Strategies of austerity used in needs assessments for personal assistance – changing Swedish social policy for persons with disabilities

ABSTRACT

The austerity measures in social welfare implemented by street-level bureaucrats in their practice are changing the direction of social policy. This article examines the strategies used by public officials in implementing austerity measures in needs assessment for personal assistance in Sweden. The article is based on a document study with N = 100 records of needs assessment for personal assistance for persons with serious functional disabilities. Findings show that the public officials at the Swedish Social Insurance Agency either limit or extend their discretion as a strategy, as well as use weak warrants as strong warrants in recommending decisions. Other strategies involve the organisational logic, fragmentation of the content in the needs assessment and division of work among the public officials. Implementing the cost-cutting goals causes severe consequences for persons with disabilities who bear the brunt by being excluded from participation in society. The social policy values of fifty years, emphasising the right to equal participation in society, are traded for economic austerity goals.

ABSTRAKT

Besparingsåtgärder i social välfärd implementeras av gatubyråkrater som i sin praktik förändrar riktningen på den förda socialpolitiken. Denna artikel undersöker de strategier som handläggare använder för att implementera besparingspolitik i utredningar av enskilda personers ansökning om personlig assistans. Artikeln baseras på en dokumentstudie av N=100 utredningar genomförda av Försäkringskassans handläggare. Resultaten visar att handläggare omväxlande begränsar eller utvidgar sitt handlingsutrymme och använder vägledande argument som styrande riktlinjer. Andra strategier som används är kopplade till logiker som gäller i organisationen, fragmentisering av data i utredningen och arbetsdelning av utredningens genomförande och beslutsfattande mellan gatubyråkrater i organisationen. Implementering av besparingsmål får allvarliga konsekvenser för personer med omfattande funktionsnedsättningar som riskerar att exkluderas från delaktighet i samhällslivet. Funktionshinderpolitikens nu 50-åriga målsättning om delaktighet på lika villkor byts i praktiken ut mot ekonomiska mål om besparingar.

KEYWORDS:

• Austerity
• personal assistance
• social policy
• street-level bureaucracy

NYCKELORD:

• Besparingar
• personlig assistans
• funktionshinderpolitik
• gatubyråkrater

Introduction

Governmental austerity budgets and policies that legitimise cuts in social spending have been a common experience in many European countries during the period following 2008 (Hayes, 2017). Austerity policies not only pose challenges for social workers’ working conditions (Pentaraki, 2018), but also for the actual assignment of their work to assess and administrate support to their clients (Hasenfeld, 2010). Public officials as street-level bureaucrats carry out policy in practice (Lipsky, 1980), most notably in their performing assessments of the right to support (Järkestig Berggren, Blomberg, & Petersson, 2010).

Sweden has been more fortunate than many other European countries in the finance crisis of 2008 and its aftermath. However, using the example of needs assessments, performed by the Swedish Social Insurance Agency (henceforth SSIA) in order for persons with serious functional disabilities to receive personal assistance, this article sets out to discuss how governmental goals to cut costs are implemented in practice and consequently how social policy is shaped and changed through the enactment of street-level bureaucratic practice. The article discusses the kinds of strategies public officials as street-level bureaucrats apply in the process and the content of a needs assessment in order to implement austerity measures governing personal assistance. The analysis is based on 100 records of applications and assessments for personal assistance processed by public officials at the Swedish Social Insurance Agency.

During the period from 2014 to 2018, the government implemented austerity measures regarding personal assistance for persons with severe disabilities, using the argument that the cost rose beyond an acceptable limit and that some of the increase was due to over-use and direct fraud (Altermark, 2018).

