Combining activity and economic efficiency? The view of Danish local policy actors on rehabilitation in elderly care

Barbara Fersch, PhDAssistant professor, Centre for Comparative Welfare Studies (CCWS), Aalborg University

Introduction

Although not being a new thought or idea, the concept of rehabilitation did recently rise very high on the agenda in Danish elderly care. In Denmark, the municipalities are responsible for the provision of elderly care, which is a universal service. That means that the municipalities are responsible for the organization and the financing of long-term care. Thus, although bound by national law, they do have a quite big influence on the actual policy making in the field. The empirical material this paper draws upon are qualitative interviews with local policy actors in two Danish municipalities, i.e. actors on the municipal level that are dealing with and / or have a certain influence on local long-term care policy. Thus, the research design and especially the choice of interviewees has been inspired by research and literature on local governance (e.g. Burau and Kröger 2004; Damgaard 2006), that is emphasizing the role and relevance of the analysis of local policy processes. The interviews have been collected as a part of a research project on the differences in the local organization of elderly care in Denmark. One of the purposes of the qualitative interviews was to identify the

Abstract:In the Danish welfare state, long-term care is a universal service that is run by the municipalities. The municipalities, although bound by a national legal framework, do have considerable autonomy concerning the concrete definition and organization of long-term care services. One of the newest “hot” concepts in Danish long-term care is (everyday-) rehabilitation of the frail elderly, which several municipalities have tried out in pilot projects and otherwise introduced over the last couple of years. The paper draws upon qualitative interviews with administrative leaders and local politicians in three Danish municipalities and discusses their understandings and expectations of the concept. A lot of the interviewees in the study, especially those from administration, refer to rehabilitation as a very promising concept within the field of elderly care. Rehabilitation is thereby presented as some kind of all-in-one solution everyone is profiting of: The older people would profit from a higher quality of living, that enables a

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understandings and interpretations of the local policy actors on what “good care” is, how it can be organized and how future challenges can be met. In the context of the financial challenges that are expected in the future due to the demographical development (more older people) and financial pressures on municipal budgets, a lot of the actors have mentioned rehabilitation as the concept that they expect to contribute most to solve future challenges in long-term care. Interestingly enough, although these actors, concerning other topics, do present very diverse understandings and interpretations (see for example Fersch & Jensen 2011), concerning rehabilitation they nearly appear to speak with one voice. In this paper I want to present how the local policy actors present the topic of rehabilitation, and discuss why they evaluate it as an especially attractive solution. I will apply an argumentative discourse analysis (Hajer 2010) in order to identify the discourses the interviewees are drawing upon, thereby clarifying the “sources” for the tempting powers of rehabilitation. Thus, international and transnational discourses within the field of social policy and ageing will be taken into account. At the same time, in the analysis I will anchor the findings in the specific Danish social policy context, thereby especially taking a recent structural reform in the landscape of elderly care into account.

Data, methodology and methods

As mentioned above, the interviews have been collected in the context of a research project on differences in the local organization of elderly care. The project’s research design is based on comparative case design logic (Antoft & Salomonsen 2007). The interviews used for this paper originate from two cases, i.e. two municipalities that resemble each other with regard to several structural characteristics, including the tax base, debt, degree of urbanization and the percentage of frail elderly who have chosen a private home-care provider. Differences can be found, however, regarding population size and how much

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money the municipalities spend per senior per year on elderly care (Indenrigs- og Sunhedsministeriet 2011). The two municipalities also differ from each other when it comes to local policies, organizational structures, and practices concerning the introduction of privatization and choice (Fersch & Jensen 2011). ) At the time of the interviewing, both oft he two municipalities were running some pilot projects on rehabilitation in the field of elderly care, including “every-day” rehabilitation through home care staff and training possibilities outside of the home. However, those pilot projects were not going on for a very long time in both of the municipalities.

