The neoliberal turn and the marketization of care: The transformation of eldercare in Sweden

Introduction

The Swedish eldercare system has, over the last few decades, undergone significant changes. Previously, eldercare provision could be described as universal, meaning a publicly provided, comprehensive, high-quality service available to all citizens according to need and not the ability to pay (Szebehely and Trydegård, 2012). Swedish eldercare can still be described as part of a universal, social democratic welfare system where care is seen as a social right that is mainly financed through tax revenues. However, transformation of eldercare in later years has been influenced by neoliberal politics, which emphasize economic efficiency and cost reduction through competition. Beginning with assumptions that economical growth is strongest when the market is not constrained by state protections, neoliberal politics encourages labour market deregulation and retrenchment of social welfare programmes (Misra et al., 2006). The neoliberal turn in eldercare can be seen as a societal logic and as organizational reforms that interrupt and change the culture and identities in publicly provided care in ways we do not fully understand (Dahl, 2012).

Eldercare has become a more diverse, multidimensional system, and a private market for home-based eldercare has been created. The numbers of eldercare providers have increased considerably, and new ways of organizing eldercare have been established (Blomqvist, 2004; Stolt and Winblad, 2009; Stolt et al., 2011). But we do not know much about the consequences of this: what impact do the logic and reform have on eldercare on different levels of organization? What does this mean for equal opportunities for care workers and recipients?

In the transformation of Swedish eldercare the notion of choice has become central, something that Blomqvist (2004) has described as a ‘choice revolution’. The opportunity for elders to freely choose their care providers has been articulated as a key to increased quality, empowerment of users and good care (Andersson, 2010; Svensson and Edebalk, 2010; Szebehely, 2005a, 2011; Winblad et al., 2009). However, the question of the elders’ needs and capacity to choose has to be raised. Being dependent on care often means one is unable to be an active citizen and thus to act according to the free choice system. Rather, free choice implies a moral obligation of citizens to be responsible and to act accordingly (Brown, 2005; Dahl, 2012).

In January 2009, the Act on System of Choice in the Public Sector was introduced (in Swedish: Lagen om valfrihetssystem [LOV] [SFS 2008:962]). The Act was supposed to provide an opportunity for interested municipalities and county councils to expose their publicly provided services to market competition, and to enable the users to choose their providers (SOU 2008:15).

In this article we aim to illustrate how neoliberal reasoning dominated the policy process leading up to the Act on the System of Choice in the Public Sector (SFS 2008:962). With the use of a discursive policy analysis we specifically explore how neoliberal logic dominated, and also how choice and equality were understood and interpreted in the policy process. Applying Carol Bacchi’s ‘what’s the problem?’ approach, we analyse how the ‘problem’ in Swedish eldercare is articulated in the LOV policy process. By focusing on policy discourses, we show how the ‘problem’ with Swedish elderly care was interpreted and understood in the reform and what solutions were suggested to solve these ‘problems’ as well as the effects and material consequences these interpretations and understanding have had on Swedish eldercare (Bacchi, 1999).

‘Eldercare for all’ – a gendered issue

The Nordic welfare state has often been described as generous and universal in the sense that the state takes extensive responsibility for care and offers services to all social groups (Anttonen et al., 2012; Esping-Andersen, 1990). The care for older and disabled people has been described as a core area of the Nordic model (Kantola and Dahl, 2005). The Nordic countries’ welfare model has also been described as women friendly, as women are not forced any more than men to choose between work and family (Hernes, 1987). In gender equality policies women’s participation on labour market has been viewed as the key to gender equality as paid work provides for economic autonomy, sometimes referred to as emancipation through employment (Le Feuvre et al., 2012). The Nordic states have strictly focused on work, and the state’s extensive responsibility for care has been described as a revolution in women’s lives, although an incomplete revolution, as its gains mostly have contributed to improving the lives of well-educated, middle-class women, while creating other inequalities between women (Esping-Andersen, 2009; Isaksen, 2010). Other have suggested that this is not just an issue of class and education; rather, it is essential also to focus on how new ways of organizing care in the Nordic countries have created new inequalities in relation to citizenship, ethnicity/race and migration (Gavanas, 2010; Isaksen, 2010; Towns, 2002). All over Europe today, we are witnessing an ageing population, women’s increasing participation in the paid labour market and lack of or dismantling of publicly provided social care, which has created a market for paid domestic work and care work in private homes, in which new inequalities between citizens have appeared (Daly, 2001; Lutz, 2011).

