrees; most were optional short courses containing 9-15 taught hours: SOU 2006:100 p. 457.
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the reform evaluations for the following decade, but there was no change of government policy to define professional roles and responsibilities in greater details. Thus the government does not appear to have considered the reform in terms of specific professional roles, knowledge or expertise at all.
Influence of the social work profession in Sweden The limited amount of previous research in this field revealed the mental health reforms did not appear to be an issue of major importance or priority for Sweden’s social workers. The profession did not appear keen to expand its power or exert influence in mental health, either as an issue of professional expertise or municipal social policy. Lindqvist et al argue that mental health social work and social perspectives have been difficult to establish, as social work with the psychiatrically disabled often has low status within social services departments.854 In his book on the implementation of the mental health reforms in Swedish municipalities, Markström writes: Established professions with Social Services Departments, for example social workers, have shown little interest in expanding their domain through the psychiatrically disabled as a group.855
Thus according to prior research, the strongly social perspective envisaged by the 1992 Mental Health Inquiry did not become reality and social workers did not appear to perceive mental health as a prioritised issue. My research generally supports the view of the previous research that the mental health reform was not generally regarded by the social work profession as a key issue for influencing government policy and steering choices. The review of SASW’s governing board minutes revealed that the mental health reform was not discussed at board level, nor were there discussions regarding how SASW could influence or enhance the reform’s social work role, despite these years representing critical time periods for the reform. The bulk of SASW governing body meetings appeared to focus on either traditional trade union issues such as pay negotiations and membership expansion. Professional issues involving influencing government were dominated by professional education, the quest for state-authorisation; later the minutes focussed on the SASW’s own self-authorisation scheme.856 An additional review of 10 years of the Swedish Association of Social Worker’s newspaper Socionomen revealed similar results. There was little discussion of the reform as a social work issue or the social perspective or role in mental health.857 The mental health reform did not appear to be the professional 854
See Lindqvist et al 2010 pp. 113-115 & 134. Markström 2003 p. 225 (my translation). 856 Based on a review of all Akademikerförbundet-SSR governing body minutes January 1993– December 1995 & January 1999–December 2000 held at the TAM-archive. 857 Review of Socionom: January 1992 to December 2001. 855
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agenda in Sweden and the reform did not appear to be considered as an opportunity for social workers to expand their professional jurisdiction and influence. However, there were some attempts to influence the reforms and in the two following sections I evaluate the ways in which the profession attempted to influence government steering. Influence of the Swedish Association of Social Workers The reform was not an issue of prioritised debate within SASW; however, there were some attempts to influence the direction of the reform and the choice of steering strategies. As in Britain, SASW favoured state social work authorisation as a mechanism to increasing professional status,. SASW also replied to government’s reform consultations (remiss) on aspects of the reform. SASW responses expressed the need for increased social perspectives and competence for the reform and emphasised the new Personal Representative role should be reserved for qualified social workers. However, SASW argued than social workers must receive special training and supervision for these roles.858 An examination of SASW responses to consultation exercises in 1992, 1999 and 2007 reveals three main themes and arguments that were used in attempts to influence government: the need for a defined social work role; the need for Personal Representatives to be social workers; and the need to link state-authorisation to the reform.859 The attempts to influence the government were often based on generic arguments of social work being the automatic choice of profession. The argument was based on the mental health reform being a municipal, social services reform, and social workers being the dominant municipal social services profession; social work was therefore, the obvious and most suitable choice for a leading reform role. However, these arguments were mainly organisational, based on social work’s municipal position; yet the SASW did not claim particular expertise and skills in mental health: on the contrary the need for special training programmes was emphasised. Defined social work role The Swedish Association of Social Workers argued strongly that social workers by virtue of their training and experience in social perspectives were most suited to leading reform roles.860 In the Association’s submission to the government in 1999, it argued that social workers needed to be given an enhanced reform role and that the profession’s knowledge of legal, organisation and psycho-social methods made them an ‘invaluable resource’ and that 858
See Socialdepartement (The Social Affairs Department) DS 1993:88 pp. 36 & 60. Akademikerförbundet-SSR remiss 1999; Akademikerförbundet-SSR remiss 2007. The 1992 remiss for was not in the archived consultation paper boxes for the period but was cited in the Association’s Governing Body Minutes FS 10-20/11-94 FS§ 3b/Annex § 3b. 860 See Ds 1993:88 p. 36 & 60; Akademikerförbundet-SSR remiss 1999; Akademikerförbundet-SSR remiss 2007; Akademikerförbundet-SSR FS 10-20/11-94 FS§ 3b/Annex § 3b. 859
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social work roles should be prioritised.861 This view was reiterated in 2007 in response to the Mental Health Tsar’s report where the SASW argued that municipal mental health services needed improved social work roles and methods, such as evidence-based social perspectives.862 Therefore, the SASW attempted over the course of the reform to influence the government to steer the staffing issues and create a specific social work reform role, rather than leaving the choice of professional competence as an issue solely for municipalities. However, in many ways the arguments appeared to be generic ‘Trade Union’ arguments based on social services being their members’ jurisdiction, rather than concrete and specific claims to professional knowledge and expertise in the mental health field. The Personal Representative scheme (Personligt ombud) The Personal Representative scheme was the strongest social work reform role created by the government; a casework role, based on social work methods. However, it was located outside mainstream municipal social services departments’ structures of. SASW attempted to claim occupation jurisdiction; that the role be reserved for graduate social workers and arguing that social work was the only suitable profession and therefore, the role should be reserved for professionally qualified social workers: The Swedish Association of Social Workers believes that the proposal on personal representatives can only be accepted on condition that representatives are well-qualified social workers who must be offered supervision and training.863
This argument is interesting, as although the association argues that the government should reserve the Personal Representative role for social workers on the basis that it is a natural social work role, yet the argument is not based on specific, professional expertise, knowledge and competence. In 1999, the Association, while acknowledging the positive results achieved by the separate and multi-disciplinary Personal Representatives pilot projects, was also opposed to the Personal Representative role being made permanent in separate structures, questioning the need for a separate organisation for reform social work.864 Thus again the attempts by the profession to lobby and influence government were based on reserving the role for their members and bringing it into SASW’s traditional municipal arena of operations. The reform & state-authorisation of social work The SASW also attempted to use the reform as a means to influencing government in its wider professional campaign to have social work accepted by Akademikerförbundet-SSR remiss 2007 pp. 1-4 (citation – my translation). Akademikerförbundet-SSR remiss 2007 pp. 2-3 & 9. 863 Akademikerförbundet-SSR remiss 1992 cited in FS 10-20/11-94 FS§ 3b/Annex § 3b. 864 Akademikerförbundet-SSR remiss 1999 p. 7. 861 862
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government as a state-authorised profession. As previously discussed, SASW applied and was rejected twice by government commissions examining state-authorisation of professions in the 1980s and mid-1990s. In 1998 the Association took the decision to develop its own self-administered authorisation for social workers.865 Thus the Association attempted to use the reform to add additional weight to its claim for government authorisation. SASW also linked the reform to the issue of state social work authorisation, attempting to influence government steering to introduce formal regulation of professional certification. SASW argued in the 1999 consultation exercise that there was a risk that the municipal mental health was too medicalised; thus the government needed to establish a defined social work role and status by creating state-authorisation of social workers.866 The argument was repeated in 2007 in a response to the Mental Health Tsar report, where SASW asserted that the government needed to improve the status and prominence of social perspectives that were often regarded as secondary to healthcare professions. SASW argued that to achieve parity, that social workers needed to be authorised with protected job-titles to guarantee a nonmedical perspective in reform services:867 A problem within mental health that our members bear witness to is that the social perspective in many places is not valued as highly as the medical perspective. One reason for this may be that social workers as a group lack authorisation. Generally today all other occupational groups in healthcare with academic degrees have occupational authorisation.868
Once again the Association attempted to influence the government in its general state-authorisedisation campaign through mental health. The general arguments were mainly based on jurisdictional closure, by restricting social work roles to qualified social workers, and also with reference to differential state behaviour to other groups with similar qualifications and roles. Alternative professional influence issues As the role of the Swedish social work profession was poorly defined regarding state-social work relationships, I reviewed other arenas such as journals and newspapers to determine whether there were alternative forms of professional influence exerted by the profession through other forums such as professional journals and media campaigns. However, in general terms I 865
See FS 21/1-99§10. The self-regulated professional authorisation scheme introduced by the Swedish Association of Social Workers set up an independent authorisation committee to deal with applications. Social workers must have a social work degree, three years work experience as a social worker, approved supervision and letters of support from two referees on the applicants’ suitability as a social worker on the basis of two years’ experience: Nämnden för Socionomauktorisation website (accessed 27/7-10). 866 Akademikerförbundet-SSR 1999 p. 9 relating to consultation on Socialstyrelsen 1999a. 867 Akademikerförbundet-SSR remiss 2007. 868 See Akademikerförbundet-SSR remiss 2007 p. 9 (my translation).
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conclude that there was relatively little interest in the mental health reform among social workers; despite mental health being a major new municipal social services function, few social workers appeared interested in being actively involved in the reform or mental health as an area of professional expertise. An editorial in the professional magazine Socionomen in 1999869 criticised the profession’s lack of reform engagement, admonishing social workers for their lack of interest in the psychiatrically disabled as a socially excluded, low-status, deprived and ‘unfashionable’ group. The article asserted that the reform had been about developing mental health social perspectives, yet social workers had been a silent and inactive voice in the reform and needed to raise their profile as the voice of social perspective: [Q]uietest it seems are social services themselves. No resignations from social workers and leading managers. ... The question is how it came to be that the social perspective of mental disorder cases and treatment disappeared. ...The question is how it came to be that social services felt so little pride over this type of activity and their results. 870
Thus the professional press felt that social workers had ignored the reform as issues of professionalisation and jurisdictional influence. It is certainly the case that my review of the professions magazine revealed very little debate on the social perspective and social work influence in the crucial reform formulation and early implementation years between 1992 and 1996. There were isolated examples of mental health interest in the social work press, such as themed mental health issues in 1996 and 1999; yet articles often focussed on medical perspectives, causing some letters to question whether social work had become assimilated by medical values.871 There was, however, coverage of social workers setting up a forum for social psychiatry,872 as well as discussion of Personal Representatives, although some social workers questioned the need for new structures to protect the psychiatrically disabled’s interests and rights against municipal social workers and county health services.873 However, it appeared that social workers interested in mental health also pursued these interests in other (licensed) professions such as psychotherapy. In 1994, 17% of newly authorised psychotherapists held social work degrees.874 Social work did not appear to see mental health as a means to establish its professional interests. Those interested in mental health often chose career paths outside traditional municipal social work
869
See Socionomen 2/1999a p. 2. Socionomen 2/1999a p. 2 (my translation). 871 Letter 3/1999. 872 The forums were designed to spread information and share knowledge and research on service developments, Although it was unclear what it achieved: See Socionomen 2/1993. 873 Socionomen 2/1999b; Socionomen 3/1996. 874 Socionomen 6/1994. 870
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such as casework roles as personal representatives or professional psychotherapists. Social work also appeared to find difficulty establishing its role in power struggles with the medical profession where the clash of culture, methods and structure found social workers marginalised in the debate. While Britain’s social workers had a guaranteed position for their social and nonmedical perspective, Sweden’s social workers found that the social perspective was derogated by the Swedish medical profession; doctors dominated the debate and questioned social workers’ professional competence:875 How should social services, which by its nature is primarily administrative and an official authority, be able to ... ‘take over’ from medical psychiatry?876
The negativity of the medical profession to social work and social services was played out in the national media, in particular on the debate pages of national daily newspapers. In one famous exchange, psychiatrist Markus Heilig argued that the reform was dominated by political ‘dogma’, claiming that municipalities lacked knowledge and competence. He argued for a return of the asylum and sole responsibility returned to psychiatry as the only competent profession capable of providing mental health services owing to its culture of “respectful care and responsibility”.877 A heated debate followed, with many letters and articles that failed to share Heilig’s nostalgia for the “caring asylum”. It was also pointed out that psychiatrists had key reform roles through discharge decisions, in some case releasing patients despite no housing being available.878 Thus there were criticisms from all sides of the reform,879 and both professionals and agencies were accused of being too bureaucratic, “big obstacles and little help”.880 The murder of Foreign Minister Anna Lindh in 2003 reignited this inter-professional conflict,881 with Heilig reasserting his view that county psychiatry should take over the 875
See Socionomen 2/1997 pp. 20-21; Socionomen 1/1998 pp. 61-62; Dagens Nyheter 13/11-04. 876 See Socionomen 2/1997 Lindberg & Wahlström p. 21 (my translation). 877 See original debate article written by Heilig: Dagens Nyheter 10/10-99. See also TT 10/10-99; Dagens Nyheter 21/10-99. 878 Dagens Nyheter 17/10-99; Dagens Nyheter 21/10-99; Dagens Nyheter 18/1-00. 879 Some criticised Heilig’s perspective and argued that most psychiatrically disabled persons had a better life outside the asylum. Users and user groups were especially critical of Heilig, and few wanted the asylum to return and argued that poor access to county psychiatry was a major problem. See discussion in Dagens Nyheter 3/1-00; Dagens Nyheter 8/1-00; Dagens Nyheter 9/1-00; Dagens Nyheter 10/2-00; Dagens Nyheter 24/10-99; Expressen 14/8-99; Expressen 8/10-99. 880 Dagens Nyheter 8/6-03. 881 See Dagens Nyheter 21/5-03; Expressen/GT 25/5-03; Expressen 2/6-03; Expressen 3/6-03; TT 12/9-03; Dagens Nyheter 26/9-03; Dagens Nyheter 27/9-03; Dagens Nyheter 28/9-03; Dagens Nyheter 30/9-03; Expressen 30/9-03; Riksdag och Departement 6/10-03; TT 6/10-03; Dagens Nyheter 7/10-03; Dagens Nyheter 12/12-03.
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entire care chain from municipalities, whereas opponents argued that contrary psychiatry itself caused many problems.882 Therefore, social work expertise appeared to be regarded as less professionally important than psychiatry and that it was medical perspectives that dominated the debate and were given considerable space in the media.883 One issue was the low level of professionalisation for the mental health reforms. According to Lindquist et al, the municipal mental health services had low status; low levels of professionalisation and services were often dependent on asylum trained staff such as mental health assistants.884 The National Board of Health and Welfare report confirmed this view that municipal mental health services tended to be based on occupational groups with low levels of formal qualifications including care assistants (vårdbiträden); nursing auxiliaries (undersköterskor); or mental health assistants (mentalskötare). Only rarely did professional groups such as nurses, social workers and occupational therapists work in direct care.885 In addition, many of the staff recruited had medical training and had previously worked in asylums; as mentioned previously over 4,000 mental health assistants transferred from health to social services as a result of the reform. According to research by Markström and Lindqvist et al, the influx of medically trained staff institutionalised the medical perspectives of the asylum and impeded the development of social perspectives. In addition, there were conflicts with municipal social services staff who perceived that the status and culture of municipal social services as being undermined:886 mental health becomes “psychiatry steered”887 rather than socially steered. Markström argues that professional interest in mental health was low: municipal services lacked staff with professional competence or status. The lack of a high-status and high-legitimacy profession further complicated the implementation of the mental health reform. In many cases staff did not choose to work in mental health, staffing policy was based on forced transfers of surplus staff.888 [T]he new operation was forced to establish itself with surplus staff that were not recruited, in the first place, on the grounds of suitable competence or experience.889
882
Opponents of Heilig argued that county psychiatric services were also to blame for scandals by releasing patients too early and failing to provide adequate outpatient and acute services. See for example Expressen 3/6-03; Dagens Nyheter 8/6-03; TT 12/9-03. 883 This conclusion is supported by Magnusson’s findings that the media mental health debate was dominated by the medical profession: 2010 p. 176. 884 See discussion in Lindqvist et al 2010 pp. 99-115. 885 Socialstyrelsen 2005 pp. 142 -145 886 See for example Markström 2003 pp. 247-258 & 310; Lindqvist et al 134-139. 887 Lindqvist et al 2010 p. 115 (my translation). 888 Markström 2003 p. 184 and 225-226. 889 Markström 2003 p. 225 (my translation).
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Eriksson confirms the picture of a reform based on low professionalisation, arguing that there was often a strong Old Maid890 game (Svarte Petter) played as professional groups attempt to pass the buck of reform responsibility to less well-qualified and paid occupational groups.891 I concluded that professionally well-equipped groups could win conflicts within care organisations in terms of avoiding taking care of various types of unpleasant and taxing problems. Paradoxically it was often the case that relatively low qualified, semi-professional groups were forced to deal with issues that others had received extensive training to deal with. 892
Thus Sweden had no role in mental health to correspond to that in Britain where social workers had a clearly identified area of professional expertise in mental health through the ASW role. In addition, social workers did not appear to perceive mental health as an area of professional opportunity to expand their professional jurisdiction. Thus mental health was an area with weak professionalisation and low interest from social work professionals. Summary: Influence of the social work profession Therefore, we can see that the SASW attempted to exert influence over the government’s steering of the community mental care reforms. However, the attempts to influence were often general arguments relating to occupational domain. Thus attempts to influence the government tended to relate to social work’s status as the natural social services profession; maintaining boundaries with other professional groups who were encroaching into the field of social services; or links to general SASW campaigns such as professional authorisation. Yet specific interest in mental health appeared low among social workers. The Association did not stress actual, specific and concrete benefits to users, nor did they stress that SASW members had crucial, specialist and expert mental health skills; in fact SASW argued that social workers would need specialist training. Instead the arguments were focussed on more ‘trade-union’ issues of members’ rights and jurisdiction. However, as we already saw from Chapter 3, the association’s strategy was not successful; reform steering was soft and neither the concrete and restricted professional roles promoted by the association, nor the demands for state professional authorisation resulted in government change. Social work’s influence was further restricted by two factors: firstly that psychiatrists, doctors and medical perspectives dominated the debate, and many asylum staff transferred to social services thereby undermining the establishment of social perspectives. The second issue was that social workers in general appeared uninterested in mental health; my analysis did not reveal mental health to be a key issue to the profession, and there was little debate on social work roles 890
Old Maid is usually referred to as Svarte Petter in Sweden. Eriksson 1998 pp. 128-129. 892 Eriksson 1998 pp. 128-129 (my translation). 891
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and social perspectives relating to mental health. There were generally low levels of professional input and influence in the services created.
Analysis: professions, influence & the mental health The reviews in the preceding sections reviewed attempted to discern patterns of professional influence that may influence governance and steering strategies. This influence has been examined from two main perspectives; the first relating to the general way in which the government is influenced by the existence of particular professions in terms of general attitude or need to identify certain tasks as professional roles; and secondly concrete influencing attempts by the profession to lobby or campaign for certain professional interests and norms that would require the government to adopt hard or soft steering strategies. Using the analysis instrument developed in Chapter 4, in the following sections I compare and contrast the results for Britain and Sweden in order to determine the extent to which the influence of professions may help us understand governance and steering strategy selection. Basis of influence The results of the basis of influence in Britain show a mixed pattern. There was reduced trust and increased state control, yet mental health social work had its own status which was recognised and accepted by the government, and the role was retained for the decade after the reform. However, the profession’s own attempt to influence was harder to determine as divisions between BASW and unions meant that the profession did not speak with a single voice which made professionally regulated influencing strategies hard to achieve. In addition, there was widespread criticism that BASW itself was fairly passive in relation to the reform and did relatively little to exert influence over government. Therefore, the main trend was towards the stateregulated professional roles where the government accepted the profession’s authority within the field, yet the professional influence was under state control. In Sweden on the other hand the professions appear to have exerted little or no influence over the reform at all. The government does not appear to have considered the reform in terms of a professions-led reform based on social work skills. There was no discussion of professional roles and staffing decisions were devolved to local agreements and negotiations between actors. This resulted in a reform with an exceptionally low degree of professionalisation for a welfare reform, perhaps reflecting the low status of mental health in general and the lack of specific social work expertise in Sweden to mirror that in Britain. In many respects the Swedish reform conforms most to the pretermitted professionalism model where governments simply do not consider professions at all. The SASW attempted to influence the government using general arguments that a reform role should be reserved for so261
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cial work, yet these arguments were often couched in trade union terms rather than being based on specific expertise. Thus social work in Sweden had a low influence; soft steering resulted from government indifference to professional roles rather than an expression of trust in professions. Control of work In the British reform the control of work displayed an increased stateregulation role, although it was not always the same form of regulation; the Conservatives focussed on social workers playing market management roles whereas Labour emphasised risk-management. The government attitude to social work was an increased regulatory influence approach; there was recognition of social work’s role, especially in mental health and through the ASW, yet there was increased focus on state priorities. Social work proved unable to regain its status as an influential bureau-profession and exert professionally-regulated influence. The contracting out of direct care services reduced the traditional, professional casework and counselling roles, and forced social workers into state-determined roles. In Sweden the government’s failure to consider professional roles meant that the control of work was neither an issue for state regulation nor granted to the profession to decide. There was no issue of control of work as the government did not have a role in influencing the content and ambition of the reform’s social roles as each municipality developed its own services. Direct influence The level of influence in the case of Britain gave somewhat mixed results. When it came to the government attitude to social work, generally for social work as a whole there was influence based on the state-controlled managerial focus and in the long-term the increased professional crowding in the mental health field as other professional such as nurses increased their activity. However, mental health was an area where the government accorded social work considerable influence through recognition of the specialist ASW role. Even though this role had been created through legislation, it was an important basis of status and gave social work and the social perspective a guaranteed place in the reform’s short- and long-term implementation. When it came to the profession’s own influence, there were many criticisms within the profession of the weak role played by BASW and the failure of the profession to defend social workers’ interests against other professions and government. The divisions between BASW and unions were problematic; the BASW’s professionalisation approaches were denigrated as “elitist” by the trade unions. There was also a loss of influence to management-focussed social work associations. Overall, however, the profession appeared conform to the state-regulated model of influence; however, the strong legitimacy granted to ASWs also demonstrates a degree of professionally regulated influence. In Sweden again the lack of consideration of professional roles 262
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meant that social work had little influence. The main consideration of government was the pragmatic and expedient management of staff transfers from county health to municipal government, even though this meant using staff trained in the medical model to develop social care services. Social workers often had few direct contacts with reform users as a result of role filled with medical staff; thus social workers often remained in traditional jurisdictions of administrative assessment and authorisation roles. Basis of professional control The issues relating to professional control represent the dilemma for professions of the trade-off between securing state-recognition and maintaining control over their own affairs and direction. In both countries the social work profession lobbied for decades for state-authorisedisation schemes as a means of obtaining a state-sanctioned professional monopoly so that there were rules and specified qualifications for who could call themselves social workers and where certain tasks and functions were reserved for registered social workers only. This had benefits for the occupational closure and the creation of legitimacy for the profession. However, he profession’s own norms and values regarding central professional issues meant that it would be important for the profession not to lose control of its own professional development and direction. Especially for a weaker public sector professions that may have lower bargaining powers that the stronger traditional free professions it would be a serious loss of professional status if professionally determined values replaced with values focussed on state-priorities. In Britain the traditional divisions between trade union and BASW professionalisation strategies meant that social work did not speak with a single voice. Yet social work had achieved a state-regulated specific occupational monopoly and jurisdiction in mental health since the creation of the ASW roles in 1983. Under the Conservative government there was no state control of the profession, whereas the Labour government introduced a stateregulated influence through the GSCC. This proved controversial within the profession as the GSCC was not the type of professional body that BASW and social workers had envisaged: social workers were a minority on the GSCC board and lacked influence. In addition, the profession lost control over a central element of professional influence, the Code of Ethics. The Code of Practice produced by the GSCC did not emphasise the professional values and ethics of professional social work practice that the profession had lobbied for. Instead, the GSCC code was narrowly focussed on control issues such as disciplinary and risk-management roles for social workers. Thus there are currently two codes in existence for professional social work, the obligatory code for registered social workers produced by the GSCC, and the professional code produced by BASW, Therefore, although the GSCC created a professional monopoly it was focussed on state rather than professional objectives and the existence of competing codes for the profession, reveals 263
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the low level of influence of BASW. In Sweden, despite considerable lobbying by the profession, the government failed to consider social work on equal terms as healthcare professionals, or even estate-agents. The government did not regard social work as requiring state-authorisation, perhaps reflecting the inability of social work in Sweden to establish a separate professional identity from municipal administration. SASW introduced its own voluntary, selfregulated, authorisation scheme although this was considered a lesser option as it did not create a professional monopoly.
Conclusions: influence of professions on steering The analysis of the historical development of the state-social work relationship shows some interesting differences; however, the results do not fully accord with my theoretical elements, mainly owing to the Swedish government ignoring professional roles in its mental health reforms. Therefore, my findings are that while Britain broadly conformed to the element of stateregulated professional influence based on a general influence of professions and usefulness of the profession as a steering instrument, in Sweden the level of professional influence on the reform was imperceptible, as the government failed to recognise professional roles at all.
Conclusions: professional influence in Britain In Britain the modes of influence of social work on the reforms steering to a large extent fulfilled a form of influence based on state-regulated influence. The profession had a strong reform presence through the social work roles and the state recognition of social perspectives in mental health through the creation of the powerful ASW role. However, this high degree of state recognition and legitimacy was regulated by legislation rather than based on the flexible trust-based relationships of professionally regulated influence. There was also a divergence between general social work whose professional status was undermined by market mechanisms and managerial roles, and mental health social work which retained a strong reform presence and status. The historical legacy appears important as social work developed early as a profession based on multiple specialisations in separate agencies, where mental health was an early area of specific mental health competence. Social work also developed as a bureau-profession in the post-war era, although professional divisions and changes in political attitudes to welfare expenditure also reduced the scope for social work influence. However, social work had a pre-existing mental health role through the ASW function. The government’s decision to retain this role at the time of the reform is evidence that the government’s decision-making was influenced by professional social 264
Professions
work, even if that influence was more instrumental as a handy steering instrument, rather than traditional values, trust and discretion. When it came to the reform, the profession itself exerted only weak influence, which was criticised within the profession. The divided nature of the profession was problematic as social work spoke with several and conflicting voices: the main professional association, BASW, focussed on professional issues only and had no role in pay and conditions; yet the trade union opposed professionalisation. Thus attempts to influence government strategy consisted of mixed messages from the profession. It was unclear what roles BASW wanted to play: its stated aim was to be a ‘professional’ body, but owing to the divisions it had no role in pay and conditions, and wanted the state to run registration and disciplinary proceedings, usually central issues of influence for professions. However, BASW had a difficult professional balance, given the long tradition of animosity to professionalisation. Yet abdicating influence over the disciplinary system was also a high risk strategy for BASW; when the state intervened and established the GSCC, there was dismay at the overt disciplinary focus and the marginal role of social workers. Therefore, BASW’s role and influence was unclear and in addition, BASW’s legitimacy as an actor was weakened as a result of the association only representing a minority of social workers. The government created professional roles, but increasingly formulated them using central priorities, focussed on organisational interpretations with legislated and state-defined roles; with emphasis on managerial and administrative systems; with state control of social work education and training; and after the creation of the General Social Care Council; with state control of the social work profession. Yet while it is clear that there was state domination, it is also clear that the state was influenced by social work as a profession; even though the government was essentially hostile to the concept of social work, it created specific social work reform roles and retained an occupational professional mental health monopoly for ASWs for the period examined in this book. However, the recent creation of AMHPs may weaken this influence. Therefore, the ‘harder’ steered and legislated social work roles were also sources of professional influence for British social work: the guaranteed and statutory ASW role gave social work occupational jurisdiction over certain parts of mental health, which in turn resulted in higher status and pay for specialist ASWs as well as conferring power in relationships with other professions. Therefore, in Britain the influence of social work generally was mixed. Social work did not always defend its professional boundaries, leading to a decline in status and influence in certain areas and the encroachment of other professions into social workers’ traditional domain. The loss of the ASW monopoly as a result of the creation of the AMHP role may lead to further decline. Thus although there were strands of occupational professional influ-
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ence, especially in the ASW role, in general the influence of the social work profession was due to state-regulated professional influence.
Conclusions: professional influence in Sweden In Sweden social work appeared to have little or no professional influence over the governance and steering strategies for the mental health reforms and does not fit the criteria of professional influence for either of the models that I developed in Chapter 4. Instead the relationship between government and social work profession in Sweden appears to fulfil the criteria of pretermitted professionalisation where the government ignored or disregarded the profession and failed to consider social work as an influence at all. So how can the complete lack of professional influence be understood? In some respects the historical background of social work in Sweden provides several clues to the lack of influence. In Sweden social work’s professional identity developed late and it was not recognised as an independent academic discipline until after 1980. Indeed its historical development as a subdivision of municipal administration led to a legacy of bureaucratic focus with professional methods such as casework coming late. In addition, social work in Sweden did not have the British history of developing in specialist organisations based on specialist knowledge and expertise. Therefore, the historical legacy was that social workers in Sweden appeared on the one hand to be less equipped for strong influence in mental health. However, in the decade prior to the reform decentralising policies and the use of framework legislation created opportunities for Sweden’s social workers to develop mental health as a new professional domain, yet they chose not to. The analysis of the actual reform areas also shows a low level of influence in both directions between state and profession: the government did not consider the reform in terms of professional roles and developing a social perspective, yet neither did the reform appear to be a central issue for social workers to develop their professional domain. So how should we understand this? The general influence of social work’s professional association appeared low for the reform, although SASW demanded social work reform roles. SASW focussed on “trade union” arguments rather than specific issues of professional competence. The reform did not appear a major issue for the SASW, more of a ‘means’ of jurisdictional expansion and closure, rather than a strong professional interest. A continuing problem was the lack of any specific social knowledge of skill in the mental health field. There was no corresponding role to the ASW role in Britain, and mental health remains an optional short course on degree programmes, covering just a few hours. Even SASW, when arguing for mental health roles to be reserved for social workers, admitted that extensive training would be needed, thus the profession lacked professional competence in the mental health field.