As local policy actors, the interviewees are all people that are in one way or another involved with local senior politics or administration: We interviewed two elected politicians (1), that is, the chair of the municipal senior committee and one other member of the committee. Additionally, we interviewed the chair of the local senior board (2). The local senior board consists of elected seniors and has an advisory function for the municipal council in all questions concerning older people. Moreover, in one municipality (in the paper called municipality A) we did interview the (3) chairman of the local division of a national interest and volunteer group of older people (Ældresagen). In each of the municipalities we interviewed as well the chair of the user board of one of the municipal elderly care homes (4). Another source has been the municipal administration; here, we have interviewed (5) the chief executive in the social administration (including elderly care) and overall head of all of the administrative staff interviewed; (6) the head of the care assessment unit. The care assessment unit has a dual role in at the one hand assessing care needs of the individual frail elder persons and at the same time controlling the quality of services provided by privat and public home care providers; (7) the head of the municipal elderly-care unit, who is the overall head of all municipal providers of elderly care; this municipal elderly-care unit is usually subdivided into sections (district organizations) and we have

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interviewed the head of one of those (8). Thus, summing up, we interviewed 17 local policy actors in the two municipalities.

As mentioned above I analysed the interviews with the help of argumentative discourse analysis. Following Hajer, this specific from of discourse analysis is especially useful in the context of policy analysis. Discourses are here defined as a set of ideas, concept and categories, that gives meaning to certain phenomena. In his conceptionalisation, Hajer is especially interested in the capacity of discourses to problematize, which is how they frame and define problems.1 Here, he especially sees the relevance of discourse analysis for the study of policies. (Hajer 1993)

One feature that distinguishes Hajer's approach from others (like the one of Laclau& Mouffe (1985)), is that the analysis of discourses here is inextricable entwined with certain practices. Central to the analysis are three elements, namely discourse, practices and meanings. One goal is to identify the meaning of the “argumentative rationality” (Hajer 2010, 276, author’s translation) that the actors are drawing upon in their accounts. In this paper this is the focus of the analysis (see below).

The core methodical “tool” in Hajer’s approach to discourse analysis is the concept of the “story-line”2: A story line combines several discursive elements to a (more or less) coherent narrative, being the continuous thread in the actors’ accounts. Another central term is discourse coalition:

A discourse coalition is thus the ensemble of a set of story line, the actors that utter that utter these story lines, and the practices that conform to these story lines, all organized around a discourse. (Hajer 1993, p. 47)

1 Foucault (1984) has used the term ”problematization”. Hajer’s approach is in general based on a Foucaultian understanding of discourse and problematization.

2 Hajer’s methodical approach has been inspired by narrative analysis. (Andrews et.al. 2008)

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In this paper I am mainly interested in the storylines that can be found in the interviewees’ accounts in order to identify the argumentative rationality of the latter. The aim is to identify the discursive sources, to clarify which elements are set together in the story lines, and how the storylines are combined.

Rehabilitation: Concepts and contexts

So, what is meant by rehabilitation in elderly care in this paper? One reason the term rehabilitation is used here is that many interviewees use it themselves. Some of the interviewees, however, use terms like”training” and”prevention” instead. However, what they mainly refer to with those terms is the provision of rehabilitative and self-help measures in the provision of home care services for older people, and, much more seldom, to the training and rehabilitation facilities the elderly can use in the given municipality.

Hannsen & Sandvin (2003) write about the concept of rehabilitation in general it was “traditionally a correcting and repairing practice, anchored in the modernistic vision of the European welfare state” (ibid, p. 24). They state about the concepts’ historical development, that it at least dates back to World War One, when the large number of injured and mutilated war veterans led to the establishment of diverse rehabilitation measures.The first policy programme on rehabilitation was introduced in Great Britain after World War Two, being worked out by the so called Tomlinson-committee.

