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

doi:10.21203/rs.3.rs-4343410/v1

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Research Article

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

https://doi.org/10.21203/rs.3.rs-4343410/v1

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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’).

Discretion

care administrators

long-term care

service allocation

welfare state

‘principle of fiduciary’

The gateway to public long-term care (LTC) services in the Nordic countries has traditionally been regarded as broad and generous, providing care services on a universal principle leading to security for both care recipients and their families (1, 2). Over the last two decades, the demand for care services among both young and older citizens has increased (3–6). As the population ages, a continued growth in demand for care services is expected. Public revenues will be reduced in the future due to a lower ratio of working-age people compared to senior citizens. This is expected to challenge the distribution of care services, and may lead to a stricter ranking of service recipients and the development of new service arrangements in LTC (7, 8). Increased standardisation of care and the development of routines has been introduced in the health and care services in the Nordic countries over the last decade with the aim of ensuring efficiency and productivity (9), just allocation, quality of care and patient safety within healthcare settings (9–12).

In Norway, service allocation is handled in the municipalities. Formally, the allocation of municipal health- and care services follows the procedural rules in the Health and Care Services Act (Helse- og omsorgstjenesteloven, 2012) and the Patient and User Rights Act (Pasient og brukerrettighetsloven, 2001). According to the Health and Care Services Act, Norwegian municipalities are obliged to offer adequate health- and care services to all citizens who have a need, independent of their age, diagnosis, sex, and ethnicity. The adequacy criterion signifies that the municipalities are responsible for ensuring that the services they offer meet recognised professional standards and requirements. This means that services should be safe, ensuring that patients and users are protected from harm to life and health (13). Hence, when a need for care services is reported, care administrators in the municipalities are obliged to investigate the need and decide within a specified timeframe whether to offer services and which services to offer. If the applicants disagree with the decisions, they are entitled to file a complaint, and the municipality has a three-week deadline to handle it. Complaints can also be forwarded to the country governor (Fylkesmannen). In either case, it shall be possible for the applicants to verify whether they have received fair treatment (14).

Approaches to service allocation have changed since the Nordic LTC services were formed around the 1970’s. At first, in Norway, managers and public administration staff in each municipality were responsible for both handling applications for care services and managing them. After some years, this practice was criticised as inefficient and leading to unequal or unjust allocations between service recipients (15, 16). New approaches to handling care administration were developed at the end of the 1990s. The model that gained most recognition was the purchaser-provider service (PPS)-executing model (17). The municipalities that adopted PPS assigned the needs-assessment to a separate unit (18), and the service providers did not have a role in making decisions (Gjerde, Torsteinsen, & Aarseth, 2016; Vabø, 2007, 2012). The development of the PPS model was associated with New Public Management (NPM) aiming to improve cost containment, efficiency, organisational flexibility and responsiveness to the service recipients’ needs (19). The model also intended to create competition between providers within the community (17, 20) and establish quasi markets (21). Similar changes in the allocation of LTC services took place in the other Nordic countries (10, 20, 22–26).

In Norway, the PPS model is still the most prevalent in medium-sized municipalities (from 5000 to 20000 inhabitants) and large municipalities (more than 20,000 inhabitants), and about half of Norway's population lives in a municipality with PPS organisation (27). However, over the past few years, new trends have started to emerge in service allocation. The divide between purchaser and provider is being modified, which has led to more cooperation between the allocation office and the service providers as well as with the users (27, 28). In another new approach, the allocation offices have been replaced by autonomous ‘early intervention teams’ that combine intensive initial follow-up and tailored approaches to new applicants using a specialised interprofessional team of providers (29, 30). The team maps new applicant’s needs, resources, and abilities, follows up on daily needs, and tests assistive welfare technology over a few weeks before making decisions on which and how much (if any) care services that should be allocated.

Cutting across the different models and approaches, making decisions on type and volume of care is reported to be both difficult and complicated work (31). Research has shown variation in levels of care (32), access to care and in case administrators’ assessments and allocation practices (32–36). Care administrators must make discretionary judgements about what is ‘adequate care’, and the work often implies ranking and comparing the health conditions of various applicants. Ethical dilemmas may emerge when care administrators must prioritise some conditions and types of care needs ahead of others (15, 31, 37, 38). In a time of increasing sustainability challenges, less is known about decision making in the allocation of LTC services. Thus the main purpose of this article is to explore and discuss these topics further. Our research questions are: What guides care administrators in reaching decisions? How and in which circumstances is the use of discretion needed in making decisions?

