Participation and Citizenship of Elderly Persons: User Experiences from Finland

Heli Valokivi, MScSocSc

Many research projects have pointed out the difficulties of elderly people and their relatives in coping with the complicated health care and social service system (Baldock 1997, 76; Glendinning 1998, 137-138). Client-centred and flexible services are often the aim of an individual worker, but the practice is often fragmented and inconvenient from the client’s point of view (Ala-Nikkola & Sipilä 1996). The service system in Finland produces more and more specialised and elaborate services, but at the same time the service user is quite confused and often lacks information about the options (Lehto 2000, 35). The person in need may be marginalised onto the edge of the service system or outside it. Her/his full citizenship may be questioned although her/his formal membership status remains unchanged. In this article I will discuss the position of aged clients and their relatives in the local health care and social service system through the concept of citizenship. I examine possibilities and forms of participation, influencing and implementation of citizenship at the grass-roots level. What does user involvement look like from the service user’s point of view?

FINNISH HEALTH CARE AND SOCIAL SERVICE SYSTEM

The Finnish welfare state developed into a Scandinavian social service state during the 1970s and 1980s (Alestalo 1994, 73; Nygren et al., 1997, 16-17). This means that the state and the municipalities are responsible for arranging and producing the health care and social services. The services are produced with public tax money for all citizens either free of charge or against a moderate fee. The municipalities are the main producers of the health care and social services (Anttonen & Sipilä 1996, 96). The reform of the state subsidy system and the implementation of the block grant model in 1993 increased municipal (local) responsibility in decision-making processes. The money received as state subsidy is no longer earmarked to certain purposes, but municipalities can decide independently on how to allocate it (Uusitalo & Konttinen 1995, 5; Sipilä & Anttonen 1994, 52-53).

In the 1990s Finland experienced a deep economic depression with the result that the Finnish welfare state has changed somewhat (Martimo 1998, 67). Public funding has diminished and emphasis has moved from universality to selectivity. In the health care and social services, means testing and differences between local systems have increased (Lehto & Blomster 2000, 173; Martimo 1998, 69-72). The thought patterns and policies adopted during the regression years have remained (Vaarama et al., 2000, 76-84). Especially care services for the elderly are determined according to the existing supply and individual needs-assessments are strictly professionally led (Kröger 2003, 32). There has been a major shift towards weakened universalism on social care services for elderly people (Kröger 2003; Lehto 1998).

The public sector produces both institutional and community-based services in Finland. In public opinion it is considered almost self-evident that the home help services and homes for the elderly are funded and run by the public sector. Traditionally, the emphasis in the care of the elderly has very much lain on the institutional sector. Since the late 1980s, one of the central aspirations in developing the service system has been to decrease institutional care and to support the possibility of living at home as long as possible by improving the community-based services, which includes, for example, support to informal caregivers (Lehto & Blomster 2000, 162). According to the most optimistic views, Finland is not dependent on the unpaid care work by women because the public sector takes part in the care of the elderly (Simonen 1993). The public service system has supported women’s full-time participation in the working life (Kiiski 1993, 16-19). Children are not responsible for the maintenance of their parents, and daughters and daughters-in-law are not publicly considered natural caregivers (Julkunen 1993, 344). Despite this, services have always been produced mostly by the informal sector, spouses, and children (Vanhusbarometri 1999, 50), but this has remained more or less invisible. The informal caregivers have in many cases had to assume the role of supplementing the public services (Anttonen & Sipilä 2000, 175; Julkunen 1993, 344). Since the 1990s informal care by relatives, neighbours, and the voluntary sector has been more systematically included as a part of the service system (Lehto 2000, 34).

The functioning of the Finnish welfare state has been fairly secure and efficient, but there are difficulties in co-ordinating the services and the benefits, due to difficulties in communication and co-operation between the professions and the agencies (Lehto 2000, 33; see also Noro et al., 1992). Fragmented and specialised services operate from different points of departure, and no one is responsible for the entity of the services needed in individual cases, so that the user may receive inappropriate services (Kraan et al., 1991, 77-78; Baldock 1993). Means testing in each domain, especially in the provision of social services has increased (Anttonen & Sipilä 2000, 175). From the citizens’ point of view, the care and services received may be random, fragmented, or non-existent.

CITIZENSHIP OF THE AGED IN THE SERVICE SYSTEM

One of the classical analyses of citizenship is written by T. H. Marshall (1950/1992). He defines citizenship as a full membership in the community. It includes three types of rights: civil, political, and social rights which have been considered as condition of citizenship. According to Ian Culpitt (1992, 6), the theory of citizenship was grounded in the primacy of the practical politics of universal social obligations and rights. Criticism has increased because the active expectations of citizenship have been combined with the passive expectations of welfare entitlements. Bill Jordan (1997, 262) points out that “in emphasising the demands of active citizenship, theorists are (usually unintentionally) strengthening the case of various kinds of exclusion.”

Citizenship has also been defined in other ways. David Phillips and Yitzhak Berman (2001, 22) formulate three strands of definitions of citizenship: (1) liberal or individualistic citizenship based on rights to membership via formal status; (2) republican or communitarian citizenship where membership is achieved by taking an active participatory role in a self-determining community; and (3) libertarian citizenship based on the demand of consumers for publicly provided goods. Multilevel, that is local, national, and transnational citizenship rights and obligations do not exist in separate spheres; rather, there is interplay between them. Citizenship itself becomes fragile. In contrast to Marshall’s initial statement, we have to consider citizenship more as a process and less as a status (Roth 2000, 26-27). Citizenship is one of the core concepts to consider citizen affiliation with different services.

