Governance, health care & volunteers : a verifiable cure for care? : researching the practices and distribution of accountability in the implementation of the Social Support Act 2015 between formal care managers and vol

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Marissa Buur 106644857

Public Policy and Good Governance Decline of the Welfare State

Supervisor: Benno Netelenbos Second Reader: Robin Pistorius Thesis 229h_{June 2018}

Word count: 21.224

Governance, Health Care & Volunteers

A verifiable cure for care?

Researching the practices and distribution of accountability in the

implementation of the Social Support Act 2015 between formal

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Abstract

This thesis researches the distribution of accountability between voluntary work managers and formal care managers in the implementation of the Social Support Act 2015 in Amsterdam. The Social Support Act 2015 has been a relevant subject of interest because it plays an important role in the recent Dutch welfare reform. The law emphasises the improvement of client’s ‘self-determination’ and participation by relying first on their social informal networks (family, friends or neighbours) or volunteers before they can claim the right to formal care.

As a reaction to the economic crises in the 1980’s and 1990’s policy descriptions were introduced that changed the governing principles of directly elected political control, the administrative roles of public servants and the notion of a passive community in modern welfare states. Ultimately, this has changed the way health-care policies in the Netherlands are governed. The implementation of the Social Support Act 2015 in Amsterdam, is a good example of the complex governing process concerning home care and voluntary work. The law is implemented by a multi-actor network, whereby the civil servants have the discretionary space to contract-out activities to voluntary work organisations. Ideally, it was expected that this would lead to cost-containment and create effective policies adjusted to the local citizens needs and demands. However, governing through networks poses problems with accountability because the voluntary commitment cannot be controlled completely due to its casual unpaid nature.

Two main accountability problems contribute to the complexity of monitoring governing processes. These are the problem of many hands and the weak visibility of the governing process. Consequently, the difficulty lies in the identification of who is responsible for political decisions, whereby ‘the rise of the unelected’ make the governing process less transparent. This threatens the civil servants’ ability to control the organisation of voluntary work within the Social Support Act 2015. In order to research this, ten managers have been interviewed and two network meetings have been attended in the case of Amsterdam.

This research shows that the organisational complexity of the law in Amsterdam has led to the disappearance of democratic accountability, the problem of many hands and the weak visibility of the governing process due to the ‘rise of the unelected’ and the cost-containment measures, effecting the voluntary commitment. Other forms of accountability (legal, social and professional) have taken the place of this democratic accountability. Through courts, client associations or the manager’s expertise citizens pose more trust in these actors rather than the elected city council. These three accountability forms are important for the citizens to hold the city council and other actors involved to account.

In practice the implementation is based on trust in relationships and interdependence. However, this research shows that the high demand for volunteers, cost-containment and the increase of complex cases creates dynamic shifts in accountability. The voluntary work managers and volunteers sometimes face the challenge of dealing with complex cases, while formal care organisations are the responsible actors. Therefore, volunteers and voluntary work managers take the responsibility for these clients, while they haven’t got the obligation nor the professional accountability to do so.

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1. Introduction

1.1 Subject

This thesis entails a research about the distribution of accountability between voluntary work managers and formal care managers in the implementation of the Social Support Act 2015 in Amsterdam. Evidently, the complex nature of the Social Support Act network has been mapped, aiming to understand how practices of accountability take shape focusing on the improvement of the voluntary commitment.

The Social Support Act 2015 has been a relevant subject of interest because it plays an important role in the recent Dutch welfare reform. The law emphasises the improvement of client’s ‘self-determination’ and participation by relying first on their social informal networks (family, friends or neighbours) or volunteers before they can claim the right to formal care. The Social Support Act 2015 is a framework law, whereby the national government has set general guidelines and decentralised the tasks, which the local councils can implement in accordance to the citizen’s local needs.

The law deems to be a challenge because of the complexity of the law, the many involved actors (with their own tasks and responsibilities), the discretionary space for the local interpretation of the law, the lack of experience with equivalent developments and the loss of democratic legitimacy.

1.2 Modernising welfare states

Since the 1970’s ideals such as New Public Management (NPM), then governance and ‘active citizenship’ have been put into motion in order to deal with the welfare crises in Europe. NPM introduced the ideal of less government focusing on the privatisation of public services by independent providers and improving the quality through cost-efficiency with performance management targets (Power 2013: 58 & Skelcher 2000: 7 & Pollitt 2015: 1309). In the 1990’s these market-based solutions were replaced by governance, which involves a complex dynamic interaction between multiple public and private actors (such as citizens, civil society associations and business) to create public policies (Skelcher 2000: 3). Finally, active citizenship occupied a big role in the modernisation of welfare states (Newman & Tonkens 2011: 9). The role of self-responsibility and empowerment within communities was emphasised to achieve community action in public policy (Iskanian & Szreter 2012: 4 & Power 2013: 58).

Mature welfare states have transformed their public policies by implementing these characteristics to enhance the effectiveness and efficiency in the health-sector. In the Netherlands the health-care reform was deemed necessary by the national government due to the rising welfare costs caused by an ageing population and the disengagement of citizens from informal care-giving tasks and the alienation of disabled and elderly citizens from mainstream society (Grootegoed 2014: 146). In order to contain these rising welfare costs and to ‘activate’ citizens to take part in the Dutch ‘participation society´ by providing informal care, the access to long-term care has been restricted to the most severely disabled without a social informal network (idem).

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1.3 Problem

In the home care sector budget-cuts and decentralisation affect the way the Social Support Act 2015 is governed. Due to these developments, local councils have to work together with private and public organisations, voluntary work organisations and citizens, to make home care realisable with the limited financial resources. Consequently, the demand for volunteers is growing because clients have to rely on volunteers or their social informal care network before they are granted the right to formal care.