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The Swedish government appeared to have an ambivalent attitude to the social work profession in the reform. The government’s actions also undermined social work’s reform role and social services professions appeared to be of secondary importance. Despite the mental health reform being a major municipal social reform where social work was the major profession, the government did not create a defined professional role and avoided recommending a clear policy for professional input to the reform in four respects. Firstly the reform lacked the strong social perspective or vision of the 1992 Mental Health Inquiry. In Sweden there was a major social reform, yet no guaranteed place for non-medical social perspectives with defined roles and responsibilities created, and the issue of professions and professional competence required for mental health social care was devolved to municipalities to decide, despite the government identifying that municipalities lacked mental health knowledge. Secondly there was evidence that pragmatism and horse-trading dominated. In a deal with local government employersassociations, the government encouraged the transfer of thousands of surplus medical staff from asylums, thus solving employers’ problems, but restricting social development when most staff were medically trained. Thirdly, psychiatry remained influential by making the key decisions, such as determining which patients were ‘fully medically treated’. Doctors still dominated the debate and care-chain decision-making in Sweden as there was no independent role for social workers such as that played by ASWs in Britain. Finally, the government created a new mental health casework role (Personal Representatives), yet it was organisationally separate from the municipalities responsible for the reform, which medicalised the new social care services. The government did not appear to consider professions or social perspective in the construction of reform roles. In addition, one of my main conclusions is that social workers themselves appeared uninterested in the reform. Judging from the discussion in the Swedish social work press it appears that few social workers were actively and professionally interested in developing mental health as a social work domain. Unlike Britain, it does not appear that mental health was considered an issue of central professional importance or potential jurisdiction for the Swedish profession. Instead, social workers appeared to ‘opt out’ of the reform. With the exception of a few mental health enthusiasts,893 most social workers preferred to remain in the traditional, welfare administration roles, while the newly recruited former asylum staff dealt with user-contacts. This may suggest that some of the earlier issues of professional identity remain.
Referred to by Markström 2003 as eldsjälar, literally “souls on fire” to depict those with a real or burning enthusiasm for mental health. 893
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Conclusions: the professional influence dimension The conclusions of Britain and Sweden that I have discussed reveal that the professional influence dimension has been more difficult to apply compared with the previous dimension on administrative traditions. Thus I must consider whether this was due to specific characteristics of the profession or reform context, or whether I need to consider whether theoretical assumptions of this dimension of the triad of influence need to be reformulated or developed further to improve applicability. There are specific areas of the case of municipal social work and the mental health reforms which may have contributed to the low professional influence. Mental health and psychiatric disability in general is considered to be a low status area within social work practice compared with working with children, the elderly and physically disabled. Therefore, the nature of the work may have been less attractive to general municipal social workers; certainly Markström 2003 found a general lack of interest among Swedish social workers for creating mental health as a new occupational jurisdiction. There is also the issue of social work as a weak profession. There is little prior research in this area; the operational culture of social work within the politically, and committee-steered social services department may put social work at a disadvantage when it comes to professional influence compared to professions operating within professionally steered organisations such as healthcare. In addition, my study has revealed that in contradiction to professional theory, state-authorisation is a major issue for social work and possibly other weaker professions that look to the state for recognition and legitimacy. Thus this is an area where more research is necessary in this area. For example the mental health reform would be analysed from a wider professional perspective to include psychiatry or nursing. Another alternative would be new comparative case studies analysing other reforms to further develop knowledge on the influence of stronger and weaker professions. I must also consider whether the results of this chapter should result in a reappraisal of the model. The decision to focus on the main profession in the field of municipal social services may mean that other professional influences were lost. For example the documents analysed for this chapter have made several references to the medicalisation of social services and the influx of nursing and other medically trained staff. This occupational crowding may have blurred boundaries between professions making it difficult for a single profession to claim jurisdiction and thereby professional influence over the mental health domain. In addition, a very strong profession, psychiatrists stood on the boundary of municipal services. Although I found no evidence of doctors’ active involvement in social care, doctors were often central decision-makers regarding discharge, admissions and treatments, thereby forcing municipal professions into subsidiary roles, reacting to the decisions of other professions. Another possibility is to broaden the category 268
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to cover all types of staffing. It appeared that staffing issues were a central reform feature in both countries, yet this did not always directly concern professional staff but had an impact on the professional sphere. The deprofessionalisation of direct care services had widespread influences. In Britain the privatisation of direct care services removed the main professional activities involving counselling and therapies with users valued by the social workers and central to their perceived professional identity. However, in Sweden, staffing issues were driven by pragmatic considerations. The government and local government associations saw transfers municipal employment as the perfect solution for the thousands of asylum staff who became surplus to requirement as a result of the reform; counties could transfer surplus staff and municipalities would obtain experiences mental health staff, albeit experienced in the medical- and asylum models. However, the transfers also created cultural conflicts with existing social services staff and the influx of medical staff hindered the development of social perspectives. In many cases social workers chose to remain in existing and familiar assessment and authorisation roles, while the medical staff in some cases merely recreated ‘the asylum in the community’ based on inflexible, institutional care. Therefore, these complex issues are topics for further research.
Final conclusions: professions & governance strategy My findings in this chapter are that the influence of professions differed. While in the British case there was some influence, in Sweden no influence was identified. This leads to conclude that professions were less influential than the previous dimension examined: administrative traditions. On the surface the development in both countries looked similar. Social work developed from charitable origins to become welfare professions, located primarily in municipal social services departments. However, these surface similarities obscure significant differences. British social work was early to ‘professionalise’, developing a strong social work professional identity through casework methods such as and mental health competence, as well as an identity and role in the post-1945 welfare state development. This position weakened from the 1970s owing to increased generalism and divided professional organisation. However, the strong social work role in mental health turned out to be a resilient feature of mental health Britain; at the reform’s start there were defined and legislated social work roles under the Mental Health Act. Although this means that social work was regulated through ‘hard steering’ strategies, paradoxically this legislated position appears to have created the conditions for higher status and greater powers for social work in Britain. In Sweden, on the other hand, social work appears to have had more difficulty in creating a separate identity and lacked an independent voice. Roles and functions were often constructed in administrative terms and social work was not an independent discipline prior to 1980, but 269
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was included in public administration degrees; thus at times the profession has found it hard to remove the administrative ‘label’. In addition, Swedish social work lacked a municipal mental health tradition or specific socialpsychiatric qualifications and training. However, unlike British social work, the profession in Sweden was more united and professionalising at the time of the reform with social work newly established as an academic discipline and the Social Services Act creating flexibilities and freedoms. In Sweden there was already soft steering and the mental health reform represented an opportunity to develop new occupational professionalism based on a major new area of jurisdiction being transferred to the sphere of social services. However, the government failed to acknowledge or legitimise the role of social work, so there was little influence. Therefore, neither country represented the bureau-professional ideal of profession-regulated influence: Britain displayed the state-regulated professional influence model, whereas the Swedish government did not consider the reform in terms of professions. However, just because in this case social work did not exert a significant influence on governance and steering, the model of the triad of influence is not necessarily undermined. The idea of national policy styles as a triad of influence over steering and governance choices is that the three dimensions might influence and combine in different ways depending on sector, case, profession and country, thus leading to different results. In the British case the existence of a profession with longstanding knowledge, expertise and pre-determined statutory role appeared to have a certain degree of influence over reform steering instruments. The Swedish government appeared to adopt strategies of pretermitted professionalism, which I discussed in Chapter 4, whereby the role and influence of professions are neglected or ignored. This also corresponds with the findings of Winblad-Spångberg894 in the case of doctors and healthcare reforms. Thus one possibility is that professions are not a strong influence on the Swedish national policy style. Thus my conclusion is that the soft steering in Sweden cannot be attributed to the influence of professions, as despite the intention to create social care services at municipal level, the government appears uninfluenced by social work, or indeed any specific profession. This is a case of paradoxes challenging some aspects of the professions literature; I identified several issues that may be worthy of further study from a professions perspective as my findings refute some aspects of professions literature. This may be related to the public sector context, the low status of mental health, or that “weak professions” have different attributes in comparison with the 19th century free professions: Professional traditions and legacies: There is a paradox that the British government, despite its ideological hostility to social models, services and social work, was sufficiently influenced to create a strong reform role whereas in 894
See concluding discussion in Winblad-Spångberg 2003 pp. 207-219.
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Sweden, the profession was ignored as policy influence; thus traditions may play a role. As in the previous chapter on administrative traditions, I found that professions have their own traditions and legacies that may impact on influence. It perhaps brings into question some of the standard professions research on professionalisation processes whereby professions can change status by undergoing certain steps. My findings were that path dependency from the historical legacy was an important and resilient feature, such as mental health specialism in Britain and the administrative focus in Sweden. Specific competence: my study also found that generic professional status appears not to be sufficient for influence; a profession needs to demonstrate specific and concrete relevance to the policy sector. Britain had longstanding mental health expertise, whereas Swedish social workers often had no specific training and were sidelined from the reform. Government recognition to confer legitimacy? The social work profession in both countries desired state regulation as a means of legitimising the profession and increasing status. Both BASW and SASW lobbied for staterecognition, although when the GSCC was created in Britain, there was much less focus on professional values than BASW had envisaged. However, the issue of state-authorisation suggests that for 21st century public sector professions the state has a central role in legitimising the profession. In addition, the state’s role in creating an occupational jurisdiction over certain areas may be a significant source of professional power and authority. This contrasts with the 19th century private practice ideal, yet nowadays even traditional free-professions such as medicine are licensed by the state. Politics & ideology: a final conclusion is that public sector professions cannot be fully independent of the underlying state values and ideology. In particular the influence of social work and the social perspective is inextricably most directly tied to the prevailing culture of the welfare state and the roles the state perceives necessary for the state to play.
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Chapter 7
Policy framing The policy framing dimension refers to the use of language and symbols in order to construct a particular story or frame for policy issues.895 This chapter studies how the underlying care ideology of Britain and Sweden may have acted as frames that influenced the differing governance and steering strategies identified in Chapter 3. The review of theoretical literature on policy framing in Chapter 4 revealed three main framing dimensions: policy problem definition, user construction and the need for state action. The government’s perceptions of the nature of the policy problem and the reform users may influence the selection of internal steering instruments selected and how governments choose to steer the municipalities implementing decentralised reforms. Using the prior research on mental health care ideology, I constructed three theoretically-guided models of care ideology, which governments could use to frame mental health policy steering. Therefore, in this chapter I use the framework developed to analyse critical texts from the reforms in Britain and Sweden to determine whether care ideology frames can aid understanding of hard and soft governance strategies used to steer municipalities by creating a discourse of a need to act in a certain manner, or indeed the possibility of a need not to act. The pre-reform rhetoric of the 1980s discussed in Chapter 2 was often framed as a need to shift from the medical model of hospital and the asylum to ideas of a disability model based on normalisation and community living. However, my analyses in this chapter do not support the assumption that this shift occurred in either country. My main findings are that political framing does appear to influence the choice of governance and steering strategy adopted. This was most visible in the case of Britain where the analysis of texts reveals a significant framing shift to a distinct risk model ideology emphasising danger, policing and control. This appears to mirror the intensification of the hard steering mechanisms identified in Chapter 3. In Sweden care ideology was harder to discern; however, government statements continued to emphasise the medical model and healthcare’s continuing role in social care and services, underlying medical expertise and soft steering. Thus 895
See Stone 1989.
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my overall conclusion is that the way that governments frame a policy problem influences the type of solutions and steering that it adopts; thus policy framing does matter to understanding the choice of governance and steering strategy.
Policy framing: operationalisation In Chapter 4 mental health was discussed from a policy framing theoretical perspective, how the type of policy problem definitions or construction of prospective service users can influence perceptions of the need for certain types of state action and steering strategy. Thus policy-makers’ underlying discourse and framing may influence strategy choice.896 Also in Chapter 4 I developed three models for mental health care ideologies: a medical model; disability model; and a risk model. The key framing indicators of each model are summarised below: Table: 7.1 – Summary: Three models of care ideology897
Characteristic
Medical model
Disability model
Risk model
Problem identification
Mental illness & diagnosis
Disability & need for normal living
Public protection
Construction of user
Patient
Citizen
Criminal danger
Action required
Treatment
Support for user decisions
Risk-management
The models and indicators will be used as ideal-type frameworks to facilitate the text analysis.898 The three theoretical models chosen are not meant to be exhaustive, but focus on central frames and arguments to enable greater understanding of steering strategy selection and whether policy framing assists theory development and helps explain governance and steering strategy.
Operationalisation & method Policy framing involves the use of language and composition of narrative “stories” for governments to describe a policy problem, identify which actors 896
See for example Rein & Schön 1994; Peters 2002; Dorey 2005; Kelman 1981. These are the same care ideology models that were presented in Chapter 4, table 4.3. 898 Ideal-type models are formed from elements of a given phenomenon to refine complex phenomena to a number of key characteristics: See Bergström & Boréus 2000 pp. 158-165. 897
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are involved and thereby justify the government action and interventions. Thus policy framing consists of two processes: firstly a selection and presentation of “facts”, and secondly, a normative or moral interpretation, to interpret and assess the facts, apportioning causation and blame. Therefore, problem definition and user portrayal are central to the causal story of what action needs to be taken.899 The method that I have chosen to analyse policy framing is a text analysis of central texts produced by the governments of Britain and Sweden to determine how they framed their underlying arguments for the mental health reforms in three categories: problem identification, user construction and arguments for state action. I classify the government discourse into patterns or frames that may influence steering strategy selection, by focusing on policy texts produced by the government in order to analyse politicians’ framing rather than that of administrative evaluators. However, in order to focus intensively on government frames, somewhat paradoxically I start by analysing non-government documents: the original mental health Commissions and Inquiries. The reason for studying these reports is to determine a baseline; the initial government steering decision was whether to adopt the inquiry recommendations, or whether to shift to a different framing discourse. In addition, Stone argues that media reports that present “facts” may also shape causal beliefs to create pressure for specific frames. Thus I also conduct a brief media analysis to study whether media mental health coverage is reflected in government policy framing.900 There are different types of text analysis methods.901 Some focus on quantitative approaches to obtain patterns of word usage: for example the number of times Social Democratic and Labour parties use terms such as socialism and workers in policy statements. A second method is to focus on words and statements in the broader context of overall arguments and messages to determine a pattern. I have chosen this latter strategy as I believe that the context of terminology is important as the wider arguments are important to policy framing. The same word may have different meanings dependent on context and usage; thus a purely quantitative word count may mislead in these instances. However, I may comment on the number of words if the pattern of words is particularly unusual; for example the word danger is used 10 times in a single sentence in relation to mental illness, then may indicate a particular frame. Yet the presentation of the facts and arguments is important: do they focus on the danger of mental illness as a public protection issue linked to a risk model or the danger to users from society through a lack of rights and discrimination linking to a disability model. In addition, one issue needs care. I have observed a tendency for policy-makers to use 899
See discussion in Stone 1989. Stone argues that media reports can shape policy frames and can influence whether the policy issue is perceived as an individual or state issue: 1989 p. 293. 901 For detailed discussion of text analysis methods see Bergström & Boréus 2000. 900
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The Governance Gap user-related terms such as ‘psychiatric disability’, ‘mentally disordered’, ‘patients’, ‘clients’, ‘users’ ‘mentally disabled’ and ‘mentally ill’ as synonyms without taking account of the different value statements that these terms imply. Although the use of language is important and these terms may contain underlying symbols, it is not always a conscious value statement and framing. Thus usage must be examined in context of the surrounding terminology nuances which would be missed using word-counting methods. The framing discourses will be operationalised by examining central government policy texts in order to analyse and classify which model best corresponds to the texts’ arguments and language. It is important to recap that this book has a social care perspective and therefore, focuses on how social care services were framed. I do not analyse sections of texts relating solely to healthcare, medical or treatment framing. In Chapter 4 I identified three characteristics for each model: the problem definition of how policy-maker’s identify and define the nature of the problem to be solved; the user construction of how psychiatrically disabled individuals are perceived; the need for state action and how the state intends to act. In addition, I have identified words and terms associated with each model. Again it is important to note that my intention is not to carry out a detailed language analysis, but to adopt a broad brush approach in order to assess whether policy framing might represent a useful approach to the development of a theory that explains governance and steering strategy selection. Thus I assess which of the model most corresponds to government framing and how this may have influenced choices of hard or soft steering. The medical model This model is operationalised by analysing the texts for references to medical issues and government frames underpinned by the following arguments: Problem definition: the problem is defined in relation to the need for medical and psychiatric treatments, medication and care; User construction: users are constructed in terms of their diagnosis, sickness or illness in a patient role as a person requiring hospital, clinical, medical or medication support; Action required: in terms of treatment and psychiatric care: treatments; medications; and need for psychiatry/medical expertise etc; Words associated with medical model: patients, drugs, medication, hospital, clinic, psychiatrist, treatment, especially inpatient etc. The medical model is usually based on the professional legitimacy of the medical profession, especially psychiatrists, and trust in their knowledge and expertise. Therefore, the steering approach would based be soft-steering: key policy decisions are located at frontline professionally steered organisations, based on professional and medical knowledge and expertise, although some systems might have centralised steering of medical practices. Thus if I see 276
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references to the need for treatment, medication or emphasis on psychiatrists as decision-makers, I will interpret this as the medical model. The disability & normalisation model This model is operationalised by references to the concepts of normal living and the individual’s own preferences and priorities. Using the elements developed in Chapter 4, and outlined in table 7.1, the arguments would be framed by government in the following manner: Problem definition: the problem is defined terms of disability preventing normal living and citizen participation, possibly in terms of societal attitudes that disable users; User construction; users are constructed as citizens with equal participation rights to live as other citizens in the community and to contribute in society, rights to normal living and necessary support; Action required: is argued in terms reducing the structural obstacles to users’ participation in society and support to enable users to make their own decisions; Words associated with disability model: Rights, citizenship, active participation, user-led services and decisions, individual decisionmaking, and user preferences and priority. The disability model can be framed from two perspectives, which result in either soft or hard steering depending on whether framing occurs from a user or state perspective. State-focussed framing is based on a discourse of the state establishing binding user rights, indicating a hard steering approach. Disability rights are legally defined and enshrined in legislation; lower levels must comply with laws and rules leaving little room for flexibility or discretion. The user-perspective approach focuses disability rights as frontline individualised freedoms, determined by users’ needs, priorities and preferences. This individualised focus of the disability model indicates soft steering; the policy-maker is responsible for the framework while details are determined by users. Thus the disability model could be framed at two levels with differing steering approaches: national level binding rights but low prescription at frontline level relating to interpretation and implementation of rights. Thus framing could be for hard or soft steering depending on which level is under examination. Risk model The risk model is operationalised in terms of risk, danger and public protection as being the underlying discourse that frames the government policy. Problem definition: defined in terms of the dangers and risk to the public of mental illness, and public protection and safety; User construction: in terms of risk, often using criminal justice language, and the level of threat or risk to society; 277
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Action required: is framed in terms of controlling and managing risks using compulsion and coercion; Words associated with risk model: risk, threat, crime, violence, fear, danger, risk-management, coercion, compulsion, force, comply.
The risk model frames mental health from a criminal justice perspective, focussing on public protection against the perceptions of psychiatric disability equated to violence and criminality. Policy framing centres on the need to develop centralised mechanisms for surveillance, monitoring and control with services adopting roles associated with police, prison and probation services. Thus the model focuses on hard steering strategies to reduce risks emphasising the need to exert control over implementers and users.
Selection of critical texts Text selection is essential for analysing the arguments and patterns of policy framing; thus it is important to select critical texts produced at key decisionmaking points where steering strategy changed, or could have changed. These key documents highlight moments where there was a window of opportunity for policy change, and will enable me to analyse underpinning arguments for policy change or no change. As previously mentioned, in both countries I included an analysis of initial inquiry reports to act as the baseline for the reforms’. The first government decision was whether to accept the inquiry’s policy frame, or whether to reject the inquiry’s analysis and substitute a government frame. I also conducted a brief media review to determine to what extent the government was influenced by media reporting. Selection of critical policy texts In Britain there were many policy changes, directives and revisions during the decade studied in this book, which meant that identifying several central policy texts was no easy task. The documents selected here represent, in my judgement, critical points where policy changes were advocated and reveal underlying policy framing. The baseline for my analysis is the Griffiths Report: Community Care: Agenda for Action 1988 upon which the reform was based. Secondly the 1989 document Caring for People set out the government’s reform proposals.902 The third document is the government’s response to scandals in the mid-1990s resulting in the 1995 Community Care (Patients in the Community) Act.903 The fourth and fifth texts are the Labour government’s policy proposals in 1998: Modernising Mental Health and Modernising Social Services, which resulted in legislative changes. These five texts trace the policy framing of community mental care in Britain. 902
The sections that relate solely to care of the elderly have been excluded from my analysis. The Act amended the 1983 Mental Health Act based on an internal review. There was no formal White Paper. Department of Health 1993b. 903
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In Sweden there were few policy changes after the original reform: however, several critical moments existed where pressures created windows of opportunity for change. I have focussed on government policy statements that were strongly related to mental health and municipal social care. The baseline document is the Mental Health Inquiry Report (Pyskiatriutredningen);904 the 1989 inquiry team was appointed to recommend reforms and reported in 1992.905 Secondly, the government formulated its reform proposals in the 1994 Mental Health Reform Proposition (Pyskiatrireformen/Proposition). A third text is unusual as it is not an official publication but minutes of a Parliamentary debate (Riksdagen: Kammerens protokoll) in October 2003 following the mental health scandals and murder of Foreign Minister Anna Lindh which I consider represented a critical moment for policy change. I focus on the framing of statements by the Minister Lars Engqvist. The government appointed a Mental Health Tsar in 2003. Although not a government document I analyse the steering framing in two documents and the extent to which they created pressure for change: a stage report on steering, Long-Term, Coordination and Engagement, (Långsiktighet, samordning och engagemang); and the final 2006 report Ambition and Responsibility (Ambition och ansvar). Media review The media review was conducted by analysing newspaper articles to determine whether there is evidence that the media discourse influenced government framing and also to confirm the main themes from my framing analysis. Two approaches were utilised; firstly I used secondary research from large-scale analyses of mental health issues in news reports: in Britain, Clement and Foster 2008, and in Sweden, Magnusson 2010.906 The second approach was to carry out my own smaller scale analysis of a sample of news articles in order to confirm the results specifically in relation to my research question relating to the mental health reform using the search terms “community care + mental” in Britain and “psykiatrireformen” in Sweden. I examined the contents of articles in several morning daily “broadsheet” newspapers in two critical periods: the pre and initial reform implementation between in the early to mid-1990s907 and long-term implementation 2002– 2006. I also carried out a brief review of headlines used in the popular “tabloid” press to see if there were differences in the language and tone used to 904
The Mental Health Inquiry was chaired by Bo Holmberg, a parliamentarian active in the parliamentary Social Affairs Committee. It is an irony that Holmberg was a leading reform supporter yet the reform’s problems were symbolised by the murder of his own wife, Foreign Minister Anna Lindh, by a mentally ill man while shopping in Stockholm in 2003, 905 Officially municipalities were meant to take a greater role in the care of the psychiatrically disabled since 1982 as a result of the Social Services Act 1980 (Socialtjänstlagen). 906 See Clement & Foster 2008; Magnusson 2010. 907 Different periods have been examined to take account of the different starting dates for the reform: in Britain articles from 1993-1995 and in Sweden 1995-1997.
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frame the reforms. In Britain a total of 49 articles were reviewed. The Independent was reviewed using the search term “Community Care Mental”; this gave 1000s of hits for the relevant period so a sample of 40 articles was used. It was not possible to review headlines for the earlier period as none of the British tabloids had an online archive dating back to 1993. However, I conducted a brief review using the term community care and analysed nine headlines that appeared in the Sun after 2002. In Sweden a total of 41 articles were reviewed: two daily broadsheet newspapers, The Daily News908 (Dagens Nyheter) and The Swedish Daily Paper (Svenska Dagbladet) totalling 30 articles using the search term “Psykiatrireformen, and the Swedish tabloid chosen was the Evening Paper (Aftonbladet) with 11 headlines.
Policy framing in Britain In order to analyse policy framing in Britain, I studies the government texts discussed above to determine whether there is a link between the frame selected and the choice of hard steering strategies in Britain. My overall findings were that throughout the period the government of Britain has used frames linked to harder steering and instrument choices. However, I identified that a shift to a strong risk model occurred in the long-term, which intensified centralisation and hard steering. The text analysis will use the theoretically guided models of care ideology developed in Chapter 4.
The problem definition The problem definition relates to the way that the policy-makers frame the problem; what problems must be addressed or resolved. This underpinning frame creates the basis for policy interventions and steering strategies. I focus on three models of care ideology: medical model; disability model; and risk model to determine which best corresponds with the way the problem was indentified and defined in policy texts. Problem definition: framing of initial reform & early years In 1988 the Griffiths Report, Community Care: Agenda for Action, made recommendations for community care policy. Although this report was not strongly ideological, and tended to focus on the type of administration issues discussed in Chapter 5, it is possible to discern some care ideology framing. Griffiths referred to the problem of low prioritisation: “community care is a 908
Originally I had intended to use Svenska Dagbladet for both sections. However, the online database did not give any hits for the period 1995-1997. I used the research database PressText and repeated the search for Dagens Nyheter. However, I obtained only nine hits. Therefore, I have included the first article of 1998 to give me a sample size of 10.
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Policy Framing poor relation; everybody’s distant relative but nobody’s baby”.909 In addition, there were some references to a normalisation and disability model where Griffiths stated that users should be “enabled to live normal lives in the community”, with services tailored to the individual’s own situation. However, on the other hand these disability references were weak; there were no references of rights and citizenship. Indeed Griffiths emphasised that the majority of care would be unpaid and voluntary, provided by family friends and neighbours.910 Thus the care ideology is weak with the reform’s baseline inquiry more of a business plan than a statement of care ideology. The government’s reform proposals, Caring for People, created the 1990 NHS and Community Care Act; the need for change was framed in terms of reversing community care’s previously slow progress.911 The actual care ideology espoused appeared a ‘mixed-bag’ of arguments, from different care ideologies, creating the impression that the care model was of secondary importance. The Ministerial foreword framed the reform in terms of a normal living, disability frame: Helping people to lead, as far as possible, full and independent lives is at the heart of the Government’s approach to community care ... to stimulate public agencies to tailor services of individual’s needs. 912
However, there were also references to the risk model and the public’s understandable “concerns” about the psychiatrically disabled in the community. In addition, the government justified the need for mental health reform using the language of the medical model and terms such as: clinical experience, and treatment efficacy outside the asylum, and drug availability.913 The government summed up its mental health reform decision as “civilised and humanitarian”.914 The language used falls short of a clear care ideology, as the statement is vague and general, it appearing more paternalistic than framed in terms of rights, expertise or risk. Thus the problem definition did not appear to be based on a very clear care ideology in Britain. The 1995 Mental Health (Patients in the Community) Act was the government’s response to the mental health scandals that occurred during the implementation of the community care reform. As previously mentioned, there was no White Paper produced for this Act which revised 1983 Mental Health Act, to enable increased monitoring in the community. The legislation was based on an internal policy review by the Department of Health requested by the Health Minister. The new legislation was controversial as it 909
Griffiths 1988 p. iv. Griffiths 1988 pp. 5-6. 911 Her Majesty’s Government 1989 p. 4. 912 Foreword by Ministers for Health, Social Security, Wales and Scotland: Her Majesty’s Government 1989. 913 Her Majesty’s Government 1989 p. 55. 914 Her Majesty’s Government 1989 p. 55. 910
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was announced just three months after the reform was finally implemented in 1993, splitting the main mental health stakeholders.915 The report acknowledges that “There was a substantial body of opinion opposed to extending existing powers.”916 The problem was framed mostly as a medical and risk problem while user opinions were ignored, and Ministerial were concerned about “revolving door patients”;917 patients who are repeatedly admitted to hospital, improve while in hospital, but relapse in the community after failing to follow treatment programmes. Thus the problem was framed as the state’s need to deal with these patients and to extend hospital treatments and medication regimes into the community.918 The problem was also identified as a lack of clarity, especially among medical staff, concerning implementation of existing laws in the community.919 Therefore, the problem was framed in medico-legal terms with an element of the risk model to enable coercive treatment in the community. Thus the main care ideology is a combination of medical and risk models; while the risk model is present, the framing focuses on coercion as a means to efficient medical treatment in the community so that people are unable to discontinue their medical therapies and drug treatments. Thus framing focuses on greater medical powers to return the psychiatrically disabled to hospital for non-compliance with treatment. Problem identification: long-term framing The 1998 policy proposal paper Modernising Mental Health: Safe Sound and Supportive was produced by the new Labour government, where mental health was one of four920 key reform priorities. Radical change was expected, owing to the Health Minister’s statements, previously mentioned in this book, that community mental care had failed and would be dismantled.921 However, the policy proposals were less extreme and community mental care remained. Policy was framed in terms of ‘failures’ of previous mental health and community care policies. The choice of title gave clues about the policy’s framing; the term ‘safe’ referring to public protection appears first, while ‘supportive’ care for users is last. Thus the text was dominated by risk 915
The main professionals such as doctors, social workers and criminal justice professionals including police and the courts were generally in favour, while employers-associations, municipalities, NHS and user- and voluntary groups were generally against and in particular the Mental Health Act Commission, responsible for monitoring implementation of mental health legislation, opposed the new legislation: See Department of Health 1993b Annex F. 916 Department of Health 1993b p. 25. 917 Department of Health 1993b p. 8. 918 Attempts to introduce coercive treatment into community care had been rejected by the High Court in the Hallstrom Case; ‘informal’ uses of the 1983 Mental Health Act may contravene the European Convention on Human Rights: Department of Health 1993b pp. 13-14. 919 Department of Health 1993b p. 11. 920 The priorities for health reform were in mental health, heart disease and strokes, cancer and accidents: Department of Health 1998a paragraph 2.3. 921 Secretary of State for Health, Frank Dobson, cited in BBC News Online 17/1-98.