Theoretical perspectives

According to the philosopher Harald Grimen applying discretion implies distinguishing something from something else and judging it (39). To make good decisions about how to distinguish between different aspects, sound judgement is needed. Thus, discretion is always connected to knowledge, reputation, and sense of judgement. The person who distinguishes between an object, statement, action, or product is attributing or disclaiming characteristics to the area of concern. In other words, a judgement is implicit or explicit based on a ‘yardstick’, (Grimen, 2009, p.2). The judgements can be about statements, conditions, actions, or products. For example, a statement can be true or sincere, an action can be expedient or right, a condition can be normal or desirable, a product good (as in a good knife) or beautiful. True statements are separated from false, wishful conditions from unwanted and a good product from a poor one. But the separation is not always easy.

Several conditions can interfere with making a good judgement, Grimen continues. Firstly, what is separated or considered might not be judged from a single perspective. To decide if an action is fit for purpose, the effects have to be predicted and considered. But the effects may contradict with each other, and consequently they have to be measured against each other before making a decision, claims Grimen. Moreover, any action might also have several unfortunate side effects. All this might complicate a decision on whether an action is fit for purpose or not. Secondly, the yardstick must be interpreted. For example, what does it mean that something is ‘normal’? Is it a statistical average, like calculating the average height of people in a country? Or is it something that goes unnoticed because it is taken for granted? It might also be unclear which yardstick should be used for the purpose (Grimen, 2009).

If we engage in these situations, we are presented with unclear circumstances that need to be treated with discretion. The US philosopher Ronald Dworkin defines discretion as: ‘The concept of discretion is at home in only one sort of context; when someone is in general charged with making decisions subject to standards set by a particular authority’ (Dworkin 1978, p.31). In this sense, Dworkin continues, discretion resemble the hole in a doughnut: there are areas which are left open by a surrounding belt of restriction. For this reason, discretion is a relative term, relative to certain boundaries. In other words, Dworkin looks at discretion as a space of freedom which is defined within certain restrictions, implemented by an authority. What Dworkin refers to as ‘standards’ are those restrictions that define the nature of discretion. These restrictions are set by a specified authority, and they are mandatory for those to whom the authority delegates the role of decision making.

The use of discretion among bureaucrats in welfare states has been discussed by several scholars, and both pros and cons for its use have been addressed. In his seminal work on ‘street level bureaucrats’, Lipsky (1980) argues that bureaucrats play a crucial role in the policy implementation process. These individuals, such as social workers and healthcare providers, have significant discretion in how they interpret and apply policies. They are often the ones making key decisions that affect individuals' lives. Due to the complexity and ambiguity of many existing policies, bureaucrats must navigate in uncertain situations and adapt to specific circumstances which require discretion. On top of this, the work situations of bureaucrats are often characterised by high caseloads, limited resources, and the need to make quick decisions (40). As the judgements made by bureaucrats are not necessarily transparent to the citizens and are operationalised as the final link in the chain of democratic governance, Molander (2012) describes the tension between democracy and discretion through a Rothstein metaphor – the ‘black hole of democracy’ (41–43). Discretionary powers are delegated and based on trust, expertise, and the expectation that the individual or entity exercising this power will act responsibly and in the best interests (‘principle of fiduciary’) of the beneficiaries (42). Critics of discretion have however opposed the principle. They point towards the risk of inequality and the difficulty of holding persons with discretionary power accountable as there is always room for arbitrariness (44). Thus, by interfering with the private sphere of the citizen, discretion threatens to undermine the rule of law (45). A legal concern which is also brought into the debate is when persons holding discretionary power do not implement the law and policies as intended (43). This may lead to conflict with the principle of equal treatment and democratic governance.