The implementation of the Social Support Act 2015 within a governance network focusing on the voluntary commitment develops challenges for accountability practices. Firstly, the problem of many hands implies that public policies are created in complex networks of actors whereby the difficulty lies in the identification of who is responsible for political outcomes in order to establish accountability. There are many actors involved whereby policies have been passed through many hands before they are put into effect (Bovens 2007: 458). Secondly, governing through networks creates a weak visibility of the governing processes. This is problematic because the elected politicians cannot be held accountable because there is a congruence between the ‘front-stage’ and ‘backstage’ processes of public policy making (Papadopoulos 2013:4). Civil servants who implement the policy in a complex care network rely on actors who are not democratically chosen and contract out voluntary activities, which they can’t control effectively. This poses a potential threat to the democratic accountability within the democracy, because activities within the law are contracted-out to voluntary work organisations. This makes it difficult for civil servants to control the voluntary commitment, because of its unpaid non-committal nature.

As a home care worker in Amsterdam, I became interested in the distribution of accountability, because I have seen in practice how the importance of care networks has increased since the implementation of the law.

Many studies have mostly researched the relationship between care professionals and volunteers. They have hardly addressed the role of accountability between formal care managers or voluntary work managers who organise activities according to the Social Support Act 2015 in Amsterdam. Therefore, the central question in this research is: ‘How does accountability take shape in the organisation of voluntary work in the Social Support Act 2015 in Amsterdam?’.

Researching the care network turned out to be more complex than expected due to the weak visibility of the governing process and the problem of many hands due to the many involved actors. In my approach to the research problem I have tried to map out the actors who are involved with the voluntary commitment in Amsterdam and how they see and experience accountability in the relationships. In order to answer the research question ten care managers have been interviewed from voluntary work organisations, home care organisations, the city council of Amsterdam, ‘Cliëntenbelangen’ and a Social Support Act Supervisor. Furthermore, I also attended two network meetings in the borough of Amsterdam South involving many care managers from different local organisations.

The voluntary work managers and formal care managers are deemed to cooperate in the care network in order to organise voluntary work. This is because clients are nowadays more dependent on their own social informal network and volunteers and less dependent on formal care (SCP 2012: 152).

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To get a better understanding, it is therefore necessary to research both voluntary work managers and formal care managers in the care network.

The city of Amsterdam was chosen as a single case study, because the city council as an actor is held accountable for the quality and execution of the Social Support Act 2015, but in practice is mainly realised through multi-actor networks.

From the data it becomes clear that governing the home care through networks in Amsterdam is challenging. On the one hand, there is the institutional complexity due to the presence of market forces and administrative practices in a network of many involved actors. On the other hand, accountability problems arise such as the problem of many hands and the weak visibility of the governing practices. Consequently, accountability is distributed amongst many actors but becomes problematic when it is passed on to volunteers who are not even responsible for care tasks or are even allowed to have this responsibility.

1.4 Readers guide

The content of the next six chapters, will contribute to the formulation and answering of the research question. In chapter two the theoretical framework is presented. This chapter provides an overview of the developments such as the transformation from a big government to a congested state, along with NPM characteristics and the emphasis on ‘active citizenship’ that have contributed to the complexity of governing through networks in Europe and more specifically within the Dutch health-care reform.

In chapter three the methodology of the research and the methodological choices (during the research process) are described. It will provide arguments about which choices have been made and the reason why.

Then a description of the implementation of the Social Support Act in 2015 is presented in chapter four. The formulated goals and expectations of the law are introduced on the national level. Then an overview is provided about the implementation of the law in Amsterdam, focusing on the voluntary commitment and neighbourhood teams.

In chapter five the organisational complexity of governing through networks in the Social Support Act 2015 is explained, while also describing the accountability problems and challenges that arise in this process. In this chapter mainly the collaboration between the civil servants, the voluntary work managers and formal care managers are described.

In chapter six an analysis about the voluntary commitment within the framework of the Social Support Act 2015 is provided. This includes a description of the voluntary commitment in Amsterdam and the main problems that arise within the implementation of the law.

Finally, chapter 7 will present the conclusion of the research whereby an answer to the research question will be formulated.

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2. Transforming public policy

This chapter describes the developments that have occurred in Western-European welfare states and specifically in the Netherlands whereby policy-making processes and policy-implementation have shifted from a traditional bureaucracy to a ‘congested state’. It will provide an overview of the developments of New Public Management, governing through networks and the rise of ‘active citizenship’. Then the implementation of NPM, governing through networks and the ‘participation society’, which changed the public policy-making and implementation processes in the Netherlands, shall be described.

It is argued that the congested state creates problems for the democratic accountability due to the multi-actor partnerships and an uncertain accountability environment of public policy-making processes. Consequently, other forms of accountability arise and two main accountability problems such as the problem of many hands and the weak visibility of the governing process shall be discussed. In addition, a debate is presented about the increasing reliance on the voluntary commitment within the Netherlands. This is necessary, in order to understand how governing through complex networks creates problems with accountability practices and its consequences on the voluntary commitment in the Social Support Act 2015.

2.1 From big government to the congested state

In the West-European context many countries have gone through multiple developments, which have changed their way of governing public policies in comparison to the traditional hierarchical top-down governing structure. From the 1950’s to the 1970’s the welfare state emerged, epitomised by large bureaucracies, expanding agendas for public action and growing state expenditures. In this period the ‘Big government’ (the traditional hierarchical organisation of national politics) had to deal with increasing responsibilities of the public sector. The complex nature of public policy cause-effect relationships where threatening the legitimacy of the governments. The governments were overloaded with responsibilities and demands, which they could not meet satisfactorily. The European welfare states along with the Keynesian economic management ideals were not producing the expected results. The large welfare bureaucracies were in crises, because they had over-reached themselves (Skelcher 2000: 4).

2.1.1 Changing governing principles

As a reaction to this crises, policy descriptions were introduced that changed the governing principles of directly elected political control, the administrative roles of public servants and the notion of a passive community in the 1980’s and 1990’s (Skelcher 2000: 5).

Firstly, in the 1980’s the characteristics of New Public Management (NPM) were introduced in the Anglo-Saxon world in response to the criticism of centralised welfare-type model of governing services. Less government became the prevailing idea. This focus on ‘not rowing, but steering’ opened up market opportunities for independent providers in delivering public services and to reduce state provision (Power 2013: 58).

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NPM introduced two main ideals, namely: the privatisation of management and public programmes from primary (elected bodies) to secondary (appointed) agencies with the accompanied responsibilities and the focus on improving the quality of public policies through cost-efficiency, contracting out services or performance management and measurement techniques (Skelcher 2000: 7 & Pollitt 2015: 1309).