In a welfare state citizens and the state have a specific, though varying, relation. Citizenship is connected with the implementation of solidarity, equality, and equity. It is believed that these are achieved through social policy benefits and services. The benefits and services differ from each other along a continuum of entitlement and eventuality. Established practice, e.g., the discretionary powers of officials, varies according to this continuum for each benefit and service (Sihvo 1991, 52). On the other hand the criticism has been voiced that the considerable responsibility of the state makes citizens and communities passive (see, e.g., Anttonen & Sipilä 2000, 16).

According to Paul Higgs (1995, 544) the concept of citizenship affiliation with old age has to be based on the notions of both public activism and a public sphere in which to act. Citizenship is also linked with everyday participation. In this perspective, dealing with the health care and social service system is connected to the citizen’s rights and the implementation of citizenship. The service system may support the equal participation of individuals as citizens (Hoggett & Martin 1994, 108), or it may fracture citizenship (Hernes 1988a, 200). As citizens, aged clients and caregivers negotiate their rights and the content and delivery of services (Hernes 1988b, 207).

Do the services support the implementation of citizenship or are they an obstacle to it? The notion of citizenship has been brought up as a source of renewal for the welfare state. This has to do with developing a new ‘social contract’ between citizens and the state in the development and delivery of services. The role of the state has changed from the service provider more to funding agent, contractor, regulator, and evaluator (Camilleri 1999, 34). The services are targeted and selected accurately and closely (Anttonen & Sipilä 2000, 176; Vaarama et al., 2000, 84, 97). The recipients are often subjected to these services instead of having their voices heard within the service system. The dominant managerial discourse on care constrains the elderly people’s sense of their possibilities (Aronson 1999, 50).

The structured dependency of older people results from a lack of resources, which in turn prevents participation in society. Lack of participation in society leads to the exclusion and marginalisation of older people. An irony of the citizenship approach is that in trying to overcome structured dependency, many proposals end up homogenising all older people into an undifferentiated group who need to be made equal. In reality citizens are encouraged to take greater personal responsibility for their life situation and needs. However, as those needing health care and social services will discover, at this point they are transformed from consumers into objects of consumption (Higgs 1995, 537-548). Capacity and the recognition of individuality are resources to enforce full citizenship.

The notion of citizenship is linked with the discussion of the quality of life (Phillips & Berman 2001, 22). Social quality is the extent to which citizens are able to participate in the social and economic life of their communities under conditions which enhance their well-being and individual potential (Beck et al., 1997, 3). Community citizenship refers to the possession by members of a community of social and cultural (lesser civil and political) rights and responsibilities as a distinct element of their national citizenship rights. The maintenance of community citizenship rights is conditional upon the community’s social quality (Phillips & Berman 2001, 24-25). David Phillips and Yitzhak Berman (2001, 18) list four continuums of social quality: (1) social-economic security/insecurity, (2) social inclusion/exclusion, (3) social cohesion/anomie, and (4) empowerment/disempowerment. The first refers to the way in which the essential needs of the citizens are met. The second refers to belonging and supportive infrastructures in preventing exclusion. The third concerns the processes which create, defend, and demolish social networks. The fourth concerns enabling people, as citizens, to develop their full potential in order to participate in social, economic, political, and cultural processes.

Legislation, official agendas, the ethical codes of social work, etc., expressly mention the clients’ participation, self-determination, and right to information concerning their own case. Nevertheless, the Finnish health care and social service system can be described as organisation- and authority-centred (Lehto & Natunen 2002, 12-13; Valokivi 2002, 27-28). The lack of client participation in the procedure and decision-making on their own case is often evident (see Metteri 2003a; Metteri 2003b). Aged persons who need health and social care services are often infirm, and their energy level and functional ability are lowered. Their participation is considered through need fulfilment, security and support networks. Their life situations, daily lives and needs act as constraints for their participation. These are people who will not come out in the street to voice their demands, at least not in person. Another problematic point is the lack of information. Information concerning the health care and social service system is fragmented. However, information is the condition to participation in planning, discussing options and making decisions. There is a need for interpreters and arbitrators between the client’s needs and life situation and the health care and social service system and its norms (see, e.g., Aronson 1999, 49-51; Holosko & Feit 1996).

DATA AND METHOD OF THE STUDY

The research data were gathered during a case management (1995-96) project of the action research type, in which the workers built up individual and needs-based service packages in co-operation with clients, their relatives, and the service network. The data for this article were gathered during the first phase of the project, before the implementation of the case management method (see Ala-Nikkola & Valokivi 1997). The target group were the elderly in a rural municipality of approximately 10,000 inhabitants. In the Finnish context such a municipality is considered middle sized.

In this article I will analyse and discuss semi-structured interviews with the aged persons and their relatives. The data and the interviewees were chosen to illustrate the complex involvement of the service users in the context of outpatient services. Within the non-institutional care the aged citizens have possibilities to participate, and there are options in the services. I look at the encounters with health care and social services as experienced and described by the aged clients and the informal caregivers. Their stories contain comments and evaluations of places, professionals, and service practices (Morgan 2000, 209). The research questions are: What do the elderly and their caregivers tell about encounters with the local health care and social service system? What kind of services do they receive and how did service use begin? How can they participate in and influence the services? How is their citizenship defined and how do they define it at the grass roots level, in the local health care and social service system?

