Dilemmas and possibilities of small care enterprises: a
mixed-methods case study of the implementation of
customer choice in Swedish eldercare
Helene Brodin
Stockholm University
[email protected]
&
Elin Peterson
Stockholm University
[email protected]
Paper prepared for the LSA meeting, New Orleans, June 2-5, 2016.
Very early draft, please do not cite or circulate!
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Abstract
This paper explores the dilemmas and possibilities of small homecare companies in the context
of the increasingly popular customer choice model in publicly funded eldercare services in
Sweden. Using a mixed-methods case study approach, the study examines how gender and
ethnicity shapes the organization and business strategies of small homecare companies in the
city of Stockholm. The results show that New Public Management in combination with the low
social status of care work affects the organization of small care companies. For example, though
all interviewed owners and managers claim to be motivated by creating better care for older
people and better conditions for the workers, these ambitions are hindered by low
reimbursement to the providers and fixed time templates for service delivery. Women in
general and women with immigrant background in particular also tend to put more emphasis on
corporate social responsibility; for instance, in relation to recruiting personnel. These different
approaches to entrepreneurship in the field of homecare affect the possibilities to company
growth and survival on the market.
Introduction
Sweden is typically known for its universal welfare system, including wide-ranging publicly
funded and provided social care services, such as eldercare. However, in Sweden as well as in
other mature welfare states, the provision of eldercare services has been greatly influenced
since the 1980s by the global wave of New Public Management (NPM) (Blomberg 2004). This
reform movement has favoured practices of the private business sector as a solution to a wide
range of perceived problems of public sector service provision. As a consequence, market
steering practices have been introduced into publicly financed eldercare in Sweden, including
the use of competition and the promotion of private enterprises (Meagher & Szebehely 2013).
Policies promoting market practices and private providers in publicly funded eldercare services
have been based on arguments about empowering users, improving quality through increased
competition, and offering more diverse forms of care adapted to an ever more diverse older
population. Recently, customer choice has emerged as the most popular symbol of these
political ambitions. The legislation introducing customer choice in Swedish eldercare, the Act on
System of Choice (LOV), is founded on strong hopes that older people’s right to choose - and
choose again if not satisfied - will strengthen the users’ voice and increase the quality of
eldercare (Government Bill 2008/09:29). Diversification has been linked to the idea that services
should be adapted to the individual needs of all older people. The diversity of providers is
guaranteed as small care enterprises are enabled to enter the care market. The emergence of
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care companies with specific linguistic and ethnic profiles has also been considered a positive
effect of the choice model and its endorsement of diversity (SOU 2014:2).
Aside from advancing services adapted to the users’ needs and wishes, the Act on System of
Choice is partly an attempt to break the oligopoly of the Swedish homecare market. A few large
corporations dominate the private homecare sector, which makes it difficult for small private
providers to enter the market (Meagher & Szebehely 2013; Pettersson & Hedberg 2013; Sundin
& Tillmar 2010). Contrary to public procurement procedures, customer choice implies that no
authorized provider has a guaranteed number of clients. In this way, customer choice is thought
to stimulate competition on the basis of quality and the development of different profiles of the
services. Small providers will then be able to take up the competition with large providers, for
example by creating distinctive profiles of the services to attract specific group of clients (SOU
2008:15). Finally, customer choice has been represented as a way to increase gender equality in
the labor market. The preparatory works of the Act on System of Choice anticipated that more
women would be encouraged to become “care entrepreneurs” as the legislation would make it
easier for small providers to obtain a foothold on the eldercare market, in particular in
homecare services (SOU 2008:15).
Regardless of the political goals, private homecare is still a branch characterised by a few big
private corporations. Four companies control more than 40 % of the market and the rest of the
market shares are scattered on approximately 800 companies (Bergman & Jordhal, 2014; Brodin
& Andersson, In Press). More than half of the homecare companies are also owned or run by
women, of whom many have migrant backgrounds (Meagher & Szebehely 2013; Pettersson &
Hedberg 2013; Wondmeneh 2013). Some studies show that women who decide to start up a
homecare company tend to engage in the field on the basis of the “rationality of caring”
(Wærness 1984), with the motivation to create better care and better conditions for their
personnel (Pettersson & Hedberg 2013). But studies also point to the fact that women-owned
small care companies have severe difficulties to survive the strong competition on the market
(Sundin & Tillmar 2010). Though there are no available statistics on company turnover, one
comparison of providers in a city district in Stockholm shows that in two years, 27% (1/3) of the
original 81 providers had disappeared from the market at the same time as 40 new providers
had been set up (Meagher & Szebehely 2013). The primary reason for this instability is that
small care enterprises are vulnerable as they usually have few clients. In 2013 approximately
25% of the private companies in Stockholm had fewer than 15 clients, which corresponds to
only three full-time employed care workers (Hjalmarsson & Wånell 2013; Meagher & Szebehely
2013). Despite the promises of the choice legislation, small care enterprises apparently still have
problems to survive the strong competition.
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This paper explores the dilemmas and possibilities of small homecare companies in the context
of the customer choice model in Swedish eldercare through a case study of the city of
Stockholm. In particular, we examine how gender and ethnicity shape the organization and
business strategies of the companies. Moreover, how do small care entrepreneurs perceive
possibilities and obstacles to deliver good care within the framework of the choice model?
