Paper for:
XX NORKOM 2011, 24-26 November, Gothenburg
The reforms of care for the elderly in Sweden, 20 years later: Is everybody happy?
Author:
Iwona Sobis, Assoc. Prof. PhD
School of Public Administration, University of Gothenburg, Sweden
iwona.sobis@spa.gu.se
Abstract
Reforms of public sector, conducted in the spirit of NPM are frequently studied by the Western and Eastern
scholars since 1990s (Hood 1995; Montin 1997; Pollitt & Bouckaert 2004; Almqvist 2006; Nemec 2010;
Drechsler 2010). The research show national variations in how the NPM idea was translated and adapted into a
country’s context and regulations. NPM is not perceived as the remedial measures for well working public sector
(e.g., Nemec 2010; Drechsler 2010; Berlin & Kastberg 2011). However, some economists advocate for the
positive impact of NPM on a state budget being in a crisis situation (Feldman & Morrisey 1990; Arvidsson &
Jönsson 1991; Newhouse 1996; Lindvall 2001; Lindqvist & Aidemark 2005; Hallin & Siverbo 2010). Instead the
representatives of New Institutionalism argue that NPM became a trendy fashion to follow independently of
economic conditions (March and Olsen 1989; Czarniawska & Sevón (eds.) 1996; Brunsson & Jacobsson at.al
2002).
The Swedish care for the elderly seems to be the interesting example of reform known as Edel-Reform and
conducted in the spirit of NPM. On the one hand, it goes across a border between welfare and health care. On the
other hand, it goes also across a border between the competences of provincial and municipal/local authorities.
The state reports, evaluations, research but also mass-media show that old people, their relatives, and staff
involved in care providing are disappointed with the free choice of care, its poor quality and poor coordination
within the network of care providers; many complain about lacking continuation, while politicians keep going
with decentralization, privatization of social and health services for elderly, and still create public sector’s
artifice competition on a market. Then, some questions should be answered: What we know twenty years later
about the consequences of the Swedish Edel-reform implemented in1992? Did the Edel-Reform conducted in the
spirit of the NPM movement really contribute to the increase of efficiency of care for elderly and its higher
quality as it is expected? What kind of knowledge about care for the elderly is still missing and should be
developed in the future?
Roland Almqvist theory about the NPM movement (2006) serves as the theoretical reference frame allowing
divides the Swedish empirical studies into three theoretical perspectives: (1) competitiveness on a market, (2)
contract management, and (3) decentralization and internal control. The purpose of this paper is to make a
comparative research synthesis about the practical implication of the NPM movement on the Swedish care for
elderly. It is argued that there are still some gaps in our knowledge about the Swedish care for elderly especially
regarding its organization and cooperation between social service and health care addressed to elderly. The NPM
theory and in consequence Edel-Reform does not work in everyday practice as it was planed and expected by the
political decision-makers. We still do not know what kind of social and health care services represent the best
practices for the future in Sweden but also in the common Europe.
Key words: NPM, public reforms, care for the elderly, welfare, health care.
It is a working paper, the first draft. Do not quote anything, please. I will be grateful for receiving any
comments, questions and observations, whether they are made at a presentation of this paper or by
email or other means.
1
1. Introduction
Reforms of public sector, conducted in the spirit of New Public Management [NPM] are frequently
studied by the Western and Eastern scholars the last two decades (Meyer at. all 1997; Power 1997;
Montin 1997; Miller & Rose, 1998; Hood 1995; Pollitt & Bouckaert 2004; Almqvist 2006; Nemec
2010; Drechsler 2010). Some researchers are talking about the emergency of NPM movement (Meyer
at. all 1997; Power 1997; Almqvist 2006). Other researchers refer to concepts such Total Quality
management [TQM], performance management or private entrepreneurship that can be perceived as
the second side of the same coin. The structural changes of public sector went across Europe. On the
one hand, they can be seen as the usually process of decentralization due to current economic situation
in each country. On the other hand, the process of decentralization was close connected to
“regionalization” subordinated the EU regulations for the member states but even some uncontrolled
globalization-forces behind.
Looking at decentralization from a national perspective, the idea was to draw together organizations,
politicians and citizens on various level of social reality to make them participate and take
responsibility for a society’s formation according to social needs and demands. Then decentralization
is conducted under such the slogans as “effectiveness and efficiency”, “customer in focus”, “free
choose of care, insurance or education”, “high quality for services”. In other words, it was a question
about customers’ many-sided opportunities to choose free among personal social services, specific
health care or other services.
Looking on the process of decentralization from the EU perspective, we have to do with the political
and administrative reforms promoted by the EU and known under the name of “regionalization in
Europe” understood as demarcation of territories, competencies and tasks, which in practice means
total changing of organizational structures, total changing of division of resources and competencies
between provincial and local actors as well within the old European democracies like those in
transition from socialism to a market economy and waiting on acceptance to become the EU members.
According to regionalization e.g., Lluís Maria de Puig representing the socialist group of
Parliamentary Assembly, she argues in her report for Committee on the Environment, Agriculture and
Local and Regional Affairs (2007) as follow:
The trend of regionalism in Europe in recent years gives an overview of the situation in the regionalized
countries of Europe. It recommends that regional self-government should be regarded not as a problem
or a danger but as an effective, unifying means of giving regions a say in political decision-making at
both national and European level. It notes that regionalism is on the rise in Europe and that the regions
are very interested in and committed to Europe. Regional autonomy must be perceived as a means of
enhancing democracy and giving it a firmer foothold in our countries, in parallel with the European
unification process and against the background of globalization. Political trends in Europe do not make it
possible to predict the future but it can be noted that the number of states is growing and that the
principle of inviolability of borders is losing ground. In the face of this changing situation, regionalism,
in its various forms, offers guarantees of greater political stability and greater respect for the Council of
Europe's values, in particular as regards the spread of democracy (de Puig 2007: 1).
Many advocate that both regionalization and globalization essentially contributed to perceiving most
administrative reforms of public sector in Europe as depended on the EU politics and regulations that
spread the institutional standards of NPM, the standard that became just a fashion to follow as the
representative of New Institutionalism perceive it (Powell & DiMaggio, 1991; Czarniawska & Sevón
2
1996; Brunsson at all 2000). However, reorganization of public organizations became controversial
issue attacked by citizens, who suddenly have been perceived as customers or clients by politicians
and professionals providing educational, social- and health care services. The reforms in public sector
have been hard criticized by mass media that “whistled loud” about any problems of this new
management within public sector in the EU countries, including Sweden.
In this article, I focus on the Swedish care for elderly. Let me quote some headings from the Swedish
everyday press like Göteborgs Posten, Dagens Nyheter or Aftonbladet availably on Internet during
2007-2011. The headings are speaking for themselves: Elderly Care with many shortcomings
[Äldrevård med många brister] (Johansson, GP: 2009-09-15), Home visits are needed to care for the
elderly [Hembesök krävs till äldrevården] (Andree, GP, 2007-10-8), Most ill elderly – a description of
the deficiencies and problems to be addressed: Memorandum [Mest sjuka äldre - en beskrivning av
vilka brister och problem som ska åtgärdas: Promemoria] (Regeringskansliet: Socialdepartamentet,
2011-06-22). Choice of Health Care is under-founded [Vårdvalet är underfinansierat] (Starzman, GP:
2011-09-25), Care-choice provides resources to those who are healthy [Vårdvalet styr resurser till
dem som är friskast] (Hansson & Larsson, GP: 2011-09-25), Hospital management breaks the quality
of care [Sjukhusledningen knäker vårdkvalite], (Malmberg Andréasson; Rutgersson och Molin, GP:
30-09-2011). Only looking at the headings, one can draw a solution that there is a seriously
discrepancy between the promise given by the decision-makers in the Edel-Reform and the Swedish
older peoples’ really needs. The customers are still the citizens, who have given a mandate in a free
election to the politicians, the citizens allowing the chosen politicians to govern in their name, to
create effective care for elderly with many choose-opportunities due to customers’ needs, the socialand health care services with a high quality.
The Swedish Edel-Reform seems to be the very interesting example of public reforms conducted in
the spirit of NPM movement. However, it should be emphasized that the Swedish institutional
standards and organizational fashions of public sector have been successfully spread among some
CEE countries in transition as good solutions and pattern to follow for the young European
democracies being in transition from socialism to a market economy and as good praxis to learn by the
CEE countries waiting on acceptance to join the EU (Sobis 2002; Sobis & de Vries (2009).
The Swedish care for elderly, in similarity to other European countries, especially the EU member
states, on the one hand, it goes across boundaries between social services and health care addressed to
elderly. On the other hand, according to regionalization and decentralization trends in the EU, it goes
across boundaries between the competences of provincial and municipal/local authorities. Some
empirical studies, state official reports and evaluations, theses on doctoral, master and bachelor levels
but also mass-media show that older people, their relatives, and staff involved in care providing for
elderly are disappointed with free choice of specialized care, its poor quality, and poor coordination
among various care providers. Many complain about lacking care-continuation that was so common
yet in 1960-70s in Sweden. One can wander; why politicians keep going with the public reforms,
decentralization and privatization of social and health services for elderly, and still create public
sector’s artifice competition on a market while no one seems to be pleased with that. Then, some
questions should be answered: What we know twenty years later about the consequences of the
Swedish Edel-reform implemented in1992? Did the Edel-Reform conducted in the spirit of the NPM
movement really contribute to the increase of efficiency of care for elderly and its higher quality as it
was expected? What kind of knowledge about care for the elderly is still missing and should be
developed in the future?