Secondly, market-based solutions to the problems of the government were being replaced in the 1990’s by more collaborative models and practices of social organisation named ‘governance’, taking part in an extensive range of public policy programmes (Skelcher 2000: 3). Governance involves a complex and dynamic interaction between multiple national, regional and local authorities, private actors such as citizens, civil society associations, and businesses. Consequently, within these governance processes new forms of horizontal and vertical coordination have developed bringing relevant actors from public and private sector together in order to solve problems. This also means that responsibilities have shifted top-down from national governments to regional and local authorities, but also side-ways to public and private sectors (Skelcher 2010: 73). Skelcher (2000) introduces this development as the ‘congested state’ implying an environment in which high levels of organisational fragmentation combined with plural modes of governance require the application of significant resources to negotiate the development and delivery of public programmes (12). In others words, the hierarchical bureaucratic organisational structure is replaced by a complex network of (tertiary) relationships between public, private, and community actors creating a dense multi-layered and largely impenetrable structure for public action (Skelcher 2007: 4). This means that tertiary partnerships manage, integrate and steer the activities of the primary and secondary bodies such rather than the primary (elected) or secondary (appointed) bodies (Skelcher 2000: 12). This transition from traditional bureaucratic steered governments to the congested state has created problems of democratic legitimacy and accountability for public policies.

2.1.2 Accountability

Governing through networks in a congested state imposes accountability problems in public policy-making processes. Accountability in general terms is a social relation between an actor and a forum, in which the actor has an obligation to explain and justify his or her conduct. The forum poses questions and passes judgement and the actor may face consequences (Bovens 2007: 450). Accountability is of great importance because it ensures the legitimacy of the public policy made and lets the actors explain and justify their intentions in which citizens and interest groups can pose questions (Bovens 2007: 462).

Two main accountability problems are discussed in this thesis. The first accountability problem is the ‘problem of many hands’. Public policies are made in complex networks of actors. Because many actors contribute to public policies in many different ways, the difficulty lies in the identification of who is responsible for the outcomes. These policies have passed through many hands before they are put into effect whereby decisions are often made in committees and across multiple desks before they are implemented. Therefore, it is difficult to unravel who has contributed in what way to the conduct of the agency to the implementation of a policy, and who and to what degree can be brought into account for it (Bovens 2007: 458).

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The second problem of accountability is the weak visibility of the policy process within a governing network. Papadopoulos (2013) claims that there is a congruence between the spheres of ‘front-stage’ and ‘back-stage’ politics, each of them operating to a distinct logic (3). This is because, the highly mediatized political party competition doesn’t have much in common with the complex policy-making processes that largely escape the public attention (idem). Democratic accountability is important to provide a democratic means to monitor and control government conduct, for preventing the concentrations of power and to enhance the effectiveness of public administration (Bovens 2007: 462). However, policy procedures in networks are often informal, opaque and therefore deemed to facilitate the achievement of compromise. Therefore, the transition from a traditional top-down bureaucracy to a multi-actor network changes the ideal of democratic accountability, because the networks are weakly exposed to public scrutiny or the scrutiny of democratic representative bodies. Moreover, those who are authorized to govern have deliberately delegated some of their power to the hands of actors who evade democratic accountability (Papadopoulos 2013: 4). There is an increasing policy-making role for bodies that are not democratically chosen. This creates a disjunction between the increasingly distinct logics of the spheres of politics and policy-making (idem). The elected politicians lose much of their relevance in situation where policy-making is increasingly negotiated because political systems face a range of functional pressures that limit their scope for steering (idem). However, with the disappearance of democratic accountability, other forms of accountability have emerged. In this research the focus lies on professional accountability, social accountability, hierarchical and legal accountability (Bovens 2007: 454-458).

2.2 International budget-cuts and ‘active citizenship’

Mature European welfare states face pressures of growing needs and limited resources resulting in international pressure to cut health-care budgets. This is because, the growing longevity and the rising number of the elderly have changed the ratio between the working and non-working populations. The old age dependency ratio put pressure on public care spending, the supply of care labour and the intergenerational social contract (Grootegoed 2013: 165). Furthermore, the imperative of economic competitiveness in a globalised market has urged the welfare states to adapt their public policies to financial developments such as the recent economic crises in 2007-2008. Along with the introduction of NPM characteristics and the ‘congested state’, the notion of ‘active citizenship’ has occupied a big role in the modernisation of European welfare states (Newman & Tonkens 2011: 9).

In the light of Big Society, European welfare states have responded to these crises by emphasising the role of individual responsibility and empowerment within communities in order to achieve community action in public policy (Iskanian & Szreter 2012: 4 & Power 2013: 58). It idealises the claim that citizens or agents know their needs better than the government, so therefore the citizens are freed from the ‘unnecessary bureaucracy and red tape’ in order to make a real difference in their communities through voluntary participation (Iskanian & Szreter 2012: 4). Citizens now act in domains that were formerly the realm of the state and focus on improving the quality of the neighbourhood in terms of quality of life and safety (Pennen & Schreuders 2014: 137). In the health-care domain ‘active citizenship’ inquires a bigger emphasis on the citizen’s own responsibility for self-care, the care of others and for the well-being of the community (Newman & Tonkens 2011: 9).

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Citizens are therefore encouraged to participate and become more ‘self-determined’ by anticipating on their own care needs, rather than passively consuming rights provided by the welfare state (Grootegoed 2013: 166). In addition, citizens are encouraged to participate in public policy deliberations or service developments, or to contribute to an ever-expanding array of governing through networks and partnership bodies (Newman & Tonkens 14).

2.3 Dutch home care reform

The ideals of NPM, ‘the congested state’, international budget-cuts and active citizenship on European level have influenced the way public policies are governed in the Netherlands. In order to deal with the ‘welfare crises’ modern Dutch (health) care policies contain elements of these ideals.