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model framing and emphasised risk and public protection policy priorities. Yet there also appeared to be a duality and contradiction in the problem framing. On the one hand the problem was framed in terms of mental illness as a common community problem, that society disabled users through prejudicial and stigmatising attitudes towards the psychiatrically disabled. Mental illness is as common as asthma. ... It isn’t well understood, people are frightened of it, and it carries a stigma that adds to the burden of the illness itself.922
Thus the government declared the problem in terms of the need for a “modern decent and inclusive society”923 based on compassionate values to overcome the stigma of mental illness, blamed on the media creating stigma: Images in the media which have shown people with mental illness to be wide-eyed, crazed or homicidal are potent – but unhelpful owing more to nightmares than to the reality of everyday life. 924
Yet the government itself chose similar language, identifying mental illness in terms of risk and danger, using language more likely to create rather than alleviate stigma by framing mental health as a danger: “There is a relationship between active mental illness and violence ... the public is understandably concerned about the risks of violence”.925 The government thus linked mental illness with violence and danger in the community: the first thing discussed in the document.926 Rather than making reassuring statements concerning the rarity of risks and the low threat of danger, the government framed mental health using the term fear: For most people, the thought of mental ill health is daunting, and even fearful. We fear the unknown: the ignorance that surrounds mental illness is particularly powerful. Mental illness strikes at the heart of our fear about loss of control, our fear of violence, and our fears for our children.927
In this short paragraph there are five references to fear in relation to mental health: fear and daunting; fear of the unknown; fears of losing personal control; fears of violence; and fears for children. These are particularly powerful and negative references to mental health, creating negative images at odds with the normalising rhetoric of mental health as an ordinary condition and
922
Foreword by Secretary of State for Health, Frank Dobson, Department of Health 1998a. See Executive Summary Department of Health 1998a. 924 Department of Health 1998a paragraph 1.11. 925 Department of Health 1998a – Executive Summary. 926 Department of Health 1998a paragraph 1.1-1.6. 927 Department of Health 1998a paragraph 1.1. 923
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government aims to reduce stigma and discrimination.928 Therefore, despite rhetoric of reducing stigma, social exclusion and discrimination, the policy problem is framed in terms of the risk, threat of violence and fear of mental illness. Thus the framing of the main problem links to the risk model. The 1998 policy proposal Modernising social services: promoting independence, improving protection, raising standards did not relate specifically to mental health, but the proposals had major implications for the provision of community mental health services. The problem was framed mainly as a risk problem; social services were “failing” in key areas, a major one being public protection.929 Mental health services were framed in terms of a need for stronger legal powers and greater coercion in the community.930 There was a need for greater central control and steering through centralisation of priorities, standards and performance targets which would control risks. Thus the care ideology framed in this text corresponds mostly to the risk model and the need for hard steering and more central control. Summary: framing & problem definition The documents examined span a 10-year period from 1988 to 1998. The analysis of the early years’ documents did not find that the government framed the reform in terms of a strong care ideology problem; there were some references to various care ideologies, yet none formed a dominant frame: most were used to justify an administrative reform ideology. References to normal living and the disability model by the government appeared more of a rhetorical frame to garner support than a clear care ideology. There were also references to the terminology to the medical and risk models as support for government arguments and actions. Yet these did not appear to be a strong or underpinning frame that permeated the reform. In the initial reform risk was hardly mentioned, although it was raised in the 1993 texts in terms of increasing efficient compulsory treatment in the community, more as legal problem for healthcare staff. Thus care ideology appeared a subsidiary issue to managerial and administrative reform in the early years. In the long-term however, there was a strong ideological shift. In the 1998 text, Modernising Social Services, there is a focus on a risk model frame; mental health was linked strongly to risk and danger. The government mental health language emphasised risk, violence crime and fear, despite apparent contradictions with stated aims of reducing stigma in mental health services and discrimination against users. Thus the later policy documents represent a significant and substantial shift from a rather weak and mixed care in care 928
Compare with the conclusions of the House of Commons report 2000 on mental health where the parliamentary committee criticises the government language and labelling of the psychiatrically disabled in this report as creating stigma, paragraphs 28 & 39. 929 The problems identified were clarity of role, consistency and inefficiency, In addition, to the public protection focus: See Department of Health 1998b paragraph 1.4. 930 Department of Health 1998b: Foreword by Secretary of State for Health, Frank Dobson.
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ideology to place a strong emphasis on risk and danger. The government framed the problem as a need for harder steering than the previous reform steering to increase control and compulsion in mental health.
Constructing the user An important part of the framing process is the way that the user is constructed and presented by policy-makers; the choice of discourse and selection of empirical data and ‘facts’ to describe and present users is an important factor for determining the type of services and steering selected. As seen from Rein’s research in the USA in Chapter 4, the psychiatrically disabled could be framed as medical, social and criminal justice problems, all requiring differing policy responses.931 This section will determine which model best describes the policy-makers’ framing of mental health users. User construction: framing of initial reform & early years In the 1988 Griffiths Report, user framing is not strongly care-oriented; the discourse emphasises users in terms of ‘client processing’ rather than an underlying care ideology.932 Indeed from a framing perspective it appears that user-involvement is placed last on the list of consultation instances, almost as an afterthought, and is not necessarily influential. Depending on the individual’s circumstances consultation might include private or voluntary carers, including informal carers, as well, of course, as the person directly affected.933
Thus there is an element of paternalism that users are not the first to be consulted regarding needs and services coming last on the list after private companies, charities and relatives, etc. Therefore, there is no evidence of a strong disability frame where users’ rights and decisions are the basis of reform services. There are a few small references to the medical model and the need for services “may stem from a medical condition that itself requires medical treatment”, and the text also refers to the medication needs of patients; yet the medical model is not strong either as there are several references to community care being better than hospital services.934 There is also one small reference to terms associated with normalisation with the phrase ‘to live as normal a life as possible’. 935 However, the care ideology is mixed and somewhat unclear. The main emphasis is paternalistic, pragmatic and busi-
931
See Rein 2006. There is a tendency for users to be described as ‘cases’ for the administrative apparatus; the “priority to be given to the case” and arrange service “delivery”: See Griffiths 1988 p. 6. 933 Griffiths 1988 p. 19. 934 See discussion Griffiths 1988 pp. 7-8 & 18-19. 935 Griffiths 1988 p. 1. 932
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The Governance Gap ness oriented; users are framed as ‘consumer’ of services that the market decides to offer rather that a user-oriented care vision. The Government reform proposals in the 1989 white paper Caring for People also espoused a mixed care ideology regarding users. There were references to normal living such as the aim for users to “live as independently as possible in their own homes, or in ‘homely’ settings in the community”. Thus independent living and own home references appear to construct users in the disability and normalisation modes. However, there are also several caveats that undermine the concept of normalisation. The government states that users will have a ‘greater individual say’936 in services, and will live in their own homes when it is ‘sensible’937 for them to do so; thus it was unclear where decision-making authority would rest and who would decide when normal living was “sensible”. In addition, as mentioned in the problem identification section, there were strong references to medical model decisionmaking for the reform such as clinical experience, treatment, drugs and medical roles.938 There is also a little risk framing with referring to the public’s “justified concern” about community care for the psychiatrically disabled.939 These limiting phrases and discourse fall short of the user-led preferences and priorities of the disability model being the underlying frame, by mixing in medical and risk models. Therefore, the government’s user framing is fuzzy; there appeared to be no dominant user framing in terms of care ideology as different models were used to justify different points. The framing of users for the 1995 Mental Health (Patients in the Community) Act in terms of care ideology mainly focuses on medical and risk related to legal issues. There does appear to be a medical model framing; the psychiatrically disabled are frequently referred to as “patients” and the report is framed in the language of the medical model using terms such as illness, treatment and medication; there was emphasis on the revolving door patient’s responsibility to “comply” with the treatment recommended by doctors.940 User opinions are mostly framed in terms of treatment, such as user reluctance to accept treatment in the community owing to: medication side effects; fears of drug dependency; refusal to accept the diagnosis; and users feeling well and not needing medication.941 There are some references to user choice, however, despite statements of user choice and freedoms, the internal report ignores the users’ opinions and inputs, in the formulation of final recommendations; user group consultations overwhelmingly oppose increased compulsion. Therefore, users are not framed in terms of the disability model, yet despite the new legislation formulated in response to crimes Her Majesty’s Government 1989 p. 4. Her Majesty’s Government 1989 p. 6. 938 Her Majesty’s Government 1989 p. 55. 939 Her Majesty’s Government 1989 p. 55. 940 See for example Department of Health 1993b p. 8. 941 Department of Health 1993b p. 8. 936 937
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and violence involving the psychiatrically disabled, the risk model does not dominate either, as the report frames general risk as low: “These cases need to be seen in perspective. The great majority of mentally ill people present no danger to others”.942 Thus I do not consider users to be framed in terms of a risk model. Therefore, the main construction of users in terms of care ideology is medical with an element of risk model, expressed in judicial terms for those who fail to comply with treatment. User construction: long term framing In the 1998 document ‘Modernising mental health services: safe sound & supportive’ users were framed by Ministers in terms of risk danger and the psychiatrically disabled as an inconvenience to other citizens: [I]t left too many people walking the streets, often at risk to themselves and a nuisance to others. A small but significant minority have been a threat to others or themselves.943
Thus the psychiatrically disabled were not constructed in terms of having citizenship rights to live as they want but in terms of being a ‘nuisance’ that annoyed ‘ordinary’ residents and in terms of being potentially violent or risky. Along with the emphasis of the risk model there was also an emphasis on the medical model with users often referred to as ‘patients’ throughout the text and references to treatment compulsion and coercion to ensure that the psychiatrically disabled are “no longer allowed to refuse to comply with the treatment they need.”944 Therefore, even the references to the medical model were in many cases framed using risk language of coercion and mandatory compliance, such as assertive outreach,945 treatment and medication compliance.946 The ‘patient’ would not have the normal adult citizenship rights to refuse treatments. Therefore, the construction of users is mostly in terms of the risk and threat of the psychiatrically disabled, with some medical model framing that emphasises coercive treatments. The 1998 ‘Modernising Social Services’ text constructed users as in terms need of social services “at a time of personal and family crisis”; this frame shifted from ideas of universal and rights-based social services, to a narrower role for social services as a crisis intervention service. However, the parts of the text that focus on mental health services frames users according to the risk model. The terminology is similar to the Modernising Mental Health text and the government argues that social services must provide support for:
942
Department of Health 1993b p. 24. Department of Health 1998a: Foreword by Secretary of State for Health, Frank Dobson. 944 Department of Health 1998a: Foreword by Secretary of State for Health, Frank Dobson. 945 Department of Health 1998a: paragraph 4.21. 946 Department of Health 1998a: Foreword by Secretary of State for Health, Frank Dobson. 943
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The Governance Gap [P]eople with mental health problems ranging from support for those with mild mental illness, up to exercising legal powers for compulsory admission to psychiatric hospital for potentially dangerous people.947
This negative tone continues in the body of the report where mental health users are framed in terms of causing damage: [P]eople with mental health problems can have damaging consequences for other people as well as the individuals themselves.948
The frame again emphasises the risk and danger linked to the mentally ill. The government are also framing social services approach to users in terms of a two-tier system. Those with ‘mild’ mental illness will receive support. However, moderate and serious mental illnesses are framed in terms of risk and potential criminality, including the need for ‘exercising legal powers’, compulsion and danger potential of users. Detention of mental health users is emphasised; the Minister frames compulsion and coercion for those who are potentially dangerous, not necessarily ACTUALLY dangerous. The psychiatrically disabled are framed in terms of criminality, risk and threat. There are a few medical references to psychiatric hospitals, yet even these emphasise hospitals in terms of custodial and prison-like institutions for incarcerating and containing those who are a potential danger, rather than therapeutic and caring. Therefore, the dominant care ideology is the risk model; the psychiatrically disabled are framed predominantly as a threat and a risk causing damage to themselves and society, and there is little reference to disability or normal living apart from those with ‘mild’ disorders. Summary: framing & user construction The analysis shows that a big shift has occurred in the framing of users. In the early reform documents there was no clear care ideology; instead, traces of a number of care models could be discerned, usually linked to ideas of efficient mental health administration. The later documents, however, represent a substantial shift in framing under the Labour government. Users were framed as risks to society using the language and symbols of criminal justice systems. In Modernising Social Services only those with ‘mild’ mental illnesses were framed in terms of support. In both Modernising Mental Health and Modernising Social Services the psychiatrically disabled users were framed in terms of risk and crime, with terms such as risk, danger, threat and damage, emphasising a lower level of civil rights for the psychiatrically disabled than the rest of the population. Ministers would not suggest compulsory detention of the general population based on the potential that they “may” commit crime alone, or without trial. A non-psychiatrically disabled person at risk of committing crimes is not detained; there would be uproar if 947 948
Department of Health 1998b: Foreword by Secretary of State for Health, Frank Dobson. Department of Health 1998b: paragraph 1.2.
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a government suggested incarcerating alcoholics and drug addicts despite the higher risks posed by these groups of committing serious crimes. The government framing was based on custodialism and a criminal justice system perspective that removes the normalisation model completely, as the psychiatrically disabled are not accorded rights to live as normal citizens, and civil liberties were reduced. The psychiatrically disabled’s civil rights depended on compliance with the state.
State action required The state action required built on the first two categories of problem identification and users into the action required by the state for the psychiatrically disabled such as services and benefits and the way the government framed the need to act in terms of the problems identified and the need to deal with the problems and issues associated with the users identified. State action required: framing of initial reform & early years As discussed in the previous sections, the 1988 text Community Care – Agenda for Action (Griffiths report) was not framed in terms of a need for state action to conform to a specific care ideology. However, the government’s framing in Caring for People 1989 state action required for the reform appeared again to be rather mixed in terms of care ideology. There is some medical model language with the government arguing the need for doctors “with particular knowledge and experience of treating patients” with mental disabilities,949 thus framing some users in treatment terms. There is a small reference to risk with mention of specific mental health riskmanagement guidelines.950 However, the underlying care ideology is not strong. The document focuses on pragmatic and practical action rather than a clear care ideology. The 1995 Mental Health (Patients in the Community) Act text, despite being a legal response to mental health scandals, was not framed in risk model terms, and indeed emphasised avoiding coercion. The Department of Health report emphasised six initial principles as the starting point for state action which included user involvement. However, the care ideology framing was broad-brush as the key principles appeared to emphasise differing care ideologies. There was some framing using terms of user-influence and disability model, emphasising users rights and freedoms: [M]ust support a programme of care which it negotiated with the patient ... must not un-necessarily limit the patient’s freedom of choice ... must
949 950
Her Majesty’s Government 1989 p. 12. Her Majesty’s Government 1989 p. 58.
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Thus users were also references to user involvement and choices with legal coercion as a last resort: [L]egal powers can never be a substitute for properly planned and delivered services, that the solutions of choice are those which are agreed with the patient and take maximum account of his or her wishes and aspirations.952
There was also some, generally mild, framing and language associated with risk models that referred to safety issues, but that emphasised least restrictive care, thus not emphasising coercion: [M]ust be applied so as to ensure the least restrictive form of care that is compatible with the patient’s health and safety and the safety of other people. 953
Therefore, the initial framing appears to be a balance of the disability model with emphasis on choice and rights such as negotiated care programmes, freedom of choice. While there are references to coercion and compulsion, patient’s health and safety is listed first before public protection. The medical model was also emphasised with references to “medical evidence” and “medical rather than legal judgement”.954 Thus the text demonstrates mixedmodels without a dominant care ideology; the early parts of the text emphasised user rights and freedoms, yet the disability frame does not really correspond with the final recommendations that largely ignored user opinions. It is possible that the disability framing was used more as a form of rhetorical framing in this instance; it was clear that the proposals were controversial with strong opposition, thus the disability framing was in order to reassure the wider stakeholders in mental health that the proposals were not solely legal and coercive by referring to users’ rights and choices even if the underlying recommendations were somewhat ‘hard’ in the form of legal restrictions and supervision of the mentally disabled. State action required: long term framing In the 1998 document, Modernising Mental Health Services: Safe Sound & Supportive, the government used the title to frame the need for services: a need for ‘safe’ services and public protection as the largest category for action with six areas of state action identified: risk-management, early intervention, new secure beds, assertive outreach, inpatient beds and a ‘modern 951
Department of Health 1993b p. 4. Department of Health 1993b p. 31. 953 Department of Health 1993b p. 4. 954 Department of Health 1993b p. 14. 952
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Thus the Minister framed a ‘modern’ legislative framework as being one that focussed on compliance, crime and risk reduction strategies. There were also references to a return to the medical model rather than citizenship rights and social needs. Doctors would determine the need for ‘treatment’ and the state would introduce powers to detain individuals without crime or trial on the basis of medical risk assessments by psychiatrists. Thus the policy was framed in terms of a strong emphasis on the risk model and a coercive form of the medical model.958 There was nothing to suggest rights-based- and userled services; users were only offered ‘consultation’, but no guarantee that services would be based on their needs. Thus Modernising Mental Health frames the need for state action in terms of risk-management and public protection. The framing and language were based on state-centric policing roles, with social services to identify and contain risks and the use of custodial mechanisms and coercion. The government focussed on the rights of the public to be protected from 100% of risks of mental illness even at the expense of the psychiatrically disabled’s civil rights such as indefinite detention of those who had never committed any crime. The individual’s right to live in the community was subordinate to compliance with state agencies. Thus the dominant care ideology framing corresponded to the risk model. The 1998 Modernising Social Services also framed government action according to the risk model. Several key areas for state action framed as improving protection, emphasising safety which is placed first, with stringent central controls through legislation, standards, inspections and regulation.959 Government action is framed in control terms: the need for standards, inspection and audit, state regulation and ‘tough new powers’.960 Thus the government framed the action required in terms of a central ‘big stick’ with words such as ‘firm action’ to emphasise the subordinate position of local social services. Municipalities implementing the reform were also subject to 955
Department of Health 1998a: paragraph 4.8. Department of Health 1998a: paragraph 4.27. 957 Department of Health 1998a: Foreword by Secretary of State for Health, Frank Dobson. 958 Department of Health 1998a: paragraphs 2.16; 4.8; and Chapter 5. 959 Department of Health 1998b: paragraph 1.11 and Chapter 4. 960 Department of Health 1998b: Foreword by Secretary of State for Health, Frank Dobson. 956
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coercion and compulsion through the framing of state action using language such as state plans to ‘drive up standards’ and ‘rigorous’ monitoring.961 The state action was also in terms of threats for non-compliance. Thus the need for state action was framed in terms of risk and danger and the need for government to seize control by declaring a need for state action for the state to control local government and social services as an issue for national policy. The previous government’s market and privatisation framing has declined; instead the need for action is framed in terms of risk and the need for a steel framework. Government action is framed as strong legal powers and compulsion and re-incarceration in mental hospitals to control the potential for danger. Thus the government approach included rewards for compliance and sanctions for failure and non-compliance by both the psychiatrically disabled and the municipalities responsible for services. However, the main care ideology is the risk model, framed in terms of protection, danger and compliance. Summary: framing & state action required The review has shown a shift in the ideological frame from the mixed models of the early documents to risk-based models. The early texts were not dominated by a single care ideology with various references to different models. The 1995 Mental Health (patients in the community) Act was a response to mental health scandal. This document was not framed in terms of the risk model; instead the care ideology was mostly medical, despite some disability and risk references. However, the Labour documents show a strong shift to risk model framing requiring central policing mechanisms. The need for state action was framed in terms of eradicating danger and assuaging public fear. Thus services were framed in terms of risk-management and state intervention to control and standardise social services.
Policy framing & the role of the media In mental health it is also debated to what extent the influences media government framing and to what extent government framing is reflected in the media coverage. This is a major issue and a study in itself, but one I will discuss briefly in order to determine whether the changing government framing relating to psychiatric disability and intensifying risk discourse can be traced to media framing and discourse. Clements and Foster analysed 1196 newspaper articles from five British national newspapers at two points, 1996 and 2005, by conducting a contents analysis. Their findings were that much of the coverage was negative which increased stigmatisation of users, and articles linked mental health with violence. In particular mental health users were subjected to stigmatising descriptions such as madman, nutter or mani961
Department of Health 1998b: paragraph 7.3 & 1.11. See also language in Chapter 7.
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ac. There was also a tendency to place a psychiatric diagnosis, such as schizophrenia, before the individual’s name, thereby associating their identity with a mental illness; in addition, headlines and picture captioning were often stigmatising. However, their main finding was that there were few differences in the nature of reporting between 1996 and 2005.962 This result is interesting as it suggests that the hardening tone and framing that I discerned in the policy framing analysis is not the result of media influences as such, but results from a dynamic political process. In order to analyse this issue further, I have conducted a brief review of 49963 articles from the broadsheet, The Independent newspaper and a review of headlines from The Sun tabloid newspaper. The purpose was not to replicate the type of frame analysis in the policy document analysis, nor Clement and Foster’s much more extensive quantitative study, but instead to triangulate results by using a sample of newspaper articles to identify what relationship existed between the articles’ main themes and government framing. The review reveals that most care ideology media framing related to user construction; the articles relating to the problem definition and need for state action tended to focus on critiquing government administrative policy. Wolff’s research on mental health policy in Britain argues that policymakers are influenced by sensationalist media coverage that “grab onto and hold onto headlines by evoking a stereotypical view of persons with a mental illness as being crazed killers” and that this type of media discourse and framing creates strong pressures and imperative for policy-makers to respond and control the situation.964 This was reflected in my article review. Indeed Morrison argues in one article that the media often use a mental illness language to describe crimes committed by the non-mentally ill, with terms involving madness and lunacy: “mad fiends and [c]razed axe killers”. This reinforces the link between mental illness and violent crime in public perceptions, even though it is a false link in cases where the person is not mentally ill.965 The article review shows a shift in coverage. At the outset there was a focus on the users as victims of care failure, emphasising the poor conditions and lack of rights facing the psychiatrically disabled in the community;966 thus optimistic government rhetoric did not match reality:
See Clement and Foster’s 2008 quantitative study and contents analysis of 1196 articles. The article review was a broad-brush review to identify common theses. Many of the articles focused on administrative and implementation issues rather than care ideology. For a list of the 49 articles reviewed for this section see Appendix A. 964 See Wolff 2002 p. 804. 965 See Independent 22/5-94. 966 There were many articles relating to problems in private and voluntary care homes unprepared for providing community mental services: For example 14 residents were sharing four rooms in a basement. Independent 19/12-93; some charities left a single untrained, unpaid volunteer to work the night shift in private care homes: See Independent 27/7-95a, 27/7-95b; and that volunteer services were in crisis attempting to fill the gaps; Independent 20/4-94. 962 963
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In the community. A nice homely word, much-loved by politicians. It evokes faded images of responsible folk popping in and out of each other’s houses, being neighbourly and supportive ... In reality ‘community’ means virtually anywhere that is neither a hospital or a prison. ... ‘community’ means living a completely isolated existence in a filthy bedsit, or stumbling around the streets, and eating out of dustbins , with no one actually caring how, or whether they live .967
However, there was a change in emphasis after the mid-1990s that focussed on crime. There appeared to be a synergy between the changed media tone and the government’s new control mechanisms. New arrangements, such as homicide inquiries, produced press releases providing ready-made media headlines which were often directly or indirectly quoted. The mentally disordered offenders were described in the way that Wolff outlined as crazed killers with terms such as “mentally deranged”;968 “stabbing rampage”,969 with one mentally ill man, dubbed the “Camden ripper” in media reports, described by the police as “evil” and by the trial judge as “depraved”.970 The tabloid newspaper framing revealed an even harder and more negative tone, with headlines focused almost exclusively on violent crime and implicit messages that the mentally ill should be locked up. Headlines included: Violent, mad … and set free; Safety first; Stalker freed to kill care worker; Why was cop killer madman on streets?971 Mental illness was framed as violence with words such as kill, killer, violent, stalker.972 Some language also framed mental illness in bestial terms: Schizo killer caged for life.973 Thus the media increasingly framed users in terms of risk and violence. However, framing does not appear to have been solely in one direction with the media influencing government. In 2000, a Parliamentary Select Committee also argued that it was the government’s own framing of mental health policy that was influencing media and public perceptions, and urged the government to modify its language and framing. 974 The Committee expressed unease over the negative effects that government mental health framing was having on public attitudes towards the psychiatrically disabled and argued that the government’s risk discourse was misleading the public: We also call upon the Government to take a more proactive approach in challenging the perceived link between mental disorder and dangerous-
967
Independent 10/1-93. Independent 25/2-94b. 969 Independent 24/12-04, See also 26/2-05. 970 Independent 26/11-03. 971 Sun 26/2-05a; 26/2-05b; 23/10-07; 25/3-09. 972 In six of the nine articles examined there were references to killer or killing: The Sun: 26/2-05a; 19/5-05; 23/10-07; 25/3-09; 2/4-04; 24/3-09. 973 The Sun 2/4-04 974 House of Commons 2000 paragraph 39. 968
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An example was where media reports had seized on the fact that 34 murders were committed by mentally disordered offenders in three years; yet in context of the total of 1000 murders committed in the period the actual risk was low. In addition, only two were stranger murders the type most feared by the public.976 Therefore, my conclusion is that media reporting was not the cause of the hard steering and risk model framing in Britain; in many cases the media were reporting government inspired policies and language. However, there does appear to have been a synergy between government and media which created a mutual pressure for risk framing and thus focussed government policy on hard steering strategies.
Discussion – policy framing in Britain In this section I analysed the care ideology used by government to frame their policy proposals by studying the framing used in a number of critical texts at crucial government decision points. There is evidence of a shift in framing. In the early texts there was no strong underlying care ideology evident; instead, the focus was administrative with rhetorical arguments drawn from several of the three care ideologies that I identified at the start of the chapter, yet without any single ideology dominating the ideas of the text. Thus the initial reform texts did not demonstrate a clear care ideology. This was also reflected in the media analysis of newspaper articles. The 1995 Mental Health Act introduced some risk discussion, yet the risk model did not dominate; instead, the problem was framed as a medical issue concerned with clarification of psychiatrists’ powers, with the problem framed in terms of treatment efficiency. The media analysis shows that this Act was under consideration, there was a general shift to more negative user language in the media with newspaper articles that emphasised mental illness and danger. The Labour government framing demonstrates a clear shift to risk framing; Modernising Mental Health and Modernising Social Services texts both used risk model language, emphasising public protection and state-centred risk and control functions for services and the discourse of mental health services focussed on a policing and custodial approach whereby the psychiatrically disabled were treated like prisoners. Thus the care ideology shifted to a discourse of ‘coercion and control in the community’. The government established a prescriptive and centralised framework for risk-management. The policy framing therefore, corresponds to the risk-management model and is associated with the need for hard forms of central steering to control and contain risks. This shift to a hard steering and risk framing approach is 975 976
House of Commons 2000 paragraph 66. See Independent 18/8-94a & 18/8-94b.
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also reflected in the article review where the tone and description of the psychiatrically disabled was negative and used the language and images of risk and crime. Indeed, the Parliamentary Health Committee warned the government that its framing had consequences on perceptions of mental health. The shift to risk model framing may be a factor in the unexplained intensification of the hard steering strategies discussed in Chapter 5 on Administrative Traditions. My findings are that the risk model and public protection emphasis required harder steering; the government developed a frame based on both administrative and individual coercion to control risks of the psychiatrically disabled living in the community under state control by applying coercive measures to the individual and local government.
Policy framing in Sweden This section analyses documents relating to the Swedish reform, following the same approach as I used for Britain. I focus on documents produced at crucial decision points in order to analyse the Swedish government’s policy framing and whether it influenced the choice of soft governance and steering strategies. My overall findings are that Sweden in many respects never fully shifted away from the medical model and strategies based on soft steering.