3
The purpose of this paper is to make a comparative research synthesis about the practical implication
of Edel reform conducted in the spirit of the NPM movement and give a better understanding for how
the Swedish research in this field has contributed to a better understanding of impact of the NPM
movement on the social- and health care for elderly. In this study, it will be used Roland Almqvist
theory about the NPM movement from 2006. He has divided the NPM into three theoretical
perspectives: (1) theories dealing with competitiveness on a market, (2) theories about contract
management, and (3) theories having in focus decentralization and internal control. These three
theoretical perspectives within the NPM movement allow me to order the currently knowledge about
the Edel-Reform and its practical implications for the Swedish care for elderly in three categories and
later on to look for farther variation in each category. It is argued that there are some gaps in our
knowledge about the Swedish care for elderly, especially regarding the organization of social- and
health services to elderly that are the common efforts of the involved actors. Probably, we have to
develop some knowledge about the synergy effect between social services and health care for the
development of best practices for the future. However, it is an empirical question of this research.
The paper is structured in a following way: Firstly after Introduction in chapter 2, it will be presented
briefly the concept of NPM to provide readers with the major ideology behind the NPM movement.
The aim is to show that the theory of NPM has become a background for the institutional changes of
welfare, a background for the many-sided reforms of public sector since 1990s in Sweden. In chapter
3, it will be presented the method for making the comparative research synthesis dealing with the
Swedish care for elderly. In chapter 4, is presented the Swedish Edel-Reform and its major objectives
to prepare readers how this reform and its practical implications have been studied and discussed by
the Swedish scholars. In chapter 5, the empirical research about the Swedish care for elderly is
presented; the empirical studies are divided into three theoretical perspectives of NPM movement as
Almqvist (2006) advocates for. There, I will identify the research that dominates our knowledge about
the Swedish care for elderly. It will be argued that various theoretical insights of NPM do not take the
same space within this research field. Finally in chapter 6, will be drown conclusion from this study
and presented the missing knowledge that should be provided in the futures.
2. New Public Management
In the literature of subject it is assert that NPM is an ambiguous concept consisting of many ideas and
many theories about how to administrate public organizations. NPM movement asks about “the
optimal leadership”. The last one is anchored in the concept of Total Quality Management [TQM] and
how to involve citizens and customers into the planning and management of many-sided services
According to Pollitt & Bouckaert (1995);
Quality has become an immensely popular term where organization of public services is concerned. It is
on the lips of politicians, managers, professionals and citizens themselves. In health care, education,
personal social services, fire services, the police and many other subsectors, commitments are being
made to improve “quality” and increase responsiveness to the ‘customers’ (clients/patients/students/
users). Brochures and booklets are being issued, reports are being written, training courses are being
delivered: ‘quality’ has become a central term in our contemporary rhetoric. It is scarcely conceivable
that anyone would wish to argue against it: like virtue it seems unopposable (p. 3).
For Roland Almqvist, the issue of quality seems also to be important, working like a light motive,
going across the three theoretical perspectives of NPM management (2006: 13-15) and coming back as
“boomerang”, as the issue that has been challenged by the political decision makers. Almqvist makes
distinctions among: firstly, the theories focusing on public organizations that are exposed into a
competition on market. This perspective provides scholars with theoretical tools to grasp how
4
competition on market is working in practice; if NPM really contributes to growing savings within
organization. According to him, this perspective allows to measure attitudes towards competition
within organizations traditionally belonging public sector. It seems that in this tradition attitudes can
indirectly concern also the quality issue that is subordinated savings.
The second theoretical perspective of the NPM management focuses on contract management i.e., on
relations between politicians (buyers) and organizations (service providers), those who produce
expected services. These relations are known in the literature of subject as a purchaser-provider model
[beställare-utförare model. In this model, politicians chosen in free democratic elections are
perceived as a legitimate power to order and buy social- and health services for the older people, while
organizations that provide these services are service providers participated also within a marketcompetition. For service providers, citizens turn into customers or clients, who not only consume the
services but also they compare level of quality among other service providers. They want have clearly
information about providers’ performance management. Thus, this perspective can be promising to
estimate: if management by contract can really provide high quality services, this perspective can
increase our knowledge about how is measured the quality of services, and if it is really good idea to
provide social services by contract management?
The third perspective concerns theories dealing with internal control, decentralization, management by
objectives but also performance management. In other words, how various activities, that traditionally
belonging to public sector, are organized after decentralization of power? Empirical studies taking a
point of departure in this theoretical perspective focus almost on practical implications of
decentralization trying to answer the questions; if decentralization really caused increase of
effectiveness, what happen with staffs’ motivation to work after decentralization, what about
qualifications and competences of staff involved and even about new recruiting to some services?
How is working in practice management by objectives and how is measured organizational
performance? Following this perspective, it can provide us with elementary knowledge about how the
Swedish researchers described the consequences of public reforms conducted in the spirit of NPM.
3. Method
The study design is a comparative research synthesis dealing with the practical implication of the
Edel-Reform on the Swedish care for elderly. I am going to use the theoretical perspectives of the
NPM movement presented by Roland Almqvist (2006: 13): (1) Public organizations’ exposure to
competitiveness on a market, (2) Management of public organizations by contract, and (3)
Decentralization and organization’s internal control to make the first selection of the Swedish
empirical about care for elderly. Secondly, the sample of studies from each theoretical perspective will
be compared farther, especially focus will be on the studies’ research purpose, asked questions and
conclusions i.e., how the Swedish scholars present the conclusions about the Edel-reform 15-20 years
later.
3.1. Selection of the Swedish empirical studies
When looking for the Swedish scientific empirical studies about the Edel-Reform, I have used a
convince sample. I have selected first the studies dealing with this issue, and which were published
during the period of 2005 – 2011 thus i.e., about 15 -20 years later from the implementation of EdelReform. I used the data-bases from the university libraries of Gothenburg, Linköping, Stockholm,
Uppsala and Umeå because it was possible access to their data-bases by Internet and some empirical
studies that were published by SKL [Sveriges Kommuner och Landsting] there is an employer and
5
association of all the counties, municipalities and regions in Sweden. Moreover, only the scientific
empirical studies availably from the mentioned data-bases as full text in PDF format were collected.
When searching for the scientific empiric studies, I have standardized the key-words. Most frequently,
I have used in Swedish and in English: (1) “Äldreomsorg Sverige [Care of elderly Sweden]” (2)
“reform + äldreomsorgy + Sweden” [reform + care of elderly Sweden], (3) “Ädelreform Sverige”
[Edel-Reform Sweden], and (4) “new public management + äldreomsorg + Sverige” [New Public
Management + care of elderly + Sweden]. When searching within data-bases of GU Library, I have
started with: “Databases/articles: topic list” having access to the all possible sources, inclusive massmedia; I got then 156 results of which, 57 results concerned the care of elderly in Sweden among the
publications 2005-2011; searching for only scientific articles, I got 20 results of which only 5 articles
concerned the reform of the care for elderly in Sweden. When I add one key-word more i.e., “reform”
+ “äldreomsorg Sverige” [reform + care of elderly + Sweden]” then the computer has selected 13
results but again only 5 articles concerned the Swedish care for elderly, the same articles as previous.
Then, I went to another data-basis i.e., “Data-basis for Social Science: Sociology and Social Work”.
First, I was looking among the abstract from Social Work. I used again the same key-words in
Swedish “Äldreomsorg Sverige (250 results) and in English “Elderly Sweden” (205 results). I added
firstly the word “reform”. Then, I have recognized the flow of article-titles that I have already seen.
Thus, I used the key-words: “new public management + care of elderly + Sweden”. I got only 3
results. Even these three articles were already selected among the first five findings. Thus, I went to
the data-bases addressed separately to Sociology. I was looking again for data dealing with the
Swedish care for elderly in each of them by using the same key-words as before. The overview of
sociological abstract resulted in finding 15 articles of which only 6 results concerned the research
issue but only 1 result proved to be a new finding in comparison to the previous searching. Third, I
was searching also within “Data-basis for Economy and Business Administration” and used almost the
same key-words however, I have added some new key words like “social service” and “contract” and
care of elderly and Sweden. I did not get any new results. The economic data-bases proved to be
structured in a different way than the data-bases for Sociology and Social Work. I wasn’t familiar with
them and did not find the relevant empirical research. Next search from the Library of GU was for
doctoral, master and bachelor theses. I have found 2 relevant results among doctoral theses. The
experiences from the GU Library proved to be instructive when searching for the studies in data-bases
from the Library of other universities. Then, I have limited my searching only to the key-word of (1)
“Äldreomsorg Sverige [Care of elderly Sweden]” that usually provides most results and (2)
“Ädelreform Sverige” [Edel-Reform Sweden], and (3) “new public management + äldreomsorg +
Sverige” [New Public Management + care of elderly + Sweden]. Data-bases from SKL provide me
with some additional studies (3 results) in this research field.
Finally, I was looking for student-theses on a bachelor level by Google using the key-words:
Äldreomsorg , Sverige (25 results) of which only 9 (I have check it ?) were related to my research
questions. In this way I have collected the necessary empirical studies (see: Attachment 1) to answer
the research questions and fulfill the aim of this paper.
1.2. Evaluation criteria for the scientific empirical studies about the Edel-Reform
The analysis of the Swedish empirical studies dealing with care for elderly is presented in Chapter 4. It
basis on 36 empirical studies: scientific articles published nationally and internationally, doctoral-,
master-, and some bachelor theses. The studies were divided in three categories according to Almqvist
model (2006: 13): (4a) Competitiveness on a market, (4b) Contract Management, and (4c)
Decentralization and the internal control. Later on, the empirical studies from each category were
6
analyzed separately when comparing the practical implications of Edel-Reform within the Swedish
care for elderly. Almqvist’s specific questions addressed to each theoretical perspective, I have
adapted to the needs of this research. Within the theoretical perspective focusing on competitiveness,
the important questions are: How competitiveness on a market within the field of the Swedish care for
elderly is working in practice? If and how competitiveness has contributed to the expected savings
within the care for elderly? What about attitudes towards competitiveness among involved staff in
cooperation when providing social services and health care for elderly? These questions are guiding
the analysis of collected studies in this category.