In the Swedish case, eldercare is clearly a gendered issue, where a majority of employees, users and care managers are women. Women also perform the majority of informal care, and since women are numerically dominant in eldercare, the consequences of the transformation of eldercare affect women more than men (Szebehely, 2005b; Szebehely and Ulmanen, 2012). Eldercare is also part of a hierarchical organizational structure where both occupations and work tasks are strongly gendered. Work conditions are often precarious, the career opportunities are limited, and the work has low status and salary (cf. Eliasson, 1992). The insufficient recognition of the value of care shows a marked gender sensitivity and is exhibited in state discourses at different levels and in relation to other professional groups (Dahl, 2010).

In Sweden there is a political consensus about the value of gender equality as a political goal. But gender equality is a constructed category replete with different meanings, depending on the context (Holli et al., 2005). It is therefore important to analyse how gender equality is understood and constructed in the reforms that are transforming the Swedish eldercare system. Even though there is a political consensus that gender equality is a political goal, the understanding of gender equality shifts and changes, according to the context (Lombardo et al., 2009).

The ‘neoliberal turn’ in eldercare

Since the early 1990s, the marketization of care has become more and more established in Swedish public eldercare, influenced by New Public Management ideology (cf. Dahl, 2009; Stolt and Winblad, 2009; Stolt et al., 2011). With emphasis on creating more effective and cost-reduced care, ideas from the market have gradually been introduced in the public service. However, the marketization within public eldercare can best be described as a quasi-market, since it differs from conventional markets; markets for eldercare are established by the public sector and providers compete to be contracted, but the providers are not necessarily driven by profit or private companies (Le Grand and Bartlett, 1993).

The objectives of the system of choice reform as stated in the Bill are to ‘strengthen the individual’s rights to self-determination and at the same time increase competition by implementing competitive tendering in care provision to increase quality and efficiency and to create more attractive work’ (Prop. 2008/09:29). The system of choice reform is, according to the Bill, expected to offer better quality for older people in need of care. Moreover, care work is expected to become more attractive as care workers have the opportunity to start their own care companies. In this sense the reform is represented as a win-win situation for all involved parties, and as a bonus, the municipalities will see a reduction in the costs of publicly provided eldercare.

To be entitled to publicly financed eldercare, elders are subjected to a needs assessment, which means that their needs are means tested and approved by a care manager (Lindelöf and Rönnbäck, 2004). In more recent years the public debate on Swedish eldercare has been marked by several scandals in which employees, relatives and elders themselves have, through the media, expressed their worries, frustrations and anger in relation to the transformation of eldercare that they experience as part of their everyday life. Several studies have indicated that the marketization of eldercare has created increased inequalities, and also that the needs assessments provided by the municipalities are arbitrary, with elders constructed as consumers of care, not as care users (Olaison, 2010; Vabø, 2011). Other studies indicate that the marketization of welfare in Sweden has not increased the quality of provided services (Hartman, 2011). Yet, while there is no evidence for the benefits of the marketization of eldercare, nonetheless there are no indications that the idea of running public eldercare as a market is being abandoned.

The marketization of eldercare has transformed elders and their relatives into managers of an ‘eldercare puzzle’ (Gavanas, 2013). As evident in the Swedish case with the introduction of the new reforms of LOV, the purpose and meanings of the concept of care have gradually been drained to fit the market language. To care for those dependent people in need of care (a care relationship), or to take care of and give personal services to those who are able to manage by themselves (a service relationship), signifies dissimilarities in relation to power (Fisher and Tronto, 1990; Wærness, 1984). A service relationship is based on a symmetrical relation, as it indicates the user’s autonomy, while the care relationship is basically asymmetrical, since it refers to the necessity of the care worker taking responsibility for the user’s wellbeing. Therefore, within this context, we need to reconsider the concept of care and the consequences of its marketization, if care and personal service to some extent become interchangeable.

In short, the public Swedish eldercare has become more diverse and complex due to marketization and the politics of care. Returning to the LOV reform, and its legislative history, how are we to understand the notion of free choice in eldercare?

What’s the problem with LOV?