The problem definition As previous discussed, problem definition relates to how policy-makers frame problems to be resolved. Problem definition: framing of initial reform & early years The Mental Health Inquiry team (Psykiatriutredning)977 was appointed by the government in 1989 to recommend reforms to mental health.978 The final report published in 1992 framed the problem in terms of needing to increase disability and social perspectives.979 The Mental Health Inquiry focussed on a user perspective of disability and disadvantage, arguing the psychiatrically disabled were a deprived and vulnerable minority group.980 The inquiry criticised current policy for emphasising the medical model; existing care organisations regarded the psychiatrically disabled as ‘medical objects’; users were ‘invalidised’ by paternalistic medical attitudes and power concentra-
The Mental Health Inquiry’s final report was wide-ranging and totalled almost 550 sides. I primarily focused on sections pertaining to municipal services as the main focus of my study. 978 Kommittédirektiv: Dir 1989:22. 979 SOU 1992:73 pp. 19-22. 980 Based on a survey of 13 living standard indicators measuring economic conditions, material standards, social participation and health indicators: See SOU 1992:73 p. 134. 977
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tions.981 The inquiry framed the problem as a need to resolve three central disability issues: a “rights perspective” to confer full citizenship rights; a “rehabilitation perspective” to increase community participation; and normalised care and community support as for other citizens. 982 Thus the problem framing corresponds strongly to the disability model; the psychiatrically disabled were to be regarded as disabled citizens with rights to live and to participate in the community, and to receive support and care services to enable normalised living. A second problem area was framed in terms of the lack of a “social perspective” and implied criticism of the dominant medical model where social knowledge and development of social care services appeared to have low status in the existing mental health organisation:983 Our opinion is that you cannot give meaningful psychiatric treatment to long term mentally disordered persons without paying attention to the social aspect.984
Therefore, the inquiry framed the need for reform in terms of a shift from the medical dominance to the development of social knowledge and expertise. The report also took up the problem of municipal ‘framing’ that excluded the psychiatrically disabled by creating structures where users did not ‘fit’ into standard disability definitions or eligibility criteria.985 Thus both language and framing were strongly associated with the disability model with references to disability, rights, citizens, participation, normalised living and a need for a social perspective. There were references to the medical model, but in negative terms as paternalism that impinged on users’ rights and choices. Thus the care ideology framing of the Mental Health Inquiry corresponds mostly to the disability model and the need for enforceable rights. The problem was framed in terms of the psychiatrically disabled’s isolation from society and dependence, emphasising their inability to cope in the community. The government describes the psychiatrically disabled as suffering: apathy, loneliness, shyness, lack of initiative, hallucinations, delusions, and an inability to withstand monotony.986 Therefore, these descriptions are generally negative and emphasise negativity and seclusion that appear at odds with the inquiry’s problem descriptions in terms of the psychiatrically disabled’s lack of rights; from the government’s problem description it is difficult to see how users would make their own decisions, live independently and enforce service rights. There is generally a paternalistic tone to the government’s proposition, which emphasises the problem also in terms of dependence on the state. There is a strong emphasis on the psychiatrically 981
SOU 1992:73 pp. 18-19; 112; 134-135 (my translations). SOU 1992:73 pp. 219-223 (my translations). 983 SOU 1992:73 pp. 206-207. 984 SOU 1992:73 p. 209 (my translation). 985 SOU 1992:73 p. 182. 986 Regeringens Proposition 1993/94:218 p. 14 (terms – my translation). 982
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disabled as dependent on the state; lacking housing; having low educational levels; being unemployed and dependent on benefits; having few social contacts and no hobbies.987 The government framed the problem from the perspective of public agencies, mainly psychiatry and insurance agencies, yet with little apparent direct voice or input from users about their own situation or problem.988 Thus there was a strong contrast between the Mental Health Inquiry’s bottom-up strong disability rights frame, and the government’s top-down frame where the problem was formulated in paternalistic and medical terms. Problem identification: long-term framing In Sweden there were few post implementation revisions and changes, unlike Britain, thus fewer policy texts to study. However, there was a strong opportunity for a change of discourse and frame during the Parliamentary debate on mental health, and it was an opportunity where any new care ideology would be visible. In these sections I focus on the statements and framing used by the Social Affairs Minister Lars Engqvist who represented the government in the debate as it is the government’s framing that is central to my study. The Social Affairs Minister’s statements were framed and formed as question-asking rather than as a Minister providing answers to parliament. Although the Minister made some references to risk and the scandals of the summer and autumn of 2003, the main framing of the problem was formulated as a duty of society to provide treatment and care: Have these people sought help? What help did they get? Why were these people who were so obviously dangerous allowed to move around freely?989
There were other references to medical and disability framing: addressing issues of access to medical services, too few inpatient beds and poor municipal social support as well as suggestions that local government failed to use state finance as intended.990 Therefore, there is not a strongly dominant care ideology in the problem formulation, although there is some framing of care need for medical and social care treatments. The reports compiled by the Mental Health Tsar, Anders Milton, in the Mental Health Tsar Inquiry (Miltonutredningen) 2003–2006 are not government policy statements but a new inquiry of investigation appointed by government in the aftermath of the summer of ‘scandals’ in 2003. The ‘Mental Health Tsar’ appointment was the main government response. The reason for including this inquiry, even though not a government statement, was that 987
Regeringens Proposition 1993/94:218 p. 14. Regeringens Proposition 1993/94:218 p. 15-16. 989 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20 (my translation). 990 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20, 27 & 34. 988
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it represented a new window for change.991 The appointment of the Mental Health Tsar was a response to the violent crime, yet there is little risk framing relating to social care in the reports.992 Unlike British reports, the Tsar emphasises mental health’s low risk: with risk related to specific diagnoses or alcohol and drug abuse rather than a general risk.993 Therefore, despite the report’s background in violent crime the problem was not framed in risk model terms. The Tsar frames problems in terms of the psychiatrically disabled not getting the services they are entitled to, and the need to improve rights and service standards to meet needs.994 There is a link to disability model framing as the language emphasised rights and entitlements to services. Thus there appears to be an underpinning discourse of disability rights, even if not as strongly stated as in the 1992 Inquiry. Summary: framing of problem identification The problem identification demonstrates some interesting issues: both of the Inquiries in 1992 (Mental Health Inquiry) and 2006 (Mental Health Tsar) used disability model frames; identifying the problem as a lack of rights and entitlement to services and arguing for enforceable rights and harder central steering. However, the government has consistently rejected this approach.
Constructing the user As previously mentioned, the way in which policy-makers’ frame and depict users, and the choice of discourse and language are important factors that influence the nature and type of policies and interventions and thus steering strategies and instruments. User construction: framing of initial reform & early years In the 1992 Mental Health Inquiry (Psykiatriutredning) users were strongly framed in disability model terms: as citizens with rights and duties, and individual support needs.995 The report emphasised users’ own opinions and participation in the inquiry process, thus based on the disability frame of participation and influence in the formulation of services and support measures. We have therefore, seen it as natural that the psychiatrically disabled individuals and their relatives can speak for themselves in this report. Their
991
The government response is problematic. It did not occur until 2009, six years after the inquiry was commissioned, and falls well outside the period to be analysed here. In addition, the government that responded was not of the same party that commissioned the report. 992 The primary focus of this book is the social care steering. I have excluded the specific section relating to inpatient medical care and court-mandated forensic psychiatric treatment. 993 See SOU 2006:100 p. 21. 994 SOU 2006:3 pp. 9-10, 21-26; SOU 2006:100 p. 34 ff & 489. 995 SOU 1992:73 p. 20, (citation – my translation).
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Thus the report underlined a care ideology of the disability model, the importance of the potential service users to speak for themselves rather than services formulated on their behalf by others in a paternalistic, top-down manner. There was language associated with risk, such as ‘fear’ and ‘prejudice’; however, the frame was society’s disabling attitudes towards the psychiatrically disabled not the risk model. Thus the language focussed on the need to change and challenge society’s negative perceptions in order to create a ‘society for all’ where they “have a rightful place in free society”.997 Thus there was strong disability framing with central principles relating to individuals that emphasised this disability perspective and framing: [S]ame rights and duties as other groups in society ... the right to service, support and care that is adapted to his individual situation and needs ... own choices and priorities ... open and normalised forms as possible out in the local community ... individual’s independence and integrity.998
Thus framing language emphasises the right of the psychiatrically disabled to influence and participate in decision-making and also corresponds to the disability model. Thus the dominant discourse and frame of the mental health inquiry are terms related to the disability model. The government’s response to the Mental Health Inquiry report was the 1994 Mental Health Reform Proposition. There was a paradox in that the government states: “Psychiatry’s diagnostic terms are a blunt instrument for describing a psychiatric disorder’s character and consequences for the individual.”999 However, the government then proceeds to do exactly this and describe the psychiatrically disabled in terms of the medical model and psychiatric diagnoses. The initial proposition pages framed the psychiatrically disabled almost entirely in medical terms such as being “patients” “psychiatric illness”, “psychiatric condition” and “mental ill health”. The language focussed on diagnoses such “neuroses”, “neurotic disorders”, “phobia” and “schizophrenia”,1000 and “symptoms” including “manic thoughts”, “delusions” and “aural hallucinations”. In general the psychiatrically disabled were framed ain passive and dependent terms; suffering a “lack of initiative and apathy” and “unable to withstand loneliness and monotony”.1001 There government also focussed on users from the perspective of medical professions with doctors and psychiatrists as key decision makers as “specialists in psychiatry … in order to classify possible disorders in the form of psychiat996
SOU 1992:73 p. 133 (my translation). SOU 1992:73 pp. 20 & 197 (my translation). 998 SOU 1992:73 p. 20 (my translation). 999 Regeringens Proposition 1993/94:218 p. 13 (my translation). 1000 Regeringens Proposition 1993/94:218 pp. 12-13 (my translations). 1001 Regeringens Proposition 1993/94:218 pp. 13-14 (terms – my translation). 997
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Policy Framing ric diagnoses”. The power to discharge the psychiatrically disabled was also framed solely as a medical decision for psychiatrists to declare users “fully medically treated”1002 without inputs from users and social services. The tone and language of the 1994 government framing displayed substantial differences from the Mental Health Inquiry as they were negative, passive and medical, and they focussed on the disabling nature of the condition rather than on what individuals might achieve with correct support. The government’s proposition framing stood in sharp contrast to the inquiry frame of independent citizens exerting their rights through their own choices, preferences and priorities, and framing was often loose, vague and open to interpretation rather than concrete rights; according to the government, mental illnesses should be “large and permanent” to accord rights.1003 There were a few disability frame references such as “normalisation” and a need for accommodation “where freedom and integrity are protected”;1004 thus there was some disability-framing language, although the word ‘protected’ could also be interpreted as paternalistic. In addition, the government also framed the psychiatrically disabled’s situation in negative terms compared with the “normal population”;1005 users live on benefits, lack social contacts, and have lower educational levels. However, although the term ‘normal population’ is one that can be used to describe the general population,1006 the choice of this term and its repeated use six times in little over one page to focus on the negative aspects of psychiatric disability frames the psychiatrically disabled in language of abnormality, that they are not considered a part of the normal population, suggesting they are not considered ‘normal’. Thus despite some very small references to disability, the dominant frame is the medical model as users are framed in terms of illness, diagnosis and symptoms where the government emphasised the psychiatrically disabled as separate from the ‘normal population’. User construction: long-term framing In the 2003 Parliamentary Mental Health Debate, user framing was harder to discern as the Minister did not depict users in great detail or in terms of an underlying care ideology. There were statements of mental illness as common in society. However, user were mostly referred to in terms of public agencies’ interventions and numbers treated.1007 The Minister emphasised a balance between user-rights and risk: 1002
Regeringens Proposition 1993/94:218 p. 40. Regeringens Proposition 1993/94:218 p. 28 (my translation). 1004 Regeringens Proposition 1993/94:218 p. 42 (my translation). 1005 In a short section of little over a page, normal population (normal population & normalbefolkning) was used six times. Regeringens Proposition 1993/94:218 p. 15-16 (my translation). 1006 The term “whole population” (hela befolkning) was also used: see Proposition 1993/94:218 p. 16. 1007 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20. 1003
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The Governance Gap You have to weigh respect for the individual against the need to give closed inpatient care to those who need it and see to it that those that do not accept voluntary care also have closed inpatient care, meaning the use of coercion. It is a complicated balance.1008
Thus although the Minister does not frame users in terms of a risk discourse, there is recognition that some compulsion may be necessary. However, in contrast to the negative tone of the British framing, the language of Swedish Ministers is much more moderate with terms such as ‘respect of the individual’ implying a disability frame, and emphasis on the reform’s benefits: The community mental care reform was characterised by a humanistic idea that thousands of people who had for decades lived their lives with their permanent accommodation being in the form on a bed in a heavily populated ward should be able to have a better life, a good life characterised by social psychiatric competence of care-givers in both municipality and county council. I have met and seen many long term ill people with an empty gaze and an extremely fragile and shame-filled self esteem who revived and found a new lease of life and role in society because their living environment was normalised. This has happened through the community mental care reform.1009
This long citation is interesting; there is no strong risk emphasis, despite the recent murder of a Ministerial colleague, yet there is not a strong disability perspective either. Users are framed in terms of their position in the care chain: from life in a heavily populated hospital ward to the competence of municipal and county care-giving staff in the community. Thus the essential aspects of disability models such as rights and individual decisions, priorities and preferences are missing. Users’ normalised living and ‘good life’ is framed in terms of agencies’ care apparatus: ‘a good life characterised by social psychiatric competence of care-givers in municipalities and county council’. Thus the user is hard to determine, but the general tone is paternalistic, with elements of the medical model. The 2003–2006 Mental Health Tsar Inquiry (Miltonutredningen) framed users in the language of the disability model. Mental illnesses and conditions were framed as restricting activity, and emphasised society’s structures and attitudes as disabling.1010 User framing focussed on citizenship perspectives, emphasising the psychiatrically disabled as the principals of mental health services, and that services should be organised from their perspective and interests.1011 The Tsar also argued that the psychiatrically disabled should be referred to in citizenship terms as users (brukare) with voice and exit opportunities to express preferences and leave services, rather than the passive and 1008
Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 34 (my translation). Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 34 (my translation). 1010 The Mental Health Tsar’s definition was based on the World Health Organisation’s definition: See SOU 2006:3 p. 14; SOU 2006:100 pp. 34-36. 1011 See SOU 2006:3 p. 18. 1009
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paternalistic terms client and patient.1012 However, the framing of terminology and preference for the term is not clear cut as research in Britain found that the psychiatrically disabled preferred being addressed as patients and clients, and only 10% or less preferred being addressed as users owing to negative connotations of the term user, such as drug-user (misbrukare).1013 The Tsar framed users in terms of guaranteed disability rights: care rights, support rights, housing rights, work rights, social rights and participatory rights. Thus users should have rights to formulate needs, preferences and priorities and to be respected; professional decision-makers should not restrict user rights.1014 Therefore, the user construction was framed using the disability frame; the Tsar constructs users as having rights to influence, preferences, priorities and participation. Summary: user-framing The documents have been analysed to determine how users were framed as the subjects of government policy interventions. Once again, the user framing of the two government inquiries used the language and framing of the disability model, with users framed as citizens with the same rights to influence and make decisions on issues concerning their own lives as all other citizens in Sweden and supported by government policy developing legally binding and enforceable rights. Thus the inquiries took a hard steering approach. The government policy framing of users, however, took a different direction, in terms of illness using language related to diagnosis, treatment and medication needs, emphasising the difference between the psychiatrically disabled and the ‘normal population’. Thus throughout the period the main government framing has been paternalistic and tended to focus on a professionally driven medical model, based on local healthcare agencies and soft steering strategies. Therefore, there has been a discrepancy between inquiries and government: expert inquiries that framed users in terms of citizenship, disability and rights, whereas government policy-makers framed the users in terms medical expertise in local care agencies. Therefore, the care ideology framing did not appear to shift from medical model framing.
1012
SOU 2006:3 p. 19. A survey of mental health users in Britain found a preference for being addressed as patients or clients; 75% preferred psychiatrists to address them as patients, and only 7% preferred ‘user’. The preferred pattern of address by social workers was less clear; 41% ‘patient’; 47% ‘client’; and 10% ‘user’: See McGuire-Sniekus et al. 2003. The reasons for these preferences are unclear. It may be linked with being treated as other patients in hospital settings. Also client may not be negatively associated with clientalism but linked to high-status professional contact such as becoming a lawyer’s client. In addition, Heffernan argues that ‘user’ can have derogatory associations such as ‘drug user’ or the term used to refer to those who take money/favours from family, friends and society without giving back: Heffernan 2006 p. 143. 1014 See SOU 2006:3 pp. 68-69; SOU 2006:100 p. 147. 1013
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State action required As previously discussed, the framing category relating to the state action required builds on the previous two categories of how the problem and users are framed. The government formulates a need for action such as types of interventions or programmes in order to resolve the situation. State action required: framing of initial reform & early years The 1992 Mental Health Inquiry (Psykiatriutredning) framed the need for state action according to the disability model with framing from a user perspective with references to the individual user’s aims and priorities as the basis of services and a shift from ‘passive’ measures such as cash benefits to ‘goal oriented’, and active measures such as rehabilitation, treatment and social support.1015 The report framed state action in terms of user-centred changes to facilitate greater integration of mental health services into the civil structures for ordinary citizens and to increase accessibility and adaptation to user needs. Public agencies must “show respect for the individual’s integrity and right to freedom of choice” and state actions should support users to “compensate for the negative social effects that the mental disorder causes the individual in everyday life”.1016 Thus state action however, was also framed more widely than a narrow focus on services and benefits; as an educational role to spread of knowledge on mental illness to reverse negative perceptions of mental illness disorders in society.1017 State action was framed in terms of the individual psychiatrically disabled person’s rights to self determination using language of individual rights and preferences: own choice, needs and priorities,1018 as well as user-led services “free from public agency and staff cultures”.1019 Therefore, state action was framed in terms of individualised services based on users’ freedoms, preferences and citizenship rights. The user-centred nature of the discussion corresponds to the disability model and a hard steering approach based on enforceable rights. The government’s 1994 Mental Health Reform Proposition (Proposition 1993/94:218) was much less disability focussed than the inquiry and lacked the Inquiry’s disability frame. There was, however, some discussion about user needs and preferences: The government believes that in the first hand it should be the individual patient’s choices and priorities that should steer the choice of housing or 1015
The inquiry report argued that the role of municipalities should be clarified in order to specify municipal responsibilities for inventory and outreach, providing personal representatives, crisis support from a social perspective, individual planning, housing, activities and supported employment schemes: See SOU 1992:73 pp. 31-42. (Citation – my translation). 1016 SOU 1992:73 p. 205 (my translations). 1017 SOU 1992:73 p. 199. 1018 SOU 1992:73 p. 23 (my translation). 1019 SOU 1992:73 pp. 42-43 (my translation).
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Policy Framing care form. It is, however, necessary that county council and municipal staff participate in individual care planning. 1020
Yet it was unclear what the conditional participation of agency staff meant in reality and whether ‘participation’ referred to supporting user choice or merely consultation where real decisions were made on behalf of users in a paternalistic manner. The need for Personal Representatives was framed by the inquiry as an important issue for user rights; yet in the Government’s proposals it was framed as a need for professional “expertise”, whereby the psychiatrically disordered need support of a “professional character ... based on expert knowledge ... [and] qualified support”.1021 Therefore, the government’s ‘expert’ frame suggested more paternalism rather than user preferences and social rights. In addition, the government did not frame the reform in terms of strong state action, and failed to specify concrete user rights. Instead the government argued for the state to delay and wait for more information; this is referred to by Markström as a “wait and see”1022 approach. The government is also unclear over the application of disability legislation: The results of evaluation ought to form the basis of the government’s future assessments concerning whether the formulation of the Disability Act is suitable regarding the mentally disordered .... [I]t is so far too early to determine how many mentally disordered will in practice be covered by the Disability Act. For, among other things, this reason it is necessary to follow closely the implementation of the law.1023
Thus there are no clear rights expressed and the government’s discourse gives an impression of not being fully prepared for the reform: definitions were unclear, concrete decisions would need to wait for evaluations of other reforms and legislation, and it was unclear how many users were covered by disability rights while the government ‘waited to see’ how municipalities chose to interpret the Disability Act. In contrast to the inquiry, the proposition emphasised the medical model. There was framing of the need for a new social perspective for community care services; instead the government emphasised continuities with county medical services under municipal control. Instead of new forms of social care, the government framed the policy as a ‘transfer’ to “build on the work” of medical services, even suggesting that municipalities could contract some services back to psychiatry to run as before.1024 The government vision was a paper transfer of services to municipality, to be contracted back so that psychiatry would continue to run the service with municipal finance. There was
1020
Regeringens Proposition 1993/94:218 p. 46 (my translation). Regeringens Proposition 1993/94:218 p. 32 (my translation). 1022 Phrase used by Markström 2003 to describe the government’s approach. 1023 Regeringens Proposition 1993/94:218 pp. 27-28 (my translation). 1024 Regeringens Proposition 1993/94:218 p. 26. 1021
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little focus on social knowledge and methods; instead the government argued that municipalities needed to recruit medical mental health knowledge: [A]n essential part of the competence provision in the new municipal services should be achieved by the transfer of nurses and mental health assistants from county psychiatry to municipalities. 1025
Thus again the government framed the need for state action in terms of the medical model. Municipal social services departments would obtain mental health knowledge efficiently by appointing the medical asylums staff. The government granted freedom to doctors and psychiatrists to define central terms by adopting a cautious language and refusing to give clear definitions: “The government does not believe it possible or suitable to define more closely the term fully medically treated in legislation”.1026 Thus there is a shift from the inquiry’s disability frame to a frame based on a paternalistic medical model based on low levels of central steering. The government frame is cautious and vague, without a strong ideological approach, deferring concrete decisions until they see what happens and devolving interpretation decisions to local agencies. The reform is based on minor adjustments to existing framework legislation, in contrast to the enforceable legal rights framed by the inquiry, and adopts a medical rather than social perspective. The government frames social services as being in need of medical knowledge from the asylums rather than new social perspectives. Thus the framing of the need for state action is framed according to the medical model. State action required: long-term framing The 2003 Parliamentary Mental Health Debate was a crucial decision point regarding state action; a government party Minister had been murdered and there was intensive public, media and opposition party pressures that the government should act. In the debate, the underlying government care ideology was somewhat contradictory with references to several frames without an apparently dominant care ideology. The Minister stated that mental health was a government priority, and ruled out a return to the asylum.1027 However, there was also little risk model framing despite the acts of violence and nor was state action framed in terms of disability model user rights. Again the government approach was cautious, not promising urgent state action; a Mental Health Tsar (psykiatrisamordnare) would be appointed,1028 and answers to the problem of care failure would be searched for “methodically” through the Tsar’s investigation and report back to government. The main 1025
Regeringens Proposition 1993/94:218 p. 92 (my translation). Regeringens Proposition 1993/94:218 p. 40 (my translation). 1027 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 34. 1028 The Mental Health Tsar was appointed in 2003 but did not publish his final report until November 27, 2006 as SOU 2006:100. 1026
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framing was that this was an area of action for local care-givers and the need to improve local medical care. The Minister emphasised medical expertise referring to the roles of psychiatrists, family doctors and specialists in psychiatry. There was also emphasis on the need for improved access to medical services such as outpatient clinics, inpatient beds and follow-ups etc.1029 However, the Minister continued to emphasise the arm’s length, and limited government responsibility to act, framing responsibility in terms of local care agencies together with the role of The National Board of Health and Welfare to follow up and act in the case of scandals and failures.1030 Thus in contrast to Britain’s reactive approach, and despite the political crisis, government framing demonstrated little urgency and no shift in framing; indeed, the Minister emphasised the limited nature of his ability to act. The 2003-2006 Mental Health Tsar Inquiry (Miltonutredningen) framed state action as supporting a disability model to enable users: “Live life as everyone else and individual’s wishes met as far as possible”.1031 The discourse was based on normalisation and individual preferences, with the state playing a central role in establishing user rights, norms and values. The wide variations in municipal interpretations of rights sent mixed messages to users, that unlike other citizens their rights were conditional and dependent. The Tsar framed norm-setting as a key issue for state action. You send signals to the person with mental disability that you do not have an specific rights, rather the ‘it all depends’. Your quality of life and opportunities to control your own life situation are determined by the economic conditions, knowledge and commitment of specifically your municipality.1032
The frame was based on a citizenship perspective and the need to develop specific, legally binding user rights to guarantee rights of “Participation in the community and in society and to be met with understanding and respect.”1033The disability frame was focussed on two levels: individual level with choice and influence rights; and collective level through rights of user groups to influence the formulation of services.1034 Therefore, the need for state action was strongly framed in terms of disability rights for the psychiatrically disabled to receive “needs adapted and coherent support”.1035 The Tsar also focussed on a more active and focussed government role, with improved steering and a central issue for state action to improve user outcomes and to ensure increased goal congruence around government inten1029
Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20, 34 & 36 (my translation). 1030 Riksdagens protokoll 2003/04:11 Minister Lars Engqvist anf. 20. 1031 SOU 2006:100 p. 149 (my translation). 1032 SOU 2006:3 p. 63 (my translation). 1033 SOU 2006:100 p. 28 (my translation). 1034 SOU 2006:100 pp. 517-518. 1035 SOU 2006:3 p. 11 (my translation).
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tions.1036 Therefore, my overall assessment is that the need for state action was framed in terms of the disability models and guaranteed disability rights. Footnote – the government’s policy response to the Mental Health Tsar The Milton Inquiry took three years to complete and was handed over just before the end of the period for this book; in November 2006 to the new right-wing-led coalition in 2006, not the Social Democratic government that appointed the Tsar. The new government’s response did not appear until May 2009 so falls well outside of my period. However, I will comment briefly. There were no new laws or major changes of direction and again the disability rights approach recommended by a government commissioned inquiry was ignored. The legislative proposals amounted to three fairly minor legislative adjustments and clarifications that took effect from January 2010.1037 Thus the focus of the government’s response was a small number of administrative changes, echoing the original reform that appeared to have come full circle. The one somewhat more significant change was increased financial steering with an earmarked investment programme starting in 2007 amounting to almost 2 billion kronor over three years, for special projects. The projects were mostly focussed on central administration and health services, although there were several special funding areas directed specifically at municipal social care services including knowledge, education and method development and finance for new service types.1038 The main area of contrast is the framing of increased financial steering through earmarked finance was not framed by the new government as ‘unconstitutional’ whereas the previous government had used this frame. Although the use of some targeted finance could not be described as ‘hard’ steering, it is a shift from the soft model adopted in previous years. The fact the new government was able to adopt harder steering strategies suggests that the previous framing may have had a strongly rhetorical element; using constitutional references as justification for its preferences for soft steering strategies. Summary: framing of state action The section on the framing of state action analysed documents spanning over a decade starting and ending with government inquiries that framed the need for government action in terms of a disability model (Mental Health Inquiry 1992 and Mental Health Tsar Inquiry 2006). However, the government’s own policy framing was less radical; primarily framing state action in medical language, but also framing in very cautious terms without urgent or reac1036
See discussion in the steering report SOU 2006:3. The legislative changes were the right for children of the mentally ill to receive information and support; a requirement for counties and municipalities to formulate cooperative agreements for mental health services; and the requirement for municipalities to identify the psychiatrically disabled and develop individual plans: See Proposition 2009/09:193. 1038 See government website: psykiatrisatsning 2007, 2008 & 2009. 1037
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tive decision-making; not even the violent acts of 2003 and the murder of a Ministerial colleague led to a change of framing. There was a substantial contrast between inquiries and government: the Swedish inquiries tended to be visionary and emphasise a clear care ideology based on a disability rights frame, whereas government framing was cautious and failed to substantially shift from the medical model, frequently characterising mental health as an issue for local and medical decision-makers. The framing of a state action need is somewhat paradoxical in the government documents as the need for state action tended to be framed as a need for the state not to act: the 1994 proposition frame was in terms of a cautious ‘wait and see’ approach and in terms of delaying strong action, whereas the 2003 debate statements was in terms of local- and executive agencies’ responsibilities, emphasising the limited role of government. Thus there was no strong discourse for state action as action was framed in terms of local and independent agencies, thus underpinning the government strategy of soft steering.