Regarding the second NPM theoretical perspective focusing on management by contract, when
reading empirical studies I have been looking for answer for the following questions: How contrasts
between the state, private and voluntary organizations is working in practice? Did purchaser
(politicians) are only at the beginning in cooperation with providers when signing a contract about
principles for care providing for elderly? What about the synergy effect in cooperation between social
service and health care provided to the older in needs? Haw can be measured quality for care for
elderly? Does it possible to measure it? How do it?
Concerning the third perspective that pays attention into decentralization and internal control, the
most important questions seem to be; if and how decentralization is working in practice? Can we find
some empirical evidence showing that decentralization caused improvement of the Swedish care for
elderly? What about motivation to work among staff involved in care providing for older people? How
decentralization influenced the competence level of staff providing care? How management by
objectives is working in practice?
These questions constitute the guiding principles to evaluate the Swedish scientific empirical studies
about the practical implication of Edel-Reform on criteria the care for elderly, 15-20 years later.
According to Almqvist (2006), each theoretical perspective of NPM movement consists of key
concepts. These concepts become the natural codes helping me to identify to make a first selection of
the empirical studies into a relevant theoretical perspective before conducting a farther analysis within
this category. When reading and analyzing the empirical studies, I was sensitive also to other aspects
that in my opinion were close related to the problem I am studying. In a table below, I present the most
representative concepts for each theoretical perspective and other important aspects guiding the
analysis of empirical studies.
Figure 1: Most representative concepts for three theoretical perspectives of NPM
NPM: s theoretical
perspectives
Competitiveness on
market
Purpose: to reduce costs and
maintain or even improve
quality
Contract Management
Purpose: to allocate risks,
responsibility and rewards
between the contractpartners by very precision of
Important concepts
Other important aspects related to the
important theoretical concepts
market, purchaser-provider model,
competitive programs, buyer, performer,
provider, customer, client, procurement,
buy, sell, offer, demand-supply, cost, cost
impact, cost reduction, saving, costsaving, efficiency, effectiveness,
competition within public sector, efficiency in
service-supply, cost-saving in public
organizations, differences in cost-saving
between groups/unites, competitive threat,
external market actors, anxiety among staff
Market discipline, purchaser-provider
model, specialization, flexibility, costsaving, internal contract, outsourcing,
contracting out, trust, sanctions, common
values, democracy-argument, customers’
influence, free choose, quality of care
contractual relationship, relational
contracting, clear roles (customer, client,
patient, user, buyer, performer, serviceprovider), responsibility between contract
partners, conflicts, increase of administrative
work, political, economic and ideological
arguments
7
mutual obligations
services, criteria for quality measure,
Decentralization and
internal control
Decentralization, delegation of tasks,
division in smaller units, division in
various markets, management by
objectives, accountability for results,
internal deregulation, flatter organization,
internal control,
Purpose: to increase the
internal and external
efficiency of municipal
districts and to increase
customers’ satisfaction and
their influence on quality of
provided services
Better management and control
(decentralization + management by objectives
+ follow up objectives = to achieve goals),
comprehensive decentralization reform,
Stadsdelsnämndsreform [District-reform],
management by objectives combined with
detailed control, commission, consultation
documents (referrals), planning-documents,
politically initiated projects,
Using this method, there is an expectation to answer the research questions and fulfill the purposes of
this study. I hope that it will be possible to find the most representative and current empirical studies
for each theoretical perspective in this research field but also to identify the gaps in our knowledge
about the Swedish care for elderly.
4. Edel-Reform
The Swedish concept of Ädel-Reform should be understood as delegation of care for elderly. This
abbreviation consists of Ä-del, there “Ä” means elderly [in Swedish: äldre] while “del” means
delegation [in Swedish: delegering]. Hence it means elderly-delegation [äldredelegationen]
(Andersson & Karlberg, 2000: 1). In this text, I will use the term of Edel-Reform or ElderlyDelegation-Reform.
The Edel-Reform was implemented on 1st January 1992 when Sweden was in a “bank-crisis”, which is
not without any importance for the character of reforms introduced within the public sector. Sweden
by years was well known in the world for its generous welfare for the citizens however, this time the
state authorities were forced to create conditions for the increase of effectiveness and make extra
savings in the state budget. The Edel-Reform was conducted in the spirit of NPM movement
associated with decentralization and privatization of some activities within the public sector.
According to the official rhetoric used by the Swedish politicians advocating for the reform, one can
have impression that this reform was introduced to improve the care for the elderly, to make it more
effective, to create much more opportunities to choose among varied and specialized services
addressed to the elderly, but also that these services will be better, with a higher quality. Otherwise,
for what did political authority introduce changes in public sector if the elderly people were almost
pleased with this service they received?
Before 1992 in Sweden, the counties were responsible for care for elderly, while the municipalities
were expected to supply local nursing homes, owned by the county. Municipalities were also expected
to cooperate with local hospitals and primary care that traditionally belonged county’s responsibilities.
Social service and health care are guided by two separate state regulations; the municipal social
services by Social Service Act [Socialtjänstlagen - SoL], while health care by Health Care Act [Hälsooch sjukvårdslag – HSL], both having focus on clients/patients’ rights and service providers’
obligations. These regulations represent somewhat different understanding for the meaning of
professionalism in each area, which in turn affects organizational structure, and culture concerning
provided services for the elderly. In the end of 1980s, the number of older people demanding
specialized care was growing rather fast. The elderly were perceived as “bed blockers” within the
sector of health care because of unnecessary over-use of technical facilities and medication provided
to this target group. The elderly demanded much more specialized social services, which were
cheaper. These social services were expected to integrate with important medical services adapted to
8
the getting older people, who became depended of specialized care. In other words, the long term
patients 65+ generated the increase of expenditures for high specialized medical treatment but also
caused growing waiting-time for other patients in needs for health care service. Anderson and
Karlberg argue: “Cost for care of a person in a specialized ward is higher than in a nursing home, even
if the ‘bed-blockers’ only use the ‘hotel-function’’’ (2000: 2). Hence, the idea to integrate some efforts
from the social care sector and from the health care sector proved an attractive solution regarding care
for elderly but also to make rational decision during the economic crisis. Thus, Government Bill
(1987/88: 176) [Regerings proposition, 1987/88: 176] on elderly care has formulated the major goals,
guidelines and proposals for the development of elderly care. On 1st January 1989, according to the
Swedish Code of Statuses – SCS: Social Service Act (1980:620) [Svensk författningssamling – SFS:
Socialtjänstlagen – SoL, 1980:620] was supplemented. By law, municipality was obligated to plan all
the efforts, interventions and actions for the elderly in consultation with County. On 13th December
1990, the Parliament made a decision to implement the Edel-Reform that came into force on 1st
January 1992. According to the reform, the municipal authorities were obligated to:
1. Take over responsibility for long-term service for elderly and disabled
2. Creating special housing for social service and health care for people with special needs e.g.,
homes, group homes, nursing homes and other sheltered accommodations
3. Establish day-time activities for the elderly and disabled
4. Take over responsibility for the local nursing homes
5. Take over responsibility for health care and simple medical technical assistance in special
housing, excluding medical intervention
6. Provide home care in the customer/patient’s own home if the municipalities sign an agreement
with the county councils to take over these home care activities in the elderly person’s own
home and to which the municipalities were liable for.
7. Local governments may, if it is agreed request to conduct experiments with taking
responsibility for primary care
8. Since 1st January, Social Service Committee [Socialnämnden] is not longer perceived as an
obligatory mandatory committee.
To start the reform and fulfill the obligations during a transition period, the state assigned 5.5 billion
SEK to restructure the social services and health care for the elderly. Plenty of other regulations
secured or completed the Edel-Reform during the period of 1992-2011. The legislative changes or
adjustments within Social Service Act and Health Act were aiming at creating opportunity for mutual
cooperation between these sectors to create synergy effect when providing care for the elderly e.g.,
Swedish Code of Statuses – SCS: Act (1993:390) [SFS: Lag 1993:390] obligated municipalities to
plan their activities for the elderly. When planning, Municipalities were expected to cooperate with
County Council and other community agencies and organizations. SCS: Act (1997:313) [SFS: Lag
1997:313] proved the most important because, it novelized the changes within SCS: Social Service
Act (1980:620) [SFS: Lag 1980:620]. In § 19 and § 20 the act explains that the social welfare
committee shall work to ensure that older people are able to live independently and under safe
conditions and with respect for their autonomy and integrity. Moreover, older people will have good
homes and give those who need the support and help at home, and other easily associable services.
These adjustments have had a decisive importance for the Edel-Reform of 1992. However, one can
observe also the changes within SCS: Health Act (1982:763) [FSF: Lag 1982:763] amended by SCS
[FSF]: Act 1992:567 that was in force 1992-07-01. According to § 24, municipality was expected to
have a nurse with a special medical responsibility [Medicinskt Ansvarig Sjuksköterska – MAS]. Since
that, it was possible to talk not only about Edel-Reform but about Whole-Elderly-Delegation-Reform
9
[Hel-Ädel]. In consequence, the health care in nursing homes and other establishments for somatic
long-term patients became an open health care in the municipality’s responsibility and “bed-blockers”
were moved to the open care. Expectation was among other to shorten the waiting queue on medical
treatment by other patients in need. According to the Government Bill (1996/97:60) [Regerings
proposition (1996/97:60)], palliative- and terminal care belongs to the first priority formulated by § 2
within Health Care Law [Hälso- och sjukvårdslag – HSL].
Shortly after, it proved that the experiences of Edel-Reform and Whole-Edel proved to be positive and
negative at the same time. Some remedial measures were necessary to introduce to improve
cooperation between social services and health care that currently shared responsibility for home
nursing, rehabilitation and other forms of assistance addressed to the older people. Neither medical
efforts nor intervention of physicians proved sufficient in relation to the really needs of the elderly
peoples (Distriktssköterskeföreningen [District Nurse Association] 2008-03-24). It appeared a problem
what kind of rehabilitative care should be paid by the Insurance Fund [Försäkringskassan] in the
framework of SCS: Act (1993:387) dealing with support and service for some disabled [SFS: LSS
(1993:387) om stöd och service till visa funktionshindrade] and what kind of rehabilitation-actions
could be considered as medical care being either in the responsibility of the County Council or the
Municipality.