The data used in this study consist of 13 semi-structured interviews; five elderly persons as care recipients (in one interview, the interviewee’s son was present) and eight caregivers of whom four were wives (in one interview, the spouse was present), two daughters and one daughter-in-law, and one volunteer neighbour. The interview themes were Everyday life, Services, Changes in services, Experiences with the different places of the service system, Needs, Hopes, and Advocate or Case Manager. The elderly, who were cared for at home, needed help in their everyday activities, from preparing meals and washing up to getting into bed. Five of them lived alone in an apartment, and eight lived with their spouse or another relative. Their ages varied from 80 to 94 years. All the wife caregivers were also aged.

The position and participation possibilities of the aged persons and their caregivers are in the focus of this study. The analysis looks for descriptions of encounters with the health care and social service system, of experiences with different service providers and of the individual service paths. Are the users partners or bystanders, actors or objects? The research looks for the forms of participation and influencing which Shemmings (1995, 43) have called participatory practices, and for the limits and possibilities of participation and collaboration. The research approach is a dialogue between a data-based analysis and a conceptual reasoning (Eskola & Suoranta 1998, 83; see also Sherman & Reid 1994). The implementation of the qualitative analysis emphasises the voice of the service users (Gordon et al., 2000, 204-208; McLean Taylor et al., 1995, 27-33).

In the first phase of the empirical analysis, the interview data were read as an entity. After becoming acquainted with the data, the researcher formulated questions from the data for a more detailed reading: How did the service use begin? What kind of encounters have the interviewees had with the local health care and social service system? How do they participate in negotiating, planning and decision-making? Are they active actors or do they withdraw? The data were coded according to these questions. Asking such questions allows an observation of the differences and similarities between individuals, roles and positions. By doing this, the use of the active and the passive voice could be reviewed. The researcher then generated data categories and concepts from and with the data, using coding as a means of achieving this (Coffey & Atkinson 1996, 26-27, 46-47). After coding and formulating analytical data categories and concepts from the data, the analysis looked for the voice of the aged speaking and acting or withdrawing in the descriptions (Rogers et al., 1994, 10). When is the speaker an active actor and doer, and when a passive object? Adopting a bottom-up approach, the researcher sought the grass-root level citizenship, its forms and conditions. The final focus of the analysis was to clarify differences in the modes of participation.

HOW DID THE USE OF THE SERVICES BEGIN?

In this section the interviewees’ descriptions of how the use of the services started will be reviewed. How does one begin to use the services? Who takes an active role? What is the process of contacting the local health care and social service system like? In the data there are four perspectives into the beginning of the services. These analytical categories are: personal initiative, activity of relatives, drifting and disagreement.

Personal Initiative and Need for Help

As one grows older, it is sometimes difficult to realise the increasing need for help in everyday life. Asking for help is not a simple matter, as is described by the aged man in the first extract.

The need for help may be hard to recognise and admit, and it may be difficult to ask for help. Where to ask? Who to contact? What are the alternatives? And who will provide the service? The health care and social service system is often unfamiliar and complicated. Service providers are not among the people one knows. This perspective has to do with the basic everyday needs and social security. The interviewee says that he needs help in order to manage. To get the help he needs in daily life, the aged person must ask for it from an outsider, an unknown person, when his own social network offers no help or there is no network. In relation to the system, the interviewee is distant and quite powerless, not a member nor a real consumer.

Activity of Friends or Relatives

In many cases a vigilant relative or neighbour is the first one to realise the need for help and services. The elderly themselves may often be comparatively passive, mostly due to their weakened or limited capacity. In the next extract the relative is active in arranging the services needed.

This interviewee was hesitant about being sent home at discharge and she admitted the need for help. The aged woman was active in making an assessment of her need and authorised her family member to seek for it. Her social network was there to support her and act on her behalf. The aged person may also reject the thought of service. In such a case the relative or informal caregiver may experience pressure from both directions. S/he assesses and sees the need for service, but the aged person her/himself is against the offered service and may refuse it. Finding out about the possibilities and discussing these with the aged person may be arduous. In such a case the caregiver or the relative has to negotiate with the aged person, other relatives or friends and the service providers.

Sometimes the actions taken do not lead to the desired outcome from the user’s point of view (neither the care recipient’s nor the caregiver’s), as can be seen in the next extract told by a daughter-in-law caregiver. She describes the care negotiations and arrangements during her and her husband’s absence.

In this extract the service offered does not meet the expressed need. The aged Taimi and her relatives prefer to arrange help at home while the relatives are away on holiday. After finding out about the alternatives, they “came up with this idea of employing someone” to meet their service need. The health care and social service system offers only short-term institutional care. The interviewee knows the two managers of the local social service system so well that she calls them by their first name. Despite this familiarity and active contacts, the daughter-in-law is unable to arrange the service which the family would prefer, and their suggestion is bypassed. The interviewee seeks for support and a solution which would ensure the needed care for her aged mother-in-law and would allow her to carry out her full participation in her social network. The service system does not offer a user-led solution. The users are objects of ready-made services. The system places the applicants before a ‘take it or leave it’ situation. Genuine options are not offered. A certain extent of social security is provided, but other dimensions of the quality of life are bypassed.

Drifting into the Use of Services

A number of aged persons describe the beginning of service use as drifting into it. Without being active themselves, they have things happen to them, as is described by the aged lady in the next extract.