Another main source of criticism stems from research on the psychology of judgement and decision-making (42). Since finding an optimal solution is sometimes impossible or impractical, heuristic approaches (cognitive simplifying techniques) can be used to speed up the process of finding a satisfactory solution (46). The heuristics reduce complex problems to simpler cognitive tasks, and lead to efficiency in decision-making. The assessments obtained by using heuristics are often good enough (42), but may also lead to systematic biases (47).

These theoretical perspectives illuminate the role of the care administrators and their work in allocating services. We will return to this in the discussion section.

Research design and participants

First we conducted semi-structured qualitative interviews with managers in service allocation units in five municipalities. Both small (under 5000 inhabitants) and medium to large municipalities (from 15.000‒120.000 inhabitants) located in different regions in Norway were chosen to ensure some variation. Afterwards, we invited three of the municipalities that had expressed an interest in contributing further to the study to select 3–5 care administrators each to take part in semi-structured qualitative interviews. Details about the participants are given in Table 1 below.

Table 1

Study participants
Participant	Municipality	Age	Education	Years in LTC	Position	Years in position	No. interviews
1	A	53	Nurse	12	Head of allocation office	4	2
2	A	41	Social worker	15	Care administrator	3	1
3	A	60	Social worker	8	Care administrator	2	1
4	A	37	Nurse	13	Care administrator	2	1
5	A	41	Nurse	14	Care administrator	5	1
6	B	62	Nurse	33	Head of allocation office	20	2
7	B	33	Social worker	13	Care administrator	2	1
8	B	61	Nurse	35	Care administrator	14	1
9	B	48	Nurse	18	Care administrator	2	1
10	B	51	Nurse	11	Care administrator	4	1
11	B	55	Nurse	24	Care administrator	2	1
12	C	53	Nurse	7	Head of allocation office	2	2
13	C	32	Nurse	9	Care administrator	1	1
14	C	39	Nurse	8	Care administrator	2	1
15	C	42	Social worker	10	Care administrator	1	1
16a/16b	D	47/51	Nurse/Nurse	10/15	Head of allocation office/care administrator	8/2	1
17	E	34	Social work	11	Head of allocation group	1	1

Data collection

The first author conducted the interviews between May 2022 and July 2023. An interview guide was drafted and informed by reports and research papers addressing care administration in LTC services. The interview guide was discussed among the co-authors and tested to ensure suitability. The five initial interviews with managers in care allocation offices were conducted over Teams. The follow-up interviews with care administrators were conducted physically in the municipalities. The interviews lasted from 40 to 95 minutes, depending on how much information the participant wished to share. All interviews took place at the offices of the care administrators and were audiotaped and transcribed verbatim.

Analysis

We used a thematic analysis (TA) inspired by Braun and Clarke (48–50). In line with the first phase of the TA approach – familiarising yourself with the data (Braun & Clarke, 2006), we began the interpretive process by reading the transcribed interview texts. The first author shared a selection of transcribed interviews and her notes from the interviews. Each co-author formulated keywords and reflections from their readings. In this process we arranged four research team meetings in which we shared and discussed our initial ideas and preliminary understanding of what the texts conveyed. When familiar with the data, we moved on to generating initial codes (Braun & Clarke, 2006, 2019). To identify a feature of the data and organise our data into meaningful groups, the first author performed the initial coding. Having identified our initial codes, we then searched for patterns in the codes that were related to our research aim. By doing so, we initiated the process of generating themes (48, 50), in which we focused attention on identifying interesting items in the data that we believed could form the basis of repeated patterns, i.e. potential themes across the data set.

In the process of reviewing themes (Braun & Clarke, 2006, 2019) we continued to explore the coded extracts of each theme to evaluate whether they formed part of a coherent pattern. We then moved on to defining and naming themes (Braun & Clarke, 2006). In this process, we attempted to refine the themes so as to capture their essence, aiming to describe our interpretations of the care administrators’ perspectives as clearly as possible. Consequently, it was possible for us to formulate the content of each theme in a in a few summary sentences. These concise formulations were then used to develop the theme titles – from working titles to final titles of the themes. An example from phases in the analysis process is enclosed in Table 2 below.

