So how did it happen then, that a law with so much promise turned into a seemingly ambitious but practically status-quo supporting steering tool of neoliberal governance? The above analysis already shows some of the myriad ways in which competing perspectives and claims were subsumed and incorporated into the hegemonic discourse. I next make some further observations about the way the hegemonic discourse managed to order the various elements at play during the policy process in such a way as to maintain the existing practices of elder care, whilst in the background the (neoliberal) reforms, which had begun already earlier, continued.
The whole concept and idea of an elder care act functioned as a floating signifier at the beginning of the process, as different interest groups and actors in the field of elder care attached differing hopes and meanings to it.
Often tied to these hopes was an idea of better or more binding regulation, which also floated around as a signifier to which different ideals were pinned.
However, as the process went on, a specific type of regulation came to be
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articulated and emerged as the hegemonic one, and with it the law itself got its shape and the floating of these various ideals came to a (partial) momentary closure when the bill was passed. For example, as discussed in chapter 4, the resource discourse, produced by many of the commenters on the draft laws, proposed that the law should force the municipalities to allocate more resources to elder care, whilst the hegemonic discourse aimed to make the service production more efficient, claiming that increasing resources is not really possible.
But before the bill was finally passed, a plurality of elements were utilized in binding together and creating this particular understanding of what kind of regulation the elder care law should be about. As preventing the escalation of service needs was seen as the only possibility to cope with the impending care deficit in the hegemonic discourse, it was tied to all the other measures introduced in the elder care act. Hence, as discussed above, the idea of prevention was a key nodal point in the process, along with the connected nodal points of what I call the dwindling resources and bureaucratic division of labour frames.78
Further elements of the discourse can also be identified which emerged as important concepts supporting the hegemonic perspective of the process.
These concepts supported the idea of preventing the increases in expenses.
Firstly, the ideas of individual needs and individualized care and services were presented as a solution and response to guarantee better care, a key demand at the beginning of the process. Care specifically tailored for each individual was to be attained through the comprehensive and timely investigation of service needs, and the planning of services that correspond to these individual needs (elder care act, section 15; HE 160/2012, 1, 32). The individuality of care services was presented as a tool to both better respond to the differing needs of people, and to make the service provision more effective. It also served to avert the suggestions to include in the law universal rights such as a right to get to go outdoors.79 As an interviewee at Valvira (the national supervision authority) put it:
78 There were no specific expressions or words in use for these ideas, rather many different expressions were utilized to convey these ideas. I nevertheless conceptualize them as nodal points, because of the repeated nature of very similar arguments: 1) claims of there simply not being enough money/resources (thus, ‘dwindling resources’); and 2) claims of there being an accepted way to manage national social policy, whereby issues are dealt with in a particular controlled and ordered manner (hence ‘bureaucratic division of labour’). One might also speculate that part of the reason these ideas did not have single terms as signifiers was the fact that they were not challenged or discussed critically during the process, but rather remained as naturalized constraints which need not be clarified.
… it’s a very individual thing, who needs to go outdoors everyday, who many times a day, who once a week, and you cannot ask because people have good days and bad days, so you cannot make a demand that everyone must get to go outside every day.
(18, 4)
Furthermore, such universal minimums were framed as a threat to the quality of care:
... [and if getting to go outdoors was a right, would it be then] that people are just moved to sit on the balcony, and that’s it? Just sit there until someone takes you away.
(18, 4)
These arguments undermine the ideas of universal service provision by framing it as contradictory to the individual needs and situations of those in need of services. Hence no provisions which would define and guarantee good quality care for instance in terms of a strong right (not a duty) to access the outdoors at certain intervals (for example, as it is stated in the law concerning prison inmates), were included in the law.80
Instead, and secondly, quality of services and care was tied to the individual treatment of care receivers. Quality thus came to mean care according to the well investigated service needs in the hegemonic discourse, whilst at the beginning of the process the idea of quality services was a floating signifier to which many different parties appealed in their demands, for instance in the comments on the draft laws (REFs).81
80 Whilst worries about the elderly not getting to go outdoors regularly in 24-hour care were voiced at the beginning of the process, this question did not gain much visibility later on. However, in 2013 there was some organizing around the issue, with a citizens’ initiative calling for the inclusion of a right to daily time outdoors in the act concerning the right of patients and clients (of social and health care services) to self-determination. However, the initiative was not successful, as it did not gather the required 50,000 signatures, remaining at only about 15,000.