Social policy of disability and the governmental steering

In Sweden, as in many other western countries over the past 50 years, the main values incorporated into disability policy have been expressed in terms of rights to participation and inclusion in society with citizenship and human rights stated globally in the UN Convention on the Rights of Persons with Disabilities (Oliver & Barnes, 2010; CPRD, 2006). Sweden contributed to these ideals in the 1960s with Bengt Nirje’s conceptualisation of ‘normalisation' referring to equality in living conditions (Nirje & Wallin, 2003). In Sweden, these values have provided persons with disabilities with certain rights, such as personal assistance, stated in the Law regulating Support and Service to Persons with Certain Functional Disabilities (LSS, 1993, p. 387). Although today the idea of normalisation at times is criticised, for example, on the basis of stereotypic gender thinking (Löfgren-Martenson, 2013), it has emphasised the right to equal participation and good living conditions for children and adults, i.e to live with their families with support services in their own homes. Since 2014 the social policy ideology is being replaced with a government policy of implementing austerity measures (Altermark, 2018) on the granting of personal assistance and initiating a commission (dir 2016:40) of changes in the LSS legislation with the explicit aim to cut costs. After criticism in the election year of 2018, this objective was changed with the aim to keep the current cost level. During 2017, 1378 persons applied for personal assistance for the first time and 85% (N = 1166) were rejected, compared to 2011 when 1740 persons applied for the first time and 54% (N = 935) of the applications were rejected by the SSIA (SSIA, 2018).

However, so far there are no changes in the law, meaning that all needs assessments must still be made according to the existing legal framework and its values of equal participation and good living conditions.

The Law regulating Support and Service to Persons with Certain Functional Disabilities (LSS, 1993, p. 387) was passed in 1993 granting the right to good living conditions through some specific services for persons with extensive and permanent functional impairment, ensuring that they receive the help they need in daily life and that they can influence the support and services they receive. The most ground-breaking aspect was the right to personal assistance for daily life, making it possible for the user to choose his/her assistant(s).

The proposition for the law stated that in assessing the needs for personal assistance, the relational model of disability (Grönvik, 2007) focusing on the barriers of the environment should be the guide, rather than a medical perspective and medical diagnosis (prop, 1992/93, p. 159, p. 55).

According to the LSS (1993, p. 38) the right to assistance applies to people who fit into any group in this classification:

1. have intellectual disabilities or autism, or who have a condition resembling autism,

2. have considerable and permanent intellectual functional impairment following brain damage sustained as an adult, as a result of external force or physical illness, or

3. have some other lasting physical or mental functional impairments that are clearly not due to normal aging, if such impairments are substantial and cause considerable difficulties in daily life and consequently, cause an extensive need for support and service.

The right to personal assistance is assessed by the municipal care office, but when support over 20 h a week is needed the assessment is made by the SSIA. The assistance is then paid by the state. SSIA is the national authority responsible for the administration of welfare benefits such as pensions, disability allowances, sickness pay and parental benefits. The SSIA receives instructions annually from the government, and the authority produces their own guidelines (SSIA, 2003) as a work tool for their staff when conducting investigations.

To be assessed as eligible for state-financed personal assistance, the first criterion is that the person needs to fit into any of the three groups mentioned above and the second criterion is that he/she must have basic needs for 20 h a week. The concept of basic needs refers to needing help to eat, to perform personal care, to dress and to communicate or needing help that requires special knowledge about the person who needs the assistance.

In 2017 the governmental instruction letter directed the SSIA to cut spending on personal assistance: ‘the SSIA shall contribute to the cutting of the development of the hours of assistance / … / the SSIA shall also ensure a thorough control to counteract any exploitation’ (Swedish Government instruction letter, 2017).

During the years 2013–2017, the Supreme Administrative Court delivered some judgments that have circumscribed the rights to personal assistance, mainly by posing limitations on what could count as basic needs which is a pre-requisite for the right to assistance. The SSIA then interprets these judgments in their guidelines to staff (Erlandsson, 2014). One such example was the judgment of the Supreme Administrative Court (case: 3527–3514) that circumscribed the basic need of help from someone with ‘special knowledge about the person' to be eligible only for persons with psychiatric disabilities. This decision excluded persons who needs assistance from someone with special knowledge due to a physical condition such as help with breathing. To be clear, persons with physical conditions can still be eligible for personal assistance on the basis of other basic needs.

The SSIA then interpreted the judgement into four questions that the SSIA officials are to investigate and answer all of them with a yes in order for eligibility: (1) Does the applicant have a substantial and lasting psychiatric disability? (2) Does the applicant need help from someone with special knowledge about him or her? (3) Is there any connection between the need for help from someone with special knowledge and other basic needs? (4) Is the need for help a consequence of the psychiatric disability? (SSIA, 2003). These questions are then further explained in detail and with examples how they should be assessed.

