Based on your reading, explain how accounting helps to structure the field of health care according to different discourses, but also highlight the limitations of accounting to deploy such discourses. You can choose to focus on the neoliberal discourse Introduction • • • • Explain how healthcare is an important issue and how there are many discourses surrounding the topic How neoliberalism can play a part in the distribution of healthcare - finding a balance between ensuring everyone has access to it while attributing costs to healthcare treatments and privatising the market. Focus on the paper of (Preston, 1992) which mentions the timeline of healthcare development from 1875 to 1980 in the USA and how healthcare was once seen as a charity but over the years turned into more of a business with less government intervention Also mention the paper of (Wallstedt, 2020) which discusses how two types of programmes concerning efficiency and individuality along with corresponding technologies influence how healthcare should be conducted in Sweden Neoliberalism assists in the distribution of healthcare by deregulating the healthcare system from a public good to a private good, in which only those that can afford to pay can seek medical treatment, which is more so the case in the USA. Poorer individuals would need to obtain private insurance to cover their medical bills. According to Preston 1992, in 1917, the League for the Conservation of Public Health, comprised of doctors, went against compulsory health insurance as they believed they should work for themselves rather than working for politicians as they would have control over their wages. • • The paper of Wallstedt 2020 looks at analysing two programmes; efficiency and individuality and operationalisation in swedish aged care. It shows how these programmes and technology are used to problematise how care should be conducted. The paper also looks at how care practitioners conduct care according to spaces of freedom gained from the two programmes. • • The paper also tries to examine and determine how a programme of individuality problematizes a programme of efficiency, and vice versa, this was done by showing how matters of individuality becomes mobilized against matters of efficiency. This becomes possible because the operationalizations are meant to render practices that are both efficient and individualized, which also tend to divide the individual and only visualize certain things, which involves their formalized needs, disabilities or costs and revenues, which render them governable. This goes against the wholeness of the individual and can be countered with arguments maintaining that calculative instruments bring about insufficient knowledge, and that there are various things that also need to be considered. -The paper also highlight the different discourses, which are key concepts to grasp to get a better understanding of the neoliberal society 1. Discourse of practices of cost control - 2. Change of medical practices leads to reorganised hospitals around departments with managers in charge of costs Costs are treated as expenditures, and break-even is realised through the minimum level of patients needed to cover costs. Discourse of justifying costs - 3. Discourses shaped by the doctors – justifying for the new practices of medicine Emergence of medical reports within the annual reports, acknowledging the kind of practise the hospital runs. There is an emphasis of the service provided, rather than the costs Discourse on cost reimbursement - Revenue covered through donation previously, but with improvement of science and new medical practise, hospital did provide a real service, with medical products so they needed to be charged to cover costs Accounting, Organizations and Society 80 (2020) 101077 Contents lists available at ScienceDirect Accounting, Organizations and Society journal homepage: www.elsevier.com/locate/aos Sources of dissension: The making and breaking of the individual in Swedish aged care €llstedt a, b, * Niklas Wa a b € Orebro University School of Business, Sweden Stockholm Business School, Sweden a r t i c l e i n f o a b s t r a c t Article history: Received 13 October 2016 Received in revised form 9 October 2019 Accepted 10 October 2019 Available online 5 November 2019 It is well known that both management and professional work in areas such as health and aged care rely upon division of individuals into categories of, for example, diagnoses or costs and revenues. The present paper turns this around and asks: what happens if individuality, the indivisible wholeness of the person, is taken seriously in such practices? If every human being is interpreted as unique and special, and their wholeness is recognised in the relationship between professionals and an individual receiving care? The paper analyses two rival programmes e those of efficiency and individuality e and their operationalisation in Swedish aged care, and show how these programmes and corresponding technologies are sources of dissension that can be used to problematise how care should be conducted. However, such dissension also opens up spaces of freedom, which allow care practitioners to conduct care differently. © 2019 Elsevier Ltd. All rights reserved. Keywords: Management control Governmentality Dissension Individualisation Aged care Individual e origin late Middle English (in the sense “indivisible”): from medieval Latin individualis, from Latin individuus, from in- “not” þ dividuus “divisible” (from dividere “to divide”). (Oxford English Dictionary) 1. Introduction An individual is, literally, whole or, as the dictionary puts it: indivisible. However, it is well known that both management and professional work in areas such as health and aged care rely upon division of individuals into categories of, for example, diagnoses or costs and revenues (Abbott, 1988; Agyemang, 2010; Almborg & Welmer, 2012; Czarniawska & Mouritsen, 2009; Jutel & Nettleton, 2011; Samuel, Dirsmith, & McElroy, 2005). Such divisions into standardised items make the individual calculable, governable and amenable to intervention (Hacking, 1985; Miller & O’Leary, 1987; Miller & Rose, 1990; Rose & Miller, 1992) for anyone interested in making a difference for that individual. Aged persons, for example, can find themselves present in a variety of places (their nursing home, a heated national debate, a budget meeting) and in different € * Orebro University School of Business, Sweden E-mail addresses: niklas.wallstedt@oru.se, niklas.wallstedt@sbs.su.se. https://doi.org/10.1016/j.aos.2019.101077 0361-3682/© 2019 Elsevier Ltd. All rights reserved. forms (a schedule item, as part of fall injury statistics, a cost and revenue) at the same time, depending on who is interested in intervening into their lives. The will to govern from a distance (Miller, 2001; Rose, 1993) €ki, Lapsley, & through accountingisation (Hood, 1995; Kurunma Melia, 2003; Power & Laughlin, 1992) and juridification €ki & Miller, 2011; Laughlin & Broadbent, 1993) of the (Kurunma public sector propel the division of the individual. According to Haggerty and Ericson (2000, p. 619) “knowledge of the population is now manifest in discrete bits of information which break the individual down into flows for purposes of management, profit and entertainment” as well as medical diagnoses and professional categorisation. This means that “individuals have become ‘dividuals’” (Deleuze, 1992, p. 5 italics in original), and if you become a customer of, for example, care services, you should prepare to become “dividualised” into subsets of yourself e subsets needed to make you calculable, controllable and economically valuable €ki & Miller, 2006; Samuels et al., 2005). (Kurunma The present paper turns this around and asks: what happens if individuality, the indivisible wholeness of the person, is taken seriously? If every human being is interpreted as unique and special, and their wholeness is recognised in the relationships between professionals and individuals receiving care? How is it possible for individuals to stand up against standardising programmes and technologies that bring about “a form of power in which the 2 €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa individual becomes an auto-regulated entity, but one for whom the standards according to which they judge their lives have been established for them” (Miller & O’Leary, 1987, p. 243)? How is it possible to alter the spaces of power relations (Foucault, 1987) where the breakdown of the whole individual into standardised, calculable and manageable “dividuals” occurs? The possibility for this, this paper argues, lies in the heterogeneity of discourse, the shortcomings of instruments of calculation, and the dissensions that follow. According to Miller and Rose, [t]he world of programmes is heterogeneous and rivalrous, and the solutions for one programme tend to be the problems for another. ‘Reality’ always escapes the theories that inform programmes and the ambitions that underpin them; it is too unruly to be captured by any perfect knowledge (1990, pp. 10e11). By exploring how actors involved in Swedish aged care struggle with such rivalry and unruliness as they debate, manage and conduct individualised services, this paper shows how spaces of dissension emerge, provoking problems but also opening up possibilities to think and act differently about the care of individuals (Foucault, 1987; Phillips, 2002). Two rival programmes are followed: (1) the efficiency programme e endorsed by the Swedish Local Government Act; and (2) the individuality programme e endorsed by the Swedish Social Services Act and its stipulations regarding how aged care should always be carried out according to a value base where the individuality of the aged person is central. These programmes should be operationalised simultaneously, both on the local and “non€ki, Lapsley, & Miller, 2011; Kurunma €ki & local” levels (Kurunma Miller, 2011). This, it will be argued, calls for an ongoing “making and breaking” of the individual on both these levels but, perhaps more importantly, also in different settings locally. Whereas the efficiency programme instigates division of the individual, transforming it into calculable spaces possible to manage economically (Miller, 1994; Samuels et al., 2005), the individuality programme tends to problematise any breakdown of the individual into standardised forms. Because the individual is seen as “whole,” the “making up” of a an individual e often in the guises of “users” or “customers” (Pflueger, 2016; Vaivio, 1999) e with certain properties can only retain stability for a brief time, as it opens itself up for critique or even becomes useless for meaningful intervention when other properties are discovered as more important. The paper hence studies “the multiple and mobile relations that form between the local setting in which accounting is operationalised and the non-local actors and agents to which they are €ki et al., 2011, p. 2), and makes the effort to linked” (Kurunma “examine the interrelations between large-scale policy reforms and the more localised re-design of management control practices and organizational arrangements for service delivery” (Kurunm€ aki & Miller, 2011, p. 222). In order to make sense of the heterogeneity of discourse, and the multiple and mobile relations between policy reforms and practice, there are other spaces than calculable spaces, and other relations than those primarily mediated by accounting instruments, requiring investigation by accounting scholars. As a contribution toward this end, this study examines such alternative spaces in the form of spaces of dissension, delineates their programmatic and technological sources, and examines the relations that are formed within such spaces. In the process, it is demonstrated how individuals in a specific context e aged persons in a welfare market e are continuously problematised, made up and broken down, as dissension emerges regarding how to care for them. In short, this paper analyses how spaces of dissension come about, where standards become blurred and where it becomes possible to think and do differently. Thus, the examined case entails “a space of multiple dissensions; a set of different oppositions whose levels and roles must be described” (Foucault, 1972, p. 155). 