The Swedish Government made the decision of the Cabinet meeting on 3 April 2003 to call a special
investigator to conduct a review about the consequences of Edel-Reform, 10 years later. In the focus
should be collaboration between municipal/local social services and health care and county health care
towards older people with complex and/or rapidly changing health-care needs. The investigator was
expected to answer the questions: 1) How health and social care can organize and ensure a high
quality on the best way i.e., availability and continuity, security and of the elderly themselves, with
regard to their social and medical needs? 2) Does the division of responsibility between the county
and the municipality is clearly and adequate? 3) How ought to be the health- and social services
organize as the best practices working in favor to the target group?
From the report of the National Welfare Board (2002) that summarized the results of Edel-Reform, it
appeared that it was observed somewhat negative development. First, it was observed a serious
imbalance between supply of special housings in relations to demands satisfying social needs and
wishes. This picture was varying from municipality to municipality and was due to various structural
factors behind. However, in this situation the only reasonable decision made by the decision-makers
(politicians) proved to make municipalities to extend much more care activities within the old person’s
own home, even if it required much closer cooperation between medical and social services.
Moreover, existing relatives were also expected to take much more responsibility for their getting
older family members. In fact, they have been forced to that; some municipalities experienced a
shortage with proper staff having necessary skills. It proved in practice very difficult to recruit nurses,
paramedical staff and nursing assistants, which of course negatively influenced the quality of care for
old people. Some remedial measures from municipalities were necessary to undertake. The
municipal/local authorities had to make the work in the care for elderly much more attractive for
potential staff in the future. First of all, municipality and county together had to work out a common
vision how to improve the care for elderly to meet the older people’s complex problems and rapidly
changing health, to secure their quality of life and quality of services provided. Secondly, it was also
the issue to provide those people with access to rehabilitation, if anyone wants to talk about “god
care”. Thus, the current research, state evaluations and reports provided the political decision-makers
at the beginning of the second decennium after the implementation of Edel-Reform with some
10
pragmatic knowledge; what has to be done in a future. The Government had to consider whether the
Swedish current care for elderly was organized as it was intended by the Edel-Reform? What aspects
of the care should be especially monitored or maybe introduced to solve some current problems at
hand? The understanding of some limitations and shortages in the care for elderly explains to some
degree why the Government ascribes a major priority to the long-term development of knowledge of
how this care should be conducted effectively and with high quality (Vård och omsorg om äldre:
lägesrapport, 2002: 9) [Health and social care for older people: progress report, 2002: 9]. Thus let us
see, what new we can learn from the latest empirical studies about the Swedish care for elderly.
5. The Swedish empirical research about the car for elderly – various types
I have collected 36 empirical studies from Sweden dealing more or less with the practical implications
of Edel-Reform on the care for elderly, 15-20 years later. A quite interesting source of empirical
research during the period of 2005-2011 constitutes not only scientific articles written by established
researchers but also theses written by the Swedish students on the bachelor, master and doctoral levels.
The Swedish universities have a long tradition to cooperate with other organizations in their
environment. Organizations from university’s environment have their own wish about what kind of
skills, competences they need for the future recruitment of working force. Thus, the university and
other organizations form together educational programs adapted to the current needs and social
development in the region/province. Those other organizations are use students to conduct the limited
research projects to identify and describe some problems or to find urgent solutions to them. Hence,
many especially theses are written as a commission however with respect for the academic guiding
principles for examination on bachelor, master or doctoral level. In my sample of empirical studies
dominates just student essays on bachelor and master levels.
Below, it will be presented the research findings being in line with each perspective of the NPM
movement. However, I find a lacking balance between the current empirical studies and three
theoretical perspectives typical for the NPM movement. Some empirical studies go beyond the NPM
perspectives or Edel-Reform but they seem to be still relevant to the shared care for elderly between
health care and social services. These studies pay attention to such issues like feeding, time for social
relations, older people’s hobby etc. to which the political decision-makers did not put too much energy
when introducing new regulations, the life aspects that have also a great importance for life quality and
the quality of care about everybody is talking but little is done.
5.1. The Swedish research about competitiveness on a market
Taking as the point of departure in Almqvist (2006: 52; 1999; 1996), who argues that in Sweden,
competitiveness is possible within the public sector, when external actors on a market create a
competitive threat. Thus, this competitive threat is supposed to be positive for growing effectiveness
when supplying social-, and health care services. Moreover, the competitiveness on the market ought
to be perceived as the major objectives behind the decrease of costs for the Swedish care of elderly
and behind the increase of its quality. Almqvist’s earlier research about the care for elderly from 1996
and 1999 showed that the competition can lead to some kind of savings. Nonetheless, the reduction of
costs did not be impressive, while anxiety among staff involved was growing after introducing a
competitive threat from a market (2006: 52ff). What says other researchers, about 20 years later?
It is easier to find the state evaluations or rapports than other empirical having anchoring in this
theoretical tradition of NPM movement. I have found only 4 studies. According to them, the purchaser
– provider model works in favor to the state budget but not necessary for the older people.
11
Thomas Wilhelmsson (2010) has examined how cost and quality of care for elderly are affected by
the share of private driven care providers and publicly financed in the Swedish municipalities. The
author has used data from the Open comparison and health and social care for older people published
by SKL [Sweden’s municipalities and counties) in 2009, there he found 28 indicators of costs for all
the Swedish municipalities to conduct a regression analysis. 135 000 users of the care for elderly were
asked to participate in the survey; they represented a little less than half of the country all users i.e.,
about 61% of the users living in special housing, and 72% of the elderly living in their ordinary
housing. Only 38% respondents from special housing and ca 75% from ordinary housing have replied
the inquiry. The result has indicated a negative correlation between the percentage of private care use
and its cost. Although a negative connection have been detected it does not mean that the private
driven care contributes to decrease of costs. The measurement of quality of care was divided into (1)
subjective perception and (2) objectively measurable quality. According to the subjective measure, a
connection shows a negative connection while the second – the objectively measured quality is
perceived as a positive connection. The difference in the results is explained by using the qualityshading hypothesis and incomplete contract. In other words, the objective quality can increase when
the hiring care service involves clarification of goals and focus on what gives a higher quality service
then it can occur some kind of competition among private actors but also even if it is only a public
care provider (p. 25ff).
Ragnar Stolt and Patrik Jansson (2006) have examined what happens with the Swedish welfare after
the implementation of Edel-Reform. The introduction of purchaser-provider model on a market caused
that providers were gradually perceived as private entrepreneurs or contractors competing with each
other. In the late 1990s, there were 10 medium-sized companies providing care for elderly but in 2006
turned into 4 concerns: Attendo Care AB, Carema Äldreomsorg AB, Aleris Äldreomsorg och
Förenade Care AB that constituted about 14 % of the total long-term care sector. The first three largest
companies saw a very bright future with an annual growth about 10%. Growth was varying and
depended on expansion by taking over other companies however. This development was also due to
the ideological forces of the right-wings ideology advocating for liberalization of a market and
development of private nursing homes. However, other factors could also be behind privatization.
Their study showed that low fixed costs characterized the new service-industry. There were no
problems with staff recruitment or its mobility. The procurement process was regulated by the state
regulations but also by the limited duration of signed contracts and provided resources for any
establishment proved to be limited. The consolidation of care companies into the concerns has helped
the contractors to take a definitely stronger position compared to the municipalities than it was
previously. Although municipalities became more professional and could make more detailed
requirements of the tender, their importance has decreased on a market. Competition with the concerns
is somewhat artificial and it is difficult to estimate it in terms of being strong or weak. No one of the
big actors on a market has an oligopoly structure i.e., dominated by a small number of sellers
(oligopolists). During the period of 1995-2006, the number of private actors has decreased in general
but the market for car for elderly is systemic increasing and locking investors.
Three years later Ragnar Stolt, this time in cooperation with Ulrika Winblad (2009) have continued his
interest in privatization of care for elderly sector. They have investigated “Mechanisms behind
privatization: A case study of private growth in Swedish elderly care”. According to them, there can
find many studies dealing with privatization of social services but few scholars have studied “the
growth of privatization in Sweden, and how the actual privatization process has been carried out” (p.
903). Thus, Stolt and Winblad fulfill the gap. They have studied the variation of privatization among
12
the Swedish municipalities and explain how different political, economic and socio-demographic
variable caused the variation in the privatization degree. It should be emphasized that the information
about political, economic and socio-demographic situation of the Swedish municipalities was derived
from different public sources. Moreover, the authors have used a longitudinal database from Statistics
Central Office in Sweden, called LOUISE - longitudinal database concerning education, income and
employment that contained the statistics from all tax-paying employees in Sweden. The data consisted
of the in-complete time series. All the data had to be adapted to the needs of research by creating a
unique set of regression coefficients for each year to make possible comparisons among the Swedish
municipalities. When reading Stolt and Winblad’s article, they are not writing about the Edel-Reform
but they focus on the privatization of the Swedish care for elderly conducted in the spirit of NPM
reforms. They show the transformation of the Swedish care for elderly from a homogenous public
sector to a more diverse market. On this market occurs competition among various care providers seen
as private entrepreneurs, which number is systematic growing e.g., from ca 1% at the beginning of
1990s to 13% in 2003. However, they argue that one can observe a great variation in the privatizationdegree among the Swedish municipalities. Stolt and Winblad draw conclusions:
Regarding the motives behind privatization we conclude that right-wing municipalities tend to introduce
private alternatives irrespective of economic situation. However, the opposite relationship is not as clear in
left-wing municipalities. They also tend to introduce privatization but rather as a consequence of either a
strained economy or influences from an adjacent neighbor that already has a high share of private elderly
care. Thus, privatization in the Swedish elderly care sector could be described as a policy diffusion process
in which economy, ideology and geographical proximity are factors intertwined in a complex relationship
(p. 911).