Coping independently would be the most desirable circumstance for the interviewee. When this is no longer possible, someone has contacted the home help agency, though she does not know or remember who it was. This is quite understandable for an aged person in need of help with her everyday coping. The interviewee describes how “they just came,” meaning the home help advisors. The aged woman is an object for the decision-making process and services. She withdraws from participation, and other actors intervene on her behalf. The need for help entails dependency on others and on the system and loss of one’s personal freedom of activity. With help and assurance from others, her basic needs are met.

Disagreeing and Dissatisfactory Initiation

In some cases the service offered does not meet the need or the expressed expectation of the aged person or the caregiver. The aged man in the next extract was visited daily by home helpers after his discharge from the hospital, but they could not spend much time in one place. The time spent with him was not satisfactory, according to his son.

In this case the aged man and his son are dissatisfied with the preparation for and content of the service. The son criticises the service system for having failed to contact, inform, and negotiate with them. Another reason for criticism is that the service did not meet the need expressed by the aged man and his relatives. He did not need help with shopping, but something else. The well-being and social quality aspects of the aged man’s life situation are not responded satisfactorily. Further on, the father and son adopt the role of a consumer (see Extract 11).

In all cases the initial phases were characterised by a relatively strong orientation to the system. The workers act as gatekeepers of a stable choice of services (cf. Cnaan 1994, 547). The constraints for the activity are rigid. The needs expressed by the aged persons, their caregivers and their family members are filtered through the constraints posed by the system, with the result that some of the needs will be met, while certain needs and citizens are left without support or services. Do services increase or decrease one’s citizenship? At any rate, the descriptions of participation are not equal among themselves. Services to which entitlement is achieved through formal status are offered, and from the consumer angle, ‘take it or leave it’ choices are offered, but the participatory dimension remains insignificant.

PARTICIPATION IN THE SERVICES

In this section I will bring up modes of participation as described by the interviewees and analysed and conceptualised from the data. The modes of participation in negotiation and decisions concerning the services and their form and intensity can vary from (1) passive disengagement from the process to (2) contacting, (3) negotiating and co-operating, (4) demanding, and finally to (5) active disengagement.

Passive Disengagement

The first mode of participation is to withdraw passively. People in need of services may disengage from the services because of a lack of capacity or will to take part in planning and decision-making. In the next extract the aged wife caregiver adopts a distant role.

The wife caregiver tells that on the husband’s discharge from hospital she has not been in contact with the institution or vice versa, although her own health is weak. She is acting very passively. She is satisfied with the “decision” made by the service provider and takes it for granted. She is an object for the system. She finds no way of intervening and makes no effort to do so. Neither the needs of the aged caregiver nor her possibilities to take care of the husband’s needs are verbalised. No one finds out whether help is needed at home. The aged couple is outside all aspects of social quality. Their citizenship can be described almost non existent.

Contacting

The second mode of participation is that the aged person contacts a service provider, but does not assume an active role during subsequent events. In many cases an aged person contacts the service provider to inform over questions concerning everyday situations.

The aged man receives home help regularly. In an unexpected situation he phones the home help advisor. The advisor arranges help for that day by making the visit herself. Here the aged man makes an contact with the service provider, acting as an informant. He has no other demands or complaints. After the first contact the service provider sorts the matter out and the aged man has no further active role. The responsibility and organisation are assumed by the worker. This episode can be defined through consumerism, where an existing agreement breaks down and the situation is resolved once a contact has been made.

Negotiating and Cooperating

The third mode of participation is to negotiate and cooperate with service providers.

In a situation involving the mother’s discharge from short-term institutional care, the daughter negotiates with the service provider. The condition of the daughter caregiver is considered (in contrast to Extract 6). They agree on the date of the next short-term period according to the daughter’s level of coping. The daughter is involved in the process of negotiating, planning, and decision-making. She has adopted an active participatory role in encounters with the service system as an actor (cf. communitarian citizenship). The caregiver and the service provider co-operate and are equally active. The caregiver refers to ‘we’ as a team. The responsibility for arranging the services needed and the complex supporting the caregiver’s coping is divided equally.

Demanding

The fourth mode of participation is to present demands in negotiations and decision-making processes. The caregiver herself may be active and demanding:

The interviewee considers that she is entitled to the services which she regards as suitable for her and her husband. It is only a matter of making a phone call. And if necessary, she contacts whoever is needed to achieve the decisions she wants:

The interviewee uses very strong I-language (“I’ve got,” “I’ll just keep nagging,” “I go as high up as I need to”). The counterpart ‘they’ refers to the service system and the workers there. Unlike the caregiver in the previous extract, this interviewee makes no reference at all to ‘us’ as a team. If necessary, she is ready to contact the director of the entire social service department, and does so, too. She not only negotiates, but also makes demands. Her expectations on the service providers are definite and unquestioned. She adopts the role of a consumer (cf. libertarian citizenship). The services are instruments for coping well with everyday life and for caring.

In the next extract, a very determined caregiver leaves her mother at the hospital:

The interviewee describes how her mother’s condition gets worse, and she is forced to take her mother to the hospital and to leave her there. She is not negotiating, but acting her demand and carrying out her will in a situation where she sees no other alternative. Her voice is heard through her action.