Using discursive policy analysis, we will now show how neoliberal reasoning dominated the policy process leading up to the Act on System of Choice in the Public Sector (SFS 2008:962) as well as explore how choice and equality are understood and interpreted in the policy process. In every policy process a representation or interpretation of ‘a problem’ is necessary, but this interpretation is not an objective policy problem. Rather it is one of many possible interpretations of the problem. To illustrate these competing understandings of a policy problem, it is necessary to shift focus from policies as attempted ‘solutions’ to a ‘problem’ to ‘policies as constituting competing interpretations or representations of a political issue’ (Bacchi, 1999: 2). The texts analysed in this article are the Act on System of Choice in the Public Sector (SFS 2008:962), the written record of the parliamentary debate on 19 November 2008 on the system of choice in the public sector, Governmental Bill 2008/09:29 (Prop. 2008/09:29, Lag om valfrihetssystem) and Swedish Government Official Report 2008:15 (SOU 2008:15, LOV att välja – Lag om valfrihetssystem). ¹

We apply a ‘what’s the problem?’ analysis to the policy process leading up to the LOV reform, focusing especially on the notions of ‘choice’, ‘diversity’, ‘equality’ and ‘gender equality’ (Bacchi, 1999). In every policy process meaning is articulated, and these articulations or discourses have important material and immaterial effects, in this particular case, on how eldercare is to be understood and organized. What presumptions are implied or taken for granted? What effects are connected to this representation of the ‘problem’? What is not problematized or is left unmentioned in the policy process leading up to the LOV reform, and also, what other interpretation or understanding of the ‘problem’ is possible (Bacchi, 1999)? Policy discourses are here understood as ways of referring to or constructing knowledge about a particular topic of practice, providing ways of talking about and forming knowledge about a policy problem (Hall, 1997). ²

Understanding ‘choice’ in the elderly care debate

The system of choice is according to this Act a procedure were the individual has the right to choose their provider of services if the provider has been procured and approved by the authorities and a contract has been established. (§1, SFS 2008:962)

In the Act on System of Choice in the Public Sector policy process ‘choice’, or more specifically the lack of choice in publicly provided care, is articulated as the main problem. Choice is repeatedly mentioned in the policy process in the different policy documents, often in relation to empowerment, diversity and quality, as here in the Governmental Bill and the Swedish government’s official report:

This is part of an effort towards centring the user, shifting of power from politicians and officials to citizens, providing greater choice and empowerment, increasing numbers of providers and creating more diversity. Through the increased user influence, service quality will rise. (Prop. 2008/09:29: 54)

The Act on System of Choice in the Public Sector is expected to bring greater choice and empowerment for older persons and persons with disabilities. The intention is, through increasing the individual’s opportunities to choose, to make publicly provided services more responsive to the individual users’ needs and wishes. (SOU 2008:15: 24)

In this policy process individual choice in care is understood as intrinsically good; and should therefore be the dominant factor shaping the activities of publicly funded welfare services, so that these can be more closely attuned to individual circumstances and to satisfy individual preferences and priorities. For elders and others in need of care, choice is fundamental for achieving citizenship, self-determination and human rights. However in the reform the specific circumstances of care for dependent elder persons are not taken into consideration, for instance not all elders are able to make choices due to bad physical or mental health, and not all have relatives around them to assist in these choices. As will be illustrated below, the actual choice that the reform entitles elders to is not in relation to what they would prefer to have an influence over.

In care situations, choice is not a one-off event; it is more of an ongoing process, renegotiated continually, as needs and circumstances change (Glendinning, 2008). However, frailty, associated with advanced age, is likely to increase the needs of ongoing care support and repeated contacts with care service providers. Further, elders might need different types of support at the same time.

In the LOV policy process competing understandings of choice are articulated. In the parliamentary debate it is stated that:

Today we are having a historical debate and tomorrow we are making a historical decision. This is a turn of perspective in Swedish welfare politics that we are realizing today. It is about going from paternalism to freedom. And as a liberal and socially engaged liberal I’m very proud of this change in perspective. It is time that the elders come into focus, not politicians or bureaucrats. (Parliamentary debate, address No. 175, Tobias Krantz, Liberal Party)