Table 2

*Example from phases in the analysis process*
_{Familiarising ourselves with the data – data extract} _{‘…and for making decisions on services, it's not clear either ... how much [services] should be allocated. So, there is an extreme amount of individual judgment here! Because ... for two apparently similar applications and similar individuals, when you start talking to them and see the specific conditions they live under or ... what networks they have around them, the decisions can be completely different.}
_{Generating initial codes} _{a. Individual judgement} _{b. Conditions and networks surrounding service applicants are different}
_{Generating themes} _{−Applicants’ house and living conditions are different and impact decisions} _{−Consideration of whether there are family members or other support networks} _{−Consideration of long−term effect of a decision} _{−Consideration of distance (centre and periphery) may impact}	_{Reviewing themes} _{Several conditions had to be judged by discretion and by collegial discussions in addition to the health and care need. This often implied consideration of the living conditions of the service applicant, if they had family or networks to support them in addition to the care services. Judgements of the long−term effect of an allocation was also considered}	_{Defining and naming themes} _{−Negotiating standards with discretion and collegial discussions}

Ethics

The study was approved by the Norwegian Centre for Research Data (Project Number [omitted for review] and was carried out in accordance with research ethics guidelines described in the Declaration of Helsinki (World Medical Association, 2013). The managers of the allocation units gave their consent for their unit to participate in the study before the recruitment of the care administrators took place. All participants gave written informed consent to participate in the study. The participants were informed of their right to withdraw from the interview without stating a reason, and data was managed with respect to the anonymity and confidentiality of all participants. All names and data about the municipalities that could lead to identification were omitted in the transcriptions.

Based on analysis of the empirical data we identified three main themes related to our research questions. These are: skills and qualifications of care administrators, negotiating standards with discretion and collegial discussions and finally complexities in deciding needs and services.

Skills and qualifications of care administrators

All participants in this study were women. They were between 32 and 62 years of age and had extensive experience in LTC varying from 9 to 32 years. As shown in Table 1, all participants were educated within health sciences and were mainly nurses. They all had additional education within management or specialist competence within various fields such as rehabilitation, geriatric nursing, psychiatry, addiction, habilitation.

At the time of the interview, 11 out of 18 participants had short experience (3 years or less) in their actual job as care administrators. Three of the five municipalities had care administrators on long-term sick leave and two had had vacant job positions for a lengthy period of time with no qualified candidates to fill the positions. At the time of the interview, three municipalities were actively hiring. The managers stated that during hiring processes they looked for qualified health professionals with substantial work experience within health and care services (home care, nursing homes, hospitals) and who were robust due to the demanding role of making decisions. A manager of an allocation office stated:

‘You need someone who can stand in a storm, someone who is robust... who can make decisions and who can... manage to speak up when it's enough. Manage to ask for help… and they [care administrators] must be interested in... law and economics… we also have the economic responsibility here, and they should also know that when they make a decision, they generate costs for the municipality and use our budget’.

Other qualifications mentioned to be required in care administrators were good knowledge of the local community, communications skills, and ability to handle short timelines and cooperate very well in a team. When a care manager in the interview had listed all qualifications and qualities she was looking for in a new employee, she exclaimed that being a care administrator: ‘...is not a job for exhausted nurses’. Care administration was generally addressed as hard work among the study participants.

Negotiating standards with discretion and collegial discussions.

In the interviews, the care administrators referred to four general laws guiding the overall service allocation: Health and Care Services Act (Helse- og omsorgstjenesteloven), Patient and User Rights Act (Pasient og brukerrettighetsloven), Health Personnel Act (Helsepersonelloven) and Specialised Health Services Act (Spesialisthelsetjenesteloven). The direct formulations used in the Acts were seldom studied by the care administrators as they were seen as much too general for daily service allocation. However, general formulations of the formal rights to receive care services were inserted as standard text in all letters sent to service applicants.

The municipalities participating in the study had developed their own service standards to better specify the conditions and criteria granting access to the different types of services. These standards were applied to clarify who should receive services. Care administrators often consulted the service standards and their colleagues to seek support for decisions in daily care administration.

