Freedom of choice or cost efficiency? The implementation of a free-choice market system in community mental health services in Sweden

Abstract

This case study investigates the implementation of a free-choice market system in community mental health services using the example of day centres for people with psychiatric disabilities. It was conducted in a major city that was about to implement a free-choice market system due to a new legislation that made it feasible. Eighteen semi-structured interviews were conducted. Agents situated in different parts of the organization were interviewed one year before and two years after the free-choice system was launched in 2010. Data showed a top-down political process. A majority of the intentions of the legislation advocated individual autonomy as the market system's main purpose; only one concerned organizational efficiency. Data reflected, however, that financial efficiency dominated the agents' experiences of the implemented system. The twofold market purpose was clearly reflected in the interviews. Front-line staff hoped for improvements mainly for the users, whereas managers mainly focused on the market as a resource allocator.

Development of a Swedish community mental health service market

“…One limit concerns the possibility that we were at the mercy of the informants presenting themselves in a good light, and perhaps the idealistic appearance was just a front. Parallel studies, however, have revealed both a strained market where profits are difficult to make (Andersson et al 2016) and the importance of close relationships with day centre service personnel from the participants' perspective (Fjellfeldt et al 2016), and these previous results suggest that the findings presented in this study can be considered valid. Another limit concerns the selection of only a single case.…”

“…Within the new system, economic compensation accompanied each individual, and providers were to deliver services that could be covered by that money. This study is part of a larger project where expectations prior to and experiences after the launch of the reform among participants, professionals, and policy-makers have been explored in the same municipality (Eklund and Markström 2014;Andersson et al 2016;Fjellfeldt et al 2015Fjellfeldt et al , 2016.…”

Outcomes of a Freedom of Choice Reform in Community Mental Health Day Center Services

“…A related study (Andersson, Eklund, Sandlund, & Markström, 2014) showed that there has been a notably slow establishment of new and alternative providers and only a handful of new organizations, besides already existing publicly run units, existed in 2012 when the data collection was completed. This may be another possible explanation for the low level of interest in moving.…”

Four features of cooptation

“…The practice of user involvement may indeed render beneficial outcomes, but such an alluring concept must be critically investigated. There is an inherent contradiction in political policy, where there is an aspiration to increase user influence and freedom of choice, at the same time as social assistance is increasingly conditioned and the social sector is expected to cut costs (Davies et al, 2014;Andersson et al, 2015). Several researchers have noted that user involvement serves to legitimize the welfare administration, while leaving limited room for service users to exert true influence (see e.g.…”