The health-care reform was deemed necessary by the national government due to the rising welfare costs caused by an ageing population and the disengagement of citizens from informal care-giving tasks and the alienation of disabled and elderly citizens from mainstream society (Grootegoed 2013: 146). The NPM-characteristics were introduced into the health-care, because it was thought to enhance greater cost-efficiency, consumer choice and effective quality service provision (Oomkens et al. 2016: 400). Performance-based contracting is a key component of NPM whereby financial or material rewards are based on achievements or measurable actions, which are related to predetermined performance targets. In the period of 2003 and 2005 the Netherlands broke with its generous and comprehensive long-term care schemes and implemented cutbacks in publicly financed care and current beneficiaries (Grootegoed 2013: 167).

The home care sector has been one of the sectors where these new developments have been implemented. The national government deemed the privatisation of the home care system necessary in order to operate more efficiently, with the expectation that market liberation would end waiting lists, reduce costs and improve the quality of the care (Staveren 2010: 2). The government believed that the existing publicly financed model, mainly focused on supply regulation and contained limited incentives for high quality and efficient provision of the home care sector. Moreover, the existing system was claimed not to be efficient enough, lacked transparency and patient orientation with limited space for innovation (Oomkens et al. 2015: 869).

Another development in the reform of the Dutch home care sector was decentralisation. Decentralisation shifted the responsibility for the implementation of home care policy from the national government to the local governments. The ideal of decentralisation was to redistribute authority, responsibility and financial resources to local governments, and local public-private actors in order to provide public services, whereby the policies could be adjusted to the local problems and citizen’s needs (Power 2013: 58 & Tonkens 2016: 61). Moreover, institutions, organisations and professionals who co-govern these home care policies receive more discretionary space to deliver custom fit care, without being troubled by national laws or expectations from the national government. However, according to Abma (2016) the ‘colonising’ trends from the system remain. This means that cost-control, the emphasis on measurable output and control remain central values in a system of facilities (2016: 26).

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2.4 Emphasising the voluntary commitment

Not only NPM characteristics and governing through networks gained more attention by the Dutch government, but also ‘active citizenship’ as discussed in paragraph 2.2. In the Netherlands the national government claimed that the citizen involvement had decreased and therefore the ability to take care of people in their own social network (SCP 2012: 152). In the Netherlands the most recent public policies have been formulated with strengthening the citizen’s informal social network and the voluntary commitment as one of the main goals. This idea is that ‘self-determination’ and ‘participation’ are essential in placing the responsibility for care from the government to the citizens. It was thought that improving the social cohesion between citizens could decrease the claim the right to formal care (SCP 2012: 256). Not only are citizens expected to be responsible for each other or their own informal social network, they are also expected to improve the neighbourhood’s facilities (SCP 2012: 259). On the community level, citizens are encouraged to be policy-engaged by providing answers for local problems with their knowledge and energy (Pennen & Schreuders 2014: 137). It particularly stresses a communitarian idea of citizenship of taking responsibility for social care in your family and your community, both as a family member and as a member of the local community (Newman & Tonkens 2011: 45). Even though the government focuses on the role of volunteers and informal social carers, in reality this ideal seems more difficult to implement.

Firstly, is there a debate about whether the voluntary commitment can be exhausted even more, because the Netherlands already has a culture of strong voluntary commitment. Almost half of the Dutch population carries out voluntary work (Tonkens et al. 2017: 8) However, within the contemporary context of the activating participation society and the ageing population the amount of volunteers needs to increase in order to make this possible. In the Netherlands women, elderly people and highly educated citizens mainly execute unpaid voluntary work. However, there is a debate whether the growing emphasis on the informal carers and volunteers is realisable, because especially intensive care tasks are causing strain and stress on the volunteers and informal carers (Gier, d. 2009: 19). With the introduction of the Social Support Act 2015 volunteers have to deal with more complex cases concerning citizens with psychiatric or long-term illnesses. On the one hand the reliance on volunteers is claimed to be restricted by the time and space citizens have to commit voluntary activities, on the other hand volunteers are more confronted with the complex cases. Therefore, it is questioned whether the expectations of citizens ‘participation’ can be achieved (Pommer & Boelhouwer 2016: 335).

Secondly, it creates a dilemma concerning the distribution of tasks. In most collaboration there is clarity about the task distribution between professionals and volunteers. Generally, professionals execute tasks concerning physical or medical care, administrative tasks or coordinating tasks, while volunteers have limited additional tasks such as social care (keeping clients company or doing small tasks around the house). However, volunteers are trusted by the formal care organisations to execute tasks professionals normally do (Tonkens et al. 2016: 29). In other words, the role of volunteers is partly shifting to an increasing replacement of professionals.

Finally, volunteers have made a shift from classical volunteers to ‘new volunteers’. The classic volunteers committed themselves unconditionally for the long-term but are being replaced by the volunteers who are mainly focused on self-development. Eliasoph (2011) introduces the plug-in volunteer who comes and goes whenever he or she wants.

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This ultimately has consequences for professionals who work with volunteers, because of the contemporary character of the voluntary commitment (Eliasoph 2011: 117).

2.5 Social Support Act 2015 and conceptual puzzle

As described in this chapter multiple ideals and developments have changed the way welfare states create and implement public health policies. The Netherlands has implemented these ideals and developments in the home care sector, namely The Social Support Act 2015. In this law the elements of NPM, governance, activating citizenship and decentralisation are combined in order to create a more cost-efficient and democratic, well-functioning home care possible. In this thesis the organisation of the Social Support Act 2015 has been examined, focusing on the voluntary commitment. The law is mostly governed through networks with NPM characteristics and ‘active citizenship’ ideals. For this reason, I am interested in how accountability is distributed through these complex networks, while the disappearance of the traditional hierarchical management has changed the traditional democratic accountability standards. As mentioned in paragraph 2.1 governing through networks implies two accountability problems that are central in this research namely: the problem of many hands and the weak visibility of policy making processes (Bovens 2007 & Papadopolous 2013). Firstly, governing through complex care networks create challenges for the way, who and to what extent relevant actors in the networks can be held accountable for their actions or the outcomes of the public policies they create. Secondly, with multiple actors involved, the policy-making process becomes weakly visible creating a congruence between the ‘front-stage’ elected politics and the ‘back-stage’ implementing processes in a multi-actor network. Politicians share the democratic accountability with involved actors who have not been democratically chosen and therefore cannot control the policy-making processes entirely. Specifically, the voluntary commitment within the scope of the Social Support Act 2015 is difficult to control due to the unpaid, non-committal nature. However, clients still want to hold the policy-makers accountable for the policy outcomes produced in these networks, which leads to distress. Consequently, within the governing process other forms of accountability arise. Therefore, I am interested in how governing through networks focusing on voluntary work described in the Social Support Act 2015 in Amsterdam takes place and how accountability is distributed in the practices of this public policy. This is important because volunteers complicate the accountability processes. Within the Social Support Act 2015 the role of volunteers is emphasised, but controlling the voluntary commitment is a complex matter because it has a non-committal, voluntary (non-paid) nature.