2. Dissension, individuality and accounting In this section, current understandings about spaces of dissension and their sources are outlined. First, the concept of dissension, and how it emerges in the world of programmes, is discussed. Then, two rival programmes e the specific programmes of individuality and efficiency e are examined and situated in discourses of marketisation, juridfication and accountingisation. This forms the analytical backdrop of the struggles to treat individuals as unique and whole in an environment fraught with dissension on both the programmatic and technological levels: Swedish aged care. 2.1. Dissension In reality, programmes are not separated: they always work in conjunction with each other. In the contemporary public sector, it is possible to point to programmes of efficiency (Miller & O’Leary, 1987), effectiveness (Almqvist, Catasús, & Skoog, 2011), marketisation (Wiesel, 2008), competition (Almqvist, 2004) and cooperation (Kurunm€ aki & Miller, 2011; LeGrand, 1999), to mention a few. These programmes are often separately articulated, sometimes seemingly contradictory, such as the demand to compete and cooperate at the same time; sometimes ostensibly congruent, such as the importance of being efficient to compete successfully on a market. Multiplicity and rivalry of programmes can become sources of dissension, in that it reveals “a contradiction that has its model in the simultaneous affirmation and negation of a single proposition” (Foucault, 1972, p. 155). In other words, dissension emerges when rival programmes conceptualise and operationalise the same “truth” differently. For example, the clear distinction between “waste” and “efficiency”, brought about by technologies such as standard costing (Miller & O’Leary, 1987) may become problematised in a programme of recycling, where the logic of the market dominates, turning waste into a resource (Corvellec, Zapata, & Zapata, 2013). In a similar vein, a programme of competition, aimed at public service output has, in later years, been complemented with a programme of cooperation aiming toward securing societal outcomes (Almqvist, 2004; Barretta, 2008; Kurunm€ aki & Miller, 2011; LeGrand, 1999). Such rivalry among programmes may lead to wide-ranging problems regarding what holds “true”: What is “waste”, and how should it be handled? Who can be seen as efficient or wasteful? Who should an organisation regard as a competitor or partner? What is a good “result” e organisational output, societal outcomes or effects on individuals? Such questions give rise to spaces of dissension that entail uncertainty, make the system of knowledge unstable, and problematise what is considered factual. According to Phillips (2002, p. 334) “[s]paces of dissension occupy a very different, if only momentary, space characterized by irregularity, abnormality, and unintelligibility; spaces within which certainty and regularity are disabled and possibilities become possible”. This means that spaces of dissension are spaces of freedom where different possible sets of knowledge can be drawn upon and power relations can be altered: in spaces of dissension, problems can be turned into possibilities. Dissension, therefore, becomes a practical matter. As Phillips (2002, p. 334) argues, “[t]hese are spaces of dissension because they are places where the incoherence and contingency of the discourse is experienced directly” (see Foucault, 1982). Dissension is made real in the daily lives of practitioners through the €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa operationalisation of rival programmes by instruments, such as standard costs or performance measures, and other mediators of relations, such as professional understandings about the relationship between service provider and service receiver. An example is Vaivio (1999), who shows how knowledge about the individual, in the form of the calculable space of the customer, encounters other ways of knowing it. By casting “the customer” as something calculable, it becomes possible to connect organisational work, through accounting instruments such as scorecards, to concerns about customer demands in the market. Vaivio shows how these connections meet resistance by local actors who have other, and closer, relationships with their customers and understand their individual desires and needs differently. In other words, the calculable space of the customer may assist those who govern organisations to increase overall efficiency when supplying customers in a market, but it may also pose problems when it comes to catering for needs specific to certain individuals. Vaivio’s study is an example of how dissension about the individual and its constitution e through accounting calculations and other ways of knowing e evolves in the daily lives of practitioners. Vaivio (1999) hence depicts a more general struggle about what should be recognised as significant, when it comes to the individual and its desires and needs. However, such “struggles are not exactly for or against the ‘individual’ but rather they are struggles against the ‘government of individualisation’” (Foucault, 1982, p. 781): they are immediate responses to “a technique, a form of power” (ibid, p. 781) that imposes narrow standards onto the individual subject (Miller & O’Leary, 1987). In other words, it is not the “individual” that is at stake in such strugglese it is its constitution. Dissension opens up a slightly different avenue for opposition, where the individual, constituted by technologies deployed by those wishing to govern from a distance, can be problematised because of other ways of knowing it. 2.2. Individuality and different versions of the individual Individualisation has been at work for a long time (Beck & BeckGernsheim, 2002). However, any delineation of a programme of individuality is in itself fraught with contradiction and dissension. For example, the project of individualisation was different within the discourse of the welfare state, compared to the liberal project of individualisation (Miller & Rose, 1990). Therefore, “a more general question needs to be asked concerning this ‘individualism’ that is so frequently invoked, in different epochs, to explain very diverse phenomena” (Foucault, 1988, p. 42). This question involves the constitution of the subject, and its relation to itself and its surroundings e its autonomy and its constitutive relationships. The concept of the “individual” entails an aspect of autonomy and uniqueness, as well as an aspect of relationship to the world of power relations (Foucault, 1987) e including technologies and other active participants capable of acting upon the actions of others (Kosmala & McKernan, 2011). Consequently, the individual is constituted differently, depending on its relationships with technologies and involved others. Within the liberal project of the market, for example, two types of individuals can be distinguished: the consumer and the productive individual. The consuming individual is constituted as an autonomous, desiring and knowing subject through practices of consumption, where they become related to each other, through products that represent their identities and desires, and in venues where these products are sold (Miller & Rose, 1997). The consumer is then complemented with “the ‘autonomous’ subjectivity of the productive individual,” which “has become a central economic resource” (Miller & Rose, 1990, p. 26). The programmes that endorse this particular individual 3 promise to turn autonomy into an ally of economic success and not an obstacle to be controlled and disciplined. The selfregulating capacities of individuals are to be aligned with economic objectives through [a] kind of loose and indirect mechanisms […]: the capacities of language to translate between rationalities, programmes, technologies and self-regulatory techniques (ibid, p. 26). In the market, individuals are subjected to both these forms e sometimes as desiring customers, sometimes as productive workers. This can be accomplished because the subject “is a form and this form is not above all or always identical to itself” (Foucault, 1987, p. 121): there is always a possibility for the subject to constitute itself differently; a possibility alleviated by spaces of dissension. Therefore, the individual subject can be constituted in many ways, in different contexts: as a desiring customer, a user with legitimate needs, a productive worker, a knowledgeable professional, or a caring lover. The constituting practices of the self are hence carried out differently, depending on within which system of knowledge and power these practices are situated (Foucault, 1988). In a professional system, such as aged care, where many practices to govern comprise close relationships between individuals and others, the formation of different subjective forms are especially intricate. Therefore, it must be underlined that “[t]he subject emerges in action within the space of intersubjectivity; as an effect of power, in action on the actions of others capable of acting on the emerging subject and other others” (Kosmala & McKernan, 2011, p. 391). Professional practices normally involve a multitude of actors, capable of acting upon others, and with different views, responsibilities and functions related to the practice e from politicians, inspectors, managers, controllers and caregivers, to the clients or patients themselves. They are all connected in loose assemblages made up by consenting and contradicting sets of knowledge and technologies, which, on the one hand, “make thoughts and actions in one locale congruent with those in another” (Miller & O’Leary, 1994, p. 40), but on the other hand, invite problematising thoughts and make opposing actions possible. In the emerging spaces of dissension, there are always problems and possibilities regarding how to care for the individual. 