After the presentation of methods and data, the paper proceeds with outlining the customer
choice model in Stockholm. The paper then continues with a description and analysis of how
small homecare companies in Stockholm are organized, primarily in relation to how gender and
ethnicity shape the business strategies of the companies. Furthermore, differences in size,
ownership and profit are analysed. In the concluding part of the paper, the findings of the case
study are contextualised in respect to national policies and goals of quality care, gender equality
and ethnic diversity.
Methods and data
The study reported in this paper uses a mixed methods case study design (Creswell & Plano
Clark, 2011). The paper therefore draws on analysis of quantitative and qualitative data on small
care companies in the context of the customer choice model in Stockholm. Specifically, the data
consist of a mapping of the total number of private homecare companies in the city; analysis of
policy documents on the choice model; and interviews with 20 owners and managers of small
care enterprises.
Both the mapping of the companies and the investigation of policies are based on digitized data
available on the website of Stockholm (www.stockholm.se). The city’s website continuously
publishes political decisions, policies and information about homecare companies. In addition,
the website publishes user surveys and results from the city’s monitoring of private providers.
Screen prints and information about all private homecare companies in Stockholm was
downloaded from the website in August/September 2015.
This paper uses data collected from the follow up reports of all the homecare providers in
Stockholm. The follow up reports constitute an important part of the city’s monitoring of both
public and private providers. The follow up reports are conducted by local authority officials and
published on the city’s website. They contain detailed information about each provider,
including the number of clients the provider has, where in the city the clients live, how many
employees the provider has, terms of employment and educational level of the employees, and
documentation practices of the provider.
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Information of all private homecare companies operating in the city in August/September 2015
(n= 133) has been collected and analysed descriptively with respect to number of employees
and number of clients. Additional information about ownership and profit of the companies has
been gathered from the website allabolag.se. (www.allabolag.se). This site is run by UC, a credit
report business corporation that gather information from Statistics Sweden, the Swedish Tax
Agency and Swedish Companies Registration Office.
This study also draws on data collected from 20 interviews with owners or CEOs of small
homecare companies in Stockholm. The key informants were selected on the basis of the
mapping of the companies and represented contrasting types of companies in relation to
company size and gender and ethnicity of the owners/CEOs. Of the selected companies, 11
were micro companies with less than 10 employees (full-time equivalent) and nine were small
companies with 11 to 65 employees (full-time equivalent). In addition, 13 of companies were
owned by women or had women as CEOs and seven companies were own by men or had men
as CEOs. About half of the owners or CEOs were born in Sweden and the others were foreignborn, primarily in Asian or African countries. The majority of the informants had a university
degree in the area of health care or social work. Nearly all also had experiences from working in
eldercare.
All interviews followed a similarly structured topic guide and the interviewees were asked to
discuss their experiences and knowledge on the basis of six different themes; (1) occupational
background and motivation for starting the company; (2) organization of the company, including
recruiting clients and personnel and strategies to survive on the market; (3) organization of the
staff; (4) organization of the care work; (5) customer choice; and (6) perceptions of possibilities,
obstacles and dilemmas of customer choice in relation to gender and ethnicity.
Rather than focusing on the sequential order of statements in individual interviews, analyses of
interviews with key informants involve finding similar topics arising from the interviews (Bogner,
Littig & Menz, 2009). Transcriptions therefore needs to be less detailed and in general only
include thematically relevant passages instead of the whole recording of the interview. Analysis
of the interviews involves three or four steps, depending on the extent to which the researcher
seeks to generalize from the study. The first and second steps of the analysis are to code and
thematically compare the interviews and the third and fourth steps involve conceptualization
and generalization of the categories emerging in the analysis.
For the purpose of this study, relevant passages in the interviews have been transcribed and
these have then been coded, compared and conceptualized thematically. The conceptualization
of themes emerging in the interviews has then been used to make empirical generalizations
about the possibilities and dilemmas of small care companies and how gender and ethnicity
shape business strategies. Quotes have been translated from Swedish to English and are
5
presented in the paper to clarify the findings from the interview data. The empirical
generalizations are described under the following themes; leading care work or leading a
company, a struggle against the system, trust and distrust, and structural inequalities and social
responsibility. An intersectional approach, focusing on how the interconnection of gendered
and ethnic power structures manifests in concrete social relations (Anthias, 2013), informs the
analysis.
Small homecare companies in the customer choice model of Stockholm
National and local policies regulating homecare
Local self-government is a principle that is enshrined in the Swedish constitution. This principle
includes that the local authorities have the right to decide over matters which they are
principally responsible for, such as eldercare. Though the national parliament guides the field of
eldercare through policies and law, the overall responsibility for publicly financed eldercare
services in Sweden, both privately and publicly provided, thus lies with politicians in the 290
local councils. Services are granted following needs assessment by the local authorities.