For example, in one municipality a care administrator described a case concerning a woman in her mid-nineties who had applied for a place in a nursing home for the second time. The woman was mentally alert but had poor physical health with painful wounds which made it hard for her to move around in her house. She spent most of the days in bed and the home care services attended to her four times a day to tend her wounds. Staff from the homecare services had notified the care administrator that the elderly woman suffered considerable pain, and she had also repeatedly stated a wish to die. She had one distant relative who visited a few times a month, and apart from that she had no visits other than from the home care staff. The care administrator stated that she had rejected the woman’s application for a place in a nursing home for the second time and referred to the service standard in the municipality for justification:

‘In our [municipal] service standard, we keep the spots in the nursing homes for people needing help around the clock and for elderly with dementia. All other cases we refer to home care services.’

The care manager explained that she felt quite certain about her decision but had still chosen to bring up the case in weekly meeting with her colleagues. When the care administrator was asked by her colleagues why she brought up the case for discussion, she stated that the old age of the woman and her known depression were disturbing factors that made her question whether the dignity of the patient was being respected and if the services offered were within the legal framework. When explaining her decision, she claimed that the elderly woman would have benefitted from getting more social contact, but that ‘people’s loneliness was not the responsibility of the municipal care services’.

The case shows that the municipal service standards were applied in order to judge and consider the decision on which care services to offer. It shows that even if the municipal service standards gave a clear direction in making decisions about care services, the care administrator still needed collegial support and discussions on the ethical side of the decision before making a final choice.

In another case, a care administrator decided to deviate from the municipal service standard. The case concerned an elderly man who had a considerable need for care services. Both frailty and cognitive decline rendered him dependent on help and care from his spouse. Healthcare staff often observed spouses on the brink of exhaustion, and alerted the care administrators and encouraged the spouses to apply for a short term stay in the municipal rehabilitation unit for their partner. The care administrators recognised that in most of these cases, the potential for rehabilitation was totally absent, but a short-term stay at such a location could take the care burden off the spouse for a while and help her or him regain energy. The municipal service standard specified that the places in the rehabilitation unit were earmarked for users with rehabilitation potential. The care administrators asserted, however, that in these cases they had to put the long-term effect first and keep the spouse healthy by helping to make them take care of themselves as well as their partner. A service administrator claimed that this could postpone the supply of care services and stated:

‘Sometimes we must think of what the long-term effect of a decision is. Is it a preventive measure? Then we use discretion. So, if they [service recipients] do not meet the conditions now, we can still approve because we see that it has a long-term effect which means that they are able to keep their level of functioning at a stable level’.

The care administrators argued that overriding the municipal service standards was favourable for everybody compared to getting another new client (the spouse) permanently dependent on care services as well.

Returning to the general laws, care administrators claimed that these were useless when it came to deciding which types of services clients should be offered, or how much help they should receive. Standardisation and care pathways were not helpful either as the applications for services for similar needs e.g. care related to cancer or hip fractures, could end up with quite different decisions. One care administrator stated:

…and for making decisions on services, it's not clear either ... how much [services] should be allocated. So, there is an extreme amount of individual judgment here! Because ... for two apparently similar applications and similar individuals, when you start talking to them and see the specific conditions they live under or ... what networks they have around them, the decisions can be completely different.

For example, two service applicants might have the same diagnosis (e.g. hip fracture) but completely different lives. One might own a comfortable house adapted to a person with mobility challenges, while another person might live in a run-down house, with an upstairs bathroom and overall poor maintenance. One service applicant might have several relatives or good supportive neighbours to reach out to, while the other might lack personal relations totally. One might live in quite a central area and have easy access to a service centre, grocery stores, pharmacy etc., while the other might live in the countryside and a long drive away.

These examples illustrate how formal laws and standards fall short in deciding who is entitled to receive care services, how much and what is ‘appropriate’ or ‘sufficient’. The municipal standards help to operationalise the phrase ‘right to appropriate care services’ and specify the conditions which must be met in order to receive care services, but the standards can also be overruled if this serves another important principle.

Complexities in deciding needs and services.

While almost all applications for care services contained an element of using discretion in decision making, the care administrators differentiated between cases requiring much discretion where the allocation process was complex and time-consuming and cases that were quite straightforward and fast to resolve.