Personal assistance in research – the meaning for users

Over the years, Nordic research about personal assistance for persons with disabilities has concluded that personal assistance provides persons with disabilities the possibility of partaking in society, living in their own homes (Giertz, 2012; Larsson, 2008), having a family (Selander, 2015) and obtaining paid employment (Dowler, 2011). A systematic review (Mayo-Wilson, Montgomery, & Dennis, 2008) concluded that personal assistance is preferred over other forms of services, often replacing informal care although it may cost more than other alternatives of support; however, further research about cost-effectiveness is needed. The contribution to empowerment in various forms for the recipients of assistance is a debated theme (Bonfils & Askheim, 2014). Also, the relationship between the personal assistant and the client has been simultaneously described as being a friendship and a tool (Egard, 2011). A study by Dunér and Olin (2018) about personal assistance provided by family members showed that it could promote as well as be a barrier to disabled people’s control over their own lives. There is no formal training needed to work as a personal assistant (Guldvik, Christensen, & Larsson, 2014) and the work role of a personal assistant has been described as ‘user-mandated logic', denoted for being based on the user’s knowledge about his/her life and needs (Järkestig Berggren, 2014).

Also, investigations of the differences and similarities among the Nordic countries in their constructions of personal assistance have presented Sweden as having a rights model and facing re-regulation by authorities (Askheim, 2008; Askheim, Bengtsson, & Bjelke, 2014).

Personal assistance assessments in research

In a study on assessments for personal assistance, Erlandsson (2014) stated that public officials at the SSIA have a high degree of discretion in the decision-making process of assessing the right to personal assistance. He describes the issue of how the public officials use their own discretion, stating that ‘The SSIA uses internal norms and guidelines and the bureaucrats working here are loyal to the organisation’s voluminous internal documents rather than to the legislative intent of the LSS.' He emphasised that the public officials at the Swedish Social Insurance Agency were norm-loyal to the guidelines of the Agency and not to the intentions of the law.

Hultman (2018) explored the assessment process for children applying for personal assistance to the municipality. She found that social workers struggled to maintain professional integrity using strategies such as defining their limits for discretion by using guidelines and transferring responsibility to other authorities. Bureaucratisation was used to objectify decisions.

Altermark (2018) studied the public statements and policy documents from the government during 2014–2016. He writes that current austerity measures target all users of personal assistance alike, while the cut-backs are legitimised by the government through their rhetoric of a ‘cost problem', in which the assistance users are deemed over-users and potential fraudsters, and the assistance companies’ only interest is maximising their profit.

Theoretical perspective

Ethics in the practice of public officials

The principle of legal certainty, highly acclaimed in the directives of the SSIA, refers to the formal aspects of foreseeable legal implications and of accountability, but also equally important is the material legal certainty that is connected to rights, citizenship and justice (Vahlne Westerhäll, 2007). The material aspect is crucial in the judgment of legitimacy of a decision and always involves a certain use of discretion in decision-making by the public official.

The public officials at the SSIA are street-level bureaucrats according to the definition by Lipsky (1980, p. 3):

[they] interact directly with citizens in the course of their jobs, and … [they] have substantial discretion in the execution of their work . . . typical street-level bureaucrats / … / and many other public officials who grant access to government programs and provide services within them. (Lipsky, 1980, p. 3)

Public officials as street-level bureaucrats are to carry out social policy, while simultaneously they are presented with the dilemma of scarcity of resources described by Lipsky (1980). To solve the dilemma, street-level bureaucrats adapt strategies to narrow the gap between available resources and needs. According to Lundquist (2001), street-level bureaucrats are expected to abide by the law. Prioritising any other policy would require very special circumstances. However, public organisations receive steering measures from the government that occasionally come into conflict with the intention of the law as seen in the example of applying for personal assistance. In order to obtain the principles of legal certainty, public officials are to focus on the process of an assessment, for example, they are to offer the applicant the opportunity to speak for his/her cause. The public official also has to focus on the substance of the matter which concerns the meaning of the facts and the consequences of a decision. Ideally, both these aspects are upheld equally. The problem begins when there is focus on one part and not the other. When there is focus solely on the process, there can be decisions taken that are in conflict with the law and cause harm. In order to be able to make complicated assessments, the public officials need a certain amount of discretion to interpret the law, to assess decisions ethically and to pay attention to both process and substance (Grimen & Molander, 2008; Lipsky, 1980, pp. 3–13; Lundquist, 2001).