Thus, independently of which political block is in power, the public reform conducted in the spirit of
NPM, they have taken over lead if not only because of economic reasons then like the idea that has it
“day” and that other follow just because of the press coming from the organizational environment.
Thus, the current fashion, spread among municipalities in Sweden (but also in other European
countries) gives tone for the public reforms.
Regarding competition, Karin Edmark (2007), in her report about strategic competition between
municipal decision-makers about spending money for childcare, school and care for elderly shows that
politicians within a municipality want to influence citizens from a neighbor municipality especially
those who are living close to a border or even working in their municipality to move to their local
community and vote in their municipalities. One conceivable criterion could be access to better social
services in neighbor municipality and better information about these services presented by local media
(p. 9). The research result confirmed a connection between the municipality and its expenditure on
care for elderly and the neighbor’s spending on care for older people however, there were no observed
a similar connection for spending money on care for children and education. The result could be
interpreted that 1, 00 SKR increase of expenditures on care for elderly at the neighbor municipality
cause the increase of expenditure to this purpose in own municipality about ca. 0, 70 SKR. However,
this survey does not give any aid to explain if municipalities really take such the strategic
considerations when making decisions about own expenditure for child-care, education and older care. It is possible to think that the results depend on municipal expenditure are not the best measure
and maybe a qualitative research in the question could give a different result.
Christian Gerlach (2005) in his master-thesis about organization and market orientation of the care for
older people in Sweden and Germany emphasize that in Sweden marketization of care for elderly has
be also security by high quality of services. According to SCS: Social Service Act 2001:453, Chapter
13
3, §1 [SoL 2001: 453, kap 3, §1]. Municipal Welfare Board is responsible for developing criteria on
the quality and to ensure their application. Procedures to achieve quality are not uniform but vary from
municipality to municipality (Socialstyrelsen 2003). Competition is always connected with quality
development, since purchasers - mostly municipal forces and performers (the producers of services)
have to take much more in account the quality. Competition often has led to the equalization of prices
between the different producers. In such cases, it is the quality, which is the main and influencing
factor behind the judgment of care services by which the elderly producer services shall be purchased
according to (Konkurrensverket, 2002: 167ff.) [Competetive Agency (2002: 16ff)]. Market orientation
and competitive tendering constitute an elementary component of elderly in Sweden. Competition and
care-market has a growing importance in Sweden. Municipalities have used models that have a
function to organize various care arrangements for car-users. The most important model in this field is
outsourcing. Customer choice models under which users themselves must choose their care providers
exist only in rudimentary extent. With the introduction of care insurance had consolidated the private
producers into a care-market with quite strong position and with an equal footing with the free public
producers. Care insurance was – beside the quality has been anchored within the social legislation of
2001, that characterize the latest most significant change in this field. Because of care insurance
future, however, is under threat because of demographic developments discussed how it can be
reformed due to cost savings.
Summing up, the purchaser-provider model introduced in the Swedish care for elderly has created
somewhat artificial competition on a market. There is still missing knowledge if competition on a
market caused expected savings in a municipal budget. Instead the number of private entrepreneurs is
growing in Sweden. The private entrepreneurs are aiming at crating big care companies to win a
definitely stronger position on a market as contractors compared to public services even if public
services still seems to be more professional in care providing. The new service industry is flourishing
but quality for provided services can be questioned. Even if Social Service Act 2001:453 is aiming at
securing the quality of health and social services and obligate municipalities to respect the state
regulations in this regard. In fact, the Swedish municipalities pay attention to the objective criteria of
care quality. However, the objective measures don’t say too much what “god service” is for the older
people and these measures can be questioned. The subjective opinions about quality of services
addresses to older people are ignored. It can be drown a conclusion that the adequate criteria that can
measure “god quality” are lacking. Moreover, research show quite clearly difficulties in recruiting
staff to care for elderly with needed competences. The care at the older people’s own housing still
seems to the cheapest solution for the municipalities compared with nursing homes. Liberalization of
care for elderly goes hand in hand with the ideology of right- wings politicians that dominate in many
Swedish municipalities after last two free elections. However, no one article pays attention to the
directives coming from the EU in this regard. There some comparative studies but they were no in
focus for this analysis. It seems that research in this category should be developed because the
municipal “pros” and “cons” caused by the privatization of care for older people do not satisfy our
knowledge about the impact of Edel-Reform, 20 years later.
5.2. The Swedish research about Contract Management
Most studies dealing with care for elderly, in the second theoretical perspective dealing with contract
management go one step farther than only competitiveness. There were collected 5 articles. This
research shows that municipality plays a new roll in the Swedish welfare state. The implementation of
Edel-Reform caused that the municipalities have to cooperate with other organizations in an
organizational environment, especially with the private actors providing various care services for
elderly.
14
The organizational environment seems to be important because, looking from the institutional
perspective; it is full of institutions like: legislative regulations, directives, guiding principles, values
and norms for behavior, artifacts, contracts, agreements, symbols, and other stakeholders having
interest in care for elderly. The organizational environment lasts organizations that want increase their
legitimacy on a market and that want to get support from other organizations when developing own
organization. The intra-organizational cooperation creates new power relations between the actors
involved, in this article; it is a question about the power relations between health care (the County
Council) and social service (the Municipality) and other stockholders. The Swedish empirical studies
e.g., Österström (2007) or Berggren (2010) use Thompson’s resource-dependence theory (1996) that
emphasizes organization’s vulnerability and its dependence of resources from surrounding. This
theory has capacity to explain: (1) why organizations cooperate, (2) what strategies they use to
cooperate, but also (3) it can explain different forms of cooperation. One of the most important issues
seems to be in this research tradition; how boundaries are defined for the shared activities, shared
responsibilities when two or more organizations are collaborating. Österström (2007) and Berggren
(2010) show that a boundary problem creates confusion, ambiguities or even struggle for power in the
interplay between the two organizations. This fight affects the organization’s development in
consequence.
Österström (2007) is critical about resource theory. He argues that that organization is presented only
from one side when using the resource theory while cooperation among more actors involved is a
complex phenomenon and the explanation referring to an organization’s rationality has to fall.
Administration is based on a clear goal-rationality and professionalism while not organizations within
an organizational environment e.g., voluntary organization does not work in line with the same kind of
rationality. Moreover, even concept “power” faces some critic. In resource theory, power is presented
almost power between organizations but it ignores the power relations within the same organization.
However, power relation in an organization can concern genus, professions, class, ethnicity etc. Thus,
the question: how organizations providing care for elderly develop demand to put the concept
“development” in another context. The study show limited knowledge about that what really occur in
everyday practice. Other theoretical perspective should be used.
Berggren (2010) has investigated e.g., how five nursing homes (2 public and 3 private) in Uppsala
practically are working with deviation reporting. The care service is obligated by the Welfare Laws
(SOSFS 2005:12 or 2008:10) to report deviation. It is important for a quality securing when providing
care for older people. This research is in line with other studies in this area and conducted by Hauge &
Heggen (2006); Mold, Fitzpatrick, & Roberts (2005); Tsai & Tsai (2008); Castle (2010); Ödegård
Kjös, Botten & Romören (2008), the studies that have shown that securing a high quality of home care
is really a challenge; it that requires a systematic work. Staff working in nursing homes is obligated to
describe measure of nursing quality, evaluate and take concrete actions to improve quality. It is
question about a good and systematic documentation perceived as a great opportunity for monitoring,
evaluation but also for creating conditions for a safe and secure care which has recommended Grimby
(1998). The Swedish current empirical studies show that staff of nursing homes seldom report
deviations. The most common arguments can be e.g., carefully documentation of incidents is a timeconsuming activity taking away the needed time for the care for elderly. Berggren’s (2010) provide
some empirical evidence that municipal and private care providers report almost the similar number of
incidences in their nursing homes ca. 8-12 per month. Many advocate for that as well public as private
care providers want at least fulfill the elementary conditions demanded by the governmental policy
recommending to follow the directives about “good care”. However, the concept of god care is still
unclear; what can constitute undisputable measure for “god quality”?
15
Szebehely (2006) previous study show that in 2005, the elderly receivers got home service from 10 %
of private care providers and 13 % of the older people got care in special accommodations that were
also run by private providers. We know quite a lot about the intentions of Edel-Reform but knowledge
about consequences for a target group is limited and insufficient. The home service has been
influenced of new governing shapes that have been introduced in many places in Sweden. These
regulations have created an increased distance between the average decision about a help initiative and
the actual performed work. The requirements on a precisely order has increased regarding the numbers
duties during a granted hours. It converted into a standardized time (5 minutes for bed-bedding, 10
minutes for napkin byte or 15 minutes for breakfast). To the new governing shapes, the average help
recipient and the home service organization and different instruments consults also the increased
emphasis of written contracts in order to govern and to measure the help initiatives and their quality
(Szebehely, 2006: 415ff).
Larsson and Shebehely (2007) emphasize that competition between municipal and private care
providers can be a very tender issue. The new concepts outsourcing and contract dominate and invade
into the Swedish care for elderly as well conducted in public as private regime. Competition on a
market now is not only regulated by the state regulations and directives for municipalities but also by
the contract between involved purchasers and providers that last only temporary, some month, some
years, due to the needs and mutual satisfaction. According to Larsson and Shebehely, the contract
management concerns one-third of the Swedish municipalities (2007: 415). Their research show that
despite of the factum that the Swedish family law does not obligates adult children or other relatives to
take over caring responsibilities for own elderly, four Swedish municipalities in 2002 had such
guidelines by the report of National Welfare Board (2003) [Socialstyrelsen 2003]. One can expect that
this development in a short time will be a pattern to follow. According to SOU 2001: 79, contract
management has also contributed to create new social inequalities; the elderly with higher education
level but also incomes tend to substitute home care by purchasing needed service on a market, while
family care has increased among older people with lower education level . Larsson and Shebehely
(2007: 416) confirm this development 6 years later. The most exciting part of their research is a
comparison what kind of assistance to the elderly was granted for 15-20 years ago. From their study it
appears, the contents of home care included details of a service nature and duties which were focused
on personal nursing. According to the regulations it has to be specified what duties have to be done
with the granted hours by care provider such as e.g., cleaning every two week, shower on
Wednesdays. It seems that recipients and nursing staff could decide by themselves in a mutual
agreement how the hour would be used in practice. Currently, from the municipal policy documents,
recommendations how long time would take same care activities; it appears rather a grim picture of
geriatric care. The development against giving help firstly to persons with big care needs has also
changed sight regarding an estimation, who that is entitled to get assistance in special home service
(2006: 418). Many older people with less extensive needs of assistance have to be today outside the
municipal obligation to provide care services.