Active Disengagement

In many cases the aged persons and their relatives or caregivers settle for the services offered. In the active disengagement mode of participation, people in need of help may disengage from the (public) service system due to dissatisfaction and a personal decision to do so. In the next extract dissatisfaction with the offered service leads to other arrangements for the necessary help:

Because the father needed more help than he received from and could be arranged by the home help agency, they decided to employ a private nurse. ‘They’ refers either to the aged man, his son and daughter-in-law or to the son and daughter-in-law. They withdraw from the public service system, and they are dissatisfied with the contribution of the service system. They justify their expectation by their entitlement. As citizens and consumers they decide to stop using and buying the public home help service and to buy the necessary service elsewhere, although the new arrangement is much more expensive for them. They decide to empower themselves by adopting the strong role of a consumer.

Some of the aged interviewees point out that they have done their part in their deal with the state, and they demand the state and the service system to take care of their part. They justify their expectations by saying that they have paid their taxes and helped build up the community. They may be disappointed with the lack of consideration and attention shown by the municipality. In such cases the interviewees describe the situation practically as a contract between themselves as citizens and the municipality (cf. liberal citizenship).

ADVOCATES

The aged persons may have limitations; they may lack the capacity, information, aspiration, etc., for making an initiative, negotiating and demanding the support and services needed (cf. Rose & Black 1985). Who act as the advocates for such persons? In the interviews both relatives or friends and workers within the local health care and social service system are described as advocates for individual aged persons and in certain situations. In the next extract the aged man’s informal support network includes two advocates:

The interviewee’s most important caregiver and advocate is the lady next door. She takes care of matters related to his everyday care and visits him on a daily basis. She is the first person whom he contacts concerning the need for help and any changes in it. The important role of the volunteer neighbour is interesting because the man is also visited daily by home helpers. Another advocate is a relative of his. Their contact is more intermittent, but it is described as a protection and security. The aged man’s own role is quite passive and withdrawn.

In the next two extracts the advocates are from the formal service system. The aged person describes and seeks allies within the service system. The advocate may be from the social services or from the health sector.

The manager of the home for the elderly is the advocate for this aged man. He describes elsewhere how the manager has previously arranged a rehabilitation period for him. He trusts the manager because of the earlier experience, but the trust is also based on the fact that the manager is a good person and suited for her work. The interviewee describes encounters with the manager as consisting of discussion, and he has an active role in negotiating issues with her. They have a cooperative relationship (cf. communitarian citizenship). In the second case the advocate is from the health care sector:

In this extract the doctor of the wife caregiver negotiates by phone with the manager of the ward on which her husband is treated. The wife caregiver is in bad health herself, so her doctor recommends that the short-term institutional care arranged for her husband should start earlier, and this is in fact arranged. Compared to the previous extract, this describes more formal act of advocacy even though both advocates are from inside the service system. Within the encounter with the doctor the interviewee has a passive role. The doctor of the wife caregiver assumes the responsibility of arranging the short-term period on the basis of the wife caregiver’s level of coping.

An aged person may cede some or all of her/his rights as a citizen–perhaps the right of speech and the responsibility for actions to either a family member or friend, or to a worker in the health care and social service system. Some aged persons retain their active role, while others assume the passive role of ‘recipient.’ Workers as advocates know the service system and the service network. Relatives and friends are usually very devoted to their close one. If a relative or a friend acts as an advocate for an aged person, co-operation between workers and the advocate is essential (Kraan et al. 1991, 186-187; cf. Cnaan 1994, 544).

DISCUSSION

If a person’s functional ability or will to participate are lowered, how can their citizenship be realised? The role of an active citizen is not the only way to realise one’s citizenship. However, the inclusion of citizens whose functional ability or willingness are lowered requires that the system and the workers in it have a sensitive ear. The risk of objectifying and by-passing the citizen is always present. One answer is to consider citizenship as a cooperative phenomenon, where individual needs are taken into account and citizens are helped to reach social quality and participation according to their ability and will. This cooperative citizenship as a process consists of all three strands of definitions of citizenship: liberal, communitarian, and libertarian (cf. Phillips & Berman 2001).

In my research data the interviewees’ descriptions of encounters with the local health care and social service system contain different definitions of citizenship and implementation of social quality. Within the encounters, the professionals may support the notion of citizenship, or they may regard the service users as objects of the system. What consequences should this have for the current work practices of the service system?

As John Baldock (1993, 3) has formulated it, “no one is likely to oppose the principle of participation in home care. Everyone is in favour of the idea that frail old people and their carers should be able to express their needs and play a part in the planning of their care.” He defines two different models of achieving participation. The first is the managed home care model which is profession-led, and the second is the laissez-faire model which is user- and consumer-led. Both models recognise a right for users to participate in the design and production of their care. How people are assessed for care and how that care is organised is related to user participation. According to my data both models are needed in practice.

As consumers or users, citizens participate by making choices between services, by enhancing the content and degree of services, and by facilitating consumer rights. The truth of this statement can be questioned. Does the consumer or user want to develop the services? (Niiranen 1998, 328). They may be satisfied with ‘good enough’ services. Vuokko Niiranen (1998, 329) formulates two aspects of participation: individual and communal. In the individual aspect the citizen is a user of services and s/he has a consumer’s rights to make choices. In communal participation the citizen is a member of her/his community and a committed partner. The consumer participates and criticises the service system from the outside and exits it when there is disagreement (cf. Extract 11). A member participates and criticises from the inside and uses his/her voice while negotiating and demanding (cf. Extracts 8 and 9).