The Act on System of Choice (LOV) was introduced in 2009 (Government Bill 2008/09:29). This
act regulates the conditions that apply when a municipality decides to allow older adults to
choose their provider of care services from a list of approved providers. Applications are open
for all legally recognized organizations and the act sets no limit on the number of providers or
the duration of the contract (Meagher & Szebehely 2013). Implementation of customer choice
in publicly funded homecare services therefore means that the older user can choose an
authorized provider to conduct the care services after the needs assessment. Consistent with
the tradition of local self-government, the Act on System of Choice does not force the local
authorities to implement customer choice in publicly funded eldercare. But they are encouraged
to introduce customer choice through financial initiatives. As a consequence, customer choice is
in use or will be implemented in approximately 61 % of Swedish municipalities and additional 11
% are investigating the possibility to introduce the model (SALAR, 2016).
Private providers deliver about 24 % of the homecare in Sweden (NBHW 2016). There are
however great local differences in the mix of public and private provision of homecare services.
Whereas the public sector still is the only provider in nearly half of the Swedish municipalities,
approximately 72 % of the homecare is delivered by private providers in the city of Stockholm
(NBHW 2016). The high share of privately provided homecare services in Stockholm related to
the fact that the city has been one of the forerunners promoting competition and choice in the
publicly financed homecare. The city decided to introduce customer choice in the publicly
6
funded homecare already in 2002, mainly with the same arguments as were put forward at the
national level in 2009 (Hjalmarsson & Wånell, 2013). As a consequence, Stockholm has today
about 133 private homecare companies and the private providers of the city deliver more than
1/3 of the total number of hours of homecare produced by private providers in Sweden (NBHW
2016). The high number of private homecare companies and Stockholm’s comparatively long
history of regulating eldercare according to the choice model makes the city an interesting case,
as this facilitates thorough explorations of how customer choice affects private enterprises in
the publicly financed eldercare.
Organisationally, Stockholm is divided into 14 city districts responsible for community services,
such as eldercare. Stockholm’s choice model is therefore regulated at two different levels; the
city council and the city districts’ councils. General policies, such as market entry requirements,
procedures for monitoring providers and payment systems for provider reimbursement, are set
by politicians in the city council. Currently, the city’s market entry requirements include general
criteria related to financial stability and trustworthiness of the provider (e.g. no criminal record)
and structure or process quality management criteria. For instance, the person in charge of daily
operations must have a relevant university degree (e.g. in social work) and at least two years
working experience in eldercare. In addition, at least half of the staff should have relevant
education, preferably corresponding to assistant nurse (Stockholm stad 2013a: 16). The
outcomes services should lead to, however, are not specified other than in general terms, such
as that the services must be of good quality and be performed in accordance with the general
goals stipulated in the legislative framework regulating social care services, i.e. the Social
Services Act (Stockholm stad 2014). According to the requirements, homecare providers are not
permitted to reject new customers but there is a possibility to delimit the geographical area to
certain city districts in which the company will operate, and to establish a capacity limit.
The district level has responsibility for oversight of performance of services, such as needs
assessments and follow-up of the providers. Each district has about 80 to 100 providers that
compete for clients (Meagher & Szebehely 2013). Provider reimbursement is connected to the
needs-assessment procedure at the district level. Following the needs-assessment and the
client’s choice of the provider, services are delivered to the clients according to a fixed time
template that stipulates the minutes or hours a person is to be assisted per day or per week,
e.g. 10 minutes three times per day for assistance to the toilet or 30 minutes once a week for a
shower. The providers are thus reimbursed for the minutes or hours their staff helps the clients,
and the reimbursement is supposed to cover all costs, including wages, administration,
documentation, meetings and transport between clients, and premises.
To receive reimbursement, the providers must have an IT-system that is connected to the ITsystem of the city. This IT-system also requires that registration and documentation of service
7
delivery are managed through smartphones. Thus, in order for the providers to receive
reimbursement for service delivery, the care workers must register the time of arrival to the
home of the older person, in a specific application in their smartphones, and log out when
leaving. Registration of service delivery is verified through a GPS function in the smartphone. In
case of exceeding the time for helping the client, the provider is obliged to report to explain
why. This organization of provider reimbursement is expected to generate better care by
encouraging providers to increase the time spent in the homes of the clients. In addition, the
system is also expected to constitute a solid basis for statistics and monitoring of the care
services (Stockholms Stad 2013b).
Characteristics of the private homecare companies in Stockholm
In 2015, there were 133 companies operating on the homecare market in Stockholm. However,
follow-up reports were missing for 42 of the companies. The quantitative analysis of the
companies’ number of clients and number of employees therefore builds on the 91 companies
for which follow-up reports are available, whilst the quantitative analysis of ownership, gender
and profit includes all homecare companies.
Analysis of the 91 companies with available follow-up reports displays a clear pattern of the
private homecare market in Stockholm (table 1). About 1/3 of the private homecare companies
have nearly 80 % of the clients in the city, whilst the remaining 2/3 of the companies have to
compete for the additional 20 %. In fact, the imbalances between small and large companies are
even worse. About eight of the companies with 76+ clients are large corporations with multiple
independent units operating all over the city. But follow-up reports are lacking for several of
these independent units belonging to the largest homecare companies. Accordingly, the
number of clients (and number of employees) is underestimated for the largest companies in
Stockholm.
In addition, the four largest homecare companies in Sweden are also represented in Stockholm.