There are some studies having focus on the care for the elderly immigrants in Sweden. Mansour
Sedaghati (2010) has made a literature review based on 18 articles representing the qualitative and
quantitative approaches. Although the literature reviews are not in focus of this study but this one
seems to be interesting and relevant. The Edel-Reform emphasized the importance of free choose of
nursing homes, specialized homes adapted to the older people’s needs or free chose of home care
provider, the study shows clearly that little has been done for the elderly people, who have another
cultural background and do not master a Swedish language. The problems doe to cultural differences
concern almost in the same way health care and social services addressed to the older immigrants
16
(Sedaghati 2010: 33). Even if one can found some positive exceptions like in the Stockholm region
there is missing knowledge about subjective experiences, expectation and requirements expressed by
the older immigrants by themselves (Sedaghati, 2010: 39). From this article can be drown a solution
that the older immigrants is not a homogeny group. They have different needs within different ethnical
groups. Political decision –makers should not ignore the idea of individualized care; it does not
concern only the older immigrants. Similar problem have even the native-born older people that no
longer understand the ground children’s society. Older people beyond the cultural differences have
also something in common; they need to get older with dignity and in the agreement with the equal
right to good health- and social care by the Swedish law (HSL 1982; SoL 2001:453). It is lacking the
Swedish research about subjective, specific needs, wishes and demands for various groups of elderly
regarding all the kinds of care for older people i.e., home care, nursing homes and sheltered housing.
These qualitative studies could essentially contribute to fulfilling the major objectives of SCS: Social
Service Act (1980:629) [SFS: Socialtjänstlagen (1980:620) much more than what is done now.
Summing up, when analyzing the Swedish empirical studier dealing with the consequences of EdelReform for the care for elderly, the reform that was conducted in the spirit of NPM and having focus
on contract management, it seems that organizational environment had played an important role; on
the one hand, it is press coming from other actors. On the other hand, organizations follow a fashion
e.g., they use local media as a source of information in order to lock the potentially customers to own
services and in this way also legitimize own activities. Contract management by the state regulations
defines clearly roles of purchaser and provider. However, in everyday practice the border between
them are not obvious until now, 20 years later. The studies show that integration between health- and
social services becomes a field of battle between County Council and Municipality. However, we still
too little know about internal struggle for power among various professional groups in an
organization. The increase of standardization of care services essentially contribute to decreasing of
quality of care services addressed to elderly. That seems that the economic financial cuts and savings
have the most negative impact on care for older people making it unsustainable. Care providers as well
from the private and the public sector hardly report incidents in nursing houses. It gives impression
that the care providers just want to show to surrounding that they do their obligation. Care quality is
questioned.
5.3. Decentralization and internal control
This theoretical perspective of NPM movement is based on the analysis of 10 articles that pay
attention to the practical implication of Edel-Reform on the Swedish care for elderly.
In December 2003, the National Welfare Board tried to explain distinctions between self-care in the
form of personal assistance and health care. The state authorities have introduced the new regulations
and guidelines supplementing the previous ones. The research from the second decennium shows that
a boundary between social services and health care was not obvious. The boundary issue seems to be
still problematic; in many cases it is a question about assigned money to service-providers, the
problematic is how to share payment for the services going across health care and social services
(Distriktssköterskeföreningen, 2008-03-24).
Since decentralization, the Swedish municipalities play a new roll in the welfare state than is also
required a new model for leadership. Julia Pettersson Selström (2009) argues that the Swedish heads
of care for elderly were expected to take inspiration in this regard from the private sector. Traditionally
before the Edel-Reform, in care for elderly there were home care assistants. Theirs role included on
the one hand an administrative authority. On the other hand, they were responsible for operational
17
activities. After 1992, home care assistants have faced a lot of critic for their double responsibility.
Their profession was perceived as fragmented thus, in line with the Edel-Reform it was expectation to
create a clear manager administrative role. Hence, a home assistance role has been divided into: 1) a
pure work leader role – manager role, and 2) assistant role – operative role. Managers in their new
professional role were lasted much more with administrative tasks and duties like e.g., finance,
responsibility for personnel and development of operative activities. Middle management positions
have been governed by various policy documents, policy decision delegations. Hence, theirs
increasing professionalism has also demanded a higher level of education to make the new leaders to
be prepare to carry out internal control - typical phenomenon for decentralization. Care for elderly
perceived as a human service organization has obligated to protect their users and make the best for
them. However, this organization should also take into account the state and society interests.
(Pettersson Selström, 2008: 4). The author answer thus the questions: what scope for action the middle
managers have in the care for elderly? Is his/her activities highly regulated by legislation, political
guidelines and objectives or has the middle managers that scope they need in order to drift the activity
independent? These questions are important especially when the poor economic growth became one of
the most important factors behind decentralization; when the economic crisis was behind privatization
of care, and its division into independent units with distinguishes features to which the Swedish
politicians delegated power and allowed the middle managers make decisions locally about efficiency
improvement, follow-up and competition on a market. The middle manger’s scope for action
understood as “the possibility that on the basis of independent decisions implement desirable
documents” (p. 4) was not enough studied before. Pettersson Selström (2008: 6) makes a distinction
between two other concepts: policy objectives understood as business objectives and policy guidelines
understood as the more detailed guidance to policy-makers when they make a decision about e.g., that
home care staff shall carry out window cleaning or if this service will be purchased and conducted by
window cleaning companies. The guidelines are intended to concretize and clarify the framework for
activities and provide municipal officials with the interpretation of laws. This study shows that the
middle managers share the opinion that they have a big scope for action, at least in deciding over their
own time and how the decisions made by the politicians and administrators will be implemented.
When the result has been analyzed on the basis of Lipsky’s theory (1080: 15) about the front line
bureaucrat and Agevall’s (2000: 22) four degrees of autonomy, it proved that the scope for action of
middle managers is rather anxious because it is limited by poor budget, regulations and political
guidelines. This study point that the new management ideas combined with clearer political objectives
can contribute to losing much more scope for action by the middle managers in the future. Moreover,
the middle managers can become a back line bureaucrats.
There are some studies that supply Pettersson Selström e.g., Dunér and Nordström (2006: 429) argue
that middle managers’ scope for actin is not in agreement with provided resources. Middle managers
are expected to save money and be satisfied with the reduced financial resources, which negatively
influence middle managers’ space for eventually maneuver. To the similar research results comes
Schartau in 1993, which suggests that nothing has changed after 13 years. The financial framework as
politicians set for care for elderly limits middle manager's scope for action. Larsson (2008: 92) adds
that politicians often encourage efficiency and financial savings without any description of how these
changes would be implemented. According to her middle managers are lacking clear directives for
actions and work development. There is also lacking a constructive dialog with the higher authorities
how to achieve the political objectives, which in consequence negatively influence the conducted
changes. Much is left to middle managers’ creativity and their capacity for innovative thinking.
18
The next interesting issue which appears from the current research is study conducted by Mina
Hagenwall and Vikki Kanias (2006). They had interest in cooperation between Municipality and
County when providing care for elderly. This research was conducted from the subjective experiences
of those involved from health care and social services. It proved that the respondents from both
organization admitted that the Council had a dominant position in this collaboration. They made
decisions, propose their point of view for workings routines and everyday duties when care providing.
They planed care for the elderly before they started collaboration, which made the municipal staff
powerless. Limited economic resources and short time for care providing were experienced as the
serious limitation and obstacles when cooperating. The Municipality as a strategy against the County
introduced a care-plan from the point of interest of Municipality but the situation did not change.
Thus, integration of efforts and collaboration between municipality and county seems to work on
paper, on the policy document but not in the everyday life. The state regulations advocating for the
mutual collaboration between health- and social services turned out into the ‘battle field’ about power,
which was not working in the older people’s favor (SOU 2000:144). However, from this study it also
appears quite clearly that the operative actions of those organizations directed to the target group are
based on a different professional logic. They have a complementary value. However, everybody
knows that but the struggle for power still dominate the arena of collaboration, the arena that is
dependent in highest degree of financial resources.
Another study conducted by Nils Olof Hedman, Roine Johansson, Urban Rosenqvist (2007) about
structural integration of home care in Swedish elderly care has showed that three are three types of
different organizational models of home confirms to some degree the previous observations. These
models represent different degrees of integration and are based on “allocate of responsibility and
provision of home care services”: 1) the County Council responsible for home care services, 2) County
Council responsible for specialized services (district nurses) and Municipality for home services; and
3) Municipality responsible for home service (2007: 4). The County Councils tended to contain
clusters of municipalities with the same organizational characteristics, which caused that these
municipality followed the County Council pattern when aid providing. Nameless, only 1% of the
Swedish municipality had changed their home care services organization in relation to the County
Council since the Edel-Reform and which was in line with this reform. The intention of the EdelReform was to give actors at the sub-national levels freedom to integrate home care according to
varying local circumstances. The result was that it has been developed sub-national interorganizational networks, the structures created at the County Councils. The last ones have taken over
the internal control while municipal actors had not too much to say, which caused a paradox outcome
that home care has not changed in practice.