Policy framing & the role of the media It is also important to analyse to what extent the Swedish government framing may have been influenced by the media. In this section I have utilised Magnusson’s extensive study of mental health in the Swedish media between 1980 and 2006.1039 In addition, I carried out my own brief review of 40 newspaper articles in order to see whether media framing and discourse have been a strong influence on government framing. Magnusson argued that since 1988, mental health as an issue has become increasingly newsworthy, classifying media reporting into three periods and categories: 1980–1987, low news interest; 1988–2001, variable media interests; 2002–2006 high media interest.1040 However, Magnusson’s picture of media reporting in Sweden diverges from the picture that we found in Wolff’s and my own review in Britain as the risk and danger reporting is less prominent. Magnusson reviewed 663 media reports and classified 40% as focussed on healthcare and legislation, whereas only 28% were focussed on crime and trials.1041 While there was increased coverage of mental health crime after the reform, negative reporting of scandals and crime did not dominate and even declined slightly during the ‘scandal period’ of 2002– 2006 which included the Anna Lindh murder. Magnusson classified news as “care” or “crime” reports: for 1988-2001, 62% were care and 38% were crime; and for 2002-2006 the number of care reports increased to 65% whereas the crime reports declined to 35%.1042 Magnusson argues that reportMagnusson’s 2010 PhD thesis in the discipline of journalism analysed mental health news reporting from a variety of perspectives. 1040 See Magnusson 2010 pp. 130-145. 1041 Magnusson 2010 p. 147. 1042 Magnusson classified reports as vård/care or våld/violent crime 2010 p. 167. 1039
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The Governance Gap ing often focussed on care failures: “linked to the perpetrator not getting enough care for their psychiatric illness”.1043 Magnusson’s findings thus accord with my study. There was a general framing of problems and even crimes in terms of care failures and a need for improved local support services, yet there was no general shift to the type of risk framing seen in Britain. In addition, Magnusson’s results also reflect my findings of an increased medical model focus. She analysed TV new reports to identify which professionals were chosen or not chosen for interview. A sample of 529 reports of the news programme Rapport found that of the interviewed professionals doctors dominated: 43% were psychiatrists, 9% other doctors, 9% lawyers, 7% psychologists and only 2% social workers. Indeed no social workers at all were interviewed after 2002.1044 Thus medical competence was clearly dominant in the choice of interview subjects with over half of those interviewed being doctors, yet very low recognition of mental health as requiring social expertise. There are broad similarities in the media’s framing of care failure and preference for medical expertise and government framing. Yet Magnusson’s study does not demonstrate a clear media care ideology as a strong influence on government framing. I have studied 40 articles and headlines in order to analyse the impact of the media on framing. In the years following the reform there were large numbers of articles focussing on individual users and how they were coping with their “new life”1045 and focussing on shortcomings in care and rights for the psychiatrically disabled;1046 in particular, only around one-sixth were accorded disability rights compared with original estimates.1047 The articles used negative language to discuss the users’ situation in the community, reflecting the government’s reform text, with terms such as isolated, passivity, weak social network and ‘left to drift’ (vind för väg). However, the general tone was that the psychiatrically disabled were victims of agencies’ failures and a perception that their care “should be characterised by respect for integrity and human dignity”.1048 In the sample of 20 newspapers between 2002 and 2006 the most common theme was how poor the access to services was and how users were not receiving the services they “have a right to”;1049 some municipalities were criticised for re-creating the asylum by using housing “with the character of the mental hospital”.1050 Thus there was a strong 1043
Magnusson 2010 p. 155 (my translation). Magnusson 2010 p. 176. 1045 Dagens Nyheter 14/12-97 (my translation). 1046 See for example Dagens Nyheter 8/3-95; 15/6-97; 20/6-97; 29/6-97; 5/7-97. 1047 Only 1300 psychiatrically disabled were accorded disability services compared with the government estimate of 7000: See Dagens Nyheter 5/7-97. 1048 See Dagens Nyheter 12/1-98 (my translations). 1049 Svenska Dagbladet 11/12-03. See also Svenska Dagbladet: 1/7-02; 16/8-02; 3/6-03b; 25/6-03; 16/9-03; 20/9-03; 2/10-03; 2/10-03b; 14/11-03; 11/12-03; 12/12-03; 10/1-04; 7/1004; 27/5-04; 29/7-05; 9/9-05 1050 Svenska Dagbladet 16/6-03 (my translation). 1044
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Policy Framing discourse that the reform’s problems were not the fault of individuals but were caused by the lack of local community support. In the later period the media debate also became more party political, which connects with Magnusson’s conclusion of more intensive news interest after 2002. Several articles took up political blame and steering, with general conclusions that all concerned, Parliament, the government and Ministers, should take more responsibility for the reform as both blocks were involved in formulation and implementation.1051 There was also a hardening of the rhetoric in the months following Anna Lindh’s death as mental health became a party political issue where the opposition demanded tough new measures in debate articles and speeches prior to the 2006 election.1052 There were also user-based articles expressing dismay at tough political rhetoric: “stop the witch-hunt against the mentally ill”.1053 The headline review used the tabloid newspaper Aftonbladet. In contrast to Britain, despite the tragic events of 2003, the focus of the headlines is not individualised on crime and perpetrators but again focuses on care failure and society’s responsibility: “Don’t lock up the sick Engqvist”; “Acts of insanity have forced government to realise the seriousness”; and “Politicians – do something”1054. Even in the midst of outrage at the murder of Anna Lindh the majority of headlines focussed on care failures by public agencies: “Too many sick left to drift”; “Mentally ill denied entry to shelters”; “1500 mental cases without care on the streets”; “Those who should have had outpatient care – forgotten”.1055 There was also an increased focus on the victims of crimes and murders by the psychiatrically disabled;1056 but usually framed in terms of the need for better care and prevention: “How could the tragedy of Åkeshov been avoided?”; “Acts of lunacy have made the government to realise the seriousness”.1057 However, once again the media framing does not appear to have been strongly influential on government policy as the media focussed on a need for harder government steering; something that the government assiduously avoided. There was a strong difference between the media coverage in Sweden compared with Britain. The type of individualised sensationalist reporting in Britain that characterised the mentally ill as animals or evil was not a central feature; even criminal acts were framed in terms of the mentally ill offender also being a victim of care failures.
1051
See Svenska Dagbladet: 16/-9-03; 20/9-03; 2/19-03b. See Svenska Dagbladet: 19/9-03; 1/10-03; 5/8-06; 6/8-06. 1053 Svenska Dagbladet 6/10-03 (my translation). 1054 See Aftonbladet 3/6-03; 17/9-03; 27/8-03 (my translations). 1055 See Aftonbladet 2/6-03; 25/6-03; 28/8-03; 1/10-03 (my translation). 1056 See Aftonbladet 30/5-06; 1/7-07. 1057 See Aftonbladet 27/5-03; 17/9-03 (my translations). 1052
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Discussion – policy framing in Sweden In Sweden I studied several documents spanning the period from 1992 to 2006; the period starting and ending with Inquiries, focussing analysis on critical points where policy change might occur. The original 1992 Mental Health Inquiry was strongly user-centred and framed in terms of the disability model and the need for strong government action in terms of guaranteed and legally binding and enforceable rights, thus emphasising a need for hard steering by government by its focus on regulatory and legal instruments. The government’s policy response, the Proposition, on mental health reform in 1994 was much less radical; the main focus was medical relating to patients, diagnosis and the need for medical expertise even in new social care services, and user framing was medical and focussed on local care agencies. Therefore, framing emphasised models associated with soft steering. The year 2003 represented a major window of opportunity for a different approach by policy-makers owing to acts of violence and a Cabinet Minister’s murder. However, no radical policy change occurred; the Minister framed the problem and need for action in terms of medical expertise and the need for the government to await further reports. The Ministerial framing emphasised local government’s failures and the government’s limited roles and responsibilities. The main action of the government was to establish the Mental Health Tsar Inquiry. The Tsar’s report identified that government steering approach as a major problem, framing a need to abolish the ‘it all depends’ culture of localism and medical decision-making. Thus the government’s approach was cautious and the main care-ideology expressed by the government was the medical model; this was framed in terms of local clinicians’ actions and the responsibility of executive agencies such as the National Board of Health and Welfare to act rather than the government. The frame chosen by the government underpinned the choice of soft steering strategies. The government framing of mental health policy in Sweden was remarkable consistently; there was no significant shift away from the medical model, which also corresponds to soft steering strategies and professional decisionmaking. However, there was also emphasis on decision-making not being a government issue: while inquiries recommended radical shifts and changes, government policy-makers had emphasised their lack of responsibility, in total contrast to the interventionist risk framing in Britain. There were key moments where radical shifts could have occurred; for example in many countries the scandals of 2003 and the murder of a Cabinet colleague would had resulted in a centralising policy shift. However, Ministers continued to frame mental health as medical and local agency issues, and thus not issues for Ministers. The main care ideology was the medical model emphasising softer steering strategies from local agencies observed in Chapter 3.
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Conclusions – policy framing in Britain & Sweden Policy framing is a dynamic element of the policy process and thus there are windows of opportunity to influence governance decisions. In this chapter I analysed how the policy framing dimension may increase understanding of hard and soft governance strategy choices by analysing texts at critical decision points of initial inquiry;1058 government policy;1059 and critical windows of opportunity for policy change in the short-term and long-term. 1060
Comparison of framing findings – summary & discussion My overall findings are that Britain shifted to a strong care ideology based on the risk model, which framed mental health in terms hard steering, whereas in Sweden policy was framed according to models associated with soft steering, in particular the medical model. Problem definition framing The analysis of the problem definition differed. In the early reform years Britain had no dominant care ideology, using references to several discourses, although it appeared as a form of rhetorical framing to justify and build support for preferred government strategies of harder steering. However, the Swedish government continued to frame mental health as a medical issue, although focussed on local agencies and medical experts, such as psychiatrists which focussed on soft steering. In Sweden this frame was maintained throughout the period 1995–2006, despite dramatic events. However, in Britain there was a strong shift under the Blair Government to the risk based framing with the problem defined in terms of controlling the danger of the mentally ill in the community, which intensified the hard steering. Therefore, there were major differences in the way that the problem was defined by governments that reflects different steering strategies.
1058
The initial mental health inquiries refer to texts for the Griffiths Report 1988 in Britain and the Mental Health Inquiry (Psykiatriutredningen)1992 in Sweden. 1059 The community care reform texts comprise of: Her Majesty’s Government 1989 Caring for People in Britain which led to the 1990 NHS and Community Care Act, and 1994 Regeringens Proposition 1993/94:218- Conditions of the Mentally Disordered in Sweden. 1060 The short-term change relates to changes that occurred within two years of the final implementation dates of 1993 in Britain and 1995 in Sweden. In Britain this refers to the 1995 Mental Health (Patients in the Community) Act. However, in Sweden there was no similar short term window of change opportunity. The long-term refers to the period between two and around 10 years after implementation. The texts for Britain are Modernising Mental Health Services and Modernising Social Services both from 1998. In Sweden I examine the statements made by the Social Affairs Minister in the Mental Health debate and the new inquiry commissioned at the same time.
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User framing The construction and framing of users also throws up interesting differences. In Britain the original reform documents lacked a clear care ideologically with references to several discourses without a dominant frame. However, there was a substantial shift in the framing of later documents where users were framed using risk model language, emphasising criminal acts and danger to the public. The risk model frame created a significant intensification of hard steering terminology. Users were framed in terms of criminality, risk and danger requiring policing to control and contain the psychiatrically disabled through hands on, hard steering. In Sweden the general tone was paternalistic. In contrast to the inquiries focus on active user decision-making and citizenship rights, the government framed users as isolated and dependent individuals who were dependent on local experts and medical decisions; yet the government denied responsibility for users framing them in terms of diagnosis and treatment, and focussing on users as an issue for local agencies and professionals that requires soft, arm’s length steering from government. State action framing The need for state action built on the previous categories whereby the government used the problem and user frames to identify its need to act. In Britain’s early documents there was some focus on individual’s freedoms and choices, which could represent a disability frame, yet which also corresponds to government market ideology. However, in the later years the need for state action shifted to the risk care ideology, where the dominant framing was the need for state action through tough new surveillance and coercive measures requiring extensive new government powers and instruments to control both the psychiatrically disabled and the municipalities responsible for their care. Thus in both periods Britain adopted a hard governance approach: however, the need for hard steering intensified with the adoption of the risk model in later years. The Swedish government adopted a different strategy as there was a focus on government non-action; thus framing was based on the government’s denial of competence to act at all. The government adopted a considered and cautious approach framing the texts in terms of not being sensible to act without more information. This approach was used both at the time of the reform where they were awaiting implementation reports on the Disability Act, and also in 2003 where the response to the scandals would depend on the Mental Health Tsar reports. However, it is interesting to note that this framing of ‘wait and see’ and ‘gather more information’ appears largely rhetorical. The National Board of Health and Welfare reported on the reform’s problem in 1996, 1997, 1998, 1999, 2003 and 2005, yet the government never did take substantive action, and by the time the Mental Health Tsar reported three years after the report was commissioned, the party which had been responsible for the report for almost 12 314
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years was no longer in power to act. There was also strong medical model framing; mental health was framed as an issue for the psychiatric expertise and medical competence of local healthcare agencies. Thus the wait and see approach, coupled with the medical model framing, underlined the government’s strategy based on soft steering. Policy framing & media analysis The media analysis mostly confirmed the policy framing analysis. In Britain the media focussed on risk perspectives, but was individualised, stigmatising the individual with derogatory language and symbols and likening the mentally ill to unpredictable killers and animals. However, my triangulation with the results of Clement and Foster’s (2008) extensive study found that media framing had not significantly changed between 1996 and 2005. Thus while government may have been influenced by the general negativity of media reporting, it does not alone appear to account for the shift to the risk model after 1998. Thus the policy framing in Britain appears to be an interactive relationship between a dynamic political framing process and the wider public discourse of which the media is a part. In Sweden, the media analysis shows that while there was increased coverage of scandals and crime, it was often framed in terms of societal and agency failures preventing users receiving care, coupled with criticisms of government inaction. This is also reflected in Magnusson’s study, which also emphasised medical framing with the dominance of psychiatrists as the main profession interviewed in relation to mental health, and reinforced the government’s own medical model framing. Thus while there is no clear evidence that the media discourse prescribed a particular government frame, it is clear that public opinion and the media are a part of the wider context of information available to government.
Conclusions My findings are that despite the similarities in the stated aims and content of the community mental care reforms discussed in Chapter 2, there were differences in the policy framing of mental health. Britain adopted frames relating to hard steering while Sweden used soft. The shift from medical model disability frame did not occur in either country; in the long-term Britain shifted to a risk frame, whereas Sweden in many respects never broke away from medical framing. The hard steering approach adopted by Britain intensified as a result of the shift to the risk model’s care ideology, which framed services in terms of an intensification of centralisation and hard steering strategies. The risk model in Britain was not only about centralised administration but it was also about framing mental health in terms of criminal justice, violence and danger requiring a strong government ‘policing’ response. My assessment is that the framing in Britain became more visionary and focussed on the care ideology beliefs and values of the government: 315
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from the initial administrative focus on privatisation and market aims to a strong care ideology based on social control and the need to restrict individual freedoms of the risk model. In Sweden the ‘visionary’ nature of the reform was more muted. Framing was cautious and avoided radical policy of visionary changes; there was little framing in terms of a grand political or policy vision for mental health. The government emphasised the need to wait and evaluate before making changes. There was also a reluctance to leave the professional medical model, and social care services were often framed in terms of medical knowledge rather than the social perspectives that dominated the inquiry report. The reform was framed in terms of incrementalism, based on small changes in legislation that emphasised local, which also emphasised soft steering mechanisms. Indeed the government framed the reform in terms of its non-responsibility to act; however, this may have been a rhetorical frame to underpin a preferred strategy of non-intervention by denying competence and emphasising the responsibility of local government in constitutional and professional (medical) terms. The government that came to power in 2006 did not find it problematic to increase the ‘hardness’ of certain financial steering instruments. Thus the framing is part of the causal story, allowing government to adopt their preference for soft steering while evading blame by claiming a need for more information or lack of power to act. Thus the expected shift from medical- and hospital-based models to normalisation and disability models failed to materialise. In general terms, Britain’s government policy framing emphasised that ‘government must act’ using an increasingly risk-based care ideology corresponding to hard governance and steering strategies. However, in Sweden framing emphasised that ‘the government’s cannot act’ as mental health’s care ideology was framed as a local agency issue for medical professionals and was therefore, not a responsibility for central government, thereby underpinning the government’s soft steering approach.
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Chapter 8
Discussion & Conclusions Governance Gap & Triad of Influence The issue of why reforms with similar ideas and contents lead to different results has puzzled political scientists for decades. In reforms where governments no longer have direct contacts with users, the main mechanism by which government policy-makers can influence the implementation of their national policy goals and programmes is through their choices of governance and steering strategies. These choices also in turn influence how government policies impact on both user-outcomes and public perceptions of policy. Thus government choices of hard or soft steering strategies are key elements of the policy process. Yet as I have demonstrated earlier in this book, policies with similar aims and contents do not always result in similar governance and steering choices: governments have preferences for different governance strategies. So how should we understand what causes governments to choose different governance strategies based on hard and soft steering? There was prior research on the concept of policy styles, yet the term was somewhat fuzzy and not fully operationalised, yet it was a useful starting point for this book. The policy styles discourse is based on ideas that various institutional and actor-centred influences form an invisible frame around the policy process and creates preferences for certain types of steering and instrument choices. The two cases of the mental health reforms in Britain and Sweden provide examples of divergent governance strategies. In the mid1990s both countries adopted similar reforms, yet while Britain chose hard governance and steering strategies, Sweden chose soft. To recap, the research question was: Why did the British government choose hard internal governance and steering strategies while the Swedish government chose soft for the mental health reforms? My research question aimed to develop theory in this under-researched area by contributing the concept of a Triad of Influences consisting of three dimensions of administrative traditions, professions and policy framing may 317
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increase our understanding of which mechanisms cause governments to choose hard and soft government and steering choices. In the pages that follow, I review the most important empirical and theoretical findings of this study. I summarise and discuss the empirical findings relating to the mental health reforms. In the preceding Chapters 5–7, I have analysed Britain and Sweden as comparative cases for each of the dimensions of the Triad of Influences, by focussing on differences between the cases for each dimension. However, in this chapter I summarise and analyse each country as an individual case; focussing on the influence of each of the three dimensions of the Triad within each country and whether any single dimension appeared to have a stronger explanatory power in the case of the mental health reforms. Therefore, as well as considering the comparative cases, the use of within-case analysis increases our understanding of how the mechanisms worked in the individual cases of Britain and Sweden. In addition, I analyse how the Triad’s three dimensions combined and interacted with one another to influence governance and steering choices for the mental health reforms. In a final empirical section, I discuss my comparative conclusions and findings relating to Britain and Sweden. I also discuss the theoretical findings and analyse the theoretical contributions of this study. I discuss the new model that I developed in Chapter 3 that links policy steering instruments with the concepts of hard and soft steering. I also analyse the models and dimensions of the Triad of Influences There is also a discussion of the nature of national policy styles as a concept and factors related to the study of policy styles from governance and steering perspectives rather than the more traditional policy-making perspective.
Empirical conclusions: the mental health reforms At the start of this book I identified the puzzle of the mental health reforms and that despite Britain and Sweden having chosen reforms with seemingly similar aims and content, that there were perplexing differences in outcomes for users. The objectives of the mental health reforms appeared comparable with objectives and measures to devolve responsibility for social care of the psychiatrically disabled from health services to municipal social services: medical and social care services were separated; municipalities became financially and operationally responsible for patients no longer requiring fulltime inpatient care; the government provided transitional finance; and roles existed for non-state providers. Therefore, it is clear that in the cases of Britain and Sweden the formulated reforms in both bore strong similarities. Despite the pre-reform discussion of user rights in both countries, this was not reflected in user outcomes. In Britain there was a gradual transition to focus on risk and danger instead, which led to the erosion of civil rights with coercive mechanisms. In Sweden, on the other hand, there was in theo318
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ry strong rights-based legislation; however, the implementation mechanisms were weak and fuzzy; many psychiatrically disabled were unable to claim their rights to a good standard of living. The reforms in both countries had discussed using non-state actors to improve quality. In Britain there was a strong emphasis on private providers and contractual arrangements, even where contractors had no experience or competence in providing services. In Sweden however, non-state provision focussed on user-led services such as Peer Support, which were highly valued by users, yet many of these user-led services closed when state stimulus finance ran out. Finally, administrative issues impacted on users. In Britain there was a strong emphasis on bureaucracy with standardised managerial models; clients processing ethos; and low user-need prioritisation as eligibility requirements were adjusted to meet budgets. In Sweden there was substantial local flexibility and freedom to interpret and formulate the reform; yet users were dependent on local prioritisation of mental health at a time of austerity. Thus there were wide variations in the ambition and generosity of reform services and reform outcomes and results varied significantly despite the policy similarities. In addition, the internal steering and governance strategies selected by the governments to steer implementation revealed wide variations. Notwithstanding the decentralising and disaggregating aims of transferring responsibility to municipalities, Britain chose hard steering strategies, which re-centralised reform control, whereas Sweden chose soft steering, which shifted responsibility to local levels and created wide variations in mental health services. It appeared that there were national differences in the policy and steering styles adopted by the two countries, yet the existing literature on policy styles does not present a ready-made approach. Thus I constructed a Triad of Influences based on three dimensions derived from theoretical research that may influence governance choices and help us understand the different policy and steering choices in Britain and Sweden. The three dimensions were Administrative Traditions based on historical and institutional influences; Professions was the influence of the sector’s main profession on steering choices; and Policy Framing was the influence of political decision-makers’ norms and values. The comparative findings were discussed in theoreticallyguided discussions in Chapters 5-7 where I analysed each dimension individually and comparatively to identify differences between the two cases. However, in the following pages I summarise my results from a national perspective using within-case analysis.1061 This will enable me to study way in which the dimensions combined to influence steering choices in each county and also possible inter-dimensions relationships.
1061
See George & Bennett 2005 pp. 17-19.
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The Triad of Influence & governance choices in Britain The empirical results for the case of the mental health reforms in Britain are summarised in the following sections. My main findings are that the administrative traditions appear a strong, but not the sole explanation as the dimension of policy framing appeared influential as well. In the case of Britain professions appeared to have a lesser impact; however, I would argue that there is some impact, as despite the Thatcher government’s general hostility to social work, the reform contained a guaranteed influence for the social perspective and created non-medical roles for social workers. Administrative Traditions The first dimension analysed was Administrative Traditions, which has been the object of prior research, yet not operationalised or studied from an internal governance and steering perspective. There were clear indications that internal government steering strategies had been influenced by the administrative traditions and in particular the levels of territorial centralisation and executive control where central structures and decision-making actors dominated the governance and steering mechanisms. This confirms some assertions of prior research of a path dependency based on historical and institutional legacies. There appeared to be strong mechanisms of an institutionalised central control apparatus. The territorial level of centralisation builds on mechanisms whereby the centre dominates the central local relationship and interactions through the unwritten constitution and the state’s strong position. There are few constitutional safeguards for local government in Britain, which means that constitutional change can occur on the basis of the government of the day passing new legislation. In addition, the high level of financial dependence of municipalities can be used as a mechanism to ensure compliance as municipal action is limited by grant conditions. Therefore, in Britain, local accountability is dominated by central decisions, which means that the constitutional position of locally elected politicians is tenuous and precarious. The mental health reform demonstrated the government’s domination of lower territorial levels. While the Griffiths Report argued that the reform should not be managed in detail from Whitehall, the government actually exerted an ever increasing ‘iron-grip’ on municipalities, starting from the market requirements and plethora of Ministerial directives, to the later powers for Ministers to remove whole municipal functions from local democratic control. The level of executive control was also a major mechanism with the Ministers playing powerful direct and reactive roles. There was strong emphasis on executive powers in relation to reform decision-making and personal Ministerial interventions were the norm. Therefore, the basic idea that the reform would be a decentralisation and that it would be based on local re320
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sponsibility for services was soon undermined. There was little separation between central and local government with the Ministers and regulatory agencies expanding their roles. Municipalities were forced into reactive modes under a constant barrage of directives and requirements from the executive and the rapidly expanding number of regulatory, monitoring and audit agencies that all issued directives, standards and ‘guidance’, as well as inspections and audits. Thus British municipalities were subjected to detailed steering and standardisation, which in turn led to an ever-increasing bureaucratisation of services and procedures in order to meet the needs of regulatory agencies for ‘auditable’ documentation. There appeared to be a synergy between the strongly centralised territorial and executive powers as a result of the few constitutional safeguards for municipalities, which meant that the centre could hold local politicians accountable to centrally determined performance indicators and that there were powers for Ministers to seize control of municipal functions that Ministers considered were performing poorly. However, this hyper-centralisation to focus municipal activities on government priorities and targets raises questions concerning the nature of local democracy and accountability in Britain. It is unclear how the local electorate can hold municipal politicians to account for local services when aims and standards are determined centrally by unelected regulatory agencies. The category of sanctions, however, showed a less clear pattern. Sanctions tended to increase and intensify under the Labour government, yet these often developed as a result of the rise in executive power. Britain lacks a system if administrative courts and sanctions. However, was also a strong focus on individual sanctions in Britain and the use of tribunals such as the Homicide Inquiry system to sanction individual professionals. Therefore, my findings show that there appeared to be a strong connection between administrative traditions and centralised forms of hard steering adopted in Britain. However, although the dimension of administrative traditions appears to be a puzzling intensification of hard steering and territorial and executive centralisation during the decade I analysed. This intensification does not appear to be explained by administrative traditions alone. Thus it appears that there are other forces of influence that influence the choice of governance and steering choices. Professions My research on the influence of professional social work in the case of the mental health reform yielded more mixed results. In many respects it appears that there was a double-Cinderella complex at work with social work as a weak profession, combined with mental health as a low prioritised area, and the psychiatrically disabled as low-status reform users, resulting in reduced professional influence over this un-fashionable area of welfare policy. The model of influence appeared overall to conform to the state-regulated model of steering. The government recognised and acknowledged the role of social 321
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work and the social perspective in mental health, and created a specific occupational jurisdiction for mental health social work. It is perhaps significant that even the Thatcher government, known to be hostile to social policy and social work, recognised social work’s reform role. Yet the influence appeared to be instrumental, the government wished to maintain the social perspective in community care and the competence and experience of social work was best suited to this role. Thus the influence of social workers appeared in some respects their own usefulness as instruments of government policy to achieve government objectives. The results do, however, contain some paradoxes and anomalies. Social work as a whole is a profession that appears to be in a phase of declining influence compared with its earlier, more bureau-professional developments. The general profession appears to be increasingly marginalised from state decision-making and engenders low trust. In recent decades, the profession has been redefined by government into bureaucratic, managerial and auditing roles. In addition, the profession is divided and cannot decide itself whether professional influence is a desirable aim. However, British social work also has a legacy of mental health work, which appears to give mental health social workers a higher level of government recognition than social work in general. This status is based on the state identifying certain tasks as a social work monopoly by creating the ASW role in the 1983 Mental Health Act. This social work monopoly and mental health influence was maintained between 1993 and 2006, and guaranteed a non-medical perspective in the reform, thus demonstrating a level of influence for social work. Thus the relationship between professions and state appears complex; it is an interesting feature that the hard steering focus of the government’s relationship to social work was through legislated roles. Yet this hard steering was regarded as a source of power and status for social workers, providing a statesanctioned occupational monopoly over parts of mental health. Therefore, the existence of mental health social work specialism was influential in the steering of legislatively defined staff roles. The government’s decision to legitimise of social work with the creation of a specific occupational jurisdiction with reserved roles suggests that the state was influenced to some extent by the profession. However, I have found no evidence that the social work profession in this case influenced the steering of other elements of the reform and In addition, professions do not help understand why the hard steering increased in intensity under the Labour government. The mechanisms are complex and the level of influence is limited; thus this dimension appears to have a lower level of explanation for the selection of hard steering in Britain. The influence of the professions dimension appears in the case of the mental health reform to have had a certain level of influence, but sometimes in combination with the other dimensions in the triad, rather than offering a standalone explanation in the case of the mental health reforms. 322
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Policy framing The dimension of policy framing was analysed to determine whether the steering strategies were selected in accordance with policy-makers’ ideological attitudes and preferences in relation to care ideology. Three dimensions were examined relating to the framing of the policy problem, users and need for state action. My analysis found that there does appear to be a link between the policy framing and the choice of governance and steering strategy. In Britain the original policy under the Conservative government was not framed strongly in terms of a coherent care ideology; arguments relating to differing frames were used to justify different state policy intentions. However, under the Labour government after 1997, there was a strong discourse shift to a risk model focussed on danger and public protection. Although this was also a discourse and frame that involved centralised hard steering, it involved a shift in perspective from administration to policing mechanisms of coercion and social control, thus representing an even harder type of steering ethos. Thus this shift in the policy frame appears to shed light on the increased intensity of centralised steering that the administrative traditions and professions dimensions failed to account for. My findings show that steering decisions are influenced by the way that government frames the policy sector or area. The underlying government frame can create the conditions for hard or soft steering depending on: how the problem is formulated and how users and state action are presented. These frames determine the government response. Thus the government may present the policy problem in several ways; as a non-government issue for the individual or market, or alternatively as an issue where state-intervention is needed. In Britain the shift to a risk frame created an underlying discourse and rationale for harder steering based on control mechanisms. Thus, policy framing represents a dynamic element of influence over governance, and is a mechanism that offers an explanation for the dynamic shifts in strategy and policy style that cannot be explained by administrative traditions. Britain – findings & conclusions The analysis shows that each of the three dimensions that I identified as a Triad of Influences had some influence over governance and steering strategy choices. Previous studies have often focussed on the roles and influence of institutional arguments; however, my approach shows that although specific aspects of administrative traditions were influential, the mental health reforms in Britain could not be understood completely through administrative traditions alone as there was a puzzling intensification of hard steering, unexplained by historical legacies. In the case of Britain, the dimension of policy framing appeared to fill the governance gap noted in the post–1997 era. The shift from a more pragmatic framing to a strongly ideological riskbased framing is a mechanism that helps us understand the increase in hard 323
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steering. The risk frames created an underlying justification for harder steering to police and manage danger. The dimension of profession had the least effect in the case of the mental health reform in Britain. However, this may be linked to the weak profession and low status of the policy area. There appeared to be interrelationships between dimensions relating to administrative traditions and policy framing. The discourse of policy actors relating to risk, danger and public protection also created an imperative for central territorial and executive action to contain these risks. The risk discourse in itself created a political risk for Ministers who must be seen to control the situation and resulted in the tightening chain of command mechanisms. Ministers were expected to act and take charge of the situation, which was done via increased reliance on specialist regulatory agencies. 1062 Thus the paradox was created whereby the discourse of risk-management and need for centralised steering and control strategies created fragmentation and division at central levels. However, the inter-relationship between administrative traditions and policy framing dimensions accounts for the intensifying spiral of hard steering identified in Chapter 3. The professions dimension at first glance appears subordinate to the other dimensions as the institutional discourse of institutional and administrative centralisation through territorial and executive controls, as well as the focus on ‘policing’ mechanisms to control risk and danger, would appear to reduce professional influence of social work. Yet there is the contradiction that the despite the government’s institutional centralisation, general control discourse and negative attitudes to social work as a profession, the government maintained a strong professional influence for social work as a monopoly jurisdiction. In addition, despite the general creation of centrally controlled health and multi-disciplinary organisations, the requirement to employ ASWs was confined to municipal employment, even if the social workers were seconded to other agencies such as mental health trusts. The analysis of Britain’s choice of governance and steering strategies was based on the combination of the three dimensions that comprise the triad of influence and demonstrated that a policy style is a combination of influences. In my judgement the institutional dimensions of the administrative traditions in combination with policy framing were perhaps the strongest influences, while in this case the profession was the weakest influence. However, my analysis demonstrated that the institutional and historical influences alone did not explain the intensification of steering; in order to for us to understand the case of the mental health reforms the policy framing dimension was pivotal influence. While the institutional and administrative 1062
For example the Social Services Inspectorate; Audit Commission; Care Standards Commission; National Institute for Mental Health; National Institute of Clinical Excellence; the General Social Care Council; and Performance Action Teams.