The main principles suggested by Tomlinson, inspired by the scientific rationalism of the time linked three successive elements: medical in-patient rehabilitation, medical out-patient rehabilitation (outside hospitals) and vocational rehabilitation. (ibid, p. 26)

However, Hannsen & Sandvin describe a gradual turning away from this strictly medical definition of rehabilitation:

[...] we have over the last couple of years witnessed a gradual widening of the perspective, from merely focusing on the restoring of bodily functions, to incorporating a stronger emphasis on participation, quality of life and the

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realization of individual goals. Hence, the scope of rehabilitation practices, and the range of professionals involved, has been substantially extended. (ibid, p. 25)

The forms of rehabilitation so intensely talked about by the interviewees appear to refer more to the latter described new forms of rehabilitation, as they do not refer to specific medical rehabilitation measures, but a more generalised effort to keep people fit or make them, fit again. According to Kümpers et al. (2010) such forms of rehabilitation did recently come on the agenda in long term care for elderly people all around Europe. In this context the authors provide the following definition:

“Preventing the person from becoming ill or frail in the first place” – primary prevention; “Helping someone manage a condition as well as possible” – secondary prevention; “Preventing a detoriation in an existing condition” – tertiary prevention; and “Providing active support to help someone regain as much autonomy and independence as possible”. (ibid, p. 5)

As one of the results in their comparative study of implementation of such prevention and rehabilitation measures in several European they describe two layers of prevention and rehabilitation in long-term care, with the first layer containing “old” and “traditional” rehabilitation measures, like e.g. preventive medical check-ups, medical rehabilitation, physio / ergo-therapy and the like. Their second layer includes

the direct and indirect preventive/rehabilitative potential inherent in organisational elements, such as elements of coordination and organisation, transition processes between services or the quality of services themselves along the individual long-term care pathway of a client. (ibid, p. 25)

The specific form of rehabilitation this paper focuses on, namely measures for older people, who already receive, or have applied for care services, can easily be subsumed under this second layer.

As mentioned above, in Denmark, elderly care (including home care and stationary care in a nursing home, practical help as well as personal help) is a universal, mainly tax-financed service. The municipalities bear the responsibility

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for providing these services and have, although bound by national law, a quite big leeway in how to organise them. Concerning elderly care, one could say, (nearly3) everything is in one hand, i.e. the one of the municipality. Thus, as Kümpers et al. (2010) point out from a comparative perspective, in Denmark the municipal level of governance does have a quite high level of steering capacity. Based on the findings of their comparative research they argue that in such contexts with strong local steering capacities it is easier to implement second-layer rehabilitation measures, as there are no conflicting interests of several actors, a setting they find in countries with a more fragmented care service landscape (like for instance in Germany and Austria). And the Danish municipal reform of 2007 seems to additionally have increased the local steering capacity when it comes to the topic of prevention and rehabilitation: The 2007 reform transferred the responsibility of all rehabilitation measures taking place outside of hospitals to the municipalities. Additionally the municipalities became responsible for all prevention and health promotion efforts. All the more, financial incentives have been installed as well – with the reform the municipalities became obliged to pay an amount to the regions (which are the level of governance responsible for health care and the operation of hospitals) depending on their citizens’ use of health care and hospitals in their municipality. Thereby successful rehabilitation-, prevention- and health promotion efforts should be rewarded. (Indenrigs- og Sunhedsministerium 2005).

Rehabilitation, prevention and the principle of helping people to help themselves are not in the least new things in Danish home care. Helping the elderly to help themselves has been one of the basic principles in the Danish national legislation on the delivery of home care since the 1980s. (Hansen et al 2011) Also, already in 1984 the municipality of Skævinge introduced an integrated health and social care model, with rehabilitation and prevention as fundamental pillars for the

3 Only nearly everything because there are private provider of home care. However, price and quality regulation and payment remains in the hand of the municipality.

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provision of home care. ( Billings & Leichsenring 2005). However, it was only until recently that the topic came heavily on the agenda. Amongst other things, the above named municipal reform of 2007 can give reasons for that (see as well conclusions).In this paper I argue that discourses of activity in gerontology and social policy, amongst other things, provide a very good context for the promotion of rehabilitation and prevention measures in elderly care. In the following section I am going to provide an overview over this development.