2.3. Constituting individuals in the programme of efficiency The possible forms of individual subjects are hence dependent on the programmatic and technological environment in which they are constituted. For individuals involved in care practices, this constitution is heavily circumscribed by rationales of efficiency and effectiveness (W€ allstedt & Almqvist, 2017), as well as pressures to become customer oriented (Wiesel, 2008), client focused (Alford & Speed, 2006) and responsive (Vigoda, 2002). The liberal constitution of the autonomous, productive and consuming individual with their own sets of competences and desires, has led to the development of individualised services: service providers have to acknowledge the individual as a rational self-interested customer, and a co-producer of services (Vigoda, 2002), and develop new ways of collaboration to bring them what they want (Kurunm€ aki & Miller, 2011). In a welfare state like Sweden, however, the constitution of the individual is played out in a contradictory environment where the boundaries between the private and the public have become blurred; where “the private” market should solve the problems of “the public” welfare state (Clarke, 2004). As a consequence, differences in rationales between the welfare state and the market provoke dissension regarding how to care for the individual, in that 4 €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa the desires of the customer have to be taken into consideration alongside the legitimate needs of the user (Krohwinkel-Karlsson & €gren, 2008). Market rationales, such as freedom of choice and Sjo competition, become problematised because the usual mechanism for such rationales to be operationalised e price e is put out of play because of collective tax funding (Samuel et al., 2005). Instead, if the ideals of the market are to be upheld, care providers have to compete, and customers have to make choices, on quality (Karpik, 2010). Consequently, the welfare market requires a stable, and purportedly objective, knowledge base to function e a kind of knowledge on which to base anything from resource allocation and competition to customer choice and political evaluation. This is where technologies come in: to solve the problems of both the market and the welfare system. Aside from marketisation, also accountingisation and juridification play a part in making up the world where welfare services are provided, and in which individuals are constituted (Hood, 1995; Laughlin & Broadbent, 1993). Whereas market rationales provide the justification for constituting the individual as customer, and legal stipulations can be used to safeguard a diverse set of user rights, only calculative devices, such as accounting, is understood to have sufficient abilities to provide both clear targets for the conduct of services, as well as being useful in evaluating them. This means that accounting, together with other calculative techniques, such as national statistics, has come to form the knowledge base from which political decisions are made and legal demands formed (Porter, 1996; Watkins & Arrington, 2007). By making it possible to evaluate how resources are used, and judge the efficiency and effectiveness of both organisations and individuals, accounting helps those interested in governing from a distance to make decisions and act upon the actions of those set to carry out service production. Accounting is, however, far from neutral (Miller & O’Leary, 1987). Instead, accounting is strongly connected to certain rationales of means-ends relationships, measurement, standardisation and causality. This accounting logic, depicted in Fig. 1, limits possibilities for evaluation, restricts the conduct of service providers, and constitutes individuals in particular ways. First, accounting needs standardised items, possible to measure “accurately”, in order to establish the causal relationships between resource use, outputs and outcomes required to evaluate efficiency and effec€rdsten Nymans, 2012). This is integral for the welfare tiveness (Sva market to function, as customers are supposed to choose service providers based on knowledge derived from accounting measures: as rational and desiring beings, customers are theorised to choose the service providers offering the best output in terms of service quality levels (Wiesel, 2008). Second, accounting has to serve the purpose of allocating resources in accordance with the legitimate needs of users: promote allocative efficiency. This calls for standardisation in two forms: (1) the “scientific” categorisations of service users according to classes of needs (Almborg & Welmer, 2012) or diagnoses (Samuel et al., 2005), followed by the construction of Fig. 1. The accounting logic. statistical or cost based formulas for allocating resources to these classes (Agyemang, 2010); and (2) the standardisation of competence of those set to serve these classes of individuals, for example, caregivers or teachers (Evetts, 2009; Lilja, 2009). By standardising both service users, and the financial, technical and human resources directed to them, it can be ascertained that “the right” individual receives “the right” amount, or quality, of services. Therefore, service users, as well as service providers e organisations and professionals e are “dividualised” into calculable spaces (Miller, 2001; Vaivio, 1999). This means that individuals are constituted as autonomous, unique decision makers at the same time as they are standardised into classes of needs and competences that should be matched: by allowing multiple possible constitutions of the individual, and by adhering to the accounting logic, the welfare market becomes a source of dissension in itself. 2.4. Programmes and technologies as sources of dissension Rival programmes are sources of dissension e often through the technologies set to operationalise them (Arnaboldi & Palermo, 2011). Several examples of failings and dissension tied to accounting exist. Exaggerated focus on technical efficiency leads to sub-optimisation and a tick box mentality (Lapsley, 2009). Accounting has problems contributing to personalised services (Needham, 2010) responsive to the individual’s needs and wants (Vigoda, 2002), and may fail to steer service delivery toward reasonable outcomes (Osborne, 2006). Debates arise over the relevance of accounting as a means for customers to choose services when service quality is the determinant (Blomgren & Sahlin, 2007). It is also argued that the combination of financial interests of market actors, diagnostic categorisation and accounting based allocation systems may “invite medicalised and pathologising responses” from service providers (Yeatman, 1998, p. 140). In other words, calculative practices, such as accounting, tend to “dividualise” the individual in particular ways, making certain properties calculable and neglecting others. They make the pathological, not the healthy, calculable. They make formal competence, not responsiveness, visual; and they make the simple, not the complex, governable. In short, accounting and calculative practices are seen as far from sufficient to secure both efficiency and individualised service provision. Dissension and resulting oppositions to certain techniques of individualisation (Foucault, 1982) are this paper’s focus. Spaces of dissension emerge from questions about the purposes, uses and functions of technologies and instruments: Are they sufficient to visualise performance and govern from a distance? to uphold fair competition? maintain equal resource allocation? allow customers to choose providers? help professionals to engage in individualised services? Spaces of dissension emanate from rival programmes, but they become “real” for involved actors when they are operationalised through technologies and instruments, and in interaction with others. After the methodology section, the empirical part of the paper will show how dissension evolves in Swedish aged care, from its programmatic and technological sources, and how the individual is made up and broken down, as a consequence. In the first section of empirical data, two legal instruments in this environment are reviewed: the Swedish Social Services Act and the Local Government Act. Recent debates about aged care are accounted for, and the standardisation of aged care professionals discussed. The following section continues with discussing and analysing three clashes between the efficiency programme, instrumentalised by the accounting logic, and the individuality programme operationalised locally in the interaction between workers/professionals and service users/customers: (1) the construction of standardised services €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa to standardised users and the tension between constructing a robust legal version of the individual while, simultaneously, forming a deeper understanding for it; (2) the pathologising and “dividualising” responses to service users that the accounting logic creates, and the efforts made to avoid such responses and to individualise care, and (3) how an accounting infused environment constitutes aged persons as rational, choosing customers, and affects providers when they try to treat these customers as individuals. 3. Methodology and case description The interest in researching the struggles to perform individualised services, while simultaneously being efficient, emerged primarily from the empirical material. It emerged as one of many in an ongoing research project based on data from the particular municipal organisation used as case here, and an effort to contextualise the work in this organisation by collecting data on aged care events and debates in the surrounding society. Guided by a broad theoretical agenda (Ahrens & Chapman, 2006) concerned with management control in care practices, the research was concerned with what seemed to matter in practice e for managers as well as co-workers (Baxter & Chua, 1998). In parallel, a range of literature on accounting, public administration and political science was consulted in order to distinguish topics of interest to the academic community. This means that during the research process, different strands of literature were problematised depending on the issues emerging from the empirical material, at the same time as these strands of literature were used to ask new questions and interpret observations in different ways. This strategy informed a process of snowball sampling (Biernacki & Waldorf, 1981) where difficulties articulated by practitioners, as well as theoretical problematisations, lead the empirical work forward. This research strategy is best described in relation to how the studied case organisation was approached. 