Disagreements about judging and defining the ‘need’ for care services were mentioned by several care administrators as an issue that was often difficult to handle, especially if it concerned new applicants about whom they had no previous information. A typical example was when a spouse, son or daughter applied for services on behalf of a partner or a parent. The application might state that the person had a large unmet care need or was becoming confused and unable to live alone. The care administrators found such information useful and correct in many cases, but they had also found service applicants in a completely different conditions, better or worse. A care administrator explained that discussions could arise between care administrators and service applicants, between care administrators, but also between the family members of the service applicant regarding what the ‘need’ consisted of:

"There can be a large degree of disagreement between children [of a service applicant] as well. The one child who lives close to his relative experiences that their level of functioning is much worse than those [siblings] who live far away and who will then invoke the right of the mother to decide for herself, for example. And then ... she…the mother… is observed ... in ... a fine blouse and a handbag and ... just a pantyhose, for example. Then it is obvious that something is not working".

In such cases the care administrators had to spend time assessing, judging and clarifying the need for help and how quickly the service applicant should receive care services. They looked for signs of cognitive decline or uncritical behaviour in the service applicant, and evaluated any incoming information about the service applicant continuously to judge if the municipality was operating within the ‘accountability’ criteria as formalised in the law.

Much time could pass, especially if there was a need to clarify the service applicant’s capacity to consent. The general practitioner was contacted to examine this. In this process, it could be difficult for the care administrators if the service applicant did not want to communicate with them and refused to open the door to healthcare staff. Often visits by healthcare staff who delivered medication and meals or offered practical assistance could provide valuable information about the condition of the service applicant and make it easier to judge the ‘need’ and the urgency of the decision.

Cases demanded less discretion if the need for care was indisputably known, and if the care service had a clear aim and timeframe. Examples of such situations were persons needing home care services to tend a wound until it healed or granting an old person living alone a place in daycare centre a few times a week to ensure healthy meals. More complex judgements had to be made if there were no openings at the day centre of if several service applicants were competing for one available spot.

Sometimes care administrators thought the service applicants requested far more care services than they needed and had too high expectations as to what they could receive. The care administrators were careful not to offer ‘too much’ and claimed it would not benefit the person. They spent time finding out about service applicants’ physical capacity prior to making decisions and conducted home visits to get to know new applicants. One care administrator explained that she had recently handled an application for practical assistance. During the home visit the administrator found that the applicant was able to bend and touch the floor and to do some cleaning herself. The care administrator decided not to offer as much help as the applicant had wished for, and included her instead in a home rehabilitation program. The care administrator said:

‘…many of the applicants can do more than they think! So, then we must figure it out. And then we'll go in and compensate for what they can't do then. We… put in some intensive home rehabilitation. We don't want to put them in a situation where we nurture them passively. So, we would like to start rehabilitation at home and … get them back on their feet quickly and enable them to fend for themselves with simple measures’.

This example shows that the care administrator’s judgement and decision relied on two considerations; first the belief that it would be better for service applicants to stay active and to master daily life and functions as long as they could, and secondly that these decisions were in line with the policy of keeping the service recipient at the lowest possible care level, saving costs in an already pressed municipal economic situation.

This study provides insights into the allocation processes of long-term care services at a time with emerging sustainability challenges, limited resources, and budget austerity. In their daily work, the care administrators claimed to comply with formal laws and policy guidelines as well as with service standards developed in the individual municipalities. The use of discretion and collegial discussions were however often pivotal for making decisions on type and level of services. Below we will discuss the use of discretion as well as the ‘principle of fiduciary’ in relation to the theoretical perspectives.

Discretion – the world beyond standards

In the theoretical background in this paper, we outlined Grimen’s (2009) problematisation of the ‘yardstick’, emphasising that good judgement is needed in distinguishing something from something else. In our empirical material we have seen how care administrators ‘walk the talk’ of Grimen in striving to define ‘need’ and judge which service is ‘adequate’. This process could be a highly complex matter. Care administrators were sometimes entangled in several opinions and spent considerable time identifying and judging what the actual ‘need’ was, looking at aspects from various perspectives prior to making decisions.