Activity in old age

In his analysis of the concept of activity within gerontology, Stephen Katz (2000) states:

The association of activity with well-being in old age seems so obvious and indisputable that questioning it within gerontological circles would be considered unprofessional, if not heretical. The notion of activity, a recurring motif in popular treatises on longevity since the Enlightenment, today serves as an antidote to pessimistic stereotypes of decline and dependency. (ibid, p. 135)

However, this has not always been the case: In his contribution, Katz traces the development of activity as a theoretical concept and an empirical and professional instrument in gerontology (predominantly focussing on the development in the North America). He revisits the old dichotomy of disengagement and activity theory in social gerontology. Atchley (2006) puts it as follows:

In the gerontology of the 1960s, activity theory and disengagement theory became opposing metaphors for successful aging. In the case of activity theory, the archetype portrayed an older person who had managed to maintain vigor and social involvement despite the vagaries of aging. For disengagement theory, the archetype image was of an older person who had voluntarily and gracefully disengaged from the hustle and bustle of midlife to a more serene and and satisfying contemplation of life from a distance. These dualistic images of two very different paths of aging have been part of Western civilization for a long time. (ibid, p. 9)

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Katz describes how subsequently in the 1960s and 1970s activity theory has “won” the battle and become the dominant theory in the field of Northern American gerontology. Later on, activity theory has also become heavily criticised by scholars of various disciplines in social gerontology. The influence of activity theory, however, persists, Katz argues, because it has become translated to policy programmes and practices in a lot of professions concerning old age:

[...] the enduring legacy of activity theory is that it provided a conceptual space for the ideal of activity to emerge and circulate expansively within aging studies and among those professions where new roles in recreational counselling, health promotion , and rehabilitation theory were being created. In other words, activity survives activity theory as a core discourse within gerontological studies [...] (Katz 2000, p. 139)

Active ageing, the now “leading global policy strategy in response to population aging” (Walker, p. 75) has, following Walker (2002) its roots in the above described activity theory as well. In the beginnings mainly located in the US, it became debated mainly concerning employment issues under the label of “productive aging” in the 1980s. (ibid)Following Walker’s account on the development of active aging as a discourse on the EU-level, it becomes clear, that in the 1990s (the time he dates the travelling of the concept to Europe) active aging mainly was a discourse connected with older workers and employment issues. However, later on, the World Health Organization (WHO) adopted the approach in a broader interpretation in an influential policy paper. The WHO defines active aging as

[...] the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age. Active ageing applies to both individuals and groups. It allows people to realise their potential for physical, social and mental well-being throughout their lives and to participate in society according to their needs, desires and capacities, while providing them with adequate protection, security and care when they require assistance. (WHO 2002, p. 12)4

4 It is rather noticeable how closely active ageing became connected to quality of life. I will come back to that topic later on in the analysis.

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Health and social services, including care, became topics addressed to be addressed as well by active aging strategies (WHO 2002). Subsequently, the EU also broadened the scope of their active aging concepts and included health issues. However, it remains an umbrella term encompassing a lot of strategies, ideas and initiatives. (Walker 2007).

The focus on activity, however, is not a topic exclusive to policies in the field of ageing. As Katz puts it:

It is not only the medical and cultural images of an active old age that have become predominant, but also the ways in which all dependent nonlaboring populations – unemployed, disabled and retired – have become targets of state policies to “empower” and “activate” them. The older social tension between productivity and unproductivity is being replaced with a spectrum that spans activity and inactivity. (Katz 2000)

This development has also been describe by scholars within other fields of social policy: Inspired by the Foucauldian concept of governmentality, Newman (2007) argues in an attempt to generalize from the field of active labor market policy on broader welfare state developments, that there has been the rise of self governance as a value and norm driven mode of governance in the field welfare state and social policy. Following Newman, this consists of “new subject positions associated with active citizenship” (ibid p. 369) being “at the centre of the normative dimensions” (ibid p.369) of the new welfare and social policy programmes.

Analysis: Local Policy actors’ view of rehabilitation

In this section I want to present the analysis of the interviewees’ account when it comes to the topic of rehabilitation. Analyzing how they spoke about the topic I want to trace what elements of which discourses they included and how and in which way they utilized certain storylines in order to argue in favor of rehabilitation measures.

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It was part of the research design to include inductive and deductive elements in the qualitative interviews. This means that several subjects have been chosen in advance to be included in the interview guide but there has as well been an emphasis on open questions and sensitivity towards subjects that have been raised by the interviewees themselves. Rehabilitation was one of the subjects that has not been in our focus before and thus came into the analysis as a topic in an inductive, bottom-up way.