In the context of the local health care and social services, citizenship rights and obligations and participation should be defined flexibly and individually. In my research data the aged persons and their caregivers described participation in multiple ways. The modes of participation varied from passive and active disengagement from the process and contacting to negotiating and co-operating or demanding. In passive disengagement the citizen withdraws passively, and in active disengagement s/he withdraws due to deciding actively to do so. In the mode of contacting, the citizen informs the service system without intending to assume an active role in the future. In negotiating and cooperating the citizen is involved in the planning and decision-making processes. In the demanding mode the citizen presents demands in encounters with service providers. The aged persons and their caregivers had actively chosen their mode of participation or had been driven into one. This brings up several questions and perspectives to be considered by the local health care and social service system. Given that the system needs to be open and recognise different modes of participation, questions related to these aspects should be asked during encounters with individual citizens: Is the client’s mode of participation desired and helpful or detrimental? How can a helpful mode be achieved and supported? What are the individual needs and how can the service system fulfil them?

Most of the interviewees were frail aged people, regardless of whether they were care recipients or caregivers. Their individual life situation varied according to capacity, resources and health. Still, they exhibited multiple modes of participation. Their individual needs were satisfied by the local health care and social service system to a varying degree. Encounters with the service system should be defined from the bottom up, starting from the individual’s life situation and capacity. Similarly, the implementation of citizenship with the aged persons and their caregivers is a multiform phenomenon. In my research data, different strands of definitions of citizenship could be found in the local context. The citizenship of aged service users may be examined as a process which supports co-operative citizenship.

Relationship and emotions are core concepts in encounters with the elderly (Austin 1996, 168-169). Advocacy work aims to support, encourage and empower the clients, so that they may participate in decision-making concerning their own case (Hugman 1991, 139; see also Rose & Black 1985; Dant & Gearing 1990, 345). A decision-making process which lies close to the client and involves his/her participation is crucial for ensuring a full participation and social quality (Braye & Preston-Shoot 1995, 80).

To ensure client participation in the service process, there should exist an alliance between the client and the worker. Alliance means a mutual commitment to supporting the client’s coping and to responding to her/his needs. The client should be truly heard and included in the negotiations and decision-making, according to the aged person’s or caregiver’s desire to participate or withdraw. Client participation can be achieved contractually. The service user is included as an equal partner in the service process. The aged person may transfer or delegate discretionary or decision-making power to a worker or an informal advocate or keep it under her/his own control. Alliances are based on mutual trust, which is an empowering element in client work. With help from the advocate, the aged person is a more equal partner in making an agreement. Individual participation and control over it are the condition for enforcing the processes of citizenship rights and obligations.

NOTE

1. All the names of persons, places and institutions have been changed. F is female interviewee, M is male interviewee, and R is researcher; [author’s comment], (blurry word) and … means interview continues from a later part.

REFERENCES

Ala-Nikkola, M., & Sipilä, J. (1996) Yksilökohtainen palveluohjaus (case management)–uusi ratkaisu palvelujen yhteensovittamisen ikuisiin ongelmiin [Case Management–a new solution for the eternal problems of co-ordinating services]. In A. Metteri (ed.) Moniammatillisuus ja sosiaalityö. Sosiaalityön vuosikirja 1996. [Interprofessional Collaboration and Social Work. Yearbook of Social Work 1996] Helsinki: Edita & Sosiaalityöntekijäin Liitto, 16-31.

Ala-Nikkola, M., & Valokivi, H. (1997) Yksilökohtainen palveluohjaus käytäntönä. Loppuraportti sosiaali-ja terveydenhuollon palvelujärjestelmää ja yksilökohtaista palveluohjausta (case management) koskeneesta tutkimuksesta Hämeenkyrössä ja Tampereella [Case Management as a Practice. Final Report of the Study on the Service System and Case Management at Hämeenkyrö and in Tampere]. Jyväskylä: STAKES raportteja 215.

Alestalo, M. (1994) Finland: The Welfare State at the Crossroads. In N. Ploug & J. Kvist (eds.) Recent Trends in Cash Benefits in Europe. Copenhagen: The Danish National Institute of Social Research, 73-84.

Anttonen, A., & Sipilä, J. (2000) Suomalaista sosiaalipolitiikkaa [Finnish Social Policy]. Tampere: Vastapaino.

Anttonen, A., & Sipilä, J. (1996) European Social Care Services: Is It Possible to Identify Models? Journal of European Social Policy 6 (2), 87-100.

Aronson, J. (1999) Conflicting Images of Older People Receiving Care. In S. M. Neysmith (ed.) Critical issues for future social work practice with ageing persons. New York: Columbia University Press, 47-70.

Austin, C. D. (1996) Case Management Practice with the Elderly. In M. J. Holosko & M. D. Feit (eds.) Social Work Practice with the Elderly. Toronto: Canadian Scholars’ Press, 151-175.

Baldock, J. (1997) Social Care In Old Age: More Than a Funding Problem. Social Policy Administration 31 (1) March 1997, 73-89.

Baldock, J. (1993) Participation in Home-based care. Paper in Innovation and Participation in Care of the Elderly–Italy meets Europe. Rome May 20-22, 1993.

Beck, W., van der Maeson, L., & Walker, A. (1997) Introduction. In W. Beck, L. van der Maeson & A. Walker (eds.) The Social Quality of Europe. Hague, Netherlands: Kluwer Law International, 1-13.

Braye, S., & Preston-Shoot, M. (1995) Empowering Practice in Social Care. Buckingham: Open University Press.