With these considerations in mind, not only were judgements about the service applicant’s health condition made, but also judgements about their surroundings. For example, was the service recipients house ‘safe enough’ (for an elderly person with frailty or cognitive impairment to live alone in, or if any relatives lived close by), ‘functional enough’ (could the person access the bedroom and bathroom by themselves), and was the house and person living there ‘clean enough’ (kept a clean house, removed trash and was able to take care of personal hygiene)? These were some conditions that frequently interplayed with ‘need’. In addition, judgement was required in considering which services would be ‘adequate’ or ‘enough’ or ‘beneficial’ for the service applicant, and the availability of these in the municipality. This illustrates a complex terrain of considerations to be taken, and the need to use discretion and collegial discussions was imperative. It supports the view that using discretion is necessary when factors are unclear or even conflicting (40, 51). Laws and standards constitute a general background framework but the use of discretion as well as collegial discussion were important tools for the care administrators in their daily work. In discussing the nature of care and discerning judgement, Alvsvåg and Martinsen (2018) claim that good judgement and discretion form a connection between a unique situation and knowledge, norms and laws (52). The use of discretion also creates links between different sources of knowledge and professional competence. Our study supports these considerations.

In the introduction to this paper, we presented the different approaches and models directing the allocation of LTC services over the years. The models reflect changing views on how close or far away the care administrator should be from the service applicant to make ‘just’ or ‘equal’ decisions and the most efficient allocating system. In the purchase- provider service (PPS) model, the gap between purchaser and provider was argued to be important to safeguard equal allocations. However, studies have shown that direct and frequent communication and cooperation between those contracting and providing the services is sorely required. Care administrators need unique updated information and knowledge of the service recipient in order to make good judgements and decisions (18, 53). This becomes especially important when knowing that the health conditions of many service recipients (especially multimorbid elderly) may shift quickly and adjustments in services must be made swiftly (54–56). Our study confirms the importance of care administrators being updated and informed about the health and life changes of service applicants. This information is crucial to make timely and sound decisions with discretion.

Between expectations and realities: Principle of fiduciary

Discretionary powers are delegated (to care administrators) and based on trust and expertise and the ‘principle of fiduciary’; the expectation that the individuals exercising this power will act responsibly and in the best interest of the service recipient (42). Care administrators in this study tried to adapt to a situation with limited resources both regarding time, personnel, and budget constraints. They complied with the current policy trend of being less ‘generous’ than before, e.g not allocating services for tasks that the applicant could perform without help (57, 58). Dilemmas occurred, however, when the care administrators saw that the services they could offer home dwelling elderly, were insufficient and rendered elderly people lonely or striving. In addition, care administrators had to handle criticism from the service recipient’s family who often demanded more or different help for a parent or a spouse. Earlier studies have addressed the issue of care administrators finding that they are pressurised by increasing expectations from the family members of service recipients (59), as well as increased expectations from the care services management to always allocate at the lowest possible level (36). As also illustrated by Lipsky, balancing these conflicting demands from both the public and higher-level authorities are challenging (Lipsky, 1980). According to Lipsky, the frontline workers holding the direct responsibility for implementing policy are constrained by organizational rules and resources. Decisions might be taken under ambiguous and challenging circumstances, which could lead to tension between adhering to formal procedures and responding effectively to the needs of the individuals they serve. This demanding situation might illuminate the fact presented in the result section; care administrators need to have targeted competence to do their work and manage the pressure. They need professional healthcare education, long term work experience in the sector, local knowledge, and the managers with responsibility to hire, demanded robust personality types. Possessing these qualifications and qualities might ease the process of handling many and sometimes conflicting demands, and handling complaints.