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traditions formed an outer filtration mechanism, there were dynamic actorrelated influences of politician’s values and beliefs together with a professions that leads to preferences for certain governance and steering decisions.
The Triad of Influences & governance choices in Sweden The examination of the policy style in Sweden demonstrated a different pattern compared to Britain as steering was strongly influenced by the dimension of administrative traditions, which remained a stable influence during the period examined and appeared to be reinforced by the policy-framing dimension relating to the medical model and lower level responsibility. Administrative Traditions In the case of Sweden there was territorial and administrative power dispersal. The tradition of local self-government in the implementation of welfare reform was influential as the use of framework legislation meant that many central reform decisions were devolved to lower territorial levels and, unlike Britain, were not determined or steered from the centre. Government policy assiduously avoided direct steering. The reform policy proposals were loose and flexible, and were based on local negotiation between actors rather than centrally determined standards and contents. In addition, there was a low level of executive steering. In contrast to Britain, Swedish Ministers have by tradition a limited steering relationship over municipalities and administrative agencies resulting in a complete absence of the flurry of central directives from Department to municipalities observed in Britain. In addition, Sweden did not have a strong “regulatory state” apparatus of executive and regulatory control agencies, auditors and inspectors producing binding standards, directives and rules that characterised the British case. The Swedish traditions were on the government providing a broad framework and executive agencies providing guidance and information, but without demanding rigid compliance from municipalities. Thus there was a lower level of Ministerial reactivity in Sweden compared with Britain. The dimension of sanctions was also that of low steering thereby conforming to the tradition. Thus the dispersal of power created the conditions for soft steering in Sweden. The doctrine of Local Self-government is an interesting aspect of the Swedish case; although it is a constitutional doctrine, it is expressed in vague, flexible and loose terms. Thus adherence to this principle appears to be more a convention; a custom that governments follow rather than a constitutional requirement. The flexibility of the doctrine also means that it is open to different government interpretations when it comes to governance and steering decisions. As discussed in Chapter 5, the Conservative-led coalition that took office in 2006 found increased financial steering less constitutionally impossible than the preceding Social Democratic government. 325
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Professions Professions did not appear to influence the Swedish reform despite the attempts of SASW to claim occupational jurisdiction. However, in general there did not appear to be a great interest in mental health among social workers in Sweden, and in particular Sweden had no mental health tradition in social work that corresponded to ASW roles and training in Britain. The government did not appear to consider the reform from a professional perspective, and, despite the social nature of the reform, social perspectives and the role of social work did not appear to be considered at all. This may be a reflection of social work’s identity problems and late establishment of professional and academic standards. The profession had difficulties in overcoming traditional conceptions of social work as a subdivision of public administration. This is supported by many of the reports produced by the National Board of Health and Welfare where politicians perceived the role of social workers to be administrative rather than professional.1063 The government was not influenced by the profession, nor were roles created for implementation; the only social work reform role was created outside of municipalities but was not reserved for qualified social work graduates. However, in many respects social workers in Sweden did not appear to have a burning interest in increasing their professional domain through mental health work; most opted to remain in traditional administrative assessment and authorisation roles. The mental health reform in Sweden was a welfare reform with an exceptionally low level of professional input. The deal between government and local government associations to transfer thousands of medically-trained former asylum staff may also have obstructed the development of social-perspectives and social work roles. Instead the government did not appear to consider the role of professions at municipal levels at all and instead, a form of pretermitted professionalism was adopted whereby the role of municipal professions was largely ignored, with the government failing to consider social workers as central reform actors. In my judgement the professions dimension does not aid understanding of the Swedish reform in municipalities. Policy framing The policy framing dimension is interesting as it demonstrates that the government did not frame its arguments for the reform in terms of a grand vision or ideology based on social-perspectives or disability. Despite the government-commissioned inquiries focussing on normalisation and social perspectives, the government itself appeared never to leave the medical model. Medical issues continued to be emphasised throughout the period, and the main reform decision-makers were doctors, which may explain the lack of impact for social workers. However, it is unclear whether it was a conscious deci1063
See for example Socialstyrelsen 2005 p. 180.
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sion by government to actually retain the medical model, or whether the government used medical arguments as part of a ‘frame of denial’ whereby the reform issues and problems were framed as decisions for local care providers and the government could deny culpability for reform problems. Users were in some cases framed in terms of the medical model, which created a lack of clarity over what the government’s underlying vision for the reform was in reality or whether the reform was more about pragmatism. Sweden – findings & conclusions In Sweden there is also evidence of inter-dimension interactions. The dominant interactions centre on central-local relationships, which appear pivotal to the Swedish reform. There was a strong relationship between the administrative traditions and the policy framing as the issue of local self-government was both an administrative tradition and institution, yet in addition, it was also used extensively rhetorically as a policy frame to justify the lack of government-steering interventions. It appeared that the issue of local selfgovernment was utilised as a rhetorical framing device by the governments between 1994 and 2006 to deny competence to act and steer the reform; certainly the government after 2006 did not find increased steering to be as constitutionally impossible as previous governments. Therefore, although the principle of local self-government is an important and resilient administrative tradition, it was also convenient as a framing discourse for rhetorical purposes to underpin a preferred method of intervention or, as in the case of the mental health reform, a government preference for non-intervention. The issue between local self-government and professions appears more complex and contradictory. The relationship between the professions essentially mirrored the administrative tradition of local decision-making. The government used the rhetoric of constitutionally guaranteed municipal selfgovernment in order to argue for non-government intervention. The government based its arguments on assertions that social care for the psychiatrically disabled was essentially a local function that should be determined locally by elected municipal politicians, and, in particular, social services departments. Yet the new social work role for the reform was not considered as an issue for local self-government; Personal Representatives were created outside of the local municipality structures. In addition, the government also placed more emphasis on medical staff than social workers; unlike Britain there was no independent non-medical role to ensure a social perspective, and doctors had sole power over admission and discharge. In addition, the government encouraged municipalities to employ thousands of medically trained asylum staff, thus undermining social perspectives. It is unclear whether the medicalisation of social care was a deliberate government strategy, reflecting an underlying vision of medicalisation in community services, or whether it represented the influence of another administrative tradition: corporatism. There is evidence in the texts that the transfer of medical staff resulted from 327
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a pragmatic negotiated solution to a staffing problem for the government and the two local government associations representing municipal and county council employers. Thus the medicalisation of social care staff appears to have resulted from administrative practicality rather than a planned government strategy; the use of medical staff was considered a fast and cheap mechanism for increasing competence, even if most had been trained under the asylum system. Therefore, there was an inherent contradiction; the reform aimed to move away from the culture of the asylum system, yet became dependent on asylum-trained staff’s medical expertise and culture for implementation as a result of pragmatic considerations. In Sweden the dimensions combined in different ways to influence governance and steering styles. The administrative traditions are the greatest influence on the choice of soft steering strategies, and in particular local selfgovernment, corporatism and low levels of executive steering. There is a synergy between the administrative traditions and policy framing which emphasised the local agencies and responsibilities. However, unlike Britain, social work as a profession appears to have had no influence despite the underlying social emphasis of the reform’s intention. Swedish social work lacked the mental health specialism that existed in Britain, and thus professional influence did not occur. This was partly as a result of the state marginalising social work in favour of medical expertise, and partly as a result of an apparent low level of interest among social workers who in many cases opted to remain in traditional, administrative tasks, and left the mental health domain to other professionals such as nurses. Another possibility is that there was a strong professional influence, but that it occurred outside of the municipal domain. The government’s emphasis on the medical model meant that psychiatrists were powerful actors and even though they were not directly active within municipalities, their decision-making powers had consequences for municipal social care services. As Swedish social work lacked the type of state-determined occupational jurisdiction granted to ASDs in Britain, they were in a much weaker position and forced into subordinate roles. Therefore, an area for future study would be to examine the professions dimension in terms of inter-professional competition to control the domain. It may be that professions were influential in the Swedish case, but were linked to the medical model rather than municipal professions.
Contrasting governance & steering In the previous section, I discussed the governance and steering of the mental health reforms in Britain and Sweden in a case-by-case. The cases of Britain and Sweden revealed that beneath the use of common terminology and arguments, such as the failure discourse discussed in Chapter 1, there were underlying differences in steering and instrument choices. In this sec328
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tion I discuss my comparative reflections and conclusions on the cases of Britain and Sweden and the community mental care reforms. Reflections on Administrative Traditions The differences in administrative traditions meant that there were different steering reactions by government to problem issues. In Britain the strength of traditions relating to territorial and executive control meant there were strong expectations that Ministers should react to policy problems. This translated into mechanisms whereby there was a trend for government to centralise and to increase Ministerial control in response to reform problems. Thus as I described in Chapter 5, the reform in Britain was characterised by executive reactivity where Ministers responded to resolve identified reform problems with new legislation, directives and guidelines thereby increasing central and executive control. Therefore, there were mechanisms whereby the government reacted to contain and control through an increased level of precision and specialisation of steering, which, in turn, required the creation of a multitude of specialist executive agencies under direct Ministerial control. These new regulatory agencies focussed on operationalising and enforcing government priorities by setting standards and targets; producing guidelines and directives; as well as carrying out inspection, audit and reporting functions. Therefore, the paradox was created where the British case was characterised by simultaneous centralisation and fragmentation. The plethora of executive agencies with multiple, and, sometimes conflicting, agendas bombarded lower tiers of government with directives, standards and targets that often contained a variety of conflicting messages. The strong and personal involvement of Ministers in the detailed implementation was also a feature that created mechanisms of additional complexity of the British case: Ministers announced a reform of the reform after a only a few months of full implementation and in the years that followed Ministers announced numerous new policies and initiatives that executive agencies and municipalities were forced to respond to. The nature of Ministerial involvement demonstrates the potential political risks of devolving power in a state where power is constitutionally centralised. There are expectations that the Ministers will take charge and demonstrate a chain of command steering influence over national reform policy, yet, in the case of decentralisation reforms, the government is supposed to have ceded certain formal powers to lower levels. Thus you have the decentralisation coupled with re-centralisation through specialist audit and regulatory agencies, which exert control over specific aspects of the devolved services such as: users, professions and elected local government. Therefore, in the British case executive agencies, especially audit agencies were used to bridge the governance gap between state and municipality and become the long are of government in local areas – just as the sheriffs and JPs had been the King’s long arm in the regions in medieval
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times. The administrative traditions dimension appears to offer a high level of explanation for the results of the mental health reform. The administrative traditions in Sweden were characterised by strong constitutional separation between policy-makers and implementers, especially relating to the doctrines of local self-government and the tradition of lowlevels of Ministerial steering of administrative agencies. Thus government mechanisms for dealing with problems were the denial of the competence to act and to claim that the problems were local operational issues, referred to by Pollitt and Bouckaert as “distancing and blaming.” strategies1064 Reform responsibility was devolved and fragmented among the 290 municipalities. Therefore, Swedish administrative traditions meant that there was no expectation that Ministers should personally intervene and steer the reform in detail. Unlike countries with a tradition of Ministerial government, in Sweden there was no expectation of a chain of command steering relationship for policy implementation from the Department to executive agencies local government. Indeed, Ministers often referred to the impossibility of steering the reform’s implementation, despite Sweden being a unitary state. There were, indeed, several options for Ministers to increase the precision of reform steering and guidance such as new legislation, written guidance or the general instructions and aims given to executive agencies (regleringsbrev), yet these were not used for the mental health reform. However, when problems emerged, the standard Ministerial1065 strategy was to proclaim the government to be unable to act for constitutional reasons. We saw in Britain that political risk avoidance required Ministers to take control and fragment responsibility upwards using Ministerial directives or specialist agencies. However, in Sweden the mechanisms for the government to avoid blame were to deny that it was permitted to take control; to devolve and to fragment responsibility downwards to municipal level; to emphasise the independence of administrative agencies; and also, in some cases, to emphasise the responsibility of Parliament for reforms. Yet we saw in the empirical footnote, that the later government did increase the ‘hardness’ of steering to a certain extent by introducing conditional grants. Therefore, in Sweden there were traditions and conventions of non-government intervention, although the extent and scope was determined by government. Reflections on professions Professions are potentially in unique positions to influence as according to Price,1066 as they form the bridge between politics and science; governments rely on professional knowledge and skills for policy implementation. The mental health reform presented an opportunity for the main social services 1064
See Pollitt & Bouckaert 2004 p. 185. See for example statements of the Social Affairs Minister: Riksdagens protokoll 6/10-03. 1066 See Price 1965. 1065
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profession, social work, to exert influence based on the professions expertise in the social-policy sphere. Yet the cases were characterised by different levels of professional influence. In Britain while general social work found itself in a weakened position, mental health social work remained a significant source of professional power and influence even if in state-regulated ASW roles; therefore, the level of influence would be low-medium. However, social workers in Sweden appeared to have no influence over reform steering: the government ignored the role of professions and social workers in the formulation of the reform, added to which, the social work profession appeared to have a generally low level of interest in the mental health reform. The different backgrounds and historical legacies of the professions in the two countries are apparent in the reform results. In Britain, social work developed a specialist mental health branch dating back as early as 1920s. Thus by the time of the reform, social work’s position in mental health was already state-regulated through ASW roles with specific methods, roles and training as well as an occupational jurisdiction for social work over certain mental health tasks. In Sweden, on the other hand, the historical legacy of social work as a branch of public administration made it difficult for the profession to establish an independent identity. The profession lacked state recognition and the state did not define a reform role for the profession. Therefore, it was difficult for social work to establish its position as a central reform actor. Despite the reform’s original aims of providing social care perspectives and services, these were never defined by the government; instead, municipalities were encouraged to solve staffing issues by inexpensive and pragmatic means through the transfer of asylum staff. In both countries at the time of the reform there is evidence of a decline in the traditional bureau-professional model of professional power and influence. However, it is unclear where this is evidence of de-professionalisation or, instead, an indication of professional influence transitioning to new forms. Modern professionals are employed in statutory roles where functions are determined by government legislation. There are few areas of professional activity that are completely unregulated by the state, thus: doctors, judges, teachers, policy and social workers all have their occupational sphere defined by state legislation or regulation. Therefore, nowadays there is less emphasis on 19th century-style self-regulation as many professions look to the state for recognition. The state has a central role in defining and maintaining a profession’s occupational jurisdiction, especially in modern “joined-up” services that cut over professional boundaries. This was a factor in the mental health reform; in Britain mental health social work had a strong state-sanctioned monopoly over certain tasks, which created power and status for the mental health specialists. However, in Sweden the government demonstrated great reluctance to define professional roles for the reform, and there was a tendency for medical professionals to take up posts in social care. Thus social workers’ traditional domain of social services departments 331
The Governance Gap was no longer the jurisdiction of social workers, as the government’s failure to recognise social work led to increasing medicalisation of social services. There were not only issues relating to the government’s relationship with the profession; the profession’s own internal organisation and support for the reform was also a major factor that influenced whether the government considered the profession as a legitimate actor and influence. Social work suffered particular problems as a weaker profession without a watertight knowledge monopoly. There was also a lack of consensus over what role professions should play. In Britain issues of professionalisation and professional power were controversial among social workers: the profession was divided between BASW and unions; not all social workers supported professionalisation; and BASW represented only a minority of social workers. Thus in Britain issues of professionalisation and de-professionalisation were issues of internal debate and division. In Sweden, however, social work had found it difficult to establish a separate professional identity from public administration. The mental health reform presented particular challenges: few social workers had mental health training; there appeared a general lack of interest regarding mental health as a professionalisation opportunity; and the government failed to identify any specific social work roles. In the reform’s implementation many social workers chose to remain in traditional administrative roles, such as benefit and service authorisation, rather than becoming actively involved in the reform. However, as previously mentioned, this left the field open to medically-trained staff that used the reform as a means of expanding their own domain into mental health. My findings on professions are that professional influence is dependent on government legitimising the profession’s role in the particular domain. The level of influence appears strongly related to government recognition of an occupational jurisdiction. There appears to be a mechanism of mutual influence whereby the profession must prove its relevance and importance to government policy on the basis of specialist knowledge and skills in return for government recognition in terms of occupational jurisdiction, discretion and influence over steering. We saw in Britain that the higher level of influence rested on earlier specialisation and mental health expertise. However, Swedish social workers were unable, and perhaps uninterested, claiming the mental health sphere and were forced to concede jurisdiction within their traditional domain of social services departments to medically-trained professions. For professions it appears that power and influence is a negotiated balance with the state, between the extremes of too much and too little statesteering. Too much state-steering means the profession loses control of its own professional identity and control to define working tasks. Yet too little state-steering may marginalise the profession or open the domain to competition from other professions as a result of the state’s failure to legitimise the profession and create a specific occupational jurisdiction. Thus both extremes can be detrimental to the profession’s influence. 332
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Reflections on policy framing The policy framing dimension focuses on the way that the dynamic preferences and values of politicians can influence governance and steering choices. This dimension also showed significant differences between the cases. My findings show that the steering styles are not only influenced by institutions and ‘rational’ actors, but that the way underlying norms and values of policy-makers influences the way that they frame the policy issue and users and subsequently the choice of governance and steering strategy. Britain saw a significant shift to a risk-based policy-framing in the later years examined by this book, which appears to be a mechanisms that corresponds with the increase in hard steering. In Sweden however, government framing focussed on the medical model. The government signalled that the main decisions would be made by doctors in decentralised healthcare structures. Thus the mechanisms were that the steering roles of government were softer and more limited as decisions were based on individual treatment needs. Policy framing demonstrates that policy decisions are not merely a decision on technical ‘tools’ but a decisions that is part of a wider political and ideological process where steering decisions are also related to the underlying ideological perceptions of the policy-problem, users and need for state action. In Britain the change to a risk discourse that emphasised coercion and control is reflected in the increased intensity of coercive and compulsory ‘policing’ methods of the selected governance and steering strategies. Sweden’s reform seemed less ideological as there appeared to be little shift away from the medical model. However, it is unclear whether the medical model was a government care ideology vision, or whether it was used as a rhetorical frame and whether it was aimed at deflecting blame onto municipalities. It could be that recurring medical model framing in Sweden is symptomatic of the reform’s lack of defined social concepts and perspectives; thus the policy framing may be one reason that the role of social professions was neglected if medical models continued to be a major policy discourse. However, it is clear that policy framing is an important dimension to understanding governance and steering decisions. The way in which policy problems, users and state actions are framed has a strong effect on governance and steering decisions. I appears that policy framing fills part of the governance gap unexplained by institutional and traditions models. Thus policy framing represents a dynamic part of a policy style where steering strategy decisions are also dependent on values, norms and care ideology. Thus my tentative suggestions to explanatory power of the three dimensions of the Triad of Influence, based on analysing the mental health reforms in Britain and Sweden, are as follows:
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Table 8.1: The Triad of Influence dimensions & level of explanatory power Dimension Administrative traditions Professions Policy framing
Britain
Sweden
High
High
Low-Medium
Zero
High
Medium
Theoretical discussion & conclusions The primary ambition of this study was theoretical development by identifying dimensions that might form a basis to explain governance and steering choices. The dimensions are drawn from several theoretical discourses and discussed and evaluated in a theoretically guided analysis. I will now review some of the central theoretical findings of my study.
Hard & soft steering – steering instrument choice The starting point for this study was the idea that there are many types of governance and steering strategy choices available to government such as regulation, incentives and information: “carrots, sticks and sermons”.1067 Much of the earlier research regarded policy-steering instruments as a linear progression from soft information instruments to hard regulatory, where incentives might be either soft or hard. In addition, much of the economicsinspired NPM presented the choice of policy instruments as rational and technical decisions where instrument choices were often mechanistic and linear processes. However, my argument in the book is that these categories are not as fixed as previous research supposes and that instead, within each category, there are harder and softer instrument choices available to government. Thus instead of being a soft to hard progression but within each category there is a scale of harder and softer instrument choices available to governments. The regulatory steering instruments (sticks) involve formal and binding rules and regulations, and are usually considered a hard and coercive form of steering owing to the level of compulsion. However, there are also softer variants: there are for instance modern forms of regulation such as framework legislation, management by objectives (målstyrning), and other less coercive types of legislation and directives. Thus there are softer forms of regulatory steering choice available. The legislation and regulations are still binding, but implementers have significant flexibility and freedom to 1067
See for example Bemelmans-Videc 1998; Vedung 1998b.
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Discussions & Conclusions
interpret, to formulate and to implement. Incentive instruments (carrots) are usually financial and induce implementers to comply with government wishes. These can be soft steering mechanisms such as grants, vouchers and services to motivate the recipient to follow government wishes. Yet there can also be harder and more coercive options available involving penalties and sanctions for non-compliance. There are also information-based steering mechanisms (sermons) which are instruments whereby governments communicate information and expectations to implementers. Information steering is considered by most policy instrument researchers as soft steering such as information, monitoring reports, or guidance. However, my argument is that even information instruments have harder variants, for example, where the information is combined with threats such as “naming and shaming” or other conditions and strings attached for those implementers who do not follow the ‘guidance’. These conditions on information instruments introduce a level of pressure that forces addressees to comply. Therefore, my first theoretical conclusion was that the discourse of policy steering instruments can be linked with the discourse of hard and soft steering. Instead of a progression from ‘soft’ information instruments to ‘hard’ regulatory instruments, there are harder and softer choices available to government in each category. The formulation of policy instrument categories as harder and softer instruments are summarised in the following table: Table 8.1: Summary – hard & soft steering instruments Instrument type Regulatory “the stick”
Hard steering
Financial/incentive “the carrot”
Information “the sermon”
Soft steering
Legislation with high level of detail and obligation. Directives and binding guidelines.
Negative incentives based on compliance and threats. Financial penalties and sanctions. Theoretically voluntary information but with threats and conditions attached.
Incentives and ‘free money’– general grants and subsidies with few strings attached.
General information. Mild persuasion forms based on ‘learning’ strategies.
Framework legislation with low level of detail and obligation. Imprecise guidelines.
One of the theoretical conclusions of this book is the development of this analysis instrument and development of a theory that within each of the categories of policy instruments there are harder and softer options available to government. Therefore, even if several governments choose, for example, to use regulation instruments, differences may still arise as within this category the governments can choose between harder and softer options. 335
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National policy styles? – reviewing the evidence Much has been written about the possibility of national policy styles influencing governance and steering choices, yet it remains a hazy concept despite numerous attempts to define it. Though it is clear that according to the assumptions of some literature the governance, implementation and steering choices are solely rational, mechanistic and technocratic process are not borne out by my results. One of the problems was that the national policy styles literature was far more developed in the policy-making phase of the policy profession with very few studies focussing on issues relating to implementation and steering. There is no single ‘logical’ path or instrument mix; the national policy style is based on a combination of institutional and actor influences. Therefore, one theoretical conclusion is that there is no single generic “one size fits all” national policy style that gives detailed insight into all the mechanisms of reform implementation that apply in all sectors. Thus while there may be certain national characteristics and common features, the models of governance and steering are much more complex and are context, sector and politically determined. So in some respects, talking about a ‘national’ policy style may be misleading as the style of policy- making is not deterministic, but rather a complex pattern of inter-relationships. Administrative traditions was one dimension of strong explanatory power, yet it did not explain all of the steering decisions observed in the cases of the mental health reforms; the dimensions of policy framing, and in the British case, professional cultures also influenced steering decisions. In this study I have examined the internal steering relationships between government and public sector agencies at lower levels charged with implementing reforms; therefore, my dimensions were constructed to represent this relationship. However, it is also possible to examine the relationship from an external steering perspective by examining the implications for endusers. Then the dimension for examination in the current ‘professions’ categories would need to be expanded to evaluate the users’ perspectives, and possibly the perspectives of other external stakeholders and interested parties. Thus this is an issue for further research. This study identified three dimensions of influence, administrative traditions, professions and policy-framing. The influence of administrative traditions on the national policy style is a stable influence, based on concepts of historical institutionalism. However, governance and steering strategies can be influenced by new administrative ideas and fashions such as NPM. This means that institutional and historical legacies are not a rigid influence on the national policy style, as there are flexibilities and windows of change. I perceive administrative traditions as a filter though which policy-makers view new ideas in public administration and management. The dimension of professions has had rather mixed results in this study as an indicator of national policy style and more research is needed using different professions, 336
Discussions & Conclusions
sectors and countries to better evaluate this dimension. However, I believe that professions do, or at least have an opportunity to, influence the steering style and I do not believe that their roles are restricted to relationships as ‘steered’ or rebellious street-level bureaucrats. Professions by their very existence offer governments a steering choice relating to the level of trust and discretion and granting freedom from steering. Professions can also influence governments to harder steering when the profession is considered a useful steering tool. Yet it may be that certain policy sectors have a higher level of professional influence than the mental health reforms such as health, military and legal reforms. While at the start of my study I regarded the mental health reform as a professional opportunity for social workers to expand their occupational jurisdiction through mental health, my findings show that the reform was not always as a mechanism for social workers to enhance professional status. The final dimension of policy framing proved to be very influential in my study, and demonstrated clearly that the historical and institutional frameworks of administrative traditions and state-professional relationships are subject to change from dynamic political and ideological ideas. The steering mechanisms may intensify, weaken or remain constant under pressure as a result of the government’s discourse and preferred care ideology. In my study I analysed the government framing in terms of three underlying care-ideologies: the medical model, the disability model or the risk model. I demonstrated in Britain that steering intensified as a result of the shift to risk-based framing that underlined the need for hard steering. However, in Sweden the government’s ideological framing remained constant and was based on the medical model and local healthcare. In Sweden even major political ‘shocks’ such as the murder of a Ministerial colleague did not result in changes to the government’s preferred steering style. Therefore, my theoretical conclusion is that the national policy style is not a rigid mechanism that provides a ready-made template that guides policymakers to choices; nor is a policy style a historically determined path. Policy styles can evolve, adapt and change as a result of political and ideological influences and framing; different policy sectors may have differing policy styles based on the balance between administrative traditions, professions and underlying policy frames. The style does not only represent institutions and actors at a formal level; the government’s values and beliefs relating to the policy issues or sector is also reflected in how it is framed and consequently steered. Thus my overall conclusion is that national policy styles are living and organic mechanisms that are constantly evolving as a result of the meeting of institutional, professional and ideological influences.
The Triad of Influences & explaining steering styles The main theoretical contribution of this PhD thesis has been the development of a theoretically derived model based on the influence of three dimen337
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sions of influence; administrative traditions; professions and policy framing to guide the structured and focussed comparison of governance and steering in the mental health reforms in Britain and Sweden. In the following sections I will review and discuss these dimensions, and in addition, consider any interactions between them. The Administrative Traditions dimension The dimension of administrative traditions is based on the idea that national historical and institutional legacies can influence the government’s selection of governance and steering choices. However, the discourse of administrative traditions had not been operationalised from an implementation and steering perspective. I developed three indicators from theoretical sources that I considered might influence the choice of internal governance and steering. The level of territorial centralisation focussed on the constitutional arrangements in the division of power and decision-making competences between the state and lower level of government. The level of executive power, was related to the opportunities for government to steer lower levels directly either through direct Ministerial intervention or directives, executive agencies or regulatory bodies. The level of formal sanctions focussed on the opportunities for the government to discipline lower levels and impose penalties directly on lower democratic levels of government who were reluctant to comply with government policy. For each of these indictors a high level of territorial centralisation, executive power or sanctions was indicative of hard steering, whereas low levels indicated soft steering strategies. These elements are summarised in the following table. Table 8.2: Administrative Traditions – influence over steering strategy Hard steering
Soft steering
Level of centralisation
High
Low
Level of executive control of administration
High
Low
Level of formal sanctions
High
Low
Administrative Traditions
In both Britain and Sweden administrative traditions appeared to strongly influence the government’s choice of governance and steering strategies. In particular the level of territorial centralisation and level of executive controls appeared to be strong influences. In my cases the level of sanctions achieved more mixed results; in some respects this can be traced to the level of executive power, and the constitutional arrangements as unitary states meant that governments had control through executive legislation. It is possible that the result was also dependent on sectors: for example, Britain has a history of sanctions and financial penalties being applied on municipal councillors 338
Discussions & Conclusions
during the rate-capping protests; yet in the case of the community mental care reforms, other mechanisms were used to enforce compliance. Sweden’s traditions, however, avoid direct sanctions and were not a reform feature. There is also the issue of inter-dimension interaction and the extent to which administrative traditions interact with other dimensions or offer a stand-alone explanation for steering choice. Although the legacies of administrative tradition are strong and influential, a recent book by Peters and Painter casts doubt on the path determinism of administrative and institutional legacies as the sole explanation for government decisions. Their study of public management reforms in a large sample of countries found that not all decisions can be traced to administrative traditions.1068 Administrative traditions appear to form the outer layer of influence; the general conditions and the level of centralisation will have a general influence on the way that reform policies are considered and interpreted within a polity. Policyframing is an important influence on reform steering, as political and ideological discourses and frames can change the institutional architecture as was witnessed by the NPM reforms in many western countries. In the case of the mental health reforms, Britain and Sweden both adopted policies described as a decentralisation and municipalisation. My findings in Britain demonstrated that the centralising tendencies resulted in government reluctance to ‘let go’ and that there were strong recentralisation tendencies through regulatory agencies and Ministerial roles. However, in Sweden, the government handed the entire reform to municipalities with low levels of government steering and involvement. In addition, professions can influence the creation and structure of institutions, especially in professionally steered institutions: for example, Rechstaat steering is influenced by legal profession; the audit society1069 of regulatory structures is influenced by the accountancy profession; health services are influenced by the medical profession. Yet in the case of mental health, social workers did not achieve this level of influence. Therefore, the administrative traditions represent a filtration mechanism though which new ideas for reform are considered, interpreted and adapted. My findings reinforce the conclusions of previous studies that institutional and historical traditions have an important influence over current administration. However, unlike some previous studies, my results demonstrate that they do not explain all steering styles alone. Other factors also influence. The Professions dimension The professions dimension of influence is based on the idea of welfare professions as a central actor in the implementation of welfare reforms and is therefore, well-placed to influence government strategies as the experts in the field. I identified two models. Firstly a traditional model of professions 1068 1069
See Peters & Painter 2010. See Power 1997.