Interestingly enough, a lot of the interviewees have brought it up in the context of the demographic development: The interview guide included a very open question about what the interviewee thinks about the demographic development in the context of elderly care. Here, many of the interviewees did present rehabilitation as a central solution to expected future problems on the financing of care because of the (expected) rising number of older people in their municipality (and everywhere)5. Thus, one of the first and main reasons the interviewees give for their enthusiasm about rehabilitation is routed to a discourses about economic efficiency (as e.g. promoted by managerialism (e.g. Clarke et. al. 2000) and New Public Management (NPM) (e.g. Ferlie et al 1996)). Indeed, two main story lines can be found in the interviewees narratives that include elements and arguments from two different discourses, namely the above discussed activity discourse and the also very dominant discourse from the world of managerialism. The following table provides a short overview:

“Storylines” on rehabilitation in the interviewees’ accounts

Activity Economic efficiency

Situation, Recipients of care services The “demographic challenge”,

5 Another solution named less frequently by many interviewees was an expanded use of new technological inventions in elderly care.

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Problem, Reasons

have a lack of quality of life, because they are dependent on others.

older people in the future will cause problem for the municipal finances, if they will have the same care services demand as the older people today.

Solution Rehabilitation measures will strengthen the quality of life of older people, because they can gain self-determination, independence, freedom and self-satisfaction.

Rehabilitation measures will reduce the number of care recipients or prohibit that care recipients will gradually get a higher demand. The municipality will save money.

Obstacle for solution

Care recipients and care staff do have the wrong attitude: Care recipients do not have the right motivation. Care workers do not have the right attitude towards the care recipients and help too much.

In the next sections I will discuss the two storylines in more detail.

The story line of economic efficiency

The reason why many of the interviewees put rehabilitation and training measures at the heart of their ideas of how to solve the future challenges in elderly care is that they expect it to save a lot of money. These measures are expected to help the elderly to get a better state of health and thus they will need less or even no home care services at all in the long run. Like the chairman of the senior board in municipality A states, it is the expectation that

the number of people who will really be in need of help is going to be lower... (Chairman of senior board, municipality A)

This is an expectation others share at well:

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All this (rehabilitation B.F.) thinking […] is certainly a combination of providing a better quality for the elderly on the one hand. But it of course also a way to bring down rate of cost increase a bit. I don’t think we can avoid cost increase because there will be more elderly. But maybe we can bring it down a little. (Head of social administration mucipality A)

Here we can already see how elements from the cost-efficiency and the activity storyline are combined. This is even explicitly stated by the interviewee and we will see later on that this combination is rather common in the interviewees account. Thus it seems that the two storylines joined together in one discourse coalition. However, it appears that the goal of economic efficiency, and thus the economic efficiency storyline is considered more important and given more importance than the activity storyline.

One head of the municipal elderly care unit talks about experiences they have made with pilot projects running in their municipality:

We have actually experimented with it now for half a year. And there are actually citizens where we (home care workers B.F.) are coming, who actually can do things themselves. Where the son, for example, thinks that we should come and make porridge and when we ask the old man himself, he says he actually doesn’t really like it “but it is my son who thinks that… I could actually very well make me a sandwich or something.” And that is thought-provoking in times in which we have to find a way to use our resources in the right way. And we have to ensure we don’t use the resources wrong. (Head of municipal elderly care unit, municipality A)

At the time the interviews took place there was not much experience with rehabilition programmes in both of the municipalities, as the pilot programs were only running for about half a year. It is notable that the above cited administrative manager (who actually is the over-all boss of all of the municipal long-term care units) illustrates her experiences and the usefulness of their new rehabilitation measures not by an example of how actual training of the older people’s abilities led to a positive result (that is, referring to the activity discourse) but by an example of how resources could be used in a better way (thus referring to the economic efficiency storyline). This seems to confirm as

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well that the storyline of economic efficiency plays an important role in this discourse coalition.