3.1. Approaching the case organisation The research was carried out between the years 2010 and 2014. It started with a review of the formal control system used in the municipal organisation studied in this paper. This review was founded on interviews with three of the top managers and four controllers working on the central level in the organisation e the city council administration e as well as access to the organisation’s web-based control system. The interviews with the controllers were done sitting down at the controllers’ workplaces, and with the web-based system open on their computers, allowing for detailed questions regarding the function of the system to be asked. During these interviews, managers and controllers articulated what they saw as problematic. Already at this junction, it became clear that the tension between exercising control by standardising decentralised service provision, while allowing providers to perform in a way that could take advantage of local understandings, was a main concern. Aged care is one such decentralised function in the municipality and the responsibility of 14 slightly differently organised district committees, hence representing a variety of locales. The aged care function in the organisation is built on a purchaser and provider solution: the 14 district committees act as purchasers and buy care services from service providers e nursing homes and domestic care providers; in-house or privately run. The district committees and their corresponding administrations are, hence, active both on the purchaser and provider sides: they are responsible for buying services, and they are also responsible for running their in-house service provider units. The case organisation and the interviewed 5 and observed informants are depicted in Fig. 2. The web-based control system, structured as a scorecard, specifies objectives and targets for a range of areas: some objectives are general whereas others are aimed at specific types of services. The objectives are central, but broken down at committee level and then at unit level (for example, the individual nursing homes). Every district committee has its budget, four-monthly reports and year-end reports documented in the system, which is also the case for the provider units (nursing homes) researched in the case. Through the system, it was possible to review the budgets and reports of all committees and units connected to aged care, and examine how each committee and unit formulates their objectives and reports on their performance. Using the data from the web-based system, interviews were organised with officials at the committee level. Officials within three district administrations were visited first to get an overview, but also officials at a special administration unit devoted to supporting the district committees with issues regarding aged care e the aged care administration e were interviewed (note that for the sake of simplicity, the aged care administration is not included in Fig. 2). The data collection then proceeded at two more districts, interviewing and observing assessors and controllers at the district administrations purchaser functions, as well as managers and staff at a total of five in-house nursing homes. 3.2. Data collection and handling When an informant was approached, an ethnographic interview technique was employed (Agar & Hobbs, 1982), interested in understanding local practices from the practitioners’ own perspectives. This called for open and broad questions where the informants, without interruption, could use their own words and tell the researcher how they experienced their work situations. This could then be followed up by more specific questions depending on insights other informants, observations on meetings, legal texts, current debates, the web-based control system, or research literature had provided. This approach could be employed because of an iterative research strategy. Each interview was carefully prepared with an interview guide specifically tailored for the particular interview. This interview guide listed a set of possible follow-up questions based on (1) what could be expected to be of concern for the particular informant, and (2) what had come up in recent interviews and observations, documents accounting for the informant’s responsibilities (in terms of targets, commitments, work routines etc.), public debates, or in relevant academic literature. In this manner, a follow-up question in an interview with an assistant nurse at a nursing home could be put together from several different sources, such as (1) an earlier interview with the nursing home manager, complaining about co-workers being too confined to work routines; (2) the nursing home’s documented quality commitments specifying that work procedures should be open and flexible; and (3) academic literature proposing that such a problem could emanate from accounting instruments being used. By combining such different sources of information, new and interesting themes could come up for discussion during interviews. Every interview was audio recorded, and notes were taken during interviews and meeting observations. These recordings and notes were then used to construct new interview guides by recurring listening sessions and re-readings. Such an iterative approach helped casting a wide net, because a range of loosely related theoretical and practical concerns could be addressed in every interview. It became possible to “zoom in” on particular problems, such as individualisation, and then proceed by focusing on what a particular informant found problematic at that €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa 6 Fig. 2. The aged care organisation and informants. particular point in time e for example the upcoming implementation of a new value base. Even if these two issues seemed inconsequential to each other in the interview, later readings of notes and listening sessions e where recordings from different interviews or notes from meetings were related to each other e could point towards new themes needing exploration; themes that required new data, such as the collection of legal texts and debate articles. The approach hence required both width and depth. Therefore, several informants, as well as the web-based system, were revisited a number of times. 15 meetings e seven budget meetings between controllers and unit managers, and eight staff meetings with purchasers and providers e were observed. In total, 55 persons were interviewed and when the discussions on the observed meetings are included, the empirical material consists of voices from more than 100 persons in the organisation. These actors all have relationships with individuals in need of care in different “dividual” shapes; and they all contribute to the story about the struggles to perform individualised care in an environment where individuals are regularly broken down into manageable “dividuals” in the name of efficiency. 4. Programmatic ideas and the “non-local” The Swedish Local Government Act (SFS 1991:900) primarily regulates the provision of services in Swedish local governments, stipulating the equal treatment of every citizen but also the economic foundation: every municipality should operate with “economic responsibility.” This vague formulation has been a discussion point among municipalities since its insertion in the Act, mostly because it can be seen as addressing both sides of “the economic”: financial prudence as well as the volume and quality of organisational output. The emphasis has been on the former aspect because of the enactment of “Special Acts” e acts devoted to special areas, such as the Education Act (SFS 2010:800) and the Social Services Act (SFS 2001:453), all having stipulations regarding service quality. Arguably, the Local Government Act works as a counterweight to the stipulations of the Special Acts, highlighting the importance 1 Available at: www.kolada.se. of efficiency: low input and high output. An important instrument supporting this is “the national benchmark database”1 where performance measures, such as average costs of aged care per inhabitant, and customer satisfaction from every municipality in Sweden are assembled on a public website. This database provides opportunities for anyone to evaluate efficiency and effectiveness of municipalities. Most municipalities try to stay close to the national standards, for example, regarding costs, but those with low costs and high satisfaction can claim high effectiveness, while those with high costs can claim that they invest more than the average in aged care. The Social Services Act opens with a statement that every citizen has the right to security, equality, and the opportunity to actively participate in society: three tenets of a democratic society that should be safeguarded by the municipalities. The Social Services Act then addresses the importance of seeing every person in need of social service as able and responsible, stressing that social services should aim at “emancipating and developing the abilities of individuals and groups.” The first section of the Act concludes that any intervention by social services must show respect for every individual’s integrity and ability to determine things e for example where they want to live e for themselves. The Social Services Act regulates a wide range of social services, and the three tenets above function as overarching principles for all kinds of social services. It also includes special sections devoted to aged care: sections subject to recent changes. In addition to the principles accounted for above, a formulation regarding a “value base” for aged care has been inserted. This formulation puts more emphasis on a dignified life and the aged person’s well-being, as a complement to the three tenets. This change, based on a central government bill (Regeringen, 2009), highlights the importance of seeing every aged person as an individual. This calls for “a situationoriented way of work” (Regeringen, 2009, p. 10), “a flexible organisation consisting of multi-disciplinary and multi-professional teams”, (ibid, p. 10), an ethical approach where “all humans have their own value, just because they are humans” (ibid, p. 22) and a point of departure ensuring that “aged men and women should be able to lead a life in line with their identity and personality” (ibid, p. 24). This new value base puts individuality and uniqueness on the same level as security, equality and the ability to participate actively in society. Every aged person should thus be treated equally but, at the same time, uniquely. €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa 4.1. Equality, needs based allocation, and the standard worker One potential problem following the inclusion of the new value base is the principle stating that when a legal change incurs additional costs for local governments, the central government has to remunerate them for those costs. The central government asserted that this legal change was too small to incur additional costs: it “only” further emphasised an already present humanistic view of the aged person. Costs could have been a major obstacle for the implementation of the value base in the municipalities, but it appeared that most Swedish municipalities had already started their own work in this respect, so there were few protests. However, there were other forces at work parallel to the value base discussion. One of the reasons for the new value base was the occurrence of a number of mistreatment scandals2 within Swedish aged care. The value base was one remedy, but another one, promoting needs based resource allocation, was also underway. It was prepared by the National Board of Health and Welfare (NBHW), the central authority responsible for issuing instructions and directives regarding social services and health care, but also, at this time, for supervision and inspections of these areas. Their problematisation of the scandals was that resources were not allocated in accordance with individual needs locally. The NBHW conducted a survey among aged persons, their relatives, and staff working