Three of these corporations are owned by European equity firms and the fourth is owned by a
Swedish financial holding company (Meagher & Szebehely, 2013). This suggests that it is very
difficult for small homecare companies in Stockholm to be able to compete with large
corporations.
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Table 1. Private homecare companies in Stockholm, divided on number of clients.
1-20 clients
24
21-50 clients
24
51-75 clients
13
76+ clients
30
Total
91
No. of
companies
No. of
20
19
5
21
65
companies
owned or led
by women
No. of clients 247
822
819
6393
8281
No. of
98,41
387,52
313,11
1516,47
2315,51
employees
(full-time
equivalent)
Proportion
83,3
79,2
38,5
70,0
68,1
(%) of
companies
owned or led
by women
Average
10
34
63
213
91
clients per
provider
Average
4,1
16,15
24,08
50,55
25,45
employee per
provider
(full-time
equivalent)
Average
2,5
2,12
2,62
4,22
3,58
clients per
employee
(full-time
equivalent)
Source: http://www.stockholm.se/-/Jamfor/?enhetstyp=c72b4fcc3f504dc4aac3303c6797d430
The quantitative analysis also shows that the majority of the homecare companies in Stockholm
are controlled or led by women. In particular, women seem to be in majority when it comes to
controlling or leading the smallest or the largest homecare companies. Men, on the other hand,
seem to control or lead homecare companies positioned in the middle of the market.
Moreover, there are very few partnerships or private unregistered firms among the 133 private
homecare companies in Stockholm (table 2). Instead, most private homecare companies in
Stockholm are unlisted joint-stock companies. Men are more often chairs in these companies,
though more women than men are CEOs.
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Table 2. Number and proportion of men and women in leading positions in private homecare
companies in Stockholm.
Number
Women
23
123
50
41
8
3
Proportion (%) of men and women
Women
Men
38
62
54
46
46
54
67
33
47
53
75
25
Men
Chair
37
Board member
103
Deputy member
59
CEO
20
Partnership
9
Private
1
unregistered firm
Total
248
229
52
48
Note: Table 2 includes information about all private homecare companies in Stockholm.
Source: http://www.stockholm.se/-/Jamfor/?enhetstyp=c72b4fcc3f504dc4aac3303c6797d430 and
http://www. allabolag.se
Even if women control or lead the majority of the private homecare companies in Stockholm,
the quantitative analysis of companies with available financial statements indicates a gendered
pattern in relation to key performance indicators (table 3). In general, joint-stock companies led
by men seem to be more profitable than joint-stock companies led by women. Moreover,
companies led by men seem to have higher net turnover per employee than companies led by
women. This indicates that there may be differences in how men and women organize their
companies and the care work, which also affect the profitability.
Table 3. Key performance indicators for joint-stock homecare companies in Stockholm with
available financial statements.
No. of joint-stock
companies
Average profit per
company (SEK in
thousands)
Average profit after
financial items per
company (SEK in
thousands)
Average net turnover
per employee (SEK in
Companies with
women in leading
positions
75
Companies with men in Total
leading positions
36
111
1 340,27
1 152
1 279,21
4 710,87
1 482,58
3 663,86
468,28
528,8
487,74
10
thousands)
Average cash position
185,31
219,18
per company (%)
Average equity ratio
32,98
42,2
per company (%)
Average profit margin
6,95
10,41
per company (%)
Note: Table 3 builds on financial statements for 2014.
Source: www.allabolag.se
196,3
36,04
8,07
Leading care work or leading the company?
The quantitative analysis of the private homecare companies is congruent with findings from
analysis of the interview data. All informants claimed that the primary motivation for starting up
a homecare company was to provide better services for older people. For example, they often
told stories about the malfunctioning of the homecare services and the undignified care that
they had seen in their professional lives, mainly as workers within the eldercare system.
However, men and women expressed rather different ideas of how to achieve the goal of better
care. Women in leading positions of small homecare companies generally said that they
preferred to participate in the planning and organization of the care work on a daily basis, to
have close contact with the staff and to meet their clients in person. For example, one woman
who had founded the company where she now was CEO said:
I’d say I know 80 % of the clients and then there’s a few who only has alarm service.
It was also my goal that I’d have a face to all of my clients. It also becomes some kind
of work-related sickness. You know every entry code; you know where they [the
clients] put their coffee. If someone [colleague] calls and says ‘I can’t find…’ then you
say ‘look there and there’. Then you start to think of this and that- he wants those
blue socks. It’s funny when you think of it, but when you’re into it, it’s just natural.
(CEO, woman Swedish-born)
Women who were CEOs also emphasized that they sometimes stepped in to do hands-on care
work. To be close to the daily operations was often conceived of as something necessary in
order to make the business work. Overall, women CEOs considered this practice a natural and
essential part of their job. They also argued that this way of organizing their work helped to
assure that the company provided good care.
Whilst women in leading positions of small homecare companies said that they wanted to be a
part of the daily care, men in leading positions generally adopted a different approach. Rather
than being involved in the daily operations, organization and provision of care services, they
focused more on overall strategic issues related to business development, leadership and
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marketing. Some of the men CEO stressed that they were also responsible for other businesses
apart from homecare and that they did not meet with the staff on a daily basis. For instance,
one man who was the CEO of a small homecare company reported:
I’m not involved in the planning of daily operations. So on my part; I’m not even
sitting together with the homecare [staff] and I work with many other things. My
role is to support the local manager. /.../ I’m in the local office about once a week.