Discretion of street-level bureaucrats

Discretion is a professional attribute that allows the street-level bureaucrat to take decisions in complex matters that cannot be fully regulated. Following this definition, it is virtually impossible to eradicate the need for discretion in matters of assessments involving weak warrants. Warrants are rules that lead from the initial premises of a case to a certain conclusion (Grimen & Molander, 2008). Weak warrants are normative and point at the circumstances that need to be considered, but they do not point out the specific conclusion. The warrants for eligibility in the classification of the LSS sometimes differ in this matter. The first two find their warrants in medical diagnoses; the warrants could then be regarded as strong and the room for discretional assessment of eligibility is minimal for the public official. The third group of the classification in the LSS does require discretional reasoning in regard to (i) what could be assessed as an impairment, (ii) whether the impairment is substantial, (iii) whether it is lasting, (iv) if it causes considerable difficulties in daily life, and (v) if these considerable difficulties cause extensive need (basic needs) for support and service. This formulation provides weak warrants for discretional reasoning. The judgments by the Administrative Supreme Court have shaped some warrants by partly defining what counts as basic needs. Obviously, though, there are still a number of issues in the law that demand further use of discretion. Street-level bureaucrats who need to prioritise among their clients and individual needs, due to lack of resources (Hasenfeld, 2010) often negotiate among individual needs using categories to establish which cases are alike and eligible for services (Lipsky, 1980).

Organisational logic

Street-level bureaucrats, working in an organisation, are incorporated in a weave of managers, governing mechanisms, guidelines, norms and culture that both define and circumscribe discretion. These street-level bureaucrats may then look upon themselves as mere tools for the organisation, abide by the management and write off their own personal responsibility. Large bureaucratic organisations such as the SSIA assign specific tasks to the staff. This work division risks alienating the street-level bureaucrat from the consequences of his/her decision and potentially also from his/her awareness of being morally responsible (Bauman, 1989 Lundquist, 2001).

Method

The data analysed for this article was obtained from a project about parenthood in personal assistance assessments carried out by the Swedish Social Insurance Agency (SSIA). For this article, we have performed an analysis of 100 records of applications and assessments for personal assistance at the SSIA. Data were subjected to a content analysis using both generic quantitative data analysis and in-depth qualitative analysis of the assessment with focus on both its process and content.

Sample

The records consist of 100 applications between 2014 and 2017 that were randomly selected from a national sample by birthdate. The records were made available by the SSIA after the study obtained ethical approval (dnr:2017/149–131). The ethical issues involve securing the anonymity of the individual records by using pseudonyms and also providing thorough descriptions of professional strategies that reveal the complexity of performing assessments.

The two main criteria for inclusion were that the applicant was being assessed for a decision to be taken regarding the right to personal assistance and that the applicant must have children under the age of 18. The latter criterion was due to this study being part of a larger project that focused on support in parenthood, although the criterion of being a parent is not of particular relevance for the aim of this article. There are only 30 applications that result in a right to personal assistance. More men (N = 58) applied than women (N = 41). The age interval most common is 40–59 (N = 68), and there are N = 15 applicants in the age group 60–65 and N = 15 also in the younger ages between 18 and 39. The most common country of origin is Sweden (N = 50) followed by origin outside Europe (N = 37). The most common diagnosis stated in the personal record is a physical disability (N = 65). The sample is further presented in Table 1 below.