Much research has been conducted about the relationship between care professionals and the volunteers who interact with their clients, or about the consequences of volunteering. However, in the Netherlands there has been a lack of research about who is precisely accountable to whom and how this takes shape in practice. For this reason, I am interested in how accountability is distributed through these complex care networks, and who is accountable to whom in the practices of organising the voluntary commitment in the Social Support Act 2015. So I would like to introduce my research question as: ‘How does accountability take shape in the organisation of voluntary work in the Social Support Act 2015 in Amsterdam?’.

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3. Methods

This chapter provides the methodology of the research and the methodological choices that have been made in the research process. In order to answer the research question, I have investigated the distribution of accountability in practices between voluntary work managers and formal care managers in Amsterdam. Therefore, multiple actors have been interviewed to understand the distribution of accountability within the implementation of the Social Support Act 2015 in Amsterdam. Furthermore, I have also attended two network meetings doing participatory observations to understand how the actors implement the Social Support Act 2015. First the research design will be discussed. Then I will discuss the case and participant selection, the data collection and analysis. Finally, my reflection on the the data collection process will be provided.

3.1 Research design

In order to answer the research question a qualitative single-case study has been conducted consisting of ten semi-structured interviews and two participatory network meetings in the case of Amsterdam. The ten respondents are managers from different organisations who are involved with the Social Support Act 2015 or who deal with voluntary organisations or initiatives. The two network meetings took place in Amsterdam South with the presence of local (voluntary work and formal care) actors. Researching the care network of the Social Support Act 2015 is rather complex, because of the many involved actors, organisations and their specialisations. Nevertheless, I have tried to map out (a part of) the network as clearly as possible in order to answer the research question.

Within the Social Support Act 2015 the focus lies on combining informal care and formal care. According to the city council of Amsterdam informal care is: ‘help and support from the entire social network (family, friends and neighbours), volunteers and social informal carers (Gemeente Amsterdam 2015: 21). In this concept there is a divide between voluntary help and social informal carers. Within this thesis, I have chosen to focus mainly on the voluntary commitment and not on social informal carers such as friends, family members or neighbours because they aren’t as visible as volunteers.

For this reason, I have named the managers from voluntary work organisations voluntary work managers and not informal care managers. Moreover, formal care managers are managers who work in organisations with active care professionals who carry out paid medical tasks, they have been educated for (wijkzorg.nl 2018).

3.2 Case selection

A qualitative single case study has been chosen. This is because a single case study helps to generate specific knowledge about the phenomenon in question and context dependent knowledge (Flyvberg 2006). This enables me to create a good detailed understanding of the phenomenon based on the gathered information in order to create a good empirical analysis (Bryman 2012: 399). Examining the distribution of accountability in a case study provides this research practical knowledge, which is necessary to understand this concept in the domain of the Social Support Act 2015.

However, a disadvantage of a qualitative research is that the results and conclusions in this research will lack the ability to make general statements and therefore reach external validity (Bryman 2012: 406). However, I will be able to reach theoretical saturation (Bryman 2012: 424).

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3.2.1 Amsterdam

Amsterdam is chosen as the mildly extreme single case study in this research, based on three reasons. Firstly, it is chosen because the Social Support Act 2015 is mostly organised through neighbourhood or city broad networks. The neighbourhood networks and city broad networks are an example of governing through networks and are therefore interesting to investigate the research question. In all 22 neighbourhood networks in Amsterdam and on the city broad level, the city council has focused strongly on the improvement of the voluntary commitment in cooperation with voluntary work organisations and formal care organisations (Gemeente Amsterdam 2015-2017: 5). These formal care organisations exist for example of social workers, client assistants, doctors, nurses and care professionals specialised with severe psychiatric, mental or physical illnesses.

Secondly, it has been a pragmatic choice because I work in a home care organisation in Amsterdam. The implementation of the Social Support Act 2015 has sparked my interest because of the growing dependence on the voluntary commitment and social informal networks in this law, whereby voluntary organisations need to cooperate with formal care organisations to create a care network for their clients. Being involved in the practice of the Social Support Act 2015, I became interested in how accountability is distributed through these networks and who is deemed responsible for clients, when (potentially) many care professionals and volunteers are involved around one client. Moreover, it has given me background information about practices within the law.

Thirdly, Amsterdam as the capital of the Netherlands is an interesting case to research, because of the citizen diversity and the number of citizens who are dependent on the Social Support Act 2015. In the city, 66.000 citizens depend on care derived from the Social Support Act 2015 in order to live longer at home or to participate within society (Gemeente Amsterdam 2015-2017: 29). Generally, 75 percent of the citizens feel hindered in their leisure activities and 70 percent feel hindered by executing daily tasks at home (Gemeente Amsterdam 2017: 218). Loneliness is also a big problem within the city, whereby 13 percent feel very lonely. That is a higher rate than the Dutch average of 10 percent. These citizens are more dependent on voluntary services and formal care through the Social Support Act 2015 (idem). In the city there is a high density of the population, which results in more anonymity and less social control making it difficult for vulnerable citizens to depend on social informal networks (Wirth 1969: 12). Therefore, it is an interesting case because many citizens in Amsterdam rely on the Social Support Act 2015 with the services and voluntary initiatives it provides. Voluntary organisations provide clients with services for chores around the house or social activities in order to prevent or tackle their loneliness, which formal care organisations cannot execute no longer, due to the budget-cuts and the performance management (Gemeente Amsterdam 2017: 218).