This citation is interesting in that it reveals how choice is regarded as the repeal of paternalism. In Wærness’s (1984) model on different care relationships, she describes a third form as a ‘treatment relationship’ which is basically paternalistic, as the professionals decide what is best for the patient/recipient of care. However, here, freedom is interpreted as the being opposite of paternalism, despite context. Do we always wish to have a choice, and if so, are we able to make a choice between different treatments? And does that equate to freedom? In the address the MP is describing the reform as historical in relation to Swedish welfare politics. The Swedish welfare state has previously been characterized by publicly provided uniform and standardized services, which were allocated through bureaucratic planning (Blomqvist, 2004). But the interpretation of choice is contested and questioned in the parliamentary debate, where the extent and limits of these opportunities to choose are under discussion. An MP from the Green Party questions the intent of the proposed reform:

A universal criticism that you can target against the free choice system act proposal is that the government has put corporate interests and circumstances before the interests of citizens and that the aim of the proposal seems to be to create more businesses. It does not aim to guarantee all citizens a right to security and to ensure that everyone gets their care needs met. In short, the government has formulated a proposal that is more about the choice of business than the choice of citizens. (Parliamentary debate, address No. 156, Thomas Nihlén, Green Party)

In this address the MP suggests that the main aim of the reform is to create a private market for eldercare, a line of reasoning that occurs in other addresses in the parliamentary debate as well. Another MP from the Left Party expressed herself in the following way:

To the right wing government, freedom of choice is about elders choosing among a number of private providers on a market. It is called a customer choice model. To me and the Left Party, this is not a real freedom of choice. If it were [free choice], elders would be able to influence the service they get, how it is done and when the provider is coming. When you are living in a home for elders, you should have influence on your everyday life. The staff should be able to tend to the individual needs. A privatization with profit making as its driving force will not achieve this. (Parliamentary debate, address No. 155, Eva Olofsson, Left Party)

In both these later addresses the understanding of choice in the proposed reform is challenged and contested, and a more nuanced and comprehensive understanding of choice in relation to care is requested. Even though there is a great emphasis on choice in the LOV policy texts, the actual freedom of choice is limited; the elders are allowed to choose between different care companies, but they cannot choose the content of care. The major reason for this is the previous needs assessment performed by the care managers, who decide on the intervention. Hence, all interventions provided for the elders need to be means tested by a care manager, regardless of private or public provision. Further, the local politicians in the municipalities have standardized the interventions, and these guidelines differ between municipalities and in how LOV is interpreted and implemented (Feltenius, 2011). In the LOV reform the logic of choice turns elders in need of care into customers, and like customers, they are expected to make their own choices, which stand in opposition to the logic of care (Mol, 2008). In the policy process the elders are understood as free agents and customers, and the reform entitles them to freely choose providers of services. The reform does not take into consideration the specific circumstances that characterize care for dependent people – characteristics such as intimacy, trust and dependency – rather, choice is seen as an end in itself. For older persons in need of care, choices are likely to be made in the context of an ongoing relationship, and even if another provider might offer a ‘better deal’, a choice might be shaped by a desire not to jeopardize an existing trusted relationship. Very few older people actually do change their homecare providers (Svensson and Edebalk, 2010). And even if they are dissatisfied with the care received, how are they supposed to evaluate and compare different providers? Furthermore, as previous studies have shown, elders are more interested in having an influence over the content of the care than they are in choosing the provider (Andersson, 2007, 2010). In a report from the Swedish National Board of Health and Welfare, one-third of the elders in the study who had chosen an eldercare provider were not aware of, or did not remember, having chosen a provider of care. Many stated that the choice about their care provider had been made during a chaotic phase of life, often when they were in bad health. They also stated that receiving home-based care as a circumstance of increased age-related frailty was a life-changing experience in itself (Socialstyrelsen, 2004).

Altogether, the LOV reform follows the neoliberal rationality, which is accompanied by the concepts of marketing, competition, free choice and customer orientation. That means that even vulnerable and frail people within the organization of public eldercare are cast in terms of market rationality. Neoliberalism produces rational actors and imposes a market rationale for decision-making in all spheres (Brown, 2005). And even more important, neoliberalism normatively constructs individuals as entrepreneurial actors in every sphere of life, which also means that rational individuals bear the full responsibility for their actions. In other words, the neoliberal citizen is turned into a calculating subject (Brown, 2005). Amongst other aspects, this results in a moral value neutrality, which has far-reaching consequences for all individuals, and specifically so for vulnerable people. There are also studies that show that not all social groups have equal opportunities to operate in the free choice systems; people with higher education have greater chances of finding the best services, which could increase inequalities in the quality of care (Glendinning, 2008). Further, in the LOV policy process competing interpretations and understandings of equality and gender equality are articulated.