Table 1. Socio-demographic data (N = 100)

		n
Gender	Man	58
	Woman	41
	Missing	1
Age	18–29	8
	30–39	7
	40–49	36
	50–59	32
	60–65	15
Country of origin	Sweden	50
	Europe	3
	Non-Europe	37
	Missing	10
Disability in application	Psychological illness	2
	Physical illness	65
	Palliative care	10
	Multiple illnesses	4
	Cognitive illnesses	15
	Missing	2
Decision on PA application	Granted PA	30
	Not granted PA, not included in classification	42
	Not granted PA, not 20 h of basic needs	24
	Retrieved	2
	Missing	2

Data analysis

For this article, we conducted a qualitative content analysis allowing for reporting both numerical data as well as qualitative themes (Krippendorff, 2004). The 100 records were analysed by two researchers independently using the same data analysis template. The analysis was conducted through two over-arching themes grounded in the theoretical approach: the substance of the records and the process of investigation as they appear through the documentation and order of actions in each record. Then both themes were analysed for subordinate categories of meaning. Analysis of the theme of substance of the data collected was also guided by questions such as whose voice was documented in the text, what kinds of documents were collected and finally, how the collected data was used to reach a decision. Concerning the theme of process of the investigation, the analysis was guided by questions about what steps were taken in the investigation and in what order, as well as how and what was documented of the process.

Findings

Among the 100 records studied, 30 were deemed eligible for personal assistance though four of them died during the assessment period. The most common reason for the rejection decision in 44 of the cases is that the person applying did not fit into the classification of the LSS. In 24 cases the person did meet the first criterion of being included in one of the groups in the LSS classification, but then he/she did not meet the second criterion of being assessed to have basic needs for 20 h per week. Two persons withdrew their application due to having spoken to a bureaucrat about the requirements for being eligible for PA.

Assessment process

The following section describes the strategies used by the public officials in the process of the assessment that reduces the number of applications granted.

The process of a personal assistance investigation is structured and standardised in format. When the person has applied for personal assistance in writing, the public official responsible for investigating the case sends out written information to the applicant. The standardised information states contact information, that if deemed necessary the public official will contact the applicant and that information will be collected from other authorities if needed. In the next step, the public official checks that the applicant is eligible for social insurance benefits in Sweden. If there is an advocate for the applicant, the public official will document whether that person has written authorisation to speak on the behalf of the applicant.

Almost all applicants in our sample marked the box on the application indicating that they wanted to present their situation themselves or through their representative, in a personal meeting with the SSIA public official.

This initial administrative procedure was executed by mail, then different processes were initiated. Sometimes the public official contacted the applicant or the representative for a personal meeting in order to gather information from the applicant about his/her situation and needs. In other cases, the public official refrained from meeting the applicant and assessed information such as a doctor’s certificate. Sometimes there was co-assessment by colleagues and/ or the SSIA internal consultant medical adviser. The arguments the public official might have for not collecting information directly from the applicant were not documented in the records.

Before a decision was made, the public official, without any exception, sent the suggested decision and the information collected to the applicant for communication.

In the cases that involved a meeting, the documentation is more comprehensive and makes use of internal documents that are divided into 14 themes of different everyday-life activities, such as communication, hygiene, food, family-life and so on, which are commented on or answered by ticking boxes. In 32 cases, the decision is taken only on a doctor’s certificate and five (18%) were assessed eligible for PA. In the 65 cases where the applicant met with the public official in person or through a representative, 25 (40%) were assessed eligible for PA.

Collection of data – not collecting the perspective of the applicant

The guidelines (SSIA, 2003) for the SSIA public officials state that first and foremost the applicant is to be heard regarding his/her needs for assistance in everyday life. Thereafter the investigation must always contain medical information about the disability and its consequences for everyday life. In the 32 cases where the bureaucrat decided not to meet with the applicant, the process of the investigation is limited to collecting documents from other professionals and then directly writing up a suggestion either for the decision or for a medical consultation with the internally employed medical adviser.

When the public official does not collect data directly from the applicant, he/she limits the data that are allowed to influence the assessment and decision. First, this procedure goes against the direct instructions of the SSIA where it is stated in the guidelines that the applicant is to be heard (Guidelines 2003:6 version 23). Overall, this approach is also questionable in regard to the Swedish Administrative Procedure Act (SFS 2017:900) that grants applicants the formal right to speak their cause by leaving oral information in cases that concern them.