I have focused on the city of Amsterdam as a whole, but also zoomed slightly into the borough of Amsterdam South. The city of Amsterdam, with a population of 853.312 (CBS, 30 April 2017), is divided in seven boroughs and 22 neighbourhoods. The borough of Amsterdam South exists of four neighbourhoods named: ‘the Pijp’, ‘the Rivierenbuurt’, ‘Oud-Zuid’ and ‘Buitenveldert/Zuidas’.

In this borough the total population entails 144.432 citizens (Gemeente Amsterdam 2017: 37). It has the highest number of citizens who are aged 60 or above namely 28.203 citizens (Gemeente Amsterdam 2017: 60). As mentioned earlier, elderly people are a target group in Amsterdam that depend largely on care financed through the Social Support Act. Moreover, this borough has made advanced progress organising voluntary work and citizen initiatives in the area.

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For this reason, this particular borough is interesting to zoom into in order to understand how different actors in the network work together and therefore understand how accountability is distributed in the interactions. A few of the respondents have connections with organisations in Amsterdam South or work in this borough.

3.2.2 Graphics: the propertion of elderly citizens in Amsterdam South

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3.3 Participants selection

For this research I have interviewed two informal care managers from the city council of Amsterdam, three home care managers, three voluntary work managers, ‘Cliëntenbelangen Amsterdam’ and a ‘Social Support Act supervisor’. These respondents have been chosen because they focus on strengthening the commitment in Amsterdam in their professions, or because they have to focus and rely on volunteers in their work environment due to the implementation of the Social Support Act 2015. The Social Support Act 2015 emphasises the strengthening and support of the voluntary commitment and social informal networks to increase the cost-efficiency. Therefore, formal care organisations need to work together with voluntary work organisations to provide clients with the required care.

All these respondents focus on providing care or focus on strengthening and supporting the voluntary commitment in the city to use it for their services. Firstly, on the one hand formal care organisations rely on volunteers from voluntary work organisations to perform small tasks around the house or social activities for their clients, which care professionals aren’t allowed to do anymore due to the budg-cuts implemented with the Social Support Act 2015. On the other hand voluntary work organisations rely on formal care organisations to refer clients to them in order to stay in business.

Secondly, as stated in the Social Support Act 2015, informal care and formal care managers focus on improving the clients’ ‘self-determination’ and participation in society by strengthening and supporting the voluntary commitment, contributing to the ideal that citizens should rely on their social informal network and volunteers first, before they are allowed to receive access to formal home care. For these two main reasons, informal care managers and formal care managers have been interviewed because they focus on the organisation of voluntary care, or depend on voluntary care, or work together with voluntary organisations to release the pressure of care professionals and to enhance cost-efficiency.

The respondents from ‘Cliëntenbelangen’ and the Social Support Act supervisor have been chosen based on their expertise. I thought they could give me a good insight about the developments and challenges within the Social Support Act 2015 that the other organisations could not provide me. At first, I thought that I had a clear vision of the care networks complying the Social Support Act. For this reason, I first started to reach out to respondents through purposive sampling. This means that the first respondents were strategically selected based on their function, how they are involved with the Social Support Act (specifically focusing on the voluntary commitment) and in what kind of organisation they worked in. During the interviews the first few respondents referred to different voluntary work organisations or addressed explicit corporations between their formal care organisations with voluntary work organisations. In the beginning my analysis was fragmented, but then I decided to investigate the network of the respondents in order to understand how accountability is distributed during the implementation of the Social Support Act in Amsterdam. This would give me a more coherent storey and the respondents could talk more about the networks they are part of and how they are held accountable for their work. Moreover, they explained how they worked together with other organisations, why that was necessary and what negative and positive effects were of the multi-actor network. This gave me a good insight in how the practices in the network are organised and how they can be held accountable for their practices.

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Therefore, I interviewed respondents from different formal care and voluntary work organisations who work together or are dependent on one another in order to understand the network of the Social Support Act in Amsterdam. Some of the interviewed respondents lead me to other important respondents in the Social Support Act network through snowball sampling (Bryman 2012: 458-459).

The majority of the respondents work closely together or know the organisations they work in, therefore it has been useful to contact participants through snowball sampling in order to understand the network they work in and how accountability is distributed. This is because, many actors contribute to the implementation of the Social Support Act and the different organisations have their own expertise. Through snowball sampling I was also invited to two network meetings in Amsterdam South, which is further explained in paragraph 3.4.2. The connections between the respondents are shown in paragraph 3.3.3.

3.3.1 Bias respondents

The overall strengths of the gathered data are that it provides a good impression about how the Social Support Act is governed through networks. Moreover, it is a large domain, which includes many different care activities and voluntary activities while dealing with a diverse group of care receivers who have a broad range of mental or physical illnesses. In addition, I’ve had five non-responses concerning local citizen initiatives and voluntary work organisations in the Borough of Amsterdam South. Unfortunately, they did not respond or were too busy for interviews. If these interviews could have been executed, I believe that I would have a more coherent storey to tell.

3.3.2 Overview of the respondents

Resp. Function Organisation

1 Civil servant City council of Amsterdam, Borough

Amsterdam South

2 Civil servant City council of Amsterdam, the

central city

3 Manager formal care Home care organisation: ‘Cordaan’ 4 Manager formal care Home care organisation: ‘Emile’ 5 Voluntary work manager Voluntary work organisation:

‘Humanitas’

6 Voluntary work manager Voluntary work organisation: ‘Stichting Senior Student’ 7 Voluntary work manager Voluntary work organisation:

‘Burennetwerk’

8 Client representative ‘Cliëntenbelangen’ Amsterdam 9 Social Support Act supervisor GGD Amsterdam

10 Manager formal care Home care organisation: ‘Evean’

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3.3.3 Overview Social Support Act network

Diagram 1 - Overview Social Support Act network, 2018.

‘Humanitas‘ Central City City council of Amsterdam ‘Emile’ ‘Stichting Senior student’ ‘Cordaan’ ‘Evean’ ‘Cliëntenbelangen’ City part Amsterdam South ‘Burennet-werk’ Social Support Act Supervisor ‘Wijkzorgtafel Zuid’ ‘Broodje Netwerk’

Blue bold circle: contacted myself Red bold circle: network meetings Snowball sampling: arrow line.