Camilleri, P. (1999) Social work and its search for meaning: Theories, narratives and practices. In B. Pease & J. Fook (eds.) Transforming social work practice. London: Routledge, 25-39.

Cnaan, R. A. (1994) The New American Social Work Gospel: Case Management of the Chronically Mentally Ill. British Journal of Social Work 24 (5), 533-557.

Coffey, A., & Atkinson, P. (1996) Making Sense of Qualitative Data. Thousand Oaks: SAGE Publications.

Culpitt, I. (1992) Welfare and Citizenship. Beyond the Crisis of the Welfare State? Guildford, Surrey: SAGE Publications.

Dant, T., & Gearing, B. (1990) Keyworkers for Elderly People in the Community: Case Managers and Care Co-ordinators. Journal of Social Policy 19 (3) July 1990, 331-360.

Eskola, J., & Suoranta, J. (1998) Johdatus laadulliseen tutkimukseen [Introduction to Qualitative Research]. Tampere: Vastapaino.

Glendinning, C. (1998) Conclusions: Learning from abroad. In C. Glendinning (ed.) Rights and Realities. Comparing new developments in long-term care for older people. Bristol: The Policy Press, 127-142.

Gordon, T., Holland, J., & Lahelma, E. (2000) Making Spaces: Citizenship and Difference in Schools. Chippenham, Wiltshire: Macmillan Press ltd.

Hernes, H. M. (1988a) Scandinavian Citizenship. Acta Sociologica 31 (3), 199-215.

Hernes, H. M. (1988b) The Welfare State Citizenship of Scandinavian Women. In K. B. Jones and A. G. Jónasdóttir (eds.) The Political Interests of Gender. Oxford: SAGE Publications.

Higgs, P. (1995) Citizenship and Old Age: The End of the Road? Ageing and Society 15: 535-550.

Hoggett, P., & Martin, L. (1994) Consumer-Oriented Action in the Public Services. Working Paper No.WP/94/23/EN European Foundation for the Improvement of Living and Working Conditions.

Holosko, M. J., & Feit, M. D. (eds.) (1996) Social Work Practice with the Elderly. Toronto: Canadian Scholars’ Press.

Hugman, R. (1991) Power in Caring Professions. Houndmills: Macmillan.

Jordan, B. (1997) Citizenship, association and immigration: Theoretical Issues. In M. Roche & R. van Berkel (eds.) European Citizenship and Social Exclusion, Ashgate: Aldershot, 261-272.

Julkunen, R. (1993) Sosiaalipolitiikkamalli, sukupuoli ja hoivatyö [The Model of Social Policy, Gender and Caregiving Work]. In O. Riihinen (ed.) Sosiaalipolitiikka 2017 [The Social Policy 2017]. Juva: WSOY.

Kiiski, S. (1993) Naisten työttömyys lisääntyy, mutta nainen pysyy työvoimassa [The Unemployment of Women Is Increasing, But Women Are Staying in the Labour Force]. Hyvinvointikatsaus 3, 16-19.

Kraan, R. et al. (1991) Care for the Elderly. Fankfurt am Main: Campus Verlag; Boulder, Colorado: Westview Press.

Kröger, T. (2003) Universalism in Social Care for Older People in Finland–Weak and Still Getting Weaker. Nordisk Sosialt Arbeid 1, 30-34.

Lehto, J. (2000) Saumaton palveluketju mosaiikkimaisessa järjestelmässä [Seamless Chain of Services in a Mosaic-like System]. In S. Nouko-Juvonen, P. Ruotsalainen & I. Kiikkala (eds.) Hyvinvointivaltion palveluketjut [Service Chains in the Welfare State]. Helsinki: Kustannusosakeyhtiö Tammi.

Lehto, J. (1998) Muuttuuko pohjoismainen sosiaali-ja terveyspalvelumalli? [Does the Scandinavian Health and Social Service Model Change?] Yhteiskuntapolitiikka 63 (5-6), 413-424.

Lehto, J., & Blomster, P. (2000) Talouskriisin jäljet sosiaali-ja terveyspalvelujärjestelmässä [The Traces of Economic Crisis in the Social Services and Health Care System]. In H. Uusitalo, A. Parpo & A. Hakkarainen (eds.) Sosiaali-ja terveydenhuollon palvelukatsaus 2000 [Social Welfare and Health Care Service Review 2000]. Stakes Raportteja 250. Helsinki: Stakes, 161-184.

Lehto, J., & Natunen, K. (2002) Johdanto [Introduction]. In J. Lehto & K. Natunen (eds.) Vastaamme vanhusten hyvinvoinnista. Sosiaali-ja terveyspalvelujärjestelmän sopeuttaminen ikääntyneiden tarpeisiin [We Are Responsible for the Well-being of the Elderly. Adapting the social welfare and health care system to meet the requirements of the elderly]. Helsinki: Suomen Kuntaliitto [the Association of Finnish Local and Regional Authorities], 11-14.

Marshall, T. H., & Bottomore, T. (1950/1992) Citizenship and Social Class. London: Pluto Press.

Martimo, K. (1998) Community Care for Frail Older People in Finland. In C. Glendinning (ed.) Rights and Realities. Comparing new developments in long-term care for older people. Bristol: The Policy Press, 67-81.

McLean Taylor, J., Gilligan, C., & Sullivan, A. M. (1995) Between Voice and Silence. Cambridge, Massachussetts, London, England: Harvard University Press.