Collection of data – not collecting any new information for the assessment

Moreover, there are cases in which there is no new information whatsoever collected for the assessment. One such example is Eva, who suffers from a neurological disease and uses an electric wheelchair. She was earlier granted 43 h of personal assistance per week by the municipality. In this assessment, the public official does not speak with the applicant and does not perform an independent investigation. Interestingly, the data presented refer to the investigation by the municipality that found a need for personal assistance of 43 h per week, but the SSIA official does not take this data into account concluding that the applicant has a basic need for only 15 h per week and is therefore not eligible for the service.

Work division in the assessment process

In assessing the right to personal assistance, the SSIA has formed a process of work division so that one public official collects the data and writes a suggestion for assessment and another senior official takes the decision. Therefore, the senior official responsible for the decision taken never speaks with or meets the applicant or his/her representative. This work division alienates the public official from the citizen applying for PA and from the personal ethical responsibility of the decision taken (Lundquist, 2001).

Overall, there is a thorough focus on the process of the assessments and less focus on gathering information from the applicant. This connects with the substance of the assessment that further highlights the content of data gathered.

Substance of the assessment

The documented investigations and assessments mostly consist of a boxed matrix and therefore present short items of information. For example, family data are not always noted in the record. The occupation and manner of livelihood of the applicant is also often missing. The assessments are performed in two steps: the first is whether the applicant is included in any of the three groups eligible for support through the LSS, and the second step is to determine whether the person eligible for support also has basic needs for at least 20 h a week. In the two steps, there are strategies used by the SSIA bureaucrat in order to limit the number of eligible applicants.

Decisions without underpinning arguments

Overall, there is a pattern that the decisions of eligibility for personal assistance are not underpinned with arguments connecting the data collected in the case to the requisites of the law. The final decision may be brief without any references, as in the case of Johan who is hospitalised with a metastatic cancer and applies for personal assistance to be able to live in his home. The SSIA decision is as follows: ‘SSIA assesses that you belong to the classification eligible for personal assistance but do not have the 20 h of basic needs'. The decision may also come in an extended format, first presenting the intention of the law with reference to a number of paragraphs and then a summary of collected data, mostly common medical record data, but still without connecting the needs presented with the intentions of the law.

Also, even the beneficiary decisions that do grant personal assistance do not connect data in the specific case with the specifications of the law in order to underpin the decision, as in the case of Lennart who applies for and is granted personal assistance due to support needs caused by a metastatic cancer in the brain. The decision does not state which category he is included in. There is a mere counting sheet with the hours and minutes granted to cover each need.

Fragmentation of support needs in activities

When an applicant is included in one of the three groups of the LSS classification, the assessment of basic needs is performed using the strategy of fragmentation of an activity. This strategy delimits what could be included as a basic need that grants the right to support, as opposed to other needs that do not. One example is the process of eating a meal which is divided into many different sub-tasks. The SSIA bureaucrat will only consider moving the food from the plate to the mouth as a ‘basic' need. All other activities, such as grocery shopping, cooking, cutting food on the plate and bringing the plate to the table, are ‘other’ needs. Even the supervision of the intake of food in case the person will choke is considered as ‘other' need. This fragmentising procedure is illustrated by the case of Salma who has a developmental disability and also some physical disabilities restricting her mobility. She applies for help with meals, but the decision of the SSIA is that ‘Basic needs with meals refer to needing help with the intake of food (moving food to your mouth). You have no such need. (0 h).' This means that the process of eating a meal will render no help with meals, even though in reality Salma would not be able to eat without assistance in the whole process of making a meal. The same fragmentising procedure is applied to all activities, such as dressing and personal hygiene, which then limits the possibility to reach 20 h a week.

Discretion used to limit or extend support

In some cases, the public official chose to use discretion that either limits the terms of support or includes persons that they deemed were eligible for support. There is the case of Adam who is diagnosed with Amyotrophic Lateral Sclerosis (ALS) and is granted support for his basic needs; he also applies for additional support for other needs, specifically two hours (120 min) a week to accompany his son to a leisure activity. The SSIA official allows 97 min a week. The reason for limiting the time applied for is not documented, nor is it documented whether the lower amount of time actually will make it possible for Adam to accompany his son to the activity.