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3.4 Data collection

For this thesis two phases of data collection have been accomplished. Combining both methods have provided me with a detailed understanding of the complexity of accountability problems and the distribution of accountability during the implementation of the Social Support Act in Amsterdam. Firstly, I conducted semi-structured in-depth interviews with ten participants, which is discussed in paragraph 3.4.1. Secondly, I conducted participant observation by attending two network meetings in Amsterdam South, which is discussed in paragraph in 3.4.2.

3.4.1 Semi-structured interviews

At first, semi-structured interviews were conducted to gather data about how accountability is distributed between voluntary work managers and formal care managers, while strengthening the commitment in Amsterdam. The semi-structured interviews gave a good insight into the manager’s knowledge and their descriptions of processes, which I would not have been able to understand without them (Harrel & Bradley 2009: 24). Moreover, it has given me the opportunity to gather perceptions from different perspectives and roles.

Throughout the data collection process the interview questions have been adjusted to the manager’s profession. In the beginning of the data collection process, I derived my questions from the ‘agenda informal care Amsterdam’, a policy note aiming to empower the voluntary commitment. When I first started the interviews I thought I had enough information about the topic within the Social Support Act 2015. However, it turned out to be more complex due to the diversity of the activities and diversity of the clients within the Social Support Act. After the first three interviews, I discovered that the formulated questions were not giving me a deeper understanding about the subject while other interesting topics arose. Therefore, I decided to adjust my topic-list accordingly and to focus on ‘information-exchange’, ‘privacy’, ‘dynamic shifts’, ‘increasing emphasis on voluntary work’ and ‘market forces’ and adjusted my topic-list accordingly. Interviewing the participants has therefore given me the opportunity to react to given statements and ask more in-depth questions about them.

As the data-collection process continued, I became better at filtering out which topics were interesting or how I could investigate the distribution of accountability. All of the respondents had very informative stories to tell and took the time to sit down and talk with me; they also made many challenges and aspects clear that I didn’t know of beforehand.

3.4.2 Participatory observation

For the participatory observation, I attended two network meetings in Amsterdam South namely: ‘Broodje netwerk’ and ‘Wijkzorgtafel Zuid’. A respondent invited me to these meetings, because she believed that I would get a better understanding how governing through networks takes place in practice. Both meetings were focussed on connecting multiple formal care managers and voluntary work managers to network and discuss local problems and possible solutions, developments and activities in the neighbourhood. While attending these meetings, I participated as a home care worker myself and as a student of the University of Amsterdam. During both meetings I made it clear that I was conducting a research about the organisation of informal care and how care organisations work together with voluntary work organisations and neighbourhood initiatives.

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During both network meetings, it became clear that it was a convenient way for many (formal and informal) care managers and civil servants to discuss local problems and potential solutions, rather than being restricted by communication through email or phone. Participatory observation is a method whereby you can observe the participant’s actions and can converse with them. This has been of great importance, to understand the ‘mundane detail’ and question ‘what is going on here’? (Silverman 2014: 118). This helped me understand how network meetings are organised, who attend these meetings and what is discussed in the particular context of Amsterdam South. Finally, participatory observation has been rather helpful in hearing the different views and perspectives on developments within the borough Amsterdam South. It has allowed me to hear people converse with each other, whom I otherwise would not have been able to meet.

3.5 Data analysis

The gathered data in this research has been analysed using an interpretative approach. Firstly, quotes were first interpreted through an inductive approach in Atlas.ti, focusing on the gathered data rather than coding based on theoretical concepts. This is called ‘grounded theory’, whereby researchers develop inductive theoretical analyses from their collected data and subsequently gather further data to check these analyses (Silverman 2014: 67). This means that I did not label the codes with theoretical concepts at first, but rather focused on interesting topics that derived from the collected data. During the data gathering period interesting topics arose such as: information-exchange, privacy, dynamic shifts in accountability, the increasing emphasis on volunteers and market forces. However, I realised I needed to combine the data to theoretical concepts. Therefore, I created ‘supercodes’ to divide my inductive findings into two separate chapters based on theoretical concepts namely: governing complexity and accountability. The ‘supercode’ ‘organisational complexity’ existed of subjects such as market forces, hierarchical structures, governing through networks and challenges. The ‘supercode’ ‘accountability’ existed of the explanations of tasks, accountability dynamics, responsibility, voluntary commitment and voluntary complexity.

3.6 Reflection

In the following section, I reflect on the methodology of my study and collected data. However, a few remarks need to be discussed about the data collection and respondents. Firstly, as mentioned in paragraph 3.1 researching the care network and the distribution of accountability was rather complex. This is because many actors are involved in the network, which also confuses them from time to time about the content of policy-documents or laws. However, a big advantage of exposing and investigating a network is that the distribution of accountability can be made clear. In this way, the roles and tasks of the involved actors and the positive and negative effects of implementing activities according to the Social Support Act 2015 are clarified. In this research, a variety of respondents have been interviewed who work in different organisations (but deal with voluntary work or activities within the Social Support Act 2015).

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One could argue that therefore the claims made in this research aren’t shared by all of the respondents, because the tasks and the type of organisations the managers work in differ. Even though, I believe strongly that I have executed a valid analysis because I have interviewed ten managers from different organisations who play a crucial role in the implementation of the Social Support Act 2015. Moreover, this also means that I have taken into account many different perspectives on the implementation of the Social Support 2015. In other words, I believe I haven’t got a one-sided view on the implementation of the Social Support Act 2015 and it made me understand the distribution of accountability practices better.

However, some of the respondents work with one another for the recruitment of volunteers or networking and some specific activities are even financed by one another. This makes is possible that during the interviews the respondents answered the interview questions in a socially desirable manner. For example, when I asked about what happens when something goes wrong for volunteers in the executing of their tasks, or when something goes wrong while implementing activities according to the Social Support Act, some did not give me any concrete answers about this.