Anna Igelström (2008) has conducted a limited research based on a qualitative approach, from users’
perspective, from their subjective perspective as care-takers in special care housing. She had interest in
how the older people experience and estimate care providing, competence of staff and quality of
provided health- and social services. She interviewed only 6 respondents, three men and three women
aged 75 years for 98 years. However, the users’ voice is important. Igelström came to the conclusions
that the nursing staff needs several different types of qualifications that constitute emotional, social,
theoretical, practical skills to create bra relations with older people, win their trust, and satisfy their
many-sided needs. The most important for the elderly people seems to be personnel’s social,
relational, socio-pedagogic, medical, and everyday practical competences. Nursing staff needs to have
the ability to create and maintain a good relationship with the users. It is also important continuity in
care providing that can contribute to the development of relationship then the nursing staff skills can
19
become more familiar to the user (p. 36). To similar conclusions Susanne Holgersson och Malin
Rööser (2008) came.
Decentralization is associated with the opportunity to free choose of nursing homes according to the
Act on the system of choice in health care - LOV [Lagen om valfrihetssystem inom vård och omsorg –
LOV] (SOU 2008:15) that was introduced 1 January 2009 and that crated national guidelines for the
choice system. The law was set up with an incentive payment of 300 million to municipality that
wanted apply about the resources and were interesting in customers’ choices. The law has been
intended as a voluntary tool for local governments to tray competitive activities in nursing homes.
Jonas Frantzich Olsson and Elisabeth Martinsson (2009) have studied how this choice system is
working in practice. In fact it is not as it was thought. According to the regulations, customer-choice
means that after the client has been granted home care, the client is allowed to choose which provider
he/she wants to use. The social workers are obligated to provide the clients with information about
choose opportunity. They are expected to behave in a neutral way when presenting various care
providers. From this research it appears that the social workers experienced their role. However,
understanding for the concept of neutrality varied among social workers. It seems that clear guidelines
would make it easier for the social workers to work neutral.
Summing up, the theoretical perspective of NPM having in focus decentralization show that the issue
of boundary going across the health- and social services but also across County Council and
Municipality has not been solved even after ca. 20 years later. Council having access to higher
resources from the beginning is in a better position and does not want to lose power and influence. The
current research perceives the relation between these two organizations it in the terms of “struggle for
power” and “the battle field” working against the elderly. Thus, quality of care can be denied. It seems
that current studies to little expose different professional logics that the professions involved have
complementary value and have to create some positive synergy effects that turn out care for the elderly
into a good care, as it recommend the state regulations. The Swedish scholars try to approach the
subjective perspective of the users of care services to ask them about experienced quality of services.
The picture is not in line with the state recommendations and guidelines neither regarding the quality
of care for elderly nor their opportunity to choose among various care providers. Thus the third
perspective on the impact of Edel-Reform on the Swedish care for elderly again shows that this
development still many to wish.
6. Conclusions
When reading international research dealing with the outcomes of NPM on public services than one
can have impression that this kind of public reform is not perceived as remedial measures for well
working public sector (e.g., Nemec 2010; Drechsler 2010; Pollitt & Bouckaert 2011; Berlin &
Kastberg 2011). Some economists advocate for the positive impact of NPM on a state budget being in
a crisis situation (Feldman & Morrisey 1990; Arvidsson & Jönsson 1991; Newhouse 1996; Lindvall
2001; Lindqvist & Aidemark 2005; Hallin & Siverbo 2010) but not necessary on the increase of
quality of provided services. Regarding care for elderly, the internal research shows that there can be
observed national variations in how the NPM idea was translated and adapted into a country’s cultural
context and state regulations e.g., Stig Montin (1997) has been talking about the NPM in a Swedish
way.
When reading the Swedish empirical studies about the Swedish care for the older people I wonder if
we can still talk about the Swedish way in forming the care for elderly. Maybe nowadays, we can find
much more similarities to other European countries in this regard. The most interesting seems to be
20
that the Edel-Reform implemented in 1992, still have not fulfilled its major objectives i.e. to create
competitiveness on a market, create opportunity to choose of many forms of care for elderly and
thanks that positively influence the development of high quality of these services. Nothing wrong is
with these goals but the problem is that this idea does not work in practice 20 years later, when the
state have adjusted and introduced supplementary regulations and guiding principles. The new
regulations like e.g., privatization of health- and social services, implementation some regulations that
made relatives e.g., children to take care for getting older parents confirm that the state can no longer
provide the welfare to which the Swedish citizens are accustomed. Thus, there is observed a wave of
structural changes of the Swedish Welfare State. It is the shift of paradigm according to which the
State makes itself free from responsibility for its citizens. However, similar trend is observed in other
European countries.
The more time has run the less can be founded empirical studies using the terms of NPM, EdelReform. It seems that the public reforms promoting privatization of health- and social services become
an obvious phenomenon for good and for bad. However, a scenario for public reforms creates some
confusions; one reform has not been finished, while the second one is starting with new “slogans”,
new visions, and new promising rhetoric. Nonetheless, it is still possible to truck the practical
implication of Edel-Reform. In this regard, the previous research provides us with knowledge about
the major conclusions from the Edel –Reform, that the Swedish politicians could draw 10 years later
and now we can see that the same problems that were identified for 10 years ago, they are not solve.
Maybe they are presented in a bit different way.
The state regulations are still in line with a political ideology represented by the right-wings politicians
being currently in power, and advocating for growing liberalizations on a market. In the everyday
press or other mass-media, one can observe a growing critic towards the Swedish care for elderly; the
issue is really blown up. Can be that interpreted that something has gone wrong? Has this reform
created to the new form of social inequality and the new form of class society? From the current
research, it appears that high vulnerable groups have been reconstructed again. According to Michiel
de Vries (2010) who argues that “what is neglected at present is likely to become dominant in the
policies of the near future” it seems highly likely that public reform in care for elderly will be current
again. What happen when the left-wing politicians will win a free election? What happen then with the
Edel-Reform? Will they have ideological power to remove the rudiments of Edel-Reform to create
pro-state and pro-social care for the elderly? Has Edel-Reform really contributed to expected
effectiveness and savings? I think that all these questions are waiting on farther research.
Attention! I have to develop the conclusions but also chapter 5.
References:
Aspalter, C. (2007). Strategies of welfare state reform in aging societies. Hallym International Journal
of Aging, 9(1), 31-31-58. Retrieved from
http://search.proquest.com/docview/61402485?accountid=11162
Agevall, L. (2000) ”Några teoretiska utgångspunkter.” I FoU 2000:3 (red) Det goda mötet – etik och
bemötande. Kronoberg: FoU-Kronoberg
Almqvist, R. (1996). Effekter av konkurrenshotet. Institute of Local Government Economics, School
of Business, Stockholm University.
Almqvist, R. (1999). Measuring of Threat of Competition – Services for the Elderly in the City of
Stockholm. Local Government Studies, vol. 25, nr 1, s. 1-16.
21
Almqvist, R. (2006). New public management – om konkurrensutsättning, kontrakt och kontroll.
Malmö: Liber.
Annerstedt, L. (1993). Development and consequences of group living in Sweden: A new mode of
care for the demented elderly. Social Science and Medicine, 37(12), 1529-1529-1538. [Online].
Available from: http://search.proquest.com/docview/61645560?accountid=11162 [30 October
2011]
Bihan, B. L., & Martin, C. (2006). A comparative case study of care systems for frail elderly people:
Germany, spain, france, italy, united kingdom and sweden. Social Policy and Administration,
40(1), 26-26-46. doi:10.1111/j.1467-9515.2006.00475.x
Blomberg, S. (2008). The specialisation of needs-assessment in swedish municipal care for older
people: The diffusion of a new organisational model : Specialiserad bistandshandlaggning inom
den kommunala aldreomsorgen i sverige - spridningen av en ny organisationsmodell. European
Journal of Social Work, 11(4), 415-415-429. doi:10.1080/13691450802075634
http://www.tandfonline.com.ezproxy.ub.gu.se/doi/pdf/10.1080/13691450802075634
Castle, G. N. (2010). What is nursing home quality and how is it measured? The Gerontologist , p.
426-42.
Cates, N. (1994). Sweden: Some current observations on health services, housing and resource
utilization for the elderly. Home Health Care Services Quarterly, 15(1), 73-73-83. Retrieved from
http://search.proquest.com/docview/61625142?accountid=11162
Directive [Dir] (2003:40) Översyn av vård och omsorg för äldre – tio år efter Ädelreformen.
Socialdepartementet: Kommittédirektiv.
Distriktssköterskeföreningen [District Nurse Association] (2008-03-24). PUNK-handbuken:
Primärvårdens Utveckling Nationell Kvalitet.[Online]. Available from:
http://www.distriktsskoterska.se/punk/handbok/PUNK3.pdf [30 October 2011]
Emilsson, U. M. (2009). Health care, social care or both? A qualitative explorative study of different
focuses in long-term care of older people in france, portugal and sweden. European Journal of
Social Work, 12(4), 419-419-434. doi:10.1080/13691450902981467
Hauge, S., & Heggen, K. (2006). The nursing home as a home: a field study of residents´daily life in
the common living rooms. Journal of Clinical Nursing , 4 April, p. 460-467.
Hedman, N.O., Johansson, R. and Rosenqvist, U. (2007). Clustering and inertia: Structural integration
of home care in Sweden elderly care. International Journal of Integrated Care – Vol. 7, 12.
[Online]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000976/pdf/ijic2007200732.pdf [30 October 2011].
Heikkila, K., & Ekman, S. (2003). Elderly care for ethnic minorities -- wishes and expectations among
elderly finns in sweden. Ethnicity & Health, 8(2), 135-135-146.
doi:10.1080/1355785032000123186
Henning, C., Ahnby, U., & Osterstrom, S. (2009). Senior housing in sweden: A new concept for aging
in place. Social Work in Public Health, 24(3), 235-235-254. doi:10.1080/19371910802595307
Holosko, M. J., Holosko, D. A., & Spencer, K. (2009). Social services in sweden: An overview of
policy issues, devolution, and collaboration. Social Work in Public Health, 24(3), 210-210-234.
doi:10.1080/19371910802595299
Government Bill [Regerings proposition] (1999/2000:149). Nationell handlingsplan för utveckling av
hälso- och sjukvården. [Online]. Available from:
http://www.sweden.gov.se/content/1/c4/14/70/aca2838a.pdf [30 October 2011]
Government Bill [Regerings proposition] (1987/88:176). Om äldreomsorgen inför 90-talet [Online].