But the primary contact is with the local manager. And the local manager has
responsibility for work environment, operations, budget and everything. /.../ So,
frontline management is something that I’ve passed some years ago. I’m not
interested in being very much involved in the operations and management on a daily
bases. I’m through with that. (CEO, man Swedish-born)
Hence, men who were CEOs of micro and small homecare companies stressed the wish to focus
on business development. Tasks related to the daily operations were therefore generally
considered the responsibility of the local manager.
Overall, men and women tended to describe very different approaches to what it meant to own
and/or lead a homecare company. These contrasting ideas of leadership also resulted in diverse
business strategies. Women in leading positions often responded that they did not want to
become too big because then they would lose contact with both their clients and their staff. For
example, one woman who was both the founder and the CEO of a small company described that
she did not want her company to become too big because then she would not be able to build
relationships with clients and to be in control the quality of the care services:
I don’t want to become that big either. I’m that kind of boss who works with the
staff. I go around to make sure that everybody is feeling good; users, personnel and
[the users’] family. I’m on the floor with them, and the staff knows this. I can show up
at any time, scheduled or not, and check the users’ experiences and stuff like that. In
some cases, when it’s about palliative [care], then I go myself too. I work so that the
users get familiar with me too. I just don’t sit and give orders. With this method, I
have succeeded today. (CEO, woman foreign-born)
Another woman who was the owner of a micro company also stated that even if she would be
able to expand the business in the future she would continue to do hands-on care work herself,
because “if you just stay at the office with the paperwork, you lose reality”. Most of the woman
who were CEOs also stressed that they would like to spend more time on organizing social
events or social meeting points for their clients, and their families. In contrast, men in leading
positions generally said that they wished they could be a little more like “real CEOs”:
12
Well, just to sit with the things a CEO is supposed to do, business management and
so, and avoid all emergency callouts/…/ Unfortunately I’ve to stay up-to-date with all
the things that happen in homecare, go to provider meetings and other things for
example. Otherwise, I’d rather be like a real CEO, who just sit around reading reports
and have check-up meetings with the personnel and things like that… but now we’re
too small for that. (CEO, man Swedish-born)
Hence, men who were CEOs tended to describe the involvement in the daily operations,
organization of the care work, and relations with staff and clients, as taking time from more
important issues such as developing strategies for efficiency, quality and expansion.
Altogether, the informants argued that the primary incentive for starting up or leading a private
homecare company was to improve homecare services for older people. But men and women
described different ways of achieving this goal. Men wanted to focus on the strategic issues to
be able to expand the business, whilst women wanted to be involved in the daily work and
therefore preferred a more slow business growth.
A struggle against the system
Another finding from the analysis of the interview data is that running a small homecare
company in Stockholm involves a constant struggle against the system. Though men and women
expressed divergent ideas of how to lead their company, all informants agreed that the way the
customer choice model operates in Stockholm generates unfavorable conditions for all parties
involved. In particular, the informants described how the fixed time templates for service
delivery and the way this is connected to the time registration system and the provider
reimbursement generate negative side-effects for them as well as for their staff and their
clients.
The informants argued that the time attached to the services is not enough to perform care
properly. Moreover, the fixed time template for service delivery creates inequalities in the
interpersonal meeting with the clients; all clients are granted the same amount of time even
though they may have very different capabilities to make use of the time they have been
granted. One CEO reported:
“[The time for] meals are usually very short. And then shower. All receive the same
[amount of time]. It can take very long time for some more disabled [people] just to
approach the bath room. For others, it goes very easy. [They] are showered within
the precise amount of time, and for some it almost takes an eternity to get there.”
(CEO, man foreign-born)
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Another obstacle for small homecare companies reported by the informants was the time
registration system with smartphones. This system was described as stressful for the care
workers and something that stole time from the clients. For example, one CEO described how
the logging in and out procedure with the smartphones created bad working conditions for the
personnel and decreased the actual time available for helping the clients:
For example, say that I’ve 20 minutes at the client’s for cooking. You know, just to
get in and take off your coat and set up the phone- then there’s already 10 minutes
gone! Then I’ve to do 10 minutes cooking. It’s nothing left of my time. It’s such a
stress! Who wants to work under those conditions? (CEO, woman foreign-born)
As mentioned, the providers are reimbursed for the service delivery reported in the city’s ITsystem. However, given the problem of short time-slots and the fixed time template for service
delivery, the informants said that it was more rule than exception that they delivered more
service than what they were being reimbursed for. According to the city’s policy the providers
have to explain the reason for running over the time, in each case. Further, the policy states that
if a provider frequently runs over the time with a client, the needs-assessment may be revised
so that the client is granted more hours for help. But this hardly ever happens according to the
informants. Instead, all emphasized that financial compensation for the overtime they deliver to
clients is to the most part rejected. One CEO described how this constant rejection of reported
overtime may have negative financial consequences for her company:
“We notice a big economic drop. In particular with big clients you run over the time.