Finally, I struggled with myself as a researcher due to my critical point of view on the implementation of the Social Support Act 2015. On the one hand, I have practical knowledge about the implementation of the Social Support Act, because I am a home care worker in Amsterdam. I work with clients who have little financial resources (and) whereby the budget-cuts have led to a decrease in their formal care allowance. In addition, they mostly have to rely on their social informal network and on volunteers but they experience this as rather stressful or hopeless because volunteers and family-members don’t have a lot of time or aren’t even available (because of the big demand of volunteers). On the other hand, the practical knowledge helped me to understand the practices, abbreviations of illnesses or practices that were discussed during the interviews. This made it easier for people to discuss the topics about the Social Support Act 2015 more intensively. It also helped me in the interviews to start a conversation about practicalities or to discuss practical examples in the Social Support Act. It seemed to me that the respondents really focused on achieving self-determination and participation for the goodwill of the clients, however practical challenges such as the distribution of accountability and the limited financial resources seemed the determining factor in providing care.

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4. Social Support Act 2015 policy context

In this chapter the policy context of the Social Support Act 2015 shall be discussed. This is important because, the context of the case needs to be provided in order to understand how the law is envisioned, in order to analyse the research problem. Firstly, the national context of the law shall be discussed. The Social Support Act 2015 is a framework law, whereby the central guidelines have been formulated by the national government focusing on active citizenship. Secondly, the local interpretation of the law as it is practised in Amsterdam is provided and the main political discussions it has fuelled.

4.1 The Social Support Act 2015 in the Netherlands

In 2007 the home care was transferred from the ‘Algemene Wet Bijzondere Ziekenkostenverzekering’ (AWBZ) to the Social Support Act. The responsibilities were decentralised from the national government to the local councils to empower the citizens. The local council became responsible for the improvement of citizen’s ‘self-determination’, participation and were deemed to stimulate ‘active citizenship’ and improve the social cohesion (Houten et al. 2008: 6). The law developed further into the Social Support Act 2015 emphasising ‘self-determination’ and participation more prominently than in the Social Support Act 2007.

The Social Support Act 2015 is an important part of the Dutch reforms in the long-term care and the decentralisations in the social domain. These decentralisations made the local councils also responsible for the implementation of the Youth Law (Jeugdwet) and aspects of the Participation Law (Participatiewet). The Social Support Act 2015 was deemed necessary by the national Dutch government, because they expected that local councils could adapt more effectively to the citizen’s needs and desires on the local level. This is because local governments have a shorter distance to the citizens and could therefore provide appropriate, necessary and effective care (Ham, v.d. 2018: 19). In addition, nowadays the government expects that citizens should live in their own living area as long as possible and should be able to participate within society with the appropriate support.

The Social Support Act 2015 is a framework law, which gives local councils the discretionary space to decide how to formulate and implement obligations formulated by the national government (Ham, v.d. 2018: 23). There are three main obligations that the local councils need to carry out. Moreover, it aims to realise an inclusive society by improving the participation and self-determination of people with disabilities or chronic psychological or psychosocial problems (Draak & Ham, v.d. 2018: 8).

Firstly, citizens in need of care can’t claim the right to formal care as easily as before the introduction of the law. They need to address their own social informal network or volunteers first, before they can receive formal care (SCP 2018: 24). The ideal is that the local councils could identify the clients’ needs better, while focusing on the contribution of their social informal network. Consequently, local councils can mainly focus on citizens with disabilities or chronic psychological or psychosocial problems (Draak & Ham, v.d. 2018: 8).

Secondly, the term ‘custom fit care’ was introduced whereby professionals were given the ability to indicate the extent of clients ‘self-determination’ (what they could contribute themselves) by focusing on their client’s abilities (SCP 2018: 24).

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Thirdly, the local councils were given the ability to contract out care tasks to stakeholders within the framework of the law, in order to stimulate innovations in the home care according to the principles of the Social Support Act 2015. They were given the responsibility to actively invest in care activities and make this realisable through the cooperation with care suppliers and care insurers (SCP 2018: 24). The local councils are free to decide how they will compensate vulnerable citizens. They can carry their responsibilities out by granting individual facilities such as home care, a wheel chair, housing facilities or collective facilities such as transport, neighbourhood facilities or buddy-projects (SCP 2018: 152).

Furthermore, this decentralisation makes ‘horizontal accountability’ possible whereby the citizens, the local communities and organisations can hold the local councils accountable for the implementation and execution of their policies rather than the ‘distant’ national government (Houten et al. 2008: 8).

4.2 The local interpretation the Social Support Act 2015 in Amsterdam

The welfare state reform has changed the role of the city council in two important ways. The civil servants have the role of facilitator and principal. This role implies that civil servants in the boroughs grant subsidies to local neighbourhood initiatives or voluntary organisations to organize activities and make home care possible as described in the Social Support Act 2015 (Gemeente Amsterdam 2015: 25).

Secondly, their role is to strengthen the informal care networks and voluntary commitment and therefore need to find, support, appreciate, match and educate volunteers and informal carers. Due to the expected increase in the reliance on volunteers, the city council also focuses on the accessibility of voluntary work. Thereby, the city council focuses on the easy accessibility of physical and digital matching places for volunteers and voluntary organisations (Gemeente Amsterdam 2015: 25).

In the city of Amsterdam citizen participation and self-determination are key-elements in the public policies of the ‘Social Domain’ that have been implemented in the city. The goal of this social domain is to create an inclusive society by enhancing the citizen’s participation focusing on health, voluntary commitment and financial stability. This social domain includes the Participation Law, the Youth Law and the Social Support Act 2015. In Amsterdam the city council stresses the importance of the citizen’s own responsibility for their lives and it is expected from citizens that they should take care of themselves and others in society. The clients who aren’t fully ‘self-determined’ should call upon their social informal network of the voluntary commitment, before claiming the right to formal care (Gemeente Amsterdam 2018: 1). Since the introduction of the Social Support Act 2015 the city council has been responsible for the realisation of home care (support) for 66.000 citizens in order for them to live longer at home and participate within society (Gemeente Amsterdam 2015: 9). Moreover, with the implementation of the law the city council is now also responsible for the support of a vulnerable group of citizens with psychical, psychiatric, sensory disabilities, a chronic illness or citizens with psychosocial problems. The tasks described in the Social Support Act 2015 include: home care (help around the house), ‘day-activities’ and ‘protected living for clients with psychiatric illnesses’ (Gemeente Amsterdam 2015: 9).