Available from:http://www.riksdagen.se/webbnav/index.aspx?nid=37&dok_id=GB03176 [30
October 2011]
Government Bill [Regerings proposition] (1990/91:14). Om ansvaret för service och vård till äldre och
handikappade m.m. [Online]. Available from:
http://www.riksdagen.se/webbnav/index.aspx?nid=37&dok_id=GE0314 [30 October 2011]
22
Government Bill [Regerings proposition] (2000/01:149). Avgifter inom äldre- och handikappomsorg
[Online]. Available from:
http://www.riksdagen.se/Webbnav/index.aspx?nid=37&dok_id=GO03149 [30 October
Karlsson, I. (2006) Att leda i kommunal äldreomsorg. Växjö: Institutionen för vårdvetenskap och
socialt arbete.
Kommittédirektiv (Dir. 2003:40). Översyn av vård och omsorg för äldre – tio år efter Ädelreform.
Beslut vid regeringssammanträde den 3 april 2003.
Konkurrensverket (2002): Vårda och skapa konkurrens. Stockholm.
Larsson, K. (2006). Care needes and home-help services for older people in sweden: Does improved
functioning account for the reduction in public care? Ageing & Society, 26(3), 413-413-429.
doi:10.1017/S0144686X06004496
Larsson, K. (2008) Mellanchefer som utvecklar. Linköping: Institutionen för beteendevetenskap och
lärande
Larsson, K. & Szebehely, M. (2006). Kapitel 16 – Äldreomsorgens förändringar under de senaste
decenierna. [Online]. Available from:
http://www.scb.se/statistik/_publikationer/le0101_1980i05_br_17_le112sa0601.pdf [5 November
2011]
Lipsky, M. (1980). Street level bureaucracy. New York: Russel Sage Foundation.
Meinow, B., Kareholt, I., & Lagergren, M. (2005). According to need? predicting the amount of
municipal home help allocated to elderly recipients in an urban area of sweden. Health & Social
Care in the Community, 13(4), 366-366-377. Retrieved from
http://search.proquest.com/docview/61540949?accountid=11162
Melander-Wikman, A., Faltholm, Y., & Gard, G. (2008). Safety vs. privacy: Elderly persons'
experiences of a mobile safety alarm. Health & Social Care in the Community, 16(4), 337-337346. doi:10.1111/j.1365-2524.2007.00743.x
Mold, F., Fitzpatrick, J. M., & Roberts, J. D. (2005). Minority ethnic elders in care homes: a review of
the literature. Age and Ageing , 11 January, p. 107-113.
Montin, S. (1997). New Public Management på svenska. Politica, 29, 3: 261-278.
Motion 1998/99: So436 Ädelreformen.
Motevasel, I. N. (2006). Senior housing in sweden-A question of class differences and collective
aging: An interview study in rental apartments and housing cooperatives. Journal of Housing for
the Elderly, 20(3), 77-77-93. doi:10.1300/J081v20n03_06
National Welfare Board [Socialstyrelsen] (2003) Ekonomisk prövning av rätten till äldre- och
handikappomsorg. Stockholm: Socialstyrelsen
Pollitt, C. & Bouckaert, G. (1995). Defining Quality. In: C. Pollit & B. Bouckaert (red.). Quality
Improvement in European Public Services – Concepts, Cases and Commentary. London: SAGE
Publications Ltd. [Online]. Available from:
http://www.google.com/books?hl=sv&lr=&id=454vT7GHxnsC&oi=fnd&pg=PR7&dq=Pollitt,+
C.+%26+Bouckaert,+G.+(1995).+Defining+Quality.&ots=8_Djfr4GNJ&sig=V9caJAGadh2nNP
kz9EwNyro7y88#v=onepage&q&f=false [16 October 2011]
Pollitt, C & Dan, S (2011). The impacts of the new public management in Europe: a meta-analysis.
Paper submitted for the EGPA permanent study group II – Performance in the public sector, 7-10
september 2011, Bucharest [Online]. Available from: http://egpaconference2011.org/documents/PSG2/POLLITT-DAN.pdf [16 October 2011]
Puig de, L. M. (2007). Regionalisation in Europe. Parliamentary Assembly: Committee on the
Environment, Agriculture and Local and Regional Affairs (Document 11373). [Online]. Available
from: http://assembly.coe.int/Documents/WorkingDocs/Doc07/EDOC11373.pdf [16 October
2011].
23
Report [Betänkande] (1990/91: SoU9) Ändrad ansvarsfördelning inom äldreomsorgen m.m. [New
responsibility division within care for elderly]. Socialutskottets betänkande. Riksdagsskrivelse
1990/91:97. [Online]. Available from:
http://www.riksdagen.se/webbnav/?nid=3322&doktyp=bet&rm=1990/91&bet=SoU9&dok_id=G
E01SoU9 [30 October 2011]
Report [Betänkande] (1990/91: SoU11) Vissa frågor om äldre och handikappade [Some question
about the elderly and disabled]. Socialdepartementet: Betänkande av Äldreberedningen. [Online].
Available from:
http://www.riksdagen.se/webbnav/?nid=3322&doktyp=bet&rm=1990/91&bet=SoU11&dok_id=
GE01SoU11 [30 October 2011]
Seldon, A. and Collings, D. (2000). Britain under Thatcher. Longman.
Szebehely, M. (2006) Omsorgsvardag under skiftande organisatoriska villkor – en jämförande studie
av den nordiska hemtjänsten, Tidskrift for Arbejdsliv, No. 8 (1) 49-66.
Sobis, I. (2002). Employment service in transition. Adaptation of a socialist employment agency to a
market economy. A case study of Lodz, Poland 1989-1998. Gothenburg Studies in Sociology No
11, Department of Sociology, Gothenburg University. (Doctoral thesis)
Sobis, I. & Vries, M.S. de (2009). The story behind western advice to Central Europe during its
transition period. NISPAcee Press: Bratislava. Also available from:
http://www.nispa.org/_portal/publication_details.php?p_id=135&style=eb
SCS: Act (1993:390) [Online]. Available from:
http://www.notisum.se/rnp/sls/lag/19800620.htm#P20_a
http://www.riksdagen.se/webbnav/index.aspx?nid=3911&bet=1980:620 [1 November 2011]
SCS: Act (1997:313). [Online]. Available from:
http://www.notisum.se/rnp/sls/lag/19800620.htm#P20_a
http://www.riksdagen.se/webbnav/index.aspx?nid=3911&bet=1980:620 [1 November 2011]
SCS: Health Act (1982:763) [SFS: Hälso- och sjukvårdslag (1982:763)] [Online]. Available from:
http://www.notisum.se/rnp/sls/lag/19820763.htm [1 November 2011]
SCS: Social Service Act (1980:620) [SFS: Socialtjänstlagen (1980:620)] [Online]. Available
from:http://www.riksdagen.se/webbnav/index.aspx?nid=3911&bet=1980:620 [30 October 2011].
SCS: Act on Assistance – LASS (1993:389) [SFS: Lag om assistansersättning, LASS (1993:389)].
[Online]. Available from: http://www.notisum.se/rnp/sls/lag/19930389.HTM [30 October 2011].
SOU (2000:144). Samverkan – om gemensamma nämnd på vård och omsorgområdet. [Oneline].
Available from: http://www.regeringen.se/sb/d/108/a/2819 [5 November 2011].
SOU (2004:68). Sammanhållen hemvård [SOU 2004:68. Shared home care]. Socialdepartementet:
Betänkande av Äldrevårdsutredningen [Online]. Available from:
http://www.regeringen.se/sb/d/189/a/26584 [30 October 2011].
Stolt, R., Blomqvist, P., & Winblad, U. (2011). Privatization of social services: Quality differences in
swedish elderly care. Social Science & Medicine, 72(4), p. 560-567.
Stolt, R., & Winblad, U. (2009). Mechanisms behind privatization: A case study of private growth in
swedish elderly care. Social Science & Medicine, 68(5), p. 903-911. ¨
Sundstrom, G., & Johansson, L. (2005). The changing balance of government and family in care for
the elderly in sweden and other european countries. Australasian Journal on Ageing, 24, S5-S5S11. [Online]. Available from: http://search.proquest.com/docview/61369874?accountid=11162
[30 October 2011].
Thorslund, M., & Wånell, S-E. (2006). Åldrandet och äldreomsorgen. Danmark: Studentlitteratur.
Tsai, H.-H., & Tsai, Y.-F. (2008). A temporary home to nurture health: lived experiences of older
nursing home residents in Taiwan. Journal of Clinical Nursing , 19 July, p. 1915-1922.
24
Trydegard, G., & Thorslund, M. (2001). Inequality in the welfare state? local variation in care of the
elderly -- the case of sweden. International Journal of Social Welfare, 10(3), 174-174-184.
Retrieved from http://search.proquest.com/docview/61426301?accountid=11162
Watt, P. A. (1998). White-collar services in local government: competition and trust. In: A. Coulson
(red.) Trust and Contracts – relationships in local government, health and public service. The
Policy Press, University of Bristol.
Vries de, M.S. (2010) The importance of neglect in policy –making. IIAS: Palgrave Macmillan.
Äldreomsorg och hälso- och sjukvård under 90-talet: Utveckling, omprövning, prioritering (2003).
Svenska Kommunförbundet och Landstingsförbundet
Ödegård Kjös, B., Botten, G., & Romören, T.-I. (2008). Quality improvement in a publicly provided
long-term care system: the case of Norway. International Journal for Quality in Health Care , 30
Jun, p. 433-438.
25