Metteri, A. (ed.) (2003a) Asiakkaan ääntä kuunnellen. Kitkakohdista kehittämisehdotuksiin [Listening to the voice of the client. From pitfalls to practice strategy developments]. Helsinki: Edita.

Metteri, A. (ed.) (2003b) Syntyykö luottamusta? Sairastuminen, kansalainen ja palvelujärjestelmä [Sickness and the system: Citizens’ needs]. Helsinki: Edita.

Morgan, S. (2000) Three prisoner’s stories. Talking back through autobiography. In J. Batsleer & B. Humphries (eds.) Welfare, Exclusion and Political Agency. London & New York: Routledge.

Niiranen, V. (1998) Kuntalaisten asiakkuus ja osallisuus järjestöissä–kooptaatiota, säästöjä, osallisuutta–vai jotain muuta? [Clienthood and Participation of Municipal Residents in Organisations–Co-opting, Savings, Participation–Or Something Else?] Kunnallistieteellinen aikakauskirja 26 (4), 326-336.

Noro, A., Aro, S., & Jylhä, M. (1992) Vanhuksen sairaalasta kotiuttaminen henkilökunnan ja potilaan näkökulmasta. [The Discharge of an Old Person from the Hospital in the Viewpoint of the Personnel and the Patient]. Helsinki: Sosiaali- ja terveyshallituksen raportteja 71.

Nygren, L. et al. (1997) New Policies, New Words–the Service Concept in Scandinavian Social Policy. In J. Sipilä (ed.) Social Care Services: The Key to the Scandinavian Welfare Model. Aldershot: Avebury, 9-26.

Phillips, D., & Berman, Y. (2001) Social quality and community citizenship. European Journal of Social Work 4 (1), 17-28.

Rogers, A. G., Brown, L. M., & Tappan Mark B. (1994) Interpreting Loss in Ego Development in Girls: Regression or Resistance? In A. Lieblich & R. Josselson (eds.) Exploring Identity and Gender. The Narrative Study of Lives. Volume 2. Thousand Oaks, London, New Delhi: SAGE Publications, 1-36.

Rose, S. M., & Black, B. L. (1985) Advocacy and Empowerment: Mental Health Care in the Community. London: Routledge & Kegan Paul.

Roth, R. (2000) Changes of New Local Policies in European Cities-time of Civil Society? In A-L. Matthies, M. Järvelä & D. Ward (eds.) From Social Exclusion to Participation. Laukaa: University of Jyväskylä, Department of Social Sciences and Philosophy, Working Papers no 106, 19-40.

Shemmings, D. & Y. (1995) Defining participative practice in health and welfare. In R. Jack (ed.) Empowerment in Community Care. Bury St Edmunds, Suffolk: Chapman & Hall, 43-58.

Sherman, E., & Reid, W. J. (eds.) (1994) Qualitative Research in Social Work. New York: Columbia University Press.

Sihvo, T. (1991) Kansalaisuus ja sosiaalihuolto [Citizenship and Social Services]. Helsinki: Sosiaali-ja Terveyshallitus, Tutkimuksia 9/1991.

Simonen, L. (1993) A Woman’s Place Is Home? Transformations of the Welfare State in the 1990s Finland. In H. Varsa (ed.) Shaping Structural Change in Finland. The Role of Woman. Helsinki: Ministry of Social Affairs and Health. Equality Publications Series B: Reports 2, 137-145.

Sipilä, J., & Anttonen, A. (1994) Finland. In A. Evers, M. Pijl & C. Ungerson (eds.) Payments for Care. A Comparative Overview. Aldershot: Avebury & European Centre Vienna, 51-66.

Uusitalo, H., & Konttinen, M. (1995) Sosiaali-ja terveyspalvelujen kehitys laman vuosina: yhteenvetoa ja tulkintoja. In H. Uusitalo & al Sosiaali ja terveydenhuollon palvelukatsaus [Social Welfare and Health Care Service Review]. Jyväskylä: STAKES Raportteja 173, 1-10.

Vaarama, M., et al. (2000) Vanhusten palvelut. In H. Uusitalo, A. Parpo & A. Hakkarainen (eds.) Sosiaali-ja terveydenhuollon palvelukatsaus 2000 [Social Welfare and Health Care Service Review 2000]. Stakes Raportteja 250, 75-98.

Valokivi, H. (2002) Ikääntynyt kansalainen ja omainen sosiaali-ja terveyspalveluissa johdon kertomana [Aged Citizen and Relative In Health and Social Services Told by Mangement]. In J. Lehto & K. Natunen (eds.) We Are Responsible for the Well-being of the Elderly. Adapting the social welfare and health care system to meet the requirements of the elderly. Helsinki: Suomen Kuntaliitto [the Association of Finnish Local and Regional Authorities], 15-30.

Vanhusbarometri 1998 [Old Age Barometer] (1999) Sosiaali-ja terveysministeriön selvityksiä 1999:3, Helsinki: STM.

Heli Valokivi is Research Fellow, Department of Social Policy and Social Work, FIN-33014 University of Tampere, Finland (E-mail: [email protected]).

[Haworth co-indexing entry note]: “Participation and Citizenship of Elderly Persons: User Experiences from Finland.” Valokivi, Heli. Co-published simultaneously in Social Work in Health Care (The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc.) Vol. 39, No. 1/2, 2004, pp. 181-207; and: Social Work Visions from Around the Globe: Citizens, Methods, and Approaches (ed: Anna Metteri et al.) The Haworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2004, pp. 181-207. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].