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regulated influence is based on concepts of bureau-professionalism and Evetts’ idea of an occupational professionalism model. Influence is based on trust-based relationships whereby the profession is accorded discretion and freedom from steering. The model emphasised soft steering strategies from the government as much of the decision-making and professional organisation relies on internal professional decisions without the input of government. The second model is state-regulated professional influence, which occurs where a professional influence exists based on the state’s need for knowledge and expertise, but where this is mediated by a state-centred and regulated form of professional influence. The state retains democratic control over professional influence and may utilise the profession as a steering form in order to achieve state priorities and objectives. Thus although professions may have extensive roles, there is less freedom as the stateprofessional relationship is more tightly controlled through harder steering strategies. Therefore, the influence of the profession according to this model is less to do with freedoms and autonomy, and more to do with the profession being utilised as an effective tool to achieve state objectives. I summarise the two main models in the following table: Table 8.3: Models of professional influence Professions-regulated influence
State-regulated influence
Basis of influence
Trust & acceptance of status
Professions under democratic control
Control of work
Devolved decision-making: professionally determined priorities
Central control: statedetermined professional priorities
Direct influence
Professional jurisdiction
Shared jurisdiction
Basis of profession control
Discretion & self-regulation: internal values
State regulation & authorisation: external values
The existence of the two models is controversial. As I discussed in Chapter 4, some literature does not regard the state-controlled professionalism as a form of professional influence at all. Instead it is classified in this literature as deprofessionalism or proletarianisation, and only the bureau-professional model is regarded as true professionalism. However, this is where my study reveals interesting results and mechanisms whereby the state plays an important part in creating occupational jurisdiction, which in turn becomes a source of legitimacy for the profession’s influence. Therefore, for welfare state professions state-recognition is important; even the archetype free pro340
Discussions & Conclusions
fession, medicine, is state-authorised in both countries. Thus state recognition was seen as the key to higher status for social work, putting them on the same terms as the state-authorised healthcare professions. However, the case of Britain shows that there are also risks of the state becoming involved in professional authorisation. BASW found itself marginalised on the GSCC board as the majority of board members were from non-social work backgrounds. In addition, the mandatory GSCC Code of Practice was very different from the professional values advocated by BASW; there was a focus on risk-management as the primary task. However, the tradition of mental health work and ASW roles created the basis of a stronger social work influence in mental health than many other areas of municipal social services. However, this dimension had the least explanatory power; in Sweden, in particular, the government did not recognise social work as having a professional role in the reform at all. This may be due to the strength of the localism discourse of the administrative traditions and policy framing dimensions, or it may be that the model needs to be developed and fine tuned as there is evidence that the medical profession may have been influential despite not having a direct municipal role. There is also the issue that social work is an acknowledged weaker profession that offers few job opportunities outside the public sector or public-financed services, and deals with the poor and disadvantaged. As a predominantly public profession social work has different pre-conditions than other professions where opportunities exist for lucrative public practice with fee-paying clients with lower power and status than other professions such as medicine and law. In previous literature there has been generally less research interest into the influence of lower status professions. In addition, the case of the mental care reforms relates to social workers dealing with some of the lowest status social work clients: the psychiatrically disabled. In addition, there were other staffing influences. In Sweden the medical framing meant that psychiatrists remained in dominant decision-making roles, and the influx of thousands of former asylum staff complicated the development of social perspective. Therefore, the dimension of professional influence is one that requires more theoretical development and empirical study in order to fully understand the mechanisms of influence. The model could be expanded to analyse a wider definition of professions than the main sector profession. Analysis of the role of a stronger, higher status profession may show a different pattern of professional influence. In the mental health reforms examining the roles of medical professionals might have demonstrated the mechanisms more clearly, for example the inter-relationships between social workers, psychiatrists and nurses who are all active within the field of mental health. Another possibility would be to expand the category to a more general staffing category in order to understand mental health, as mental health remained an extremely low-professionalised area; in Britain the use of independent contractors was based on volunteers and minimum-wage staff, whereas Sweden’s 341
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use of mental care staff recreated the asylum in the community. The professions dimension is certainly interesting an issue for further research so my results relating to social workers can be compared with a different profession or reform to determine how the model responds to different data. The issue of dimension interaction is interesting in the case of professions. At the start of this chapter the whole case analysis of the reforms in Britain and Sweden has helped identify the interactions and relationships between dimensions. In this general discussion of professions, an analysis of interaction between dimensions identified areas where the administrative traditions and policy framing might interact with the professions dimensions to strengthen or weaken its influence. In some countries and sectors the administrative traditions may institutionalise the influence of a particular profession, thus creating a strong influence on steering for particular professions: institutions dominated by lawyers may prefer for legal mechanisms, or there could be strong influences in certain sectors for professions e.g. medicine or the military. In addition, the use of a particular policy framing discourse can also determine the influence of professions in a positive or negative direction: for example, under Margaret Thatcher’s governments the influence of accountants increased owing to the discourse of financial management and systems of cost control, whereas the status of welfare state professions such as social work declined. But, as we have seen, there was still some influence in the British case. This I believe that the professions dimension is an area of influence, yet one where the contribution to governance in complex and where more research is needed. My PhD thesis is a contribution to this research, yet the dimension requires more development and analysis, for example, using different professions, sectors and countries. The Policy Framing dimension The final dimension of the triad of influences is the idea that the underlying policy discourse and government framing of policy problems, users or state action influences the type of steering strategies that would be deemed appropriate. I formulated three theoretically derived indicators of policy framing. Firstly is the element of the problem identification and the way in which the government defines and classifies the policy issue. Secondly is the construction of reform users and how they are perceived by government. The final element is the formulation of a need for state action and the type and form that the government believes is required. I used these three categories and existing literature on mental health policy to formulate three models of care ideology. The medical model was based on soft and trust based steering. The risk model was based on ideas of low trust and high state control and therefore, hard steering. The disability model could be constructed as a soft or hard frame depending on the framing perspective adopted: top-down central regulatory framing or bottom-up individual user-preferences. These models were operationalised in Chapter 7 and are summarised in the table below: 342
Discussions & Conclusions Table: 8.4: Policy framing – influence over governance & steering strategy Characteristic
Medical model
Disability model
Risk model
Disability & need for normal living
Public protection
diagnosis
Construction of user
Patient
Citizen
Criminal danger
Action required
Treatment
Support for user decisions
Risk-management
Problem identification Mental illness &
The result of my evaluation of policy framing as a dimension shows that the government choice of care ideology had a strong influence of steering decisions, and explains the unexpected increase and intensification of hard steering unexplained by the administrative traditions dimension. Thus was particularly evident in the British case and the move to a risk-based care ideology as well as also in Sweden’s reluctance to shift from the medical model. Thus the policy framing approach adds a new dimension to standard institution and actor interaction models that make up the national policy style genre. The concept of policy framing represents how political-level beliefs and values influence reform choices of steering strategies. The choices of governance and steering strategy are influenced not only by institutional path dependencies, but also by the values, norms and ideological beliefs of policy-makers. However, this is an area that requires more research to evaluate whether my results are replicated in other cases and countries. There is also the issue of interaction effects. There is a strong relationship between policy-framing and professions. For example in the mental health reforms many of the discourses and policy frames contain implicit suggestions of the influence of a particular profession: the medical model suggests for example, the influence of doctors. In addition, certain policy frames can influence institutional development; for example the risk model may create a perception of need for increased judicial control institutions such as the quasi-judicial homicide inquiries in Britain or increased procedural controls as a result of the lower level trust in professions than under traditional bureauprofessional models such as standard-setting and auditing agencies. Therefore, the dimension of policy framing as an influence over governance and steering strategies has yielded interesting results in my study. Theoretical findings & conclusions I have therefore, reviewed and analysed the three dimensions of the Triad of Influence and conclude that the triad appears to offer a useful theoretical approach with which to analyse governance and steering choices. More work
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is needed, however, to evaluate the model in different contexts, to increase understanding of modes of governance. Diagram 8.1: Triad of Influences
Administrative traditions
Policy framing
Professions
It is important that the Triad of Influences be considered a flexible model of dimensions that combine and influence governance strategies in different ways dependent on the national and policy context. The idea of the triad was not to create a rigid and deterministic model, but to develop theoretically derived dimensions that may help us understand the puzzle of the mental health reforms, and that may have a wider applicability to other countries, policy processes and reforms. However, more work is needed to develop and test the dimensions. In the case of the mental health reforms the dimension of professions represented a lower level of explanation than the other two dimensions of administrative traditions and policy framing. It is possible that the professions dimension needs reformulating or that the results may have been caused by the combination of a social work as a weaker profession in combination with mental health as a low status area of welfare policy. Therefore, further study with different professions and sectors is needed.
Overall findings & final conclusions In this study I have studied the governance gap of why governments choose different governance and steering strategies relating to soft and hard steering for reforms that were similar in construction, aims and content. I identified that governments have different policy styles based on a combination of institutional, actor and ideological elements. I developed a theoretically 344
Discussions & Conclusions
guided model based on a Triad of Influences model consisting of administrative traditions, professions and policy framing. These dimensions appear to offer a useful approach for the developing theoretical explanations for governance and steering choice. However it should be recognised that the Triad of Influence is a flexible analytical framework where the dimensions of policy styles can combine in different ways; not all of the dimensions may have equal analytical power in all countries and all cases. This was observed in the case of the mental health reforms in Britain and Sweden. The dimension of administrative traditions was influential in both countries and showed that constitutional doctrines, conventions and historical legacies have a considerable influence over modern-day decisions. In particular the territorial and administrative relationships between central and local government had a strong influence. However, in contrast to some previous research, my findings were that administrative traditions were not the only influence. My findings were that policy framing also influenced governance and steering strategy as the underlying values and beliefs of the government created a preferences for certain types of steering, and in the case of the mental health reforms, was used to justify an intensification of centralisation and government intervention in Britain, or in the case of Sweden, it was used to justify the government’s preferences of low levels of central steering. In the case of the mental health reforms, the professions dimension gave more mixed results. It revealed that there were interesting differences between the two countries; in Britain professions had defined roles yet were strongly steered by government, whereas in Sweden there was no defined role and professions were largely ignored by government. However, the empirical results of the professions dimension did not fully correspond to the way in which the model was formulated. It may be that this dimension requires more development or it may be that the particular circumstances of municipal social care services based on a weak profession and low status users may have affected the result. Therefore, more research with other cases and professions is needed. The final message of this book is that governance and steering strategies are not, as sometimes assumed by NPM models, the result of mechanistic decision-making by rational actors where there is a ‘single logical path and instrument’. Instead there are a number of options available to governments with which to fill the governance and steering gap. The concept of the Triad of Influence helps understand that governance and steering preferences are the result of dimensions that influence government decision-making at several levels: the administrative traditions form an outer filtration mechanisms through which policy and administrative reforms are perceived, however professions and policy framing also signify dynamic influences at sectoral and actor levels, which shape governance and steering preferences. Thus the governance gap is filled with the dimensions of the Triad of Influence that operates at different levels, national, policy sector and actor levels. These dimensions can combine in different ways, which in turn create specific in345
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fluences and pressures for specific governance and steering strategies. As we have seen in the case of the mental health reforms, the specific combinations of these influences led to governance and steering choices that were hard in Britain and soft in Sweden. Thus this PhD thesis aimed to identify a national policy style, my findings are that the idea of a single national policy style may be misleading, as there is uncontested style that operates in the same way in all policy sectors and for all reforms, Instead, the “black box” of the governance gap is filled with complex interactions between national, sector and actors that combine in different ways to influence governance and steering styles.
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Appendix A: Media review articles Britain Article review: The Independent Period 1: 1993-1995– Independent – search term “community care mental 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
10/1-93 “Care in the community: Ben Silcocks’s mauling by a lion at London Zoo has highlighted the plight of the mentally ill” J Jones. 29/3-93a “Community care: Launched with modest expectations”, R. Waterhouse. 29/3-93b “Community care: the users’ guide”, R. Waterhouse. 29/3-93c “Community care: Three years’ preparation ends with a scramble”, R. Waterhouse. 13/8-93a “Bottomley plans new controls of mentally ill”, R. Waterhouse. 13/8-93b “New rules on mental patients, but no extra cash”, R. Waterhouse. 19/12-93 “Breaking out of the asylums”, M McFayean. 25/2-94b “Leading article: Empty gestures fail the mentally ill”, Leader. 20/4-94 “Care in the community: Patients ‘left isolated and destitute’”, R. Waterhouse. 22/5-94 “Fear of the strangers who live in darkness at the edge of town”, B Morrison. 18/8-94a “Minister in care killings row”, R. Waterhouse. 18/8-94b “Leading article: Cruel care for the mentally ill”, Leader. 19/8-94 “Does the community care?: Diverse provision for the mentally ill brings its own problems,” R. Waterhouse. 9/9-94 “Leading article: Whitehall’s fiefdoms fail the mentally ill”, Leader. 10/10-04 “Bottomley rejects national standards in community care”, S Ward. 17/1-95a “Schizophrenic’s knife attack was ‘predictable’”, R. Waterhouse. 17/1-95b “Officials ‘blocked report on killing’”, R. Waterhouse. 27/7-95a “Breakdown of care led to hostel killing”, N Timmins & I Mackinnon. 27/7-95b “Damning report criticises care authorities”, I Mackinnon & N Timmins. 25/8-95 “Community care “haphazard and confused’” G Cooper.
Period 2: 2002-2006 – Independent – search term “community care mental 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
21/7-02 “MPs revolt over plans to lock up the sick” S. Goodchild. 4/8-02 “Blunkett plans to detain more psychopaths” J Dillon. 4/8-02 “More locks, but less care for patients” C Newbon. 19/11-02 “Jeremy Laurance: Fear is the worst way of managing mental health”. 2/2-03 “Mentally ill at risk of violent abuse” S. Goodchild. 17/8-03 “Probation staff left to cope with mental illness” S. Goodchild. 26/11-03 “Inquiry into doctors who freed ‘ripper’ before more killings” M. Hickman. 12/12-03Julia Neuberger: our treatment of the mentally ill is a test of society”. 22/2 04 “Hundreds of adults still locked in asylums” M. Gould. 26/2-04 “Delivering care in the community” G. McCann. 24/12-04 “New doubt about care in the community after stabbing rampage injures five” J. Bennetto,. 9/1-05 “Mental health helpline to close as government cuts £1 million funding” J Thompson,. 26/2-05 “Is there such as thing as care in the community” M. Frith. 17/3-05 “Jeremy Laurance: the truth about care in the community”. 27/3-05 “Would this Mental Health Bill have stopped the killing? No” S Goodchild 15/3-06 “Deborah Orr: If we really want to help disabled people we could begin by seeing them” 26/3-06 “Madness: Britain’s mental health time bomb” S. Goodchild.
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The Governance Gap 18. 11/5-06 “One tragedy that testifies to a decade of neglect” Leader. 19. 15/10-06 “Mentally ill ‘still being denied a basic level of care’” S Goodchild & J Owen. 20. 8/11-06 “A disturbing indictment of our values and priorities” Leader.
Headline review: The Sun – search term “care in the community” 1. 2. 3. 4. 5. 6. 7. 8. 9.
9/9-04 “Curbs on Mental patients”. 26/2-05a “Violent, mad … and set free”. 26/2-05b “Safety first”. 2/4-05 “Schizo killer caged for life”. 19/5-05 “Cop killer held indefinitely”. 20/5-05 “String of fatal blunders”. 23/10-07 “Stalker freed to kill care worker”. 25/3-09 “Why was cop killer madman on streets?”. 24/3-09 “Zito’s killer ‘set for release’”.
Sweden Article review: Dagens Nyheter & Svenska Dagbladet Period 1: 1993-1995 – Dagens Nyheter – search term: “psykiatrireformen” 8/3-95 ”Äldrecentrum oroas av psykiatrireformen: Äldre psykiskt sjuka glöms bort” A Johansson. 2. 19/9-95 ”Psykiatrireformen klar”. 3. 15/6-97 ”Sjuka registreras utan att tillfrågas: psykiatri” J Brinck. 4. 20/6-97 ”Uppror mot nytt register”, J Brinkc. 5. 29/6-97 ”Beckomberga sjukhus: Fastlåsta i ett ingenmansland” J Brinck. 6. 5/7-97 ”Ledare: Rätten till ett värdigt liv: det måste gå att bryta de psykisktsjukas passivitet och isolering” Ledare. 7. 4/11-97 ”Pengar finns anslagna” K. Vinterhed. 8. 5/11-97 ”Med respekt for de udda – lagom mycket stöd” K Vinterhed. 9. 14/12-97 ” Daglig stöd nyckel till eget boende” K Vinterhed. 10. 12/1-98 ”Ledare – pension ja – men förs vård” Ledare. 1.
Period 2: 2002-2006 – Svenska Dagbladet – search term psykiatrireformen 1. 1/7-02” Vård på patienternas villkor”, ledare,. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
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16/8-02”100 av 179 saknade säng”, insändare. Staffan Hellgren (direktör Stockholm Stadsmission). 3/6-03a ”Bodström bör ta honom med sig i fallet”, M Abrahamsson. 25/6-03 ”Psyksjuka portade från härbärgen”. 16/9-03 ”Psykiatrisamordnare tillsätts”. 19/9-03 ”Centralisera psykiatri” Debatt. 20/9-03 ”aningslöst stänga mentalsjukhus” C Pegel. 29/9-03 ”Vem blir brottsling?” A Haag. 1/10-03 ”KD: ge psyksjuka alternativfängelser” O. Nilsson. 2/10-03a ”Engqvist må lovar men pengarna är slut” A. Johnsson. 2/10-03b ”Allt är inte kommunernas fel” Ledare. 6/10-03 ”Hård kritik mot psykvården” . 11/12-03 ”Skärp kritik mot kommuners psykvård”. 12/12-03 ”Psykiskt sjuk får inte hjälp”, A-L Haverdahl. 10/1-04 ”Ett välfärdens sammanbrott”, Ledare. 7/10-04 ”Bättre samverka än att lägga ner” P. Persson & P. Håkansson, Debatt. 29/7-05 ”Ökat antal personer behöver god man”,. 9/9-05 ”kommunerna sviker de psyksjuka” K Krantz. 5/8-06 ”FP vill ha mer tvång i psykvården”
Appendix 20. 6/8-06 ”FP vill ha mer tvång i psykvård”.
Headline review: Aftonbladet – search term Psykiatrireformen 1. 2. 3. 4.
27/5-03 ”Hur kunde tragedin I Åkeshov ha undvikits?”. 2/6-03 “Alltför många sjuka lämnas vind för väg”. 3/6-03 ”Lås inte in de sjuka Engqvist”. 27/9-03 ”Politiker – gör något”.
5. 6. 7. 8. 9. 10. 11.
25/6-03 ”Psyksjuka portas från härbärgarna”. 28/8-03 ”1500 psykfall utan vård på gatorna”. 17/9-03 “Vansinnesdåden har fått regeringen att inse allvaret”. 1/10-03 ”De som skulle fått öppenvård glömdes bort”. 2/10-03 ”Det här räcker inte Engqvist”. 6/10-03 ”Hård kritik mot vården av psykiskt sjuka” 1/7-07”Vår dotter mördades också av en psyksjuk”.
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Regeringens proposition (Swedish Government Bills) 1993/94:218 Psykiskt stördas villkor. 2000/01:90 Ny socialtjänstlag mm. 2008/09:193 Vissa psykiatrifrågor mm.
Sveriges Författningssamling (SFS) (Sweden Code of Statutes) Lag (1966:293) om beredande av sluten psykiatrisk vård i vissa fall Lag (1980:620) socialtjänstlagen, (SoL). Lag (1982:763) om hälso- och sjukvård (HSL). Lag (1990:1404) om kommunernas betalningsansvar för viss hälso- och sjukvård. Lag (1991:1128) om psykiatrisk tvångsvård (LPT). Lag (1991:1129) om rättspsykiatrisk vård (LRV). Lag (1993:387) om stöd och service till vissa funktionshindrade (LSS). Lag (2001:453) socialtjänstlagen, (SoL)
Official Publications Audit Commission (1986) Making a reality of community care, London: HMSO. (1992), The community care revolution: personal social services and community care, London: HMSO. (1993), Taking care: progress with care in the community, Health & Personal social services Bulletin no. 1st December 1993. (1994), Finding a place: a review of mental health services for adults, London: HMSO. (1997) Take your choice: a commissioning framework for community care, London: Audit Commission.
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Department of Health (1990) Community Care in the next decade and beyond, London: HMSO.
(1991) Care management and assessment: Practitioners’ Guide, London TSO. (1993a), Implementing community care: Populations needs assessment – good practice guidance, London: HMSO. (1993b) Legal powers on the care of mentally ill people in the community: report of the internal review, Department of Health, August 1993. (1994) Monitoring and development: first impressions – April- September 1993, London: Department of Health. (1998a) Modernising mental health services: safe, sound and supportive, London: Department of Health. (1998b) Modernising social services: promoting independence, improving protection, raising standards, London: Department of Health (1999a) National Service Framework for Mental Health – modern standards and service models, London: Department of Health. (1999b) Review of the Mental Health Act 1983: Report of the expert committee, London: Department of Health. (2000a) The NHS Plan: A plan for investment. A plan for Reform. London: Department of Health. (2001) Desk research on recruitment and retention in social care and social work, Eborall C,& Garmeson, K, August 2001. (2000b) Effective Care co-ordination in Mental Health: Modernising the Care Programme Approach, London: Department of Health. (2002) A guide to social services performance star ratings, London: Department of Health, (2003) Promoting the status of social work: A consultation of the timetable to implement protection of the title ‘social worker’: London: Department of Health. (2004) Open letter to social workers – Draft Mental Health Bill, R Winterton, Minister of State for Health. (2008) Explanatory memorandum: The Mental Health (Approved Mental Health Professionals) (Approval) (England) Regulations, 2008, 2008 No. 1206.
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LAC (91)12, Community care: Review of residential homes provision and transfers, Local authority circular, August 1991. LAC (92)12, Housing and Community Care 24 September 1002 Local authority circular, (Joint circular with the Department of the Environment, circular 10/92). LAC (92)15 Social care for adults with learning disabilities (mental handicap), Local authority circular, October 1992. LAC (93)4, Community care plans (consultation) directions 1993, Local authority circular, 25 January 1993. LAC (94)12, Community care plans (independent sector non-residential care) direction 1994, Local authority circular, March 1994. LASSL (94)4, Guidance on the Discharge of mentally disordered people and their continuing care in the community, Local Authority Social Services Letter, May 1994. LAC (95)19 Community Care plans from 1996/97, Local authority circular, 29 September 1995. LAC (96)8 Guidance on supervised discharge (after-care under supervision) and related provisions. LAC (98)11 Community care – special transitional grant guidance 1998/99. LAC (99)27 A new approach to social services performance: Consultation responses and confirmation of performance indicators, Local authority circular, July 1999. LAC (2004)24 Community Care Assessment Directions. LAC (2005)11 Mental Health Grant Guidance 2005-06.
Homicide Inquiries South West London & St. Georges Mental Care Trust, (2000), Report on the inquiry into the care and treatment of Anthony Joseph, December 2000. Bury Primary Care Trust (2003) Report of the inquiry in to the care and treatment of Simon Rawcliffe by Mental Health Services of Bury, June 2003. Blackburn with Darwen Primary Care Trust (2003), The report of the independent inquiry into the care and treatment of Mark Harrington, November 2003. Medway Primary Care Trust & Medway Council (2006), Independent inquiry into the care and treatment of Richard Loudwell, March 2006. South West London Strategic Health Authority (2006), Report of the independent inquiry into the care and treatment of John Barrett, NHS London , November 2006.
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House of Common Select Committees House of Commons Social Services Committee (1985) Second report from the Social Services Committee: Community Care with reference to adult mentally ill and mentally handicapped people 1984-85 session, Volume I, London, HMSO. House of Commons Select Committee on Health (2000) Provision of NHS Mental Health Services, Fourth Report, Parliamentary session 1999-2000, HMSO: London
Länsstyrelsen rapport (County Administrative Board Reports) Länsstyrelsen i Dalarnas Län, (2003), Kommunernas planering för personer med psykiska funktionshinder i Dalarnas län, Rapport 2003:21. Länsstyrelsen i Dalarnas Län, (2004), Kommunernas insatser för personer med psykiska funktionshinder i Smedjebackens kommun i Dalarnas län, Rapport 2004:06. Länsstyrelsen i Jönköpings Län, (2004), Kommunernas planering för psykiskt funktionshindrade i Jönköpings Län, Meddelande 2004:2. Länsstyrelsen i Kalmar Län, (2006), Får personer med psykiska funktionshinder ett bra stöd? Kartläggning och granskning av kommunerna verksamhet för personer med psykiska funktionshinder i Kalmar Län, Meddelande 2006:11. Länsstyrelsen i Norrbottens Län, (2003) Kommunernas insatser för personer med psykiska funktionshinder: socialtjänsten insatser i Piteå kommun. Länsstyrelsen i Skåne Län (2001), Psykiatri och socialtjänst i samverkan: en uppföljning av psykiatrireformen i Malmö. Länsstyrelsen i Stockholms län, (2003), Tillsyn av verksamhets planering och utbud av insatser, Rapport 2003:24. Länsstyrelsen i Stockholms län, (2004) Kommunernas insatser för personer med psykiska funktionshinder: Östermalms stadsdel. Länsstyrelsen i Uppsala Län, (2003), Kommunernas insatser för personer med psykiska funktionshinder: tillsyn av verksamhetsplanering och utbud av insatser i Uppsala län, Meddelande 2003. Länsstyrelsen i Värmland, (2003), Kommunernas insatser för personer med psykiska funktionshinder: slutrapport från granskning av verksamheten 2002-2004 i Värmland, Rapport 2003:20. Länsstyrelsen i Västernorrland (2007), Ambition och ansvar – nationell strategi för utveckling av samhällets insatser till personer med psykiska sjukdomar och funktionshinder (SOU 2006:100) – Yttrande 17/4-07. Länsstyrelsen i Västmanlands Län (2003), Kommunernas planering för personer med psykiska funktionshinder i Västmanlands län, Rapport 2003:7.
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Länsstyrelsen i Östergötland, (2003a) Kommunernas planering för psykiskt funktionshindrade, Rapport 2003:17. Länsstyrelsen i Östergötland, (2003b) Uppföljning av psykiatrireformen i Motala, Rapport 2003:19.
National Health Service Executive: Health Service Guidelines HSG(94)27, Guidance on the discharge of mentally disordered people and their continuing care in the community, Health Service Guidelines 10 May 1994. HSG(95)45 Arrangement between health authorities and NHS Trusts and private and voluntary sector organizations for the provision of community care services, Health Service Guidelines, 26 September 1995.
Other official reports: Britain Department of Transport, Local Government & the Regions, (1998) Modern Local government: in touch with the people, London: DTLR. Griffiths, R (1988), Community Care Agenda for Action – a report to the Secretary of State for Social Services, London: HMSO. Care Services Improvement Partnership, (2006) The social work contribution to mental health services: The future direction. Report in response to the discussion paper.
Other official reports: Sweden Riksrevisionen, (2009) Psykiatrin och effektiviteten i det statliga stödet, Riksrevisionen 2009:10. Socialdepartement, (1993) Sammanställning av remissyttranden över psykiatriutredningens slutbetänkande, (SOU 1992:73): Ds 1993:88.
Social Services Inspectorate, (2003) Performance ratings for social services in England – November 2003, London: Department of Health. (2004a) Treated as people: An overview of mental health services from a social care perspective 2002-04, London: Department of Health. (2004b), Old virtues, new virtues: an overview of the changes in social care services over the seven years of joint reviews in England 1996-2003, London Department of Health.
Socialstyrelsen (The National Board of Health & Welfare) (1980) Riktlinjer för 80-talets psykiatriska vård, Socialstyrelsen anser 1980:2. (1982) Psykiatrisk vård utan mentalsjukhus, Socialstyrelsen redovisar, 1982:8.