in provider units, to secure evidence that systematic under-staffing was the main problem throughout the country. The survey came back with devastating results: whereas the respondents were generally satisfied with the competence of the staff, there was serious dissatisfaction with the low number of staff.3 The NBHW also made surprise inspections on a wide range of nursing homes all over Sweden, also with discouraging results. The NBHW had already been working with directives defining and prescribing formal competence, their latest publication highlighting 12 competence areas needed for proficient work in aged care (Socialstyrelsen, 2011). Such classifications enable measurement of competence, making the competence level of, for example, individual nursing homes or whole municipalities comparable through the national benchmarking database and other outlets. Because of these measurements and competence standards, provider units are thought to have incentives to keep up the basic competence level among their staff. Competence e the quality of the worker e was hence “known”: the next step was to address the staffing issue in terms of sheer numbers. However, although the worker could be standardised, the individual user in need of care could not, according to the new value base. Therefore, allocation of staff resources had to be made on the grounds of service needs and not just based on the number of individuals in a nursing home, calling for local and recurring assessments of these needs. According to a new NBHW directive (Socialstyrelsen, 2012) this should become the responsibility of the purchasing municipality’s care assessment units. In order to be flexible e the need for services may change e the assessors should make new assessments of the staffing needs for every provider unit, as often as once a month. A template for calculating local staffing was issued together with the directive. Starting from the individual needs of every aged person in the nursing home, the template could be used to assess 2 The scandals have rocked Sweden’s view of itself as a welfare country. Aged people have starved to death in nursing homes, and people suffering from dementia have been locked up instead of cared for. 3 Vad tycker du om bemanningen i demensvården? Resultat av Socialstyrelsens webbenk€ at 14 september e 7 november 2011. Available at: http://www. socialstyrelsen.se/nyheter/2011november/Documents/Resultat-av-enkat-2011-1107.pdf. 7 the total staff needed every single hour of the day (3 staff between 7 and 8 am, 4 staff between 8 and 9 am), depending on, for example, breakfast time or shower time. The staffing was to be related primarily to the needs of the aged persons living at the nursing home, but there could also be differences depending on the working environment, or available technical assistance, which could increase or decrease staffing needs. Where the work hours in nursing homes were formerly decentralised to the provider, it should now be regulated in explicit detail by care assessors from each municipality’s central purchaser unit down to the hour e arguably contrary to the new value base endorsing a “situation-oriented way of work”. This time, the protests were significant. The Swedish Association of Local Authorities and Regions (SALAR) quickly issued a petition4 stating that their members (the municipalities) should not follow the directives from the NBHW. Funding was a main issue. Because the NBHW approach was that the new directives only corrected what the municipalities themselves had failed to manage, the municipalities could not expect any additional funding from the central government (a directive from the NBHW can be seen as a legal change that may incur additional costs, as discussed above): the new obligations to allocate according to needs were not new at all. The petition from SALAR made the NBHW publish an illtempered debate article in one of Sweden’s biggest newspapers with the title “SALAR wants to stop regulations supposed to secure the needs of the aged”.5 The arguments from the NBHW emphasised the satisfaction of individual needs, also raising concerns of equality and distrust toward the providers of services, arguing that they only wanted to keep costs down. SALAR wrote a reply the same day in the same newspaper,6 going for the throat of the NBHW while deflecting from financial issues. SALAR wrote: The new directives are, mildly spoken, rigid and bureaucratic. The aged persons are not seen as individuals, but as part of a collective. But aged, fragile humans need adjustable care with the ability to change, sometimes from day to day. Monthly decisions by [the municipalities’ purchaser functions] are, in these cases, not a defendable solution. The decisions have to be made close to the person they concern, that is, by the care staff working alongside the aged. Two opposing views emerge: one that proposes standardisation in the name of equality and in order to make resource allocation amenable to evaluation and inspection; and one that proposes flexibility and autonomy to situate and individualise care, albeit with a strong eye toward cost effectiveness. NBHW can only affect aged care through regulative directives and subsequent follow-ups and inspections based on these directives. They can raise the distrust argument, attributing financial considerations to the arguments of SALAR and representatives of aged care providers in order to implement more directives and inspections. SALAR and aged care providers, on the other hand, have found a strong argument in the individualisation aspect of the value base when arguing for autonomy and minimal regulation. As will be shown, the dissension on the non-local level between different rationalities, drawing on various discourses, is also present on the local level as 4 €r 13:2. Available at: http://brs.skl.se/ Sveriges Kommuner och Landsting, cirkula skbibl/cirkdoc.jsp?searchpage¼brsbibl_cirk.htm&search1_cnr¼13% 3A*&op1¼&type¼&all¼1&db¼CIRK&from¼61&toc_length¼20&currdoc¼73. 5 Available at: http://www.dn.se/debatt/skl-vill-stoppa-regelverk-som-skasakra-aldres-behov. 6 Available at: http://www.dn.se/debatt/socialstyrelsen-satter-sig-over-lagen. €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa 8 they are operationalised. 5. The local making and breaking of the individual Aged citizens in Sweden become part of aged care upon own choice. They are, in this sense, constituted as customers: there is a freedom to choose where you want to live. On the other hand, because aged care, to a high degree, is tax funded,7 you are not necessarily eligible for care just because you choose it. The Social Services Act stipulates that anyone in need of services should have it, to uphold the three tenets of security, equality and participation in society, but that no-one should be forced to it. Therefore, an assessment regarding someone’s need to become the resident of a nursing home has to begin with an application from that individual. Only then is an assessment carried out to ascertain whether the individual needs to move from their own home to a nursing home or not. The assessment is based on the three primary tenets of the Social Services Act: it should determine if the aged person is insecure, does not have equal opportunities in life compared to other aged persons, and if there are insufficient opportunities to be a part of society. If this is the case, and there are no other remedies8 to these inadequacies, the person may move to an apartment in a nursing home: the individual becomes constituted as a service user with legitimate needs.9 5.1. Creating the legally robust “dividual” Because the operationalisation of these tenets is far from straightforward, there are professional assessors working in Swedish municipalities, operationalising the stipulations of the Social Services Act. They normally have a range of instruments helping them to make the necessary decisions e local instruments that can look different in different municipalities. In the organisation researched here, a mapping instrument, based on nine categories of daily life, is used. The instrument is qualitive, works partly as an interview guide, and is supposed to support the assessor to gather the aged person’s life biography and current situation. These knowledges e the biography and the mapping of the current situation e form the foundation for a qualitative understanding of the aged person’s eligibility for an apartment in a nursing home. This understanding is then supported by a formal calculation of 23 criteria which gives the assessed person a score between 1 and 2410, where 1 is in least need of care and 24 in most 7 The Swedish government system gives the local governments responsibility for their own finances. Municipalities are free to levy taxes from their citizens in the form of income tax. There are several other sources of income for the municipalities, for example, the possibilities to charge customers with fees. For persons living in nursing homes, the fees consist of a fee for services, rent payments and a fee for meals. In the municipality researched here, these fees are set and procured by the providers, although the municipality determines a maximum level of fees and rents. Provider competition is assumed to keep fees low. The municipalities subsidise most of the providers’ costs for care services through the remuneration system, whereas the providers’ costs for rent and meals are supposed to be covered by the customer. In order to secure that care services are subsidised, that is, payed for to a high extent by taxes and less by customers, the Swedish central government issues a directive each year on the maximum level of the care service fee. The central government also issues directives regarding the minimum amount of money an individual should have left every month after paying the fees, in order to cover living expenses. If an individual has a low income, the municipality have to subsidise costs for fees and/or rents for that particular individual. 8 For example, different kinds of domestic care. 9 To distinguish between the different constitutions of the individual, it will be referred to as “user” and “customer” respectively. Other terms, such as “resident”, will also be used to indicate other ways the individual may be constituted. 