81 As the hegemonic discourse is largely created through the documents, arguments and material produced by the ministries and other governing bodies, further attempts to define quality in a specific way can be found in administrative documents of elder care. These definitions can be quite far removed from the everyday understandings of good care, such as in the most recent national quality recommendation concerning services for the elderly:
The quality of services means the ability of the service to respond to the investigated service needs of the clients systematically, effectively, according to the regulations and cost-effectively. Quality service maintains or improves the functional capacity of the client and increases health benefits, but also secures good palliative and other care at the end of life. Good quality service is a) effective and safe; b) customer-oriented, and responds to the needs of the customer and c) well coordinated. (STM 2013:11, 10)
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The attitude of care workers and nurses was also emphasized as important in securing quality of services, as is explained in the objectives of the elder care bill:
The provisions concerning the principles in responding to service needs might cause [care workers] to have to check their attitudes toward aged customers, and to renew the caring methods in use. The effects of these provisions extend to the immediate superiors of the workers, as they are in a key position when there is a need to change the attitudinal atmosphere and work culture of the unit.
The experience of the customer of the quality of services is essentially affected by how his/her individual needs and wishes are taken into account, in what form his/her service is realized and how the staff responds to him/her.
(He 160/2012, 19,27)
Here increased regulation is seen to be necessary:
The basic provisions concerning the rights and proper treatment of a customer and patient are included in the [relevant acts concerning customers and clients]. These however, are general [acts] and require more specific provisions, in which the special needs of aged people are taken into account.
(He 160/2012, 19)
Again, the idea that better resourcing might be of importance in securing better care fades from view when focus is placed on the level of the individual.
Third, living at home and home care were a repeatedly expressed principle which would play a central role in the reformed elder care services.
It was framed in terms of individual treatment and care, and choice, as it was assumed by almost everyone commenting on the issue during the process that everyone’s first choice is to live at home as long as it is possible. But this ideal of living at home was also a contested concept, a floating signifier, at some points, as it was challenged as the best solution, and even framed as a potential lack of care, neglect and abandonment of old people. Different arguments were put up criticizing the notion of living at home as the best policy: There was critique about the insufficiency of existing home services, with for example THL quoting figures which showed that the experienced deficit of home care has tripled since 2004 (StVM comments, THL). The National Audit Office, too, already in 2010, argued that objectives set for home care services have not been accompanied with adequate resources, which has in practice led to a reduction in the quality of services.
Furthermore, the practices in home care and how municipalities charge for it vary a lot between regions, and it is unclear what is in fact meant by home care. According to the Audit Office, the idea that home care is a cheaper option compared to institutional care also does not always hold (National
Audit Office 2010, 8). Similarly, the Finns argued that, ‘the prospect of emphasizing home care is humane, but institutional care should not be run down gratuitously, as those in the worst shape do not cope with home care’
(StVM 27/2012, Protest 2). Interviewee of SuPer (the union of practical nurses) also argued:
That people can live at home in principle is not a bad thing. But it must be resourced in such a way that it works, and that’s a bigger question then. But home care should not be chosen on the basis of its being cheap and easy.
(I5,4)
Another critique of home care maintained that there will inevitably be people who at some point cannot live at home anymore, even if they wanted to, and it will be important to make sure they get institutional care when needed.
This news article is from 2014, also showing that the debate concerning elder care still continues:
In my [Paavola’s] opinion an elderly person cannot be made to evaluate what is the best care for them; rather, they need guidance. A person with dementia (muistisairas) might think that home is the best place for him/her, even though in reality this is not the case.
(Kantomaa 2014)
Silja Paavola, a representative of the practical nurses union SuPer, here articulates the kind of reality of care relations which is largely absent from the hegemonic discourse which instead emphasizes individual choice and decision making. Paavola seems to understand care in the sense that Mol (2008) has discussed it as a logic of its own, where what is central is not what people want, but what they need.
The pervasiveness of care relations and the way people continuously care for each other, and how these relations and work is made invisible in politics based on the ideal of an autonomous citizen (chapter 2), also came up in the interviews. The NGO representatives critiqued the way family care relations are not recognized in municipal home care services:
There are really a lot of people who the municipality classifies as being [receivers of]
home care, and then they sort of forget that this home care is not enough… There are all the time these family members involved, either living there too, or otherwise managing the household.
(I4, 9)
These types of articulations, however, were rare during the policy process.
They were either ignored, or the demands implied in them were averted by reference to the nodal point of bureaucratic division of labour, through which – it was assumed – eventually all these issues would be managed in the best
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possible way. Next I will look into the ways the hegemonic discourse managed to do this. A focus on the level of regulation and indirect steering was central here, but procedures and structures of representation also proved significant.