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(1996a) Psykiatrireformen: årsrapport 1996, Socialstyrelsen följer upp och utvärderar 1996:4, Socialstyrelsen: Stockholm. (1996b) Rättmedicinalverkets föreskrifter och allmänna råd om läkarintyg enligt 7§ lagen (1991:2041) om särskild person utredning i brottmål mm. SOSFS 1996:15. (1997a) Handikappreformen: slutrapport 1997, Socialstyrelsen följer upp och utvärderar 1997:4, Socialstyrelsen: Stockholm. (1997b) Är vi på rätt väg?: årsrapport för psykiatrireformen 1997, Socialstyrelsen följer upp och utvärderar 1997:6, Socialstyrelsen: Stockholm. (1997c) God psykiatriskvård på lika villkor, Socialstyrelsen följer upp och utvärderar 1997:8, Socialstyrelsen: Stockholm. (1998) Reformens första tusen dagar: årsrapport för psykiatrireformen 1998, Socialstyrelsen följer upp och utvärderar 1998:4, Socialstyrelsen: Stockholm. (1999a) Välfärd och valfrihet: Slutrapport from utvärderingen av 1995 års psykiatrireformen, Socialstyrelsen följer upp och utvärderar 1999:1, Socialstyrelsen: Stockholm. (1999b), Rättsmedicinalverkets föreskrifter om fördelning på undersökningsenheter av läkarundersökningar vid särskild personutredning i brottmål och av rättspsykiatriska undersökningar, SOSFS 1999:19. (2000) Socialstyrelsens allmänna råd om kvalitetssystem inom socialtjänstens individ och familjeomsorg SOSFS 2000:15. (2002) Socialtjänstlagen: Vad gäller för dig från 1 januari 2002 (lättläst), Stockholm: Socialstyrelsen. (2003) Kommunernas insatser för personer med psykiska funktionshinder: tillsyn av verksamhetsplanering och utbud av insatser, Socialstyrelsen & Länsstyrelserna Stockholm: Socialstyrelsen. (2005a) Kommunernas insatser för personer med psykiska funktionshinder – slutrapport från en nationell tillsyn Socialstyrelsen & Länsstyrelserna 2002-2004, Stockholm: Socialstyrelsen. (2005b) Perspektiv på… Kommunernas insatser för personer med psykiska funktionshinder: Slutrapport från en nationell tillsyn, Socialstyrelsen & Länsstyrelserna Stockholm. (2008) A new profession is born: personligt ombud, PO Socialstyrelsen: Stockholm.
Statens Offentliga Utredningar: SOU (State public inquiries) SOU 1992:73, Välfärd och valfrihet, service stöd och vård för psykisktstörda, Slutbetänkande av psykiatriutredningen, Stockholm: Socialdepartementet.
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SOU 1999:97 Socialtjänst i utveckling, Stockholm: Socialdepartementet. SOU 2006:3 Långsiktighet, samordning och engagemang: en strategi för statlig styrning på psykiatrins område: Rapport 2006:3 från Nationell psykiatrisamordning, Stockholm: Socialdepartementet. SOU 2006:100 Ambition och Ansvar: Nationell strategi för utveckling av samhällets insatser till personer med psykiska sjukdomar och funktionshinder – slutbetänkande av nationell psykiatrisamordning, Stockholm: Socialdepartementet 2006. SOU 2006:100 Ambition and responsibility: National strategy for development of society’s initiatives for individuals with mental disorders and disabilities, summary, Final report of the National Psychiatric Services Coordination, (English version), Stockholm: Socialdepartementet 2006.
Sveriges Riksdagen 1993 Socialutskottets betänkande 1993/94:SoU28; Psykiskt stördas villkor. 2003 Socialdepartementet, Direktiv 2003:133 En nationell psykiatrisamordnare. 2003 Kammarens protokoll, 2§ Aktuell debatt: den psykiatriska vården, Riksdagens protokoll, 2003/04:11 Måndagen den 6 oktober.
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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsP olicyAndGuidance/DH_4010395 Department of Health Website, page, History of the Mental Health Act 2007, (accessed 10/2-10) http://www.dh.gov.uk/en/Healthcare/Mentalhealth/DH_4084645 English History & Heritage guide, http://www.britainexpress.com/History/index.htm (accessed 28/5-10). Family action website, about us, history, (accessed 13/7-10) http://www.familyaction.org.uk/section.aspx?id=31 General social Care Council (GSCC) website, (accessed 10/8-10) http://www.gscc.org.uk/Home/ Institute of Mental health Practitioners, www.markwalton.net accessed 2/4-06 Keays, D. (1987) ‘Aids, education and the year 2000!’ Interview with Margaret Thatcher, Published in Women’s Own Magazine on 31/10-87 pp. 8-10. Online from the Margaret Thatcher Foundation Archive (accessed 9/4-10). Labour Party Manifesto 1995, downloaded from BBC news (accessed 9/6-10). http://news.bbc.co.uk/2/shared/bsp/hi/pdfs/13_04_05_labour_manifesto.pdf Länsstyrelsernas website, http://www.lansstyrelsen.se/lst/en/ accessed 22/6-09. Mental Health Act Commission Homepage, http://www.mhac.org.uk/ (accessed 27/8-06). Mental Health History Timeline, Andrew Roberts, University of Middlesex, (accessed 4/12-09)http://studymore.org.uk/mhhtim.htm#1913BoardofControl MIND, (2005) Social care and mental health: Mind and current developments in adult social care MIND response to government green paper on social care (accessed 26/6-06) http://www.mind.org.uk/NR/rdonlyres/6A3CFEAE-31274235-B384-643252245457/3154/socialcare.pdf Nämnden för Socionomauktorisation, (accessed 27/7-10) http://www.socionomauktorisation.nu/ Ramon, S. (2001) Options and dilemmas facing British mental health social work, Mental Health Social Work, Mental Health in Higher Education Network (accessed 18/7-10). Riksdagen: Psykiatrisatsning http://www.sweden.gov.se/sb/d/2881 (accessed 8/7-10) Riksrevisionen, (2009) Dokumentation av Riksrevisionens seminarium den 23 november 2009: Psykiatrin i läkarutbildningen och vårdens behov, http://www.riksrevisionen.se/upload/3269/Dokumentation_psyk_sem.pdf RSMH/National Association for Social and Mental Health/ Riksförbundet för social och mental hälsa website http://www.rsmh.se/historia.shtml RSMH/ National Association for Social and Mental Health/ Riksförbundet för social och mental hälsa 2007, Vad tycker RSMH? Intressepolitiskt program, http://www.rsmh.se/Intressepolitiskt_program.pdf (accessed 22/1-10)
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Other reports British Medical Association, (1995) Survey on the impact of the implementation of the community care reforms, British Medical Association: Health policy and economic research unit. Henwood, M, (1995), Making a difference: Implementation of the community care reforms two years on, Nuffield Institute for Health Community Care Division & Kings Fund Centre. Kaye, C &, Howlett, M, (2005) Today and tomorrow: better services for mental health? A national survey of NHS Mental Health Trusts, The Zito Trust. Northern Centre for Mental Health (2004) Social worker leading roles in mental health: adjustments to change, new ways of working and other potential soluntions, Durham: Northern Centre for Mental Health.
Sveriges Kommuner & Landsting/Svenska Kommunförbundet Circulars 1993:44 Kommunernas roll inom vårdsektorn (KOMVård) 1993:85 Lag om stöd och service till vissa funktionshindrade (LSS) 1994:110 Riksdagsbeslut om psykiskt stördas villkor. 1995:47 Kommunernas ansvar och uppgifter för vuxna som är medicinskt färdigbehandlade inom den slutna psykiatrin 1995:100 Kommunens hälso- och sjukvårdsansvar 1998:188 Medicinskt färdigbehandlade personer med utagerande beteende rapport från Socialstyrelsen
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2000:141 Samverkansprojekt kring människor med svåra psykiska och sociala funktionshinder samt utagerande beteende - efterlysning av exempel 2004: 61 Handikappnycklar - en modell för analys och reflekterande 2005:34 Överenskommelser mellan staten, Svenska Kommunförbundet och Landstingförbundet om en fortsatt satsning för utveckling av primärvården, och äldrevården respektive psykiatrin. Newsletter Aktuellt om SKL:s arbete inom psykisk ohälsa: november 2009 Aktuellt om SKL:s arbete inom psykisk ohälsa: mars 2010. SKL Publications/handbooks/Books Svenska Kommunförbundet (2000) Utvecklingen av kommunal hälso- och sjukvård, Ahlsén, K. Olofsson, R. Åhs, U. Albinsson M, Björck, M. Olsson, Karin. Svenska Kommunförbundet (2001) LSS & psykiska funktionshinder: att tänka på i det professionella mötet med personer med psykiska funktionshinder, Stockholm: Svenska Kommunförbundet Sveriges Kommuner & Landsting. (2008) Jämförelser mellan kommuner utifrån brukarrelaterad information inom äldre- och handikappomsorg — Kostnad Per Brukare (KPB): analysrapport,. Bengt, A. & Thorell Y.
News articles – national press & media British newspaper/news articles BBC news online 17/1-98, ‘Care in the Community to be scrapped’, http://news.bbc.co.uk/2/hi/uk_news/48168.stm accessed 18/1-07 BBC News online 26/11-99a, ‘At risk councils speak out’ http://news.bbc.co.uk/2/hi/health/534848.stm (accessed 19/5-10) BBC News online 26/11-99b, ‘Private firm to run Islington’s schools’, http://news.bbc.co.uk/1/hi/education/536949.stm (accessed19/5-10). BBC News Online 9/7-01, ‘Boost for mental health care.’ http://news.bbc.co.uk/2/hi/health/1430596.stm (Accessed 17/11-09) BBC News Online 23/12-04 ‘Most mentally ill pose no threat’ (accessed 7/8-10) http://news.bbc.co.uk/2/hi/health/4122017.stm Guardian 17/11-06, ‘The Mental Health Bill – questions and answers’, D. Batty. Guardian, 29/1-07 ‘One hundred years of non-penal servitude’, A. Travis. Guardian 10/3-10, ‘Social work needs and independent college’, H Dawson. Independent 2/7-92, ‘Parliament & Politics: Watchdog gives warning over care funding’, I Mackinnon.
378
References Independent 10/1-93, ‘Care in the community: Ben Silcock’s mauling by a lion at London Zoo has highlighted the plight of the mentally ill’, J Jones. Independent 23/2-93 Major on Crime: ‘Condemn more, understand less’, D MacIntyre. Independent 12/3-93, ‘Councils told to ‘hide’ care services shortfall’, R Waterhouse. Independent 19/3-93 ‘‘Pledges broken’ over community care funding: All-party committee criticises failure by ministers’, R Waterhouse. Independent 29/3-93a, ‘Community Care: Three years’ preparation ends with a scramble’, R Waterhouse. Independent 29/3-93b, ‘Community care launched with modest expectations: After a two-year delay, this week sees the introduction of a radical reform of social welfare, with a new system of payment and provision’, R Waterhouse. Independent 29/3-93c, ‘Community care the user’s guide: what the policy will do, who it will help, who pays’, R Waterhouse. Independent 8/7-93, ‘Experts split over control of mentally ill: MPs condemn community supervision orders’, S Watts. Independent 19/7-93, ‘The tragic scandal of a schizophrenic killer nobody stopped’, R Waterhouse & R Williams. Independent 12/8-93a, ‘Mentally ill to be better supervised: Changes to community care likely to include the power to recall patients’, R Waterhouse. Independent 12/8-93b, ‘Compulsion can be caring too: A review of provision for the mentally ill is announced today’, M Mervis. Independent 13/8-93a, ‘Bottomley plans new controls on mentally ill: Government proposals to counter community care problems contain no offer of additional resources’, R Waterhouse. Independent 13/8-93b, ‘New rules on mental patients, but no extra cash’, R Waterhouse. Independent 12/8-93a, ‘Mentally ill to be better supervised: Changes to community care likely to include the power to recall patients’, R Waterhouse. Independent 12/8-93b, ‘Compulsion can be caring too: A review of provision for the mentally ill is announced today’, M Mervis. Independent 13/8-93a “Bottomley plans new controls of mentally ill”, R. Waterhouse. Independent 13/8-93b “New rules on mental patients, but no extra cash”, R. Waterhouse. Independent 24/8-93 ‘Social workers defend training: Discord over race awareness studies’, E Oxford. Independent 19/12-93, ‘Breaking out of the asylums: Once they were conveniently locked away in mental hospitals. Today the mentally ill are back on the streets, more visible than at any time in living memory’, M Mcfadyean. Independent 25/2-94, ‘Bottomley admits more help is needed to the mentally ill: Catalogue of failure and missed opportunity in schizophrenic’s treatment led to killing’, N Timmins. Independent 20/4-94 “Care in the community: Patients ‘left isolated and destitute’”, R. Waterhouse
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Independent 26/2-94, Letter - Clunis case reveals the community unprepared for care, from Mr T Roddis. Independent 20/4-94, ‘Care in the community: Patients ‘left isolated and destitute’ – policy for rehabilitating mentally ill people is failing in practice select committee finds’, R Waterhouse. Independent 22/5-94 “Fear of the strangers who live in darkness at the edge of town”, B Morrison. Independent 23/6-94 “Government rejects MP’s proposals on mentally ill”, R. Waterhouse. Independent 17/8-94 ‘Killings by mentally ill ‘avoidable’: Psychiatrists urge more coordination between professionals and closer supervision of patients’, R Waterhouse. Independent, 18/8-94a “Minister in care killings row”, R. Waterhouse. Independent 18/8-94b “Leading article: Cruel care for the mentally ill”, Leader. Independent 19/8-94 “Does the community care?: Diverse provision for the mentally ill brings its own problems,” R. Waterhouse. Independent 9/9-94, ‘Leading article – Whitehall’s fiefdoms fail the mentally ill’. Independent 10/10-94, Bottomley rejects national standards in community care, S Ward. Independent 17/1-95a, ‘Schizophrenic’s knife attack was ‘predictable’’, R Waterhouse. Independent 17/1-95b, ‘Officials ‘blocked report on killing’’, R Waterhouse. Independent 17/1-95c, ‘Leading Article: Care endangering the community’. Independent 17/2-95, ‘Mentally ill face paying for after-care’, R Waterhouse. Independent 17/3-95, ‘£540m plea for mental health’, R Waterhouse. Independent 27/7-95a, ‘Breakdown of care led to hostel killing: catalogue of failure caused death of volunteer’, N Timmins & I Mackinnon. Independent 27/7-95b, ‘Damning report criticizes care authorities: Newby Inquiry – Chairwoman will appeal to health minister for funds to prevent more deaths’, N Timmins & I Mackinnon. Independent 29/7-95 “Community care ‘going to NHS trusts’”, N Timmins. Independent 25/8-95 “Community care “haphazard and confused’” G Cooper. Independent 26/9-95 “Better funding holds key to improved care: analysis” N Timmins. Independent 28/12-95 “Charter to tackle fears over mentally ill”, (article not attributed) Independent 6/1-99, ‘Mentally ill ‘guilty of fewer murders’’, L Jury. Independent 20/4-99, ‘‘Failure of system’ led to PC’s death’, I Burrell. Independent 7/5-99, ‘Mentally ill kill 40 people a year’, C Norton. Independent 21/7-02 “MPs revolt over plans to lock up the sick” S. Goodchild. Independent 4/8-02 “Blunkett plans to detain more psychopaths” J Dillon. Independent 4/8-02 “More locks, but less care for patients” C Newbon.
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References Independent 19/11-02 “Jeremy Laurance: Fear is the worst way of managing mental health”. Independent 2/2-03 “Mentally ill at risk of violent abuse” S. Goodchild. Independent 17/8-03 “Probation staff left to cope with mental illness” S. Goodchild. Independent 26/11-03 “Inquiry into doctors who freed ‘ripper’ before more killings” M. Hickman. Independent 12/12-03Julia Neuberger: our treatment of the mentally ill is a test of society”. Independent 22/2 04 “Hundreds of adults still locked in asylums” M. Gould. Independent 26/2-04 “Delivering care in the community” G. McCann. Independent 24/12-04 “New doubt about care in the community after stabbing rampage injures five” J. Bennetto,. Independent 9/1-05 “Mental health helpline to close as government cuts £1 million funding” J Thompson,. Independent 26/2-05 “Is there such as thing as care in the community” M. Frith. Independent 17/3-05 “Jeremy Laurance: the truth about care in the community”. Independent 27/3-05 “Would this Mental Health Bill have stopped the killing? No” S Goodchild Independent 15/3-06 “Deborah Orr: If we really want to help disabled people we could begin by seeing them” Independent 26/3-06 “Madness: Britain’s mental health time bomb” S. Goodchild. Independent 11/5-06 “One tragedy that testifies to a decade of neglect” Leader. Independent 15/10-06 “Mentally ill ‘still being denied a basic level of care’” S Goodchild & J Owen. Independent /11-06 “A disturbing indictment of our values and priorities” Leader. Management Today 1/1-96, ‘The Davidson interview: Derek Lewis’, Management Today, A Davidson. The Sun 9/9-04 “Curbs on Mental patients”. The Sun 26/2-05a “Violent, mad … and set free”. The Sun 26/2-05b “Safety first”. The Sun 2/4-05 “Schizo killer caged for life”. The Sun 19/5-05 “Cop killer held indefinitely”. The Sun 20/5-05 “String of fatal blunders”. The Sun 23/10-07 “Stalker freed to kill care worker”. The Sun 25/3-09 “Why was cop killer madman on streets?”. The Sun 24/3-09 “Zito’s killer ‘set for release’”. The Times, 24/4-10, ‘Speaking in haste from a ministry in meltdown after Baby P’ Case, R Bennett.
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Swedish newspaper articles Aftonbladet 27/5-03 ”Hur kunde tragedin I Åkeshov ha undvikits?”. Aftonbladet 2/6-03 “Alltför många sjuka lämnas vind för väg”. Aftonbladet 3/6-03 ”Lås inte in de sjuka Engqvist”. Aftonbladet 27/9-03 ”Politiker – gör något”. Aftonbladet 25/6-03 ”Psyksjuka portas från härbärgarna”. Aftonbladet 28/8-03 ”1500 psykfall utan vård på gatorna”. Aftonbladet 17/9-03 “Vansinnesdåden har fått regeringen att inse allvaret”. Aftonbladet 1/10-03 ”De som skulle fått öppenvård glömdes bort”. Aftonbladet 2/10-03 ”Det här räcker inte Engqvist”. Aftonbladet 6/10-03 ”Hård kritik mot vården av psykiskt sjuka” Aftonbladet 1/7-07 ”Vår dotter mördades också av en psyksjuk ”. Aftonbladet, 28/8-08 ’Psykiatrin funkar inte – och ingen tycks veta varför’ Dagens Nyheter 8 /3-95 ”Äldrecentrum oroas av psykiatrireformen: Äldre psykiskt sjuka glöms bort” A Johansson. Dagens Nyheter 19/9-95 ”Psykiatrireformen klar”. Dagens Nyheter 15/6-97 ”Sjuka registreras utan att tillfrågas: psykiatri” J Brinck. Dagens Nyheter 20/6-97 ”Uppror mot nytt register”, J Brinkc. Dagens Nyheter 29/6-97 ”Beckomberga sjukhus: Fastlåsta i ett ingenmansland” J Brinck. Dagens Nyheter 5/7-97 ”Ledare: Rätten till ett värdigt liv: det måste gå att bryta de psykisktsjukas passivitet och isolering” Ledare. Dagens Nyheter 4/11-97 ”Pengar finns anslagna” K. Vinterhed. Dagens Nyheter 5/11-97 ”Med respekt for de udda – lagom mycket stöd” K Vinterhed. Dagens Nyheter 14/12-97 ” Daglig stöd nyckel till eget boende” K Vinterhed. Dagens Nyheter 12/1-98 ”Ledare – pension ja – men förs vård” Ledare. Dagens Nyheter, 8/5-98a, ’Efter psykiatrireformen: utskrivna patienter försummas’, L. Brattberg. Dagens Nyheter 3/12-98a, ’Havererad psykvård Östermalm. Kommunen har inte klarat av att ersätta den stängda slutenvården’., A. Bodin. Dagens Nyheter 3/12-98b, ’Öronmärkta pengar användes olämpligt. Anslag på 6 miljoner gick in i löpande verksamhet’, A. Bodin. Dagens Nyheter, 13/12-98, ’Psykiskt handikappade utstötta på Östermalm’, P-O Larsson. Dagens Nyheter, 10/10-99 ”Återupprätta mentalsjukhusen”:, DN Debatt, M Heilig. Dagens Nyheter, 17/10-99, ’Repliken: ”Goda asyl har aldrig existerat”’. DN Debatt, K. Grunewald. Dagens Nyheter, 21/10-99, ’Psykiatrireformen under luppen’, C. Friborg, Ledare. Dagens Nyheter, 24/10-99, ’Repliken: ”Slutenvård förvärrar för psyksjuka”’, DN Debatt J-O Forsen. Dagens Nyheter, 3/1-00, ’Önska inte mentalsjukhusen åter’, Leader. Dagens Nyheter, 4/1-00, ”Reformen ett misslyckande”.
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References Dagens Nyheter, 8/1-00 ’Psykiatrireformen har gett många ett bättre liv’, DN Debatt, G Ahnlund. Dagens Nyheter, 9/1-00 ”Utan tvångsvård återstår bara döden” DN Debatt, L Jacobsson. Dagens Nyheter; 18/1-00 ’Hemlösa inte fler men mer utsatta’, Ledare. Dagens Nyheter, 10/2-00 ”Utskrivna mår bättre” Psykologen har följt 900 ”Patienterna är inte så kriminella som det påståtts”. Dagens Nyheter 23/3-03, ’Utnyttjad och otillräcklig i vården’, G. Svensson. Dagens Nyheter, 21/5-03, ’Rusta upp psykiatrin’ ledare, Dagens Nyheter 8/6-03, ’Psykvården schizofreni’. L Norrman. Dagens Nyheter, 26/9-03, ’Många får inte tillräcklig vård’, E Lundborg, A. Sjöblom. Dagens Nyheter 27/9-03, ”Vi arbetar inte med andra tips nu”, A. Hellberg. Dagens Nyheter, 30/9-03 ”Det måste vara lättare att tvångsvårda”, E Lundborg. Dagens Nyheter 12/12-03, ’Svidande kritik mot psykvården’, I Wadendal. Dagens Nyheter 2/6-04 ”Oacceptabelt stoppas nya psykiatripengar” kommunal självständighet får inte stå i vägen för en nödvändig statlig satsning”, Debatt Anders Milton. Dagens Nyheter 13/11-04 ’Han lekte med schizofrena’ A. Benderix. Dalademokraten 9/1-02 (2002) ’Fasta paviljongen kom till för vårddömda patienter’, Engvall, R. Expressen, 14/8-99, ’Adam är inte ensam’, S Hobohm. Expressen, 8/10-99, ’Förre ÖB måste vårda sin son själv: ”Nu är det ingen som egentligen tar ansvar”, P. Nordström. Expressen/GT, 25/5-03 ’En sjuk psykvård’, J Fredriksson. Expressen, 2/6-03, ’Vansinnesfärden: antalet vårdplatser halverat – polisen rasar’, A.S Wiren, M Pettersson, C Garme. Expressen, 3/6-03, ’Döden i Gamla stan’, E Erfors. Expressen 18/1-04 ’Lars Engqvist Socialminister – hur kunde det gå så fel minister? Lars Engqvist om psykvården, make och Perssons groggar’, C Hagen. Riksdag och Departement, 6/10-03, ’Engqvist sätter sitt hopp till psykiatrisamordnare’, R Hermansson. Riksdag och Departement, 17/11-03, ’Psykiatrisamordnare tillsätts’, R Hermansson. Svenska Dagbladet 1/7-02” Vård på patienternas villkor”, ledare,. Svenska Dagbladet 16/8-02”100 av 179 saknade säng”, insändare. Staffan Hellgren (direktör Stockholm Stadsmission). Svenska Dagbladet 3/6-03a ”Bodström bör ta honom med sig i fallet”, M Abrahamsson. Svenska Dagbladet 25/6-03 ”Psyksjuka portade från härbärgen”. Svenska Dagbladet 16/9-03 ”Psykiatrisamordnare tillsätts”. Svenska Dagbladet 19/9-03 ”Centralisera psykiatri” Debatt. Svenska Dagbladet 20/9-03 ”aningslöst stänga mentalsjukhus” C Pegel. Svenska Dagbladet 29/9-03 ”Vem blir brottsling?” A Haag. Svenska Dagbladet 1/10-03 ”KD: ge psyksjuka alternativfängelser” O. Nilsson. Svenska Dagbladet 2/10-03a ”Engqvist må lovar men pengarna är slut” A. Johnsson.
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The Governance Gap Svenska Dagbladet 2/10-03b ”Allt är inte kommunernas fel” Ledare. Svenska Dagbladet 6/10-03 ”Hård kritik mot psykvården” . Svenska Dagbladet 11/12-03 ”Skärp kritik mot kommuners psykvård”. Svenska Dagbladet 12/12-03 ”Psykiskt sjuk får inte hjälp”, A-L Haverdahl. Svenska Dagbladet 10/1-04 ”Ett välfärdens sammanbrott”, Ledare. Svenska Dagbladet 7/10-04 ”Bättre samverka än att lägga ner” P. Persson & P. Håkansson, Debatt. Svenska Dagbladet 29/7-05 ”Ökat antal personer behöver god man”,. Svenska Dagbladet 9/9-05 ”kommunerna sviker de psyksjuka” K Krantz. Svenska Dagbladet 5/8-06 ”FP vill ha mer tvång i psykvården” Svenska Dagbladet 6/8-06 ”FP vill ha mer tvång i psykvård”. Tidningarnas Telegrambyrå (TT) 16/12-98 ’Personalombud kan ge bättre liv’. Tidningarnas Telegrambyrå (TT), 10/10-99, ’Psykiater: Psykiatrireformen ledde till misär’. Tidningarnas Telegrambyrå (TT) 6/10-03, ’Hårdkritik mot vården av psykiskt sjuka’, L Idling.
Social Work profession documents Akademikerförbundet-SSR/Swedish Association of Social Workers (via Tjänstemannarörelsens arkiv & Museum –TAM-arkiv)
Governing body minutes (Förbundsstyrelsen – protokoll) FS 10-20/11-94 FS§ 3b/Annex § 3b FS 21/1-99§10
Consultation statements (Remissyttrande) 1999 Akademikerförbundet-SSRs synpunkter på Socialstyrelsens slutrapport av psykiatrireformen ”Välfärd och Valfrihet”, 15/9-1999 2007 Akademikerförbundet SSR yttrande över ”ambition och ansvar” – slutbetänkande av nationell psykiatri samordning SOU 2006:100, 7/12-2007.
British Association of Social Workers (1990) Community Care: whose choice? Managing care – the social work task. London BASW. (2006a) Proposals for amendments on ASW/AMHP related issues. (2006b) Parliamentary briefing paper of the Mental Health Bill. (2006c) Defending the position and ensuring the independence of the AMHP.
ASW leads network (accessed via the Social Perspectives Network for Modern Mental Health http://www.spn.org.uk/index.php?id=1017 – last accessed 29/7-10) (2006a) Newsletter October 2006. (2006b) ASW Workforce Survey.
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References
Professional Press: Newspapers1070 Community Care Community Care 19/9-92, ’A vision of the future’ Community Care 15/5-00 ‘The management myth’ M. Langan. Community Care 28/3-02 ‘Danger lurks in the management maze’, Y Roberts. Community Care 30/5-02, ‘Ten Social services departments given zero stars and four to face intervention’. Community Care 11/7-02 ‘Lets rally round an ethical code’ L. Timms, N. Mapston. Community Care 10/10-02 ‘Rebirth of a profession’ Community Care 24/10-02 ‘Career moves’ Manthorpe, J. Bradley, G. & Carlin J. Community Care 5/12-02 ‘Behind the headlines’ Community Care 13/2-03 ‘A no win situation’ Community Care 9/10-03 ‘Policy’ L. Revans. Community Care 3/11-03 ‘Registration – checks defy user ethos’, M Samuel. Community Care 14/6-04 ‘Let’s be hearing you’ M. Benn. Community Care 17/6-04 ‘Identity crisis looms’ K. Leason. Community Care 8/7-04 ‘Death of the department’ R. Jones. Community Care 25/11-04 ‘Six days to go’ Ian Johnson BASW Community Care 2/6-05 ‘Workforce association chair to restore profession’ Community Care 12/1-06 ‘Workplace – Mental health staff put low morale down to workload and role changes’, Simeon Brody. Community Care 2/7-07 ‘Ethical practice in social work – the GSCC and the conduct process, C. Jerrom.
Social Work Press Editorials British Journal of Social Work (1993) Editorial, ‘Community Care, social work and social care’, Challis, D. & Hugman, R. 1993 23 pp. 319-328. British Journal of Social Work (1996) Editorial, 1996 26, pp. 151-152, Mullender, A, & Francis Spence, M. British Journal of Social Work, (2005) Editorial, 2005, Vol. 33 pp. 565-567, I Johnson, Director BASW Practice, (1998a) Editorial, 1998 Vol. 10, No. 1 pp. 3-4, Williams B. Practice (1998b) Editorial, ‘Lean and mean: The future of Social work education!’. 1998, Vol. 10, No. 2 pp. 3-4.
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This section relates to newspaper type articles and editorials. The research papers from the British Journal of Social Work are located under author names in the literature sections.
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Socionomem Tidning (Social worker newspaper) 2/1993 ’Stort intresse för nybildat forum for socialpsykiatri’. 6/1994 ’Fler socionomer blir leg. Psykoterapeuter’ 3/1996 ’Ingen har tidigare sett helheten hos våra klienter’. 2/1997 ’Bör psykiatri föras över till socialtjänsten?’, Lindberg & Wahlström. 1/1998 ’Södertäljemodellen för psykiska långtidssjuka’. 2/1999a Ledare: ’När fan går på torra land’. 2/1999b ’Personligt ombud – ett varningstecken för samhället’, P Brusén 3/1999 Letter C Mironidou.
Reference works Longmans Contemporary English Nationalencyklopedin Oxford English Dictionary.
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