10 The applicant receives one base point, therefore the minimum score is 1, and the maximum score 24. need of care. The qualitative understanding and the calculation are brought into daily meetings with colleagues, where every assessor brings up current cases in order to get feedback from the others. Here, the qualitative understandings play an important role, as the colleagues have met hundreds of aged persons, helping them contextualise the stories about aged indviduals in need of care. In this arena, the decision of eligibility is made, although the formal decision is made and documented by the responsible assessor in a template. The point system is also supposed to visualise the resource consumption of an individual: someone needing more care is understood to be more resource consuming than someone needing less. Therefore, the calculation of the 23 criteria is categorised into 3 levels corresponding to financial remuneration for the nursing home into which the aged person will move. 1e8 points gives a remuneration level of 1, 9e16 points remuneration level 2 and 17e24 points remuneration level 3. For the municipality, a higher assessed level means greater costs since the individual needs more care and services, while it means more revenue for the provider. Therefore, controllers keep track of how many of each level are decided on a monthly basis. Controllers use this for budgeting purposes, but the statistics are also vital for the assessors to determine the equality of assessments throughout the organisation. If assessors at one district administration decide upon a significantly higher percentage of “level 3’s” than all the other districts, there are concerns about unequal assessments with some providers receiving more resources than the needs of their users justify. Thus, each district’s purchaser budget is compared to an “average assessment”, meaning that negative budget deviations are an indication of unequal and “too generous” assessments: financial matters play an indirect role in the regulation of professional assessments, alongside the organisation’s assessment instruments and the experience of the assessors and their colleagues. During an interview with a care assessor manager, the question of who decides the “eligibility level” e the level of need that justifies the move to a nursing home e came up. She said: The Social Services Act and the instructive documents from our organisation are very general. We try to follow them as well as we can. It is mostly about experience. We get feedback from our colleagues, the users themselves and their relatives. Sometimes there are appeals, and then our decisions are treated in a court of law, and if they go against [us], we have to change something. Therefore the assessors want to know the aged person’s biography well, in order to be comfortable with the decision. However, as it has to stand up in court, the formal decision has to be tightly connected to the Social Services Act and its local operationalisations. This makes the wording of the formal decision important: it always refers to the tenets of the Social Services Act and to the nine areas of the mapping instrument. In this way, a legally robust paper-version of the individual is constructed from a significantly broader knowledge base. This legally robust “dividual” is directly related to service needs and could therefore, theoretically, be used to calculate how much staff is required to care for the individual on average e as NBHW would wish. It is not used this way here, but it is used to follow up changes in service needs e something extensively exploited by providers, as will be discussed later. Several dilemmas follow from this “dividualisation” of the individual into a legally robust paper-version. One dilemma is the result of a control system feature in the municipality: managing for results. In this municipality, “results” are not only budgeted measures accounted for in annual reports, but also a range of other €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa things, noted in various reports and discussed on meetings from the individual level, to committee and council levels. The care assessors’ most important results relate to the individuals. This is a significantly different rationale than the one maintained by law: it is a more open source of knowledge about the individual. Working with both these rationales sometimes highlights severe ethical problems. A care assessor manager remarked: Working with managing for results means that we look upon the consequences our decisions have for the individual. Sometimes we can see that our decisions, although they are consistent with the law, will have negative consequences for the individual. That is hard. An example is that the assessors often decide for domestic care, instead of a move to a nursing home, because the legal system allows for (sometimes even dictates) it e even if the assessors’ experience tells them that the person would be better off at a nursing home. The extensive knowledge of “the whole” individual problematise the standardised, legally robust, “dividual”, and may show that what is legally right may be ethically wrong. Another dilemma that follows is that the individual sometimes does not meet the standards. The instruments do not capture the amplitude of some matters. According to one informant, the assessment instruments capture characteristics that are “highly correlated,” making resource allocations skewed toward certain conditions. For example, the instruments fail to capture severe dementia combined with strong physical abilities. One such case was related during an observed assessor meeting. The case was clear in terms of eligibility, but no provider seemed to have the resources to care for this individual’s special needs. During the meeting, the assessors recapped several similar cases as examples and brainstormed nursing homes that might suit this person. This was never resolved as there appeared to be no suitable care provider for this individual. There seem to be two reasons for this. The first is discussed above; that the instruments and the correlated remuneration levels do not cover such needs. The second is that the “nursing home market” is constructed not on the basis of supply/demand, but on supply/needs, where the needs are decided by the Social Services Act and the local instruments that operationalise it, whereas the supply is dependent on the correlated remuneration levels. According to a controller responsible for constructing the remuneration levels, the levels were decided by a long series of simulations where different costs and threshold levels were simulated and put against the financial consequences they would have for a standard nursing home with standard clientele. The decided levels were supposed to make as little impact on the standard nursing home as possible. The supply of nursing homes is thus adapted not to the biography of the individual, but to the legally robust paper-version of the individual and standardised financial remuneration. 5.2. Pathologising responses: accounting logic and the market The assessors have an obligation to assess needs: they have to discover the inabilites of individuals applying for aged care. However, the Social Services Act stipulates that every individual should be assessed on the grounds of their abilites. The value base, according to which every human should be seen as a whole, able individual, furthers this perspective. This is something that both care assessors and providers have to work with and resolve. One solution that may be used by assessors is, instead of prescribing services, to consult a physical therapist which could lead to therapy and rehabilitation of an inability. This is expensive and takes time. Therefore, the care assessors at one purchaser unit became happy 9 when a private physical therapy provider offered consultations for free. The happiness soon lessened, as it was acknowledged that this offer would violate the principle of fair competition. This provider would have an unfair advantage, if customers were to exercise their right to choose e both because physical therapy might be chosen over other kinds of services, and because this particular provider would have the advantage over other therapy providers. As the assessors are the only ones considered impartial, they should do the assessments by themselves. Being competent primarily in assessing inabilities the pathologising effects of the system remain. The providers have similar problems, especially regarding the remuneration system. For the providers, the more their users are assessed as “in very bad shape,” the higher the remuneration. Users with “level 1” assessments are seen as unprofitable, while “level 3” users are normally more profitable. This kind of allocation is a direct consequence of the accounting logic: the individual most in need of resources should have them. Provider managers, responsible for both costs and revenues in their units, spend much time thinking about these levels. In one observed meeting (in December) between a provider manager and controller, they discussed next year’s budget. The provider manager had the problem that three “level 3” users had just passed away, and were replaced by a “level 1” and two “level 2” users. This meant that the nursing home would go into next year with a revenue base significantly below last year’s average (against which next year’s costs were budgeted). It seemed difficult to cut sufficient costs, so they were instead discussing the possibility of increasing revenues: which individuals that might “level up.” In the middle of this discussion, the provider manager suddenly stopped talking, closed her eyes and whispered: “This is awful; we are sitting here wishing for these poor humans to get worse.” Seconds later the discussion continued. One opportunity to “raise the level” of the users for the providers exists: thorough documentation. Through professional documentation, the providers can show the care assessors that their users are wrongly assessed. The formal decision made by the care assessor is mirrored by a documented care plan constructed by the provider. Every time something happens in the provision of services that indicates that a user’s need is higher than the formal decision assumes, the deviation is documented. This may then be used to convince the care assessors, in a professional manner, that a user needs to “level up”. Also at the provider level, the system works towards finding the “hidden” inabilities of the individuals, rather than seeking the abilities that may help them get better. 5.3. Taking the individual seriously When faced with the task to choose nursing home, it becomes difficult for individuals to exercise their role as customers. Partly because of the abundance of nursing homes in the city, partly because the supply of services is based on formalised needs (see above), which makes it difficult for providers to differentiate themselves in the eyes of the customers. The studied municipal organisation tries to remedy this by publishing essential provider data on their web-page. The published data are primarily the results of yearly, third party conducted, customer satisfaction surveys on topics such as care quality, food standards and activities. Other data include the competence level of staff,11 results from inspections, and the provider unit’s quality commitments e articulations of the service quality the provider promises their customers. 11 Competence level is measured as percentage of staff satisfying NBHW’s basic competence criteria (Socialstyrelsen, 2011). This, and customer satisfaction measures, are also published in the national benchmark database and in the municipality’s annual report. 