Competing understandings of ‘diversity’ and ‘equality’

The Act on System of Choice in the Public Sector promotes diversity and provides increased opportunities for small businesses, non-profit actors and cooperatives of various kinds to enter the market. A majority of health and social care employees are women, and the Bill gives them a new opportunity to start a business within the line of business in which they were previously employed. (SOU 2008:15: 25)

As illustrated in the quotation above, the Act on System of Choice in the Public Sector was argued as providing a way to increase diversity and also as offering an opportunity to increase female entrepreneurship within care companies. When we analysed the policy process, it became clear that the term diversity mainly referred to the encouragement of multiple actors in elderly care, not in relation to social stratification in any sense. Similarly, equal treatment and non-discrimination were articulated and understood only in relation to the different providers of care services.

The demand of equal treatment and non-discrimination means that all applications from providers, if they participate in the system of choice, should be treated equally in all parts of the process. Factors such as nationality or place of establishment should be of no concern. (Prop. 2008/09:29: 61)

The analysis of the Governmental Bill (2008/09:29) and the Swedish Government Official Report (2008:15) shows that little or almost no attention is directed to structural societal stratifications such as gender, class or education (with the exception of female entrepreneurship, which will be discussed further below). In the parliamentary debate, on the other hand, equality was used as a main argument amongst those against the reform. In this line of argument the MPs articulated their fear of the reform creating unequal care and problematic work conditions for care workers.

We know that those who demand the most are those with strong resources, with high education, who are able to speak up for themselves, who have had a good life and are used to making people listen to them. But these are not the ones with the greatest needs, which often are those who are not able to speak up for themselves. (Parliamentary debate, address No. 155, Eva Olofsson, Left Party)

In analysing the LOV policy process, the opposing and competing articulations of equality become apparent. Transformations in the eldercare system have greater importance for women than for men, as a majority of the users, informal carers, eldercare workers and managers of care for the elderly are women. As mentioned above, class, gender, ability and ethnic background have consequences for elders and their relatives’ opportunities to manage the ‘care puzzles’. In the text of the government’s proposal, ‘gender equality’ is mainly understood as increased female entrepreneurship. As women constitute a majority of public sector employees, the LOV reforms are expected to encourage many women to start enterprises in their own areas of work.

Through facilitating and encouraging municipalities and county councils to implement free choice, innovation and diversity are encouraged and better opportunities are created for female entrepreneurship, and opportunities for small companies to provide services to the public sector are increased. (Prop. 2008/09:29: 134)

In the text of the government’s proposal, there is an assumed understanding that increased competition on the eldercare market will create better opportunities for women to establish small businesses, and that this is equivalent to improved working conditions within eldercare. An increase in small women owned eldercare companies is described in the policy text to improve working conditions, career opportunities and status in the clearly gendered eldercare work. However, a case study in a mid-sized Swedish municipality has shown that this correlation should not be taken for granted (Sundin and Tillmar, 2010). The study concluded that a market for eldercare had been created in the community, but this was not a market where large companies and small companies competed on equal terms. Small companies that were established when the reform was introduced, mostly owned by women, had a hard time competing with the large companies, mostly owned by men, which had been established on the private market. In this local level study of eldercare outsourcing, Sundin and Tillmar (2010) argued that the eldercare had been masculinized, as most of the owners and managers were men, but the actual eldercare work was still performed by predominantly women.

Free choice will most likely create better work conditions for employees, as the system contributes to increased competition on the labour market, and through that the system makes it possible for the employees, if they so wish, to instead run a company within these different areas. (Prop. 2008/09:29: 18)

The small companies that had been approved and procured as eldercare providers in the municipality investigated above had difficulties getting customers. Their services were not chosen, and as a few of the customers did actively choose new providers, the companies ended up with fewer assignments than they had planned and hoped for. In other words, it was hard for small companies to get established as care providers. Small and constantly changing demands made it hard for companies to plan their activities and their employees’ workdays (Sundin, 2011). In a study of the domestic service market, similar patterns appeared; the demand for domestic services varies greatly not only over the week and seasonally but also on a daily basis. This variation makes it difficult to plan the company’s service assignments and creates precarious, temporary and unstable work conditions for the employees, mostly women (Kvist, 2013). The neoliberal turn in eldercare claiming to centre on the individual choice of persons in need of care runs the risk of creating unequal care that decentres the eldercare worker and creates a liminal and precarious work position. Care needs to be valued as a central concern of human life and contextualized politically, and not seen as a private virtue (Tronto, 1993). Thus, our policy analysis of LOV reform reveals the other side of the coin of the supposed win-win situation for care recipients and care workers.

