When standards fall short: The use of discretion and just allocation of long-term care services

Abstract

Background Care administrators in long-term care (LTC) are ‘gatekeepers’ to the services and handle applications, investigate care needs, and decide if, what and how much services applicants are entitled to receive. Various models of service allocation have been in operation in the Nordic counties since the inception of LTC services in the 1970s. The main drivers of the development of allocation models have been concerns about service inequality among users, quality of care, patient safety, and the overall efficiency within healthcare settings. While care administrators have several laws and guidelines to aid their decision making, the use of professional discretion is known to be widespread but less investigated. In the context of Norway, this article seeks to explore: What guides care administrators in reaching decisions? How and in which circumstances is the use of discretion needed in making decisions? Method Qualitative in-depth interviews with 5 managers in care administration and 13 care administrators in 5 municipalities. The material was analysed using thematic analysis. Results Solid professional competence, experience from the health and care sector and personal strength to handle complex situation were seen as prerequisites guiding care administration. Laws governing access to services are broad and general, and more specific service standards were developed in the municipalities to guide the work of the care administrators. Discretion was applied constantly and regarded as both a necessary and valuable tool. Cases typically negotiated by discretion involved cases where there were disagreements about the need for care, diffuse care needs, or difficulties in predicting which service would be the best or most effective for the service applicants. Conclusion We argue that the care administrators hold a substantial responsibility and are often challenged to allocate equal and just services. The use of discretion is a valuable and necessary part of handling care applications and contributes to the integrity and trustworthiness of the care administrators and the care services. However, reforms and standardisations put a heavy pressure on care administrators and may restrict the freedom entrusted to them since they must comply with more and stricter criteria in service allocation. This might hamper care administrators’ opportunity to apply discretion and act in the best interests of the service applicant (‘principle of fiduciary’).