10 €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa There are hence incentives for the providers to have high staff competence levels, high levels of satisfaction, no complaints in inspections, and sensible and attractive quality commitments because customers, presumably, choose providers by relying upon these aspects. This theory stands strong. Although provider managers argue that choices are mostly based on word of mouth, as well as visits and inquiries directly to the nursing homes, most of them take the measures seriously: they can never be certain to which extent prospective customers use the data to choose. The constitution of a rational, knowledgeable customer persists. Different measures provoke different problems regarding how to care for the individual. Some informants are critical of using competence levels as benchmarks for quality. An aged care manager criticised the system, arguing that the efforts to maintain high and measureable basic competence hamper the development of special competences. Since only basic competence is visualised and accounted for, there are no reasons to develop staff expertise in, for example, dementia care. Another aged care manager, arguing for the importance of such expertise, saw her numbers fall as she put more resources into developing expert rather than basic competence. She was worried: “We know that things are getting better, but we can’t show it,” she said. The measurement of standardised competence levels hence follows the accounting logic: it is easy to measure, and it can be used to show that resources are directed to user needs. However, such focus on visibility and matching may have little effect, locally. An assistant nurse claimed that, although finding competence development positive, “many times those things you have learned when you go to courses disappear, because there is no time to practice what you have learned.” Sending staff to courses, to gain formal competence, matters more than putting their new knowledge to work. This exacerbates the problems of keeping up care quality at the work place, where personnel with special or other areas of expertise are neglected e contrary to the ideas of “multiprofessional teams” and “situation-oriented way of work” put forward in the value base. Customer satisfaction surveys provoke other problems. The formal surveys, conducted by a third party, create uncertainties regarding response rates, who answers (the aged person or a relative), and which expectations lie behind responses. Some of the nursing homes therefore experimented with their own measurements. One of them had its staff interviewing the customer three times a year, thus gaining a 100% response rate. This nursing home also complemented the measurement with a survey of the staff, where they answered similar questions as the customers on service quality. Instead of one measure of each topic, they ended up with three, sometimes conflicting ones, that could be circulated among staff, the aged persons, and their relatives in order to understand what needed to be done and for whom. This added to dissension, and made it possible to, according to the manager, “direct efforts in the right direction” by opening up for more conversation and bringing in other perspectives on care services. The expectations of customers are a problem in its own right. Constituting themselves as customers, the aged persons often expects the nursing home to be a “hotel” e a place providing services. The staff, on the other hand, sees their role as maintaining the abilities of the aged persons. The staff should make the nursing home as home-like as possible which entails the continuous reinforcement of daily activities: cleaning, washing dishes, and setting tables. Far from the “hotel ideal,” this makes some customers dissatisfied. Despite the risk of dissatisfaction, the management and staff of several providers work hard with the ambition to involve the aged in daily activities. They put much effort into listening to every individual’s wants and desires, sometimes treating the aged person as a customer wanting services, sometimes as a human being in a home-like relationship with staff and other residents. Issues are resolved on a daily basis e sometimes risking measurable satisfaction levels to suffer. Different performance measures hence “dividualise” individuals in different ways. Caregivers are “broken down” to competence levels, and customers become their own levels of satisfaction: these are the things that should be managed according to the accounting logic. Also resource allocation practices contribute to this. When sitting in with the controller, away from the nursing home, it is logical for a manager to hope for the users to become sufficiently worse to “level up”. When back at the nursing home this is unthinkable. The same manager, who was discussing the revenue side of the budget above, was followed to a staff meeting just a few days later and the discussions were all about helping individuals get better e with no consideration of remuneration issues. Remuneration levels are financial problems requiring discussion with the controller, to grasp the challenges that lie ahead. Caring for individuals, on the other hand, involves each individual, whole, person: the pathological, calculable “dividual” that generates income can be restricted to the compounds of the budget meeting. The struggle to provide individualised care also affects the documentation routine. From a remuneration perspective, the care staff should look for any individual needs and inabilities missed by the assessor, and document deviations. Focusing on standardised catagories of disability, such documentation may contribute to “levelling up” a user, but fail in conveying unique experiences about care that works for specific individuals in specific circumstances. Several providers, therefore, started to document “salutogenic12”, focusing on meaningfulness and “the healthy” in humans, and “empathetic”, from the perspective of the individual. This is done in the name of care quality and individualised care, but to the detriment of a revenue management practice made possible by the accounting logic. Conundrums and dissension emerge: individualised efforts make it difficult to manage revenues, but revenues directly impact the possibilities to conduct care at the providers e they limit staff availability during the day which, in turn, limits how individualised care can be conducted. Shortage of staff leads to daily problematisations of work and multiple dissensions regarding how to care for the individuals. Therefore, several providers have ongoing discussions regarding what should matter most: efficiency or individualisation. Many discussions revolve around mundane matters, such as when the residents should get out of bed, who should have a bib at lunch, who should be fed and who should be encouraged to eat by themselves. It is always more efficient to get everyone out of bed at the same time, put a bib on everyone and feed anyone who eats slowly. However, in the name of individuality, it has to be allowed if someone wants to sleep in, and eat breakfast in their apartment. Similarly, anyone who refuses a bib should not have to wear one, even if it would mean more laundry; and if someone wants to eat themselves, they should not be fed, even if it takes three times longer and the washing of dishes is delayed. The decisive criterion for how to go about when taking care of, for example, “Judith”, is the question: “Am I doing this as Judith wants?” This entails drawing up plans and creating routines, sometimes only for the purpose of not following them e something that has proved confusing, calling for new and different ways of thinking and doing. This way of thinking often manifest itself in self-reflective propositions, put forward by managers and coworkers: “But think if it was you who sat there at the dinner table?” or “What if it was your own mother who would receive that kind of treatment?” These propositions are seconded by a growing 12 A term coined by psychologist Aaron Antonovsky (see Antonovsky, 1996). €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa body of literature with titles like “Antonovsky not Maslow e for a €berg, 2005). Focusing on meansalutogenic care” (Westlund & Sjo ingful care of whole individuals (Antonovsky), rather than certain basic needs (Maslow), such propositions seem to affect the conduct of care in similar ways as the ones drawing on the accounting logic. By including both the self and the other in the equation, staff strives toward a possibility to conduct care services for the individual whole. 6. Discussion What happens when the individual is taken seriously? When an individuality programme based on wholeness is operationalised side by side with an efficiency programme resting on division? As anticipated from governmentality-based accounting literature, there are significant difficulties in doing this, because “dividualisation” and standardisation are integral for making people governable (Miller & O’Leary, 1987): the programme based on division would be expected to take over and subjectify the individual accordingly. This case, however, provides a different story that may afford interesting implications for governmentality based analysis. 6.1. Non-local discourse, contradictions and operationalisations The efficiency programme is a strong adversary for those struggling to provide individualised services, because efficiency becomes connected to ideas of equality through the accounting logic. Efficiency and equality also have strong support from legal texts. As a consequence, NBHW can focus on equality and how individual needs can be secured by more concrete instruments, connecting resources in the form of standardised workers with formally assessed needs. However, counterarguments of individuality and heterogeneity can be mobilised e also supported by law. The argument by SALAR is not only that every individual is unique; the argument is also that things could change from one day to another. This denies the operationalisation of an idea of equality by instruments of calculation: the debate between NBHW and SALAR shows how the individual is, on the one hand, broken down to relatively stable needs but, on the other hand, constituted as something unstable and unpredictable that can only be appropriately cared for in local practices. According to governmentality approaches, the construction of stable and evaluable representations of practice e calculable spaces e is integral for government at a distance (Miller & Rose, 1990; Miller, 1994, 2001). For non-local governors far away from practice, it would thus appear contradictory to endorse something that denies standardisation and possibilities for intervention. However, this is exactly what is done with the Social Services Act: it is explicitly stated that practice needs to be situated and therefore, to some extent, ungovernable. The idea of uniquely situated practices should permeate Swedish aged care: individuality and uniqueness should become operationalised locally, as much as economic responsibility, equality and security. This is problematic for the actor supposed to carry out evaluation in practice, the NBHW. From their perspective, the recognition of a “whole” individual constitutes it as something seemingly impossible to control. NBHW can try to fight this, by voicing suspicions that SALAR wants to avoid higher costs for staffing. However, when contradicted with arguments from the value base, the emphasis on bureaucratic instruments, standards and regulations may come up short. 