You run over the time and then you’ve to explain why you did it. We know why. The
client’s service decision includes too little time so you run over. They [big clients]
have so many visits [per day] and such huge need for care so you run over the time,
let’s say, 20 minutes every day. It’s nothing strange with that, if a client has eight or
six visits every day. It’s nothing if you’ve clients with mobility problems. And even if
you explain, they reject [reimbursement for the overtime].” (CEO, woman Swedishborn)
The informants also argued that the time registration system was ineffective as it increased time
and costs for administration. For instance, the CEOs said they had to devote a considerable
number of hours to check the time registration of the personnel, and to write explanations for
running over time with clients. In addition, the informants claimed that the reimbursement for
service delivery was too low because several important expenditures were not covered, such as,
transport between clients or clients’ cancellations of service delivery. Moreover, the informants
underlined that the reimbursement per hour is the same regardless of whether the service is
delivered Tuesday morning or Saturday evening. Thus, the provider reimbursement does not
14
cover inconvenient working hours supplement, even though this supplement is included in the
care workers’ wages.
Overall, the informants identified several problems in relation to how the choice model of
Stockholm functions, particularly the minute-steered care delivery, the digital time registration
and the low reimbursement level. These were all experienced as obstacles for providing good
care. On one hand the informant emphasized that they did their best to deliver good care
despite of these obstacles, although many times “outside of the framework”, i.e. to deliver
more care services than what they were being reimbursed for. As one CEO said:
We give good care but we go outside the framework in order to do this. We want to
have a clear consciousness, to be able to sleep at night. (CEO, woman foreign-born)
On the other, the informants also described how the lack of reimbursement for extra service
delivery may have negative consequences for small care companies, because they are
vulnerable to insufficient financial compensation for care workers’ wages and overtime.
Trust and distrust
A third finding from the interview data is that the customer choice model of Stockholm poses
particular challenges for small care companies to represent themselves as trustworthy providers
of care services. Nearly all informants described how they had to work very hard to convince
local authority officials that they were honest companies.
The informants partly related the lack of trust in small care companies to the excessive number
of competitors on the homecare market in Stockholm. Though all informants claimed that in
theory freedom of choice and competition resulted in improved quality of eldercare, they also
argued that there were too many companies operating on the homecare market in Stockholm.
Sometimes this resulted in sharp practices. For example, most of the informants had
experiences of competitors trying to snatch their clients with offers of microwaves or
porcelains. Another example of sharp practices was that competitors could call the informants’
clients and promise that if they changed provider to the competitor, one single person would
attend to their care needs at all times. In addition, the informants mentioned that personnel
sometimes could sell lists of clients to competitors when leaving a company. The informants
also said that too many competitors could result in fraud, as the city could not control and
supervise all the companies. Both sharp practices and fraud was described as something that in
particular affected the reputation of small private homecare companies, as they were usually
those who became associated with such procedures.
15
The general perception of the informants was that bigger care companies, particularly the
largest corporations, had a privileged position and received better treatment on the city’s part
than small companies. For instance, one CEO mentioned that when the city introduced the time
registration system, it was presented in such a way that he felt as the city suspected that all
small care companies were cheats:
Cheating has occurred in the homecare services before and there are a lot of known
cases. But that doesn’t mean…I still think 95 % [of the small care companies] are
honest /…/ The media image gave rise to this system [the time registration of service
delivery]. They [the city] will stop the cheating. But they don’t have to treat
everybody as cheats. (CEO, man Swedish-born)
In this context, some of the women CEO who were foreign-born also said that they felt as their
company were particularly scrutinized just because of their foreign background. For example,
one CEO of a small care company described how authority officials immediately come for
inspection every time she reports a non-conformance, but this does not happen to her
competitors who are Swedish-born:
You’re more subjected to controls, you know. /.../ If someone says the tiniest little
thing then they come at once for a control. But not to those who are Swedes. /…/ So
it can be the smallest of things. We’re being watched more than others. (CEO,
woman foreign-born)
However, even more problematic than being subjected to erratic controls was the informants’
experiences of conflict of interest among the local authority officials responsible for the needsassessment of older individuals applying for services. The choice policies of the city allow local
authority officials to recommend providers to the older individual applying for services, if the
client asks for it. The policies instruct the needs-assessors to offer information on the basis of
the older person´s life situation, preferences and needs and that they may “present two or
more alternatives” (Stockholm stad 2013b: 11). However, this lack of transparency of what
information the local authority officials use when they introduce two or more providers was
described as unfair. Some informants thought the recommendations depended on how many
clients the provider had, whilst others thought they were based on results from the user
surveys. Because of the lack of transparency, the informants argued that there was no way to
know if the needs-assessors were impartial or recommended friends or family. Indeed, some
argued that the local authority officials “have their favorites” and they have the power to make
some companies successful. Those who had complained also said that they had been punished
with no recommendations of clients for a period of time. One CEO simply stated that the local
authority officials thus had the power to ruin a small company. Another CEO argued that the
local authority officials’ behavior was official misconduct:
16
Never in my life had I thought that there could be official misconduct in Sweden! You
discover that there’s official misconduct also in the Swedish system. This is obvious
for us. (CEO, woman foreign born)
Altogether, analysis of the interview data indicates that the customer choice model in
Stockholm has generated problems of distrust. The informants reported such problems in
relation to the practices emerging from the existence of too many companies, harsh
competition and insufficient or distorted surveillance. The owners and CEOs of small homecare
companies felt particularly disadvantaged as they were the usual suspects of fraud and
malfunctioning enterprises. Some of the women who were foreign-born also had experienced
that their companies were object of stricter monitoring and control because of their origin.