Conclusions

Our analysis shows that in policy discourse ‘choice’ is expressed as intrinsically good for all, without any consideration or reflection on societies’ social stratifications based on gender, age, class, ethnicity, race and education. We have showed how the arguments in the LOV reform followed a value-neutral reasoning emphasizing entrepreneurial aspects of care work instead of equality and gender sensitivity. That is, gender equality is constructed as equal competition in a care market that is unfriendly for women in its consequences. It is important to consider that eldercare is a gendered issue. The majority of users, workers (both formal and informal) and care managers are women; any change in the eldercare system will, therefore, have more comprehensive consequences for women (Szebehely, 2005b; Szebehely and Ulmanen, 2012). In the LOV reform elders are seen as free and active agents who are able to choose, and this is also assumed to be something that they all have requested. The care is expected to improve for elderly users, for instance, by increased participation and influence over care and the scheduling of care, while simultaneously, this must be accomplished without more costs and within the same time limits. Paradoxically, however, while seeing the individuals as free agents and consumers of welfare services, regardless of vulnerability and poor health, the meaning of care is disintegrated, as it seems to be interchangeable with personal service (see Wærness, 1984). Therefore, we claim that it is of utmost necessity to reintroduce the distinction between a care relationship and a service relationship in the performance of eldercare. Being dependent on personal care is not the same as buying services on a market. Furthermore, emphasizing the individual’s free choice has pushed the responsibility for care onto elderly people and their relatives (Brown, 2006). The discourse on consumerism of care not only violates the care relationship, but it also violates the fact of a shared human vulnerability. Being dependent on care means to some extent always being vulnerable. Further, and even more important, we need to be aware that we all share vulnerability as human beings (Turner, 2006). If we regard care as rights connected to citizenship, the basic fact of vulnerability means that the less able run the risk of being overshadowed by more able-bodied individuals. However, as a relational concept, care cannot be regarded as an individual responsibility. As we have tried to illuminate, the neoliberal logic favours individualization and a demand for responsible, active citizens without consideration taken of social stratifications based on gender, age, class, etc. (see Dahl, 2012).

In the LOV reform equality is interpreted to mean ‘equal competition for eldercare providers’ or ‘increased female entrepreneurship’. The way that equality is argued to be obtained through equal competition is misleading and a false statement, as it says nothing about how this is supposed to be achieved. And as we have shown, the gendered consequences of the reform are devastating since care work which is coded as female work is transformed into a commodity on the market, but nevertheless is devalued when performed by women. This misrecognition of care has increased with the implementation of the Act on System of Choice in the Public Sector (SFS 2008:962), for instance by worsened working conditions, and limited flexibility and time for care (Kvist, 2013). The gender equality gains that are supposed to occur with increased female entrepreneurship are questionable in terms of their gender insensitivity, and as previous studies have indicated, the introduction of the LOV reform has paradoxically masculinized eldercare in the sense that most of the owners and managers are men, while the actual eldercare work is still performed predominantly by women (Sundin and Tillmar, 2010). Furthermore, gender equality is solely articulated and interpreted in relation to eldercare as work, and not for the users of care. The idea of seeing elders as active consumers of care rests on the assumption of equal opportunities of care, putting a heavy burden on the elders themselves as well as on their relatives, most of whom are daughters (Szebehely and Ulmanen, 2012).

The neoliberal politics in Swedish public eldercare have had great influence in the provision of care, with consequences for all parties involved, and specifically so when legislation might increase inequalities for users, relatives and care workers. The neoliberal turn in eldercare policies can be seen as part of a more general transition away from the universal and generous Nordic welfare model towards a more limited non-inclusive welfare model, fuelled by the false claim of ‘equality’ and free choice. Thus, the neoliberal turn in eldercare claiming to centre on the individual choice of persons in need of care runs the risk of creating unequal care that decentres the eldercare worker and creates precarious work positions mainly occupied by women and often by migrants.