6.2. The problem of “instruments” The fieldwork in this paper shows a range of mediating 11 instruments (Miller & O’Leary, 2007) e “instruments [that] operate as both means of representation and means of intervention” €ki & Miller, 2011, p. 222) e and how they mediate be(Kurunma tween different stakeholders in different contexts. For example, an instrument such as the resource allocation model connects the practices of assessors and providers by binding together documentation with the legally robust paper-version of the individual. By making revenues dependent upon a particular type of professional documentation, such an instrument mediates between the efficiency program and practice, contributing to “dividualising” the users of care services into calculable spaces of inabilities, needs and revenues. Such instruments, together with, for example, market rationalities and ideas about fair competition, participate in forming the assemblages that operationalise programmes by connecting practices, and making them reliant upon each other. Such “dividualisation” is, from earlier studies based on governmentality approaches, to be expected. In the case of this paper, individuals are regularly broken down to subsets of themselves e their knowing, choosing or pathological selves e when customer satisfaction indexes become connected to budget practices through customer choice, prompting caregivers to aim for customer satisfaction, while searching for inabilities that can be used to maximise revenues. The particular oppositions against such “dividualising” practices, are however less expected. This partly takes place by adapting instruments, to make them cohere with the programme of individuality. Examples, such as the new way of documenting “salutogenic” and empathetic, or the collection of contradicting satisfaction measures from different sources, shows how instruments can be adapted to provide spaces of dissension where other sources of knowledge can be included and put to work. However, such practices do not cohere with the accounting logic and makes it difficult to show efficiency and effectiveness to outsiders. Locally, thus, there are daily struggles to determine how to conduct care e more in line with the efficiency programme, and as stipulated by the accounting logic, or in line with the programme of individuality. Such struggles are never resolved, but are conducted in spaces of dissension where stable, calculable spaces, constituted by instruments adhering to the accounting logic, “compete” with situated knowledge mediated by language as a “technology of thought” (Miller & Rose, 1990, p. 5). Such dissension makes it possible to conduct care differently, and as a consequence, the individual is broken down, made up again, and re-mobilised several times a day. This means that studies centering on accounting instruments as primary mediators of relations may overlook struggles that bring forth other kinds of “truth” and other ways of knowing (Deleuze, 1986); situated knowledge that create dissension with knowledge constituted by calculative techniques (Foucault, 1982). In a local setting, the mobilisation of “Judith” e a situated knowledge e can be as powerful as any knowledge mediated by accounting instruments. Self-reflective propositions e putting someone in another’s place e are powerful ways to mediate relations between non-local, programmatic articulations, and the local practice that does not involve instruments. To account for struggles between different kinds of knowledge, the analysis needs to be broadened, taking into consideration that there are active participants everywhere, acting directly upon the actions of others e not only through instruments (Kosmala & McKernan, 2011). A manager can criticise the work of caregivers, suggesting they should do something different based on observations of actual practice, while a relative to an aged person in a nursing home may react directly upon the perceived treatment of this individual. The mentality of government e the governmentality e is put to work both from a distance, through instruments, and on site, through direct actions upon the actions of others. 12 €llstedt / Accounting, Organizations and Society 80 (2020) 101077 N. Wa 6.3. The contextualised individual Thus, “different spaces of dissension” (Foucault, 1972, p. 152, italics removed), can be found both locally and non-locally. As a result, care practice is problematised on a daily basis: few things are entirely stable. Different understandings of the individual, and of how daily work should be conducted in order to care for the individual, regularly come together in practice. Dissension over seemingly mundane matters emerges, and as individuals are related to other aspects of practice, different propositions on how to conduct care come to the surface. For example, something as basic as “sleeping in” could easily be problematised. Is it a hotel service aimed at satisfying a customer, or does it mimic home-like conditions, allowing the aged person to feel as a whole, albeit fragile, human being? The answer is never given; instead it is articulated over and over again in spaces of dissension created by programmatic and technological tensions, experienced “here and now”. Rival programmes can also operate and dominate in different locales, simultaneously and without clashing, while individuals move between them and constitute themselves accordingly (Foucault, 1987). Nursing home managers can align themselves to the efficiency programme and the accounting logic in one context, and utilise the instruments that construct the calculable spaces of the customer or user (for example in a budget meeting). Later, they can, without much difficulty, switch to the individuality programme in another locale (for example in a staff meeting in the nursing home), rely on different ways to render the individual knowable and mobilise “Judith” or “your mother”, prompting selfreflection and empathetic care practices. By keeping the two incompatible versions of the individual apart, spatially, it is possible to conform to both the efficiency and individuality programmes. Such ongoing contextualisations deny the subjectification of individuals e the aged persons as well as the ones caring for them e into governable spaces (Miller & O’Leary, 1987; Miller & Rose, 1990). Technologies do not necessarily make thoughts and actions in one locale congruent with those in another (Miller & O’Leary, 1994). Instead, and according to Foucault (1987, p.128, italics added), “[t]here is always a possibility, in a given game of truth, to discover something else and to more or less change such and such a rule and sometimes even the totality of the game of truth”. Because of dissension, something else is regularly actualised, appealed to and looked for in practice (Deleuze, 1986): rival programmes and insufficient technologies invite problematising thoughts that have no clear relation to any stable knowledge. Phillips (2002, p. 340) formulates it this way: “In confronting the present with contradictory accounts of the present, the existence of spaces of dissension and freedom are revealed e spaces in which certainty and action are problematised and, thus, become objects for reflection”. Because the world of programmes tend to be heterogeneous, such spaces of dissension and freedom may exist anywhere contradictory accounts of the present are available. It is demonstrated it in this study, but also evidenced by, for example, Vaivio (1999). Therefore, the traditional governmentality-based research that usually focuses on how individuals become governable through the construction of calculable spaces, can be complemented. Such complementary studies could analyse how dissension comes about; how individuals, as a consequence, regain a sense of freedom and become able to stand up against subjectification, with the effect that government from a distance becomes problematic. 7. Conclusion The world of programmes is heterogeneous and saturated with rival understandings about what matters. As a consequence, dissension emerges regarding what is “right”, “wrong”, “good” or “bad”: because of dissension, seemingly dominant understandings of the world can be problematised. This paper makes an effort to examine how a programme of individuality problematises a programme of efficiency, and vice versa, by showing how matters of individuality becomes mobilised against matters of efficiency. This becomes possible because the operationalisations supposed to render practices both efficient and individualised tend to “dividualise” the individual and only visualise certain things, such as formalised needs, disabilities or costs and revenues, and render them governable. This will arguably always go against the wholeness of the individual and can therefore be countered with arguments maintaining that calculative instruments brings about insufficient knowledge, and that there is always something else that needs to be taken into consideration. This something else resides beyond the spaces programmes and technologies provide: there is always the other (Kosmala & McKernan, 2011) that has to be taken into consideration in these processes. For governmentality based accounting research, this means that a more general question about “where” arises: where, in terms of discursive and technological spaces; and where e in and between which locations e can a certain mode of knowledge be constructed, contained or dispersed? And where does dissension and otherness break down this same knowledge, and interfere in the identity formations and constitution of the individual subject (see Spence & Rinaldi, 2012)? If also the elusive “something else” e what remains “uncaptured” by certain methods of knowing e plays a part, alongside dissension, this would help us to understand the failings of programmes (Arnaboldi & Palermo, 2011; Rose & Miller, 1992) and the processes at work undermining them. Two more things can be said. Firstly, the constitution of the individual, and the oppositions forming against it in spaces of dissension, are specific and situated (Foucault, 1982). Therefore, these things appear different in different practices, as well as in different national and legal contexts. These differences need to be explored in a variety of settings e in other professional practices as well as in more traditional business settings. Secondly, rival programmes are sources of dissension that are materialised through technologies and relationships with others, “opening up sequences of argumentation, experiment, verification, and various inferences; [making] possible the determination of new objects, [defining] new concepts or [modifying] the field of application of those that already exist: but without anything being modified in the system of positivity of the discourse” (Foucault, 1972, p. 154). The study of spaces of dissension and their sources may therefore show the local movements “within” discursive systems, enable an analysis on how “the individual” evolves in western society, and suggest which resources are available to change its constitution. Acknowledgements The author wishes to thank Roland Almqvist, Paul Andon, Marion Brivot, Wai Fong Chua, Bino Catasús, Kajsa Hallberg Adu, Jaromir Junne, and the MUSICA research group for comments on earlier versions of this paper. 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