Overall, the informants described the local authority officials as powerful actors on the
homecare market given their tendency to favor certain companies on unclear or partial
grounds.
Structural inequalities and social responsibility
A fourth finding from interview data is that the problems small care companies experience
within the customer choice model of Stockholm relates to a broad spectrum of structural
inequalities in society. In general, the informants considered that customer choice had
encouraged women and immigrants to start and lead private enterprises. They noted that many
care companies are led by women entrepreneurs, often with long previous experience within
the health and social care sectors. The presence of immigrant led companies was described as a
sign that the choice model also granted possibilities for immigrants to enter the labour market.
This was considered positive in the light of the great difficulties many immigrants encounter in
finding a job. In line with this idea, one CEO argued:
When you speak about profits in the welfare sector you forget that it’s women, often
with immigrant background, who start and run this [businesses] and who have
succeeded in doing this themselves. (CEO, man Swedish-born)
However, another CEO contrasted this positive aspect of more women immigrants leading
companies in the homecare sector with overall inequalities on the labour market; starting up a
company may be immigrants only chance to enter the labour market. In addition, this CEO
argued that the homecare market was a very tough sector to operate within, and that both
owners of small care companies and their employees were generally underpaid.
Then we shouldn’t forget the low wage trap. I’d like to see all those entrepreneurs, if
you look at the number of hours they dedicate, and compare that with the wage
17
they´re able to set [for themselves], I’m sure they’ve the absolute lowest wages. And
then the employees you attract will be those who think that they can only take, or
work in, low wage professions. (CEO, woman Swedish-born)
The informants also related the difficulties they experienced as owners and CEOs of small
homecare companies to the low status of eldercare in society. For example, the problems of low
reimbursement levels for service delivery were generally defined as a consequence of low
priority of eldercare. Moreover, the informants described how the low status of care work
created problems in relation to recruiting and keeping qualified personnel. All emphasized how
complicated it was to attract personnel with the right skills. Given that the official policy of the
city is to increase the proportion of nursing assistants in the homecare sector, many were
worried about their possibilities to comply. The difficulties of attracting skilled staff were
generally related to the low status of homecare. Bad working conditions and low wages meant
that nursing assistants often left their jobs in homecare for work in residential care or hospitals.
For example, one CEO stated:
It’s a status thing. They think that they’ve a better future in hospitals, I don’t know.
They advance, more secure employment, predictable working hours, you have fixed 8
hours in a row. Here you run between different places. But I think it’s most about
status, “I work in a hospital” instead of “I work in homecare”. (CEO, man Swedishborn)
Some owners and CEO also expressed scepticism about the city’s attempt to raise the
status of homecare by increasing the proportion of nursing assistants. They argued that
because the provider reimbursement does not cover all the costs related to service
delivery, the providers cannot offer wages high enough to attract skilled staff. Informants
who shared this negative view on the city’s staffing policies also stressed that anyone with
a good heart could do the work, and they talked about care work as mainly warming food,
housework and walks with older people, emphasizing that it is not about health care.
In contrast to this pessimistic and de-professionalizing outlook on homecare, other
informants described how they had adopted a strategy of social responsibility to recruit
and train personnel. In particular foreign-born women who were CEOs described how they
intentionally picked foreign-born women as staff, based on their personal qualifications as
fitting in care work for older. These were generally women who had not had a job in
Sweden before, and who thus had great difficulties of integration in society. By working in
eldercare these women improved their language skills and then they were encouraged to
study to achieve the level of nursing assistants. For instance, one foreign-born woman
who was the founder and CEO of a company reported:
18
We invest especially in immigrant women, those who have never worked in Sweden.
We take them as trainees for two, three months, and then we talk with the
Employment Agency. We send them to study to become nurse assistants or assistant
nurses. They study through distance teaching. They start working for us when we see
that they’re suitable to work with older people and that older people like them. I
have 11, 12, 13 who we sent to study as nurses assistants and they’re so nice
personnel. They’ve never worked in Sweden but they’ve been here for 10, 15, 20
years. (CEO, woman foreign-born)
The strategy to recruit immigrant women to work in the homecare sector was however not only
described in terms of social responsibility but also as having a downside. Some informants
related the difficulties facing small homecare companies to the fact that this is a field dominated
by women, of whom many also are immigrants. These informants argued that politicians and
policymakers do not really care about developing better policies and regulations because
homecare is a sector dominated by those who are on the lowest rung of the ladder. For
example, one woman, who was the founder and CEO of a company, wondered in what other
areas in society the conditions that apply to homecare would have been accepted. She saw this
as a question of immigrant women’s lack of voice:
Homecare is a service that’s often performed by women, and where employees of
foreign origin are overrepresented. This implies that our voice does not…[count]
that’s what I think. It’s like: take it or leave it. You’re used to getting lower pay and
you don’t have such a loud voice. But I think that if men had been overrepresented
among homecare employees and owners, things would have been different. (CEO,
woman foreign-born)
On one hand, the informants thus implied that customer choice had provided opportunities for
women in general and immigrant women in particular to set up and run their own business in
the homecare sector. On the other, the informants argued that homecare is a lowly prioritized
and low paid sector and that the overrepresentation of immigrant women in homecare is
associated with overall structural inequalities in Sweden. Some informants, primarily women
who themselves were foreign-born, tried to counterbalance these inequalities by developing
recruitment strategies particularly focusing on immigrant women who have been long-term
unemployed. At the same time, these strategies were also perceived as having negative sideeffects. The more the homecare becomes dominated by those who have the least opportunities
to influence policies, the less the odds that the conditions will improve.