The use of the ‘principle of fiduciary’ among care administrators can also be discussed in light of current health and care reforms. A prime focus in policy and reforms today is ‘active ageing’ that emphasises enablement and rehabilitation to encourage self-sufficiency and postpone the need for care services (60–62). The current trend in municipalities is to establish specialised teams with staff focusing solely on rehabilitation (63) and working to ensure that elderly people can live longer in their own homes in accordance with the ‘Live safely at Home’ reform (64) Efforts are made to try to rehabilitate and train users in self-mastery prior to making any decisions on allocating care services. The participants in our study were responsible and largely loyal to policy directives but also encountered dilemmas such as allocating services within the ‘accountability’ criterion knowing that the service applicant (or the spouse) would have been better off with more help or other services. In our material we notice a trend to rank physical healthcare needs ahead of psychological and emotional needs. Such ordering of needs runs counter to the professional obligation to provide holistic care or whole person care (65). Even if the allocation is within one standard or ‘yardstick’ (e.g municipal standards), it might contradict other standards at work. For example, the professional ethical guidelines for nurses state that ‘…The nurse takes care of individual patients' needs for holistic care, and supports human resources, coping, hope and courage to live’ (66). This reflects a paradox and tightrope, forcing care administrators to balance policy on the one hand and the opportunity to use discretion on the other. Under these circumstances, it is questionable whether the allocations made are in the best interest of the service applicants. The scope to act in the best interests of the service recipients seems to be compromised or narrowed and challenged.

Another aspect of knowing what would serve the service recipients best is that situations can be totally unpredictable, making it difficult to make a qualified guess/decision. A situation can have so many outcomes and may be influenced by a number of unknown factors. Care administrators also speculated about the long-term effects of their decisions, e.g. if allocating increased home care services would lead to improvement in the lives of service recipients or passivism which eventually would be negative. Nevertheless, estimating and predicting these side effects was presented as hard and almost impossible work.

Lipsky's work highlights the importance of understanding the role and experiences of the frontline workers in the effective delivery of public services and the impact of their decisions on the recipients of those services (40). In a time of increased standardisation and reforms pressing for less generous services, we question how much leeway is left for discretion? In the future, care administrators will handle application from service applicants living with more complex health and care needs in their individual homes. If the pressure on case administrators is such that it jeopardises their ability to use discretion and the principle of fiduciary, we risk being left with standards and less space for individual solutions.

Also, our material shows that care administrations must have many qualifications resembling the forces of ‘super women’ to handle the job. They often had to make decisions under unclear situations and for vulnerable service applicants with unpredictable health conditions. Participants in all five municipalities addressed the topic of sick leaves among care administrators, which might point towards the precariousness of these positions.

Care administrators handle an increasing number of applications from a diverse group of citizens of all ages with different reasons for needing care. The care administrators are familiar with policy guidelines and standardised municipal criteria for accessing care services and strive to comply with them. As we have seen in this study, a large part of the work related to service allocation is, however based on the use of discretion. Contrary to the critics of discretion who point to the risk of inequality or that other policies than intended are being implemented, we argue that discretion is a necessary tool in safeguarding just allocations. Service applicants have different situations, and the use of discretion may help to tailor the services individually. However, we are concerned about the opportunity and leeway for applying discretion in the future. Reforms and standardisations may displace the freedom which is entrusted to care managers by regulating more and applying stricter criteria. For example, when spaces in nursing homes are earmarked for elderly needing help 24/7, care managers will be compelled to allocate services to a large group of marginal and frail home dwelling elderly in their individual homes. Such reductions in the care portfolio is likely to violate the ‘principle of fiduciary’ and compromise or limit care managers right and ability to use discretion.

We have also seen that care administrators handle many and sometimes conflicting expectations. In line with national policy, they are to allocate adequate care at the lowest possible level. At the same time, they must be sensitive to the needs of service applicants and handle demands and complaints from service recipients and their families. To cope with the pressure, care administrators need solid competence and qualifications within health and care as well as personal strength and communication skills.

Ethics approval and consent to participate:

The study was approved by the Norwegian Centre for Research Data

Funding declaration:

The project is funded by the Research Council of Norway, grant number: 296728

Data availability declaration:

The datasets generated and/or analysed during the current study are not publicly available due to the protection of the participants and the municipalities anonymity that was granted them prior to the interviews. Anonymised short summaries of the interviews can however be made are available from the corresponding author on reasonable request.

Competing interest declaration:

The authors declare that they have no competing interests.

Author Contribution

LT lead the project, collected the data, lead the process of analysis and wrote the full manuscript. RH, AUO and RS contributed from project commencement in defining the research questions, commented to the research design, interview guides, contributed to analysis and interpretation of data and commented to drafts of the article. All authors have approved the submitted version.

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No competing interests reported.

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

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