The storyline of activity

However, although I stated above that the storyline of economic efficiency is given a lot of importance in the interviewees’ accounts, the activity storyline does take a lot of space as well. A lot of the interviewees state that rehabilitation measures will improve the quality of living of the elderly by strengthening their self-determination:

[…] it is very important that we do everything for helping people to help themselves, to support the aged with that. On the one hand in order to help them to get a better quality of life. The more you can manage yourself, handle yourself and the more independent you get, the bigger gets the quality of life. And then there is the other, the economical side of it. There is simply not enough money to continue with care like it is right now. And here I think one has spoiled the older people to much. There has been too little focus on at one should train oneself… (Chairman of the senior board in municipality A)

This interviewee, again, emphasized the combination of the two storylines, however with stronger focus on activity. The above cited interviewee is also not the only one who strongly connects activity with quality of life – this proclaimed relationship can be found in many of the interviewees’ statements. Thus, elements of the activity discourse can be found quite directly – as written above, quality of life is at the heart of the WHO’s definition of active ageing.

The head of the district organization in municipality A describes the interrelation like that:

[…] I think actually that most of the people would like to be independent. There are of course always people who think that it is nice [to have home care B.F.], because their only contact to the world is the one that comes from home care. But I think far the most of those who live at home would like to be free of home care, because it gives them the freedom to do what they want. They don’t have to sit there and wait for the home carer to come. And a lot of them think as well that they can do the things better which is surely how it is. Plus

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it gives certain self-satisfaction by being able to take care yourself. (Head of disctrict organisation municipality A)

Thus, many of the interviewees identify several positive consequences of the introduction of rehabilitation and training measures for the elderly themselves, such as self-determination, independence, freedom and self-satisfaction. Those consequences all refer to an active lifestyle, which is depicted extremely positive by the interviewees. This strongly mirrors the rhetoric of the activity discourse (Katz 2000).

Obstacles

However, the interviewees also raise some problems in this context:

Well, we actually do think that it strengthens the quality of life of the elderly to be as self-sufficient as possible. But, clearly, there are some dilemmas as well, because the citizens have contacted home care to get some help and not to get to know that they can do it themselves. (Head of social administration, municipality B)

This quote already implies one of the biggest problems for the implementation and success of the initially highly praised rehabilitation and training measures many of the interviewees talk about, namely the mentality and motivation of the elderly. Some of the interviewees also connect the problem to work practices of the employees in home care. The chair of the senior board in municipality A claims that the elderly are

too spoiled. There is too much service and there is too little help to become self-sufficient. And it can be that the home helper is like the housewife and says that one can do things faster oneself instead of instructing the older people and helping them to do things themselves. This pampering can also come from a shortage of staff or too little money, as the staff can do it much faster themselves instead of teaching the older people. (Chair of senior board, municipality A)

This proclaimed relation between the practices of the home care staff and the mentality (spoiledness) of the elderly is also mentioned by other interviewee, like e.g. the politicians in municipality B:

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And so all of our staff should have a new perspective on their profession, so that it should be forbidden to come in and say “What can I do for you today, Mrs Jensen” It should be “What can YOU do today, Mrs Jensen?” And then Mrs Jensen tells what she can do. And then one can look at what she cannot, what she can get help for. But it should be turned round. (Head of senior committee, municipality B)

We want to turn things around a little bit so that our home carers become upskilled as ... –how can I say this- …trainers instead of caregivers if I can call it that way. So they get involved in maintaining people’s ability and mobility. (Member of senior committee, municipality B)

The head of the municipal elderly care unit in municipality A, who, due to her own work position as the leader of all elderly care units in the municipality, is much closer to the actual work practices of the care workers than e.g. the politicians are, talks a bit different about the problem: Her opinion on this subject is very much informed by what she sees in her daily work as the head of the care workers. All the more, she sees herself as a part of this group, as she refers to it as “we”:

Interviewee: And we also do have an upbringing that if we meet older people, we help them with the clothes. We do it just to be nice. From now on we shouldn’t do that anymore. Here we ourselves have to work on it. Because the more we do the harder it gets for them. The more they do themselves the better they can do it. So here we have a culture that will really undergo a seismic shift one can say. That’s our experience. (Head of municipal elderly care unit, municipality A)