19
Discussion
The legislation introducing customer choice in Swedish eldercare, the Act on System of Choice
(LOV), was founded on strong hopes that the right for older people to choose the provider of
care services would strengthen their voice and increase the quality of eldercare (Government
Bill 2008/09:29). Customer choice was also defined as a way to support small care companies
and to encourage women to become ‘care entrepreneurs´ (SOU 2008:15).
This paper has demonstrated that the implementation of customer choice in publicly funded
homecare services for older people in Sweden has generated new possibilities but also several
dilemmas related to small homecare companies. To the most part, both the possibilities and the
dilemmas relate to gendered and ethnic inequalities.
Given the long tradition of publicly funded and provided care services, Sweden has together
with the other Nordic countries often been represented as “women-friendly” (Hernes 1987).
This idea has however been widely challenged by Nordic scholars, who have highlighted that the
public responsibility for service provision has not changed the fact that eldercare has continued
to be undervalued and low paid work dominated by women (Borchorst and Siim 2002; Peterson
2011; Stranz 2013; Trydegård 2012). The findings of this study suggest that the implementation
of customer choice in publicly funded homecare services has not contributed to change these
gendered inequalities. In keeping with the promises of the choice legislation, women seem to
have been inspired to set up their own business in the homecare sector. But contrary to the
goals of the act, customer choice does not seem to have ended the imbalances on homecare
market between small and big companies, at least not in Stockholm where large corporations
still dominate the market. These disproportions on the homecare market between large and
small companies make it very difficult for small private companies to enter the market as well as
to have a voice in policymaking (cf. Meagher & Szebehely 2013; Pettersson & Hedberg 2013;
Sundin & Tillmar 2010). Women have thus been encouraged to become ‘care entrepreneurs’
but the great majority of them are in a very insecure and weak position.
Furthermore, this study indicates that small care companies are particularly vulnerable to local
policies. Low reimbursement levels for service delivery in combination with policies inspired by
NPM create huge obstacles for small care companies to make both ends meet. In this context,
both Nordic and international studies show that quality in eldercare is correlated with the
working conditions in the sector: the better the working conditions the higher the probability to
deliver services of high quality (Meagher & Szebehely 2013). In particular, research show that it
is crucial to support the decision latitude of the care workers, as this enables them to be flexible
in meeting the users’ varying needs. Thus, the short time-slots and the fixed time template for
service delivery associated with the regulation of the choice model in Stockholm do not only
20
decrease care workers decisions latitude but is also a threat to the necessary preconditions for
good quality of care.
Anglo-Saxon research has demonstrated that policy reforms inspired by NPM tend to reinforce
gendered substructures and to promote behavior associated with traditional perceptions of
masculinity, such as competitiveness, risk-taking and dominance (Connell 2006). Also Swedish
studies show that NPM has tended to reinforce gendered organizations and favored leadership
styles and organizational behavior associated with traditional norms of masculinity (Sundin &
Tillmar 2010). In addition, some Swedish studies indicate that ethnic inequalities overlap with
the gendered inequalities in the organization of eldercare (Thörnquist 2013).
The findings of this case study both support and challenge these conclusions. On one hand, this
study indicates that policies inspired by NPM have indeed reinforced gendered and ethnic
inequalities in the publicly funded homecare in Sweden. Homecare has been and continues to
be a field dominated by women, and many of the workers as well as owners and CEOs of small
care companies are also immigrants. Policies reducing the autonomy of care work, for example
by introducing standardized templates for service delivery, or neglecting financial compensation
for care work, thus have severe negative consequences for the women and/or immigrants who
work in or lead homecare companies. On the other hand, findings of this study challenge the
idea that NPM has been followed by a change of leadership styles and norms of behaviour from
values associated with care (cf. Wærness 1984) to risk-taking and dominance. At least in the
case of the small companies investigated in this study, homecare still seems to be a branch very
much characterized by ethics of care and not profitmaking.
The CEOs and owners who participated in this study all shared the ambition to create better
care for older people and better conditions for their personnel but they expressed different
views on leadership. The findings of this study suggest that both gender and country of origin
influence the organization and business strategies of small care companies. Women seem to be
more focused on organizing and leading the daily care work, whilst men give the impression of
being more interested in planning and leading the company at the strategic level. Moreover,
women in general and women with immigrant background in particular also seem to put more
emphasis on the social aspects of entrepreneurship in the field of homecare; for instance, in
relation to recruiting personnel. These different approaches to management may also explain
why care companies led by women appear to be less profitable than care companies led by
men.
21
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