Hence, two obstacles for the successfulness of rehabilitation measures in elderly care are named by the interviewees, namely motivation / mentality of the elderly and the related practices of the employees. In the analysis of the interviews it becomes clear as well, that the obstacles and problems are defined by the interviewees as somehow being the “wrong” attitude by the employees and especially the elderly themselves. What the interviewees refer to is the “ideological” or attitudinal dimension of rehabilitation. One of the interviewees is quite explicit about this and describes rehabilitation as follows:

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It is an overall process that is going on everywhere in the social administration. And every division and unit ought to think “rehabilitation” instead of “compensation”. So, the process that has been put to work is more an ideological one. One in which all divisions individually should try to work out to work with it in order to find out which way to go […] (Head of care assessment unit, municipality A)

Further on, the same interviewee is critical about the huge burden rehabilition is after her opinion placing on the shoulders of the individual home carer:

Well, the biggest joker in rehabilitation is the motivation of people. And that is difficult to alter as a home carer. Well, the motivation to be self-sufficient, where does it come from? Many years ago it was an honour for people not to go on pension. That’s not how it is today, right? They think it is something they have a right to. The motivation to be self-sufficient was much bigger 50 years ago. […] Where is the motivation to be self-sufficient today? How can we work on it? That’s not easy to change by the individual home carer only, I think. I think that is too big a demand… (Head of care assessment unit, municipality A)

Thus it is once again not the practicalities of rehabilitation but the “ideological”, “attitudinal” or motivational aspect that is in the center of her understanding of the concept of rehabilitation.

Having a closer look, the general line of argumentation almost appears as somehow paradoxical: In unison, the interviewees depict rehabilitation extremely positively as bringing a lot of great effects for the older people themselves, like e.g. a better quality of life, freedom, self-determination and self-satisfaction. Thus they are clearly referring to the understandings and the conceptual and ideological underpinnings of the activity discourse. However, it appears in the accounts on obstacles for rehabilitation to be mainly the elderly themselves and their “wrong” attitude that are in the way, despite being understood as the ones that are supposed to profit the most. Thus, an “ideological” or “motivational” change of the elderly seems to be necessary. Obviously their “wrong” attitude seems to make them blind for the proclaimed great gains that, following the interviewees accounts should be in it for them. In the chosen discourse-analytical framework, one could argue that the obstacle the local policy actors are

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identifying is, that the frail older people and the care workers do not embrace the activity discourse (or at least not strong enough).

Conclusions

With the help of discourse analysis, we could trace the argumentative rationality of rehabilitation as a very popular “do-it-all device” amongst local policy actors in Denmark. Thereby the storyline of economic efficiency seems to provide the stronger argument in favor of the implementation of rehabilitation. However, the activity storyline appears to include the moral basics as well as the possible solution to the proclaimed obstacles for rehabilitation measures to unfold their proclaimed great potential. In general in the analysis I show that the two storylines combined have become really “successful” in the context of Danish elderly care.

How is it possible that the two storylines can be so very well combined? Kümpers et al. (2010) have pointed out, that this combination is also to be found all over the EU. However, I am arguing, it is the specific Danish context that especially strengthens this specific discourse coalition: First, a rather extensive local steering capacity seems to be necessary in order to be able to expect financial benefits from rehabilitation, which is the case in Denmark. The municipality is the entity that is both responsible for the over-all planning and the financing of elder care. Thus, the municipal actors can apply a certain holistic approach to the organisation of elder care, which is necessary to see rehabilitation measures as cost efficient in the long run.

The administrative reform of 2007, as stated above, strengthened this connection in the field of elderly care: First, it gave the responsibility of rehabilitative and preventive measures to the municipalities. Second it even installed financial incentives for the municipalities in order to establish rehabilitation and prevention programmes. In other words, here practices were installed that

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conform to the discourse of economic efficiency and, at the same time, reproduce them when it comes to rehabilitation in elderly care. Thus, the strong emphasis on economic efficiency of the local policy actors makes sense.

References

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