In a few other cases, the SSIA bureaucrats grant the right of support weighing in the burden of the situation for the spouse and children, although this is not an assessment criterion. An example of this is Eric, who in his mid-forties has developed dementia. The account of the SSIA official presents the situation of the family with a stressed wife trying to keep control of him and his needs, help her 10-year-old daughter who has developed anxiety syndrome and work full-time at the same time. Eric is granted support 24 h a day due to the need for extensive support underpinned by the argument that the wife is living under stressful circumstances.

In some cases, the public officials at SSIA widen their discretion to a point where they enter into the jurisdiction of the medical professions. In these cases, the public official questions the facts of the medical information provided. One such example is a young woman Ana, who is diagnosed with autism. The bureaucrat criticises the diagnosis and rejects it on the basis that ‘it is not clear on what grounds the diagnosis is made'. The medical diagnosis is then rejected as medical information and as a valid fact in the decision-making process.

Using weak warrants as strong warrants

To limit support when assessing needs, another strategy used by SSIA bureaucrats involving their discretion is to treat weak warrants as strong ones. One example concerns the assessment of whether an impairment is lasting:

Esther, who suffered severe bleeding in the brain a year earlier and since then has been hospitalised for care and rehabilitation, applies for personal assistance since she has moved back home. The home-care given by the community is not sufficient, and her husband drives back and forth from work to attend to her during the day. Assessments from the physician, physiotherapist and occupational therapist report that the woman suffers from severe brain damage with extensive physical and cognitive impairments causing need for help in all basic everyday life activities such as ADL and assistance with meals. The prognosis from the medical professional is that she will continue to have lasting need for care in her basic everyday life activities, and the gains from any further rehabilitation are not expected to improve her status. Nota bene, there is no further rehabilitation planned. However, the public official assesses that progress from further rehabilitation is not exhausted and therefore the impairments are not proven to be lasting. Therefore, Esther is not included in the category eligible for personal assistance.

Another woman, Aida, also suffering from physical and cognitive impairments after a severe stroke applies for personal assistance while living at home. The bureaucrat cancels the meeting with Aida, documenting that the medical judgment provides enough information to decide on eligibility for PA. Consequently, Aida is not granted any opportunity to speak for her cause. Her application is then rejected with the assessment from the SSIA:

It is not made clear whether the impairment will be lasting since there is rehabilitation going on. The medical assessments describe that the prognosis is that her impairment will persist, but a few minor improvements after intense training might occur./ … / Based on these facts it is not proven by medical judgment that her impairments are lasting although they are substantial and cause considerable difficulties in daily life and consequently, cause an extensive need for support and service.

In these cases, the public officials use ‘rehabilitation' (even when not actually planned) as a strong warrant that automatically leads to rejection. In doing so the public officials avoid discretional consideration of the medical assessment that points to a long-term extensive need for support in everyday life. ‘Rehabilitation' is used as a warrant to reject the assessment of the medical profession and legitimise their own assessment.

Overall, in none of the analysed records is there a risk assessment or consideration of the consequences for the applicant when he/she is not granted personal assistance. Nor are there any notes of referral to any support services or the local municipality. Research could be an informed source of knowledge for underpinning the argument of a decision taken in a case, but there are no references to research or, for that matter, evidence of practice in any case.

Discussion

In analysing the strategies used by the public officials in the example of needs assessments for personal assistance, it becomes evident that they operate in line with what Lipsky (1980, p. 83) describes as strategies used in order to reduce the gap between existing resources, or rather the government’s austerity goals, and the achieving objects. The strategies used by the SSIA public officials that we have identified are making active use of their discretion, combined with the organisational logic and structure of their work.

Active use of discretion

One of the main findings is that the public officials at SSIA use their discretion actively as a strategy in their work. As shown they apply weak warrants such as the concept of ‘rehabilitation' as a strong warrant that then leads to rejection. Sometimes they do the reverse and treat medical diagnoses that are otherwise considered as strong warrants as weak warrants when questioning the legitimacy of a medical diagnosis. In a few cases, the public officials use their discretion to acknowledge other information collected such as the situation for the family and weigh this information in the assessment of the impact of the disability on everyday life.

Furthermore, when discretion is used to decide not to obtain information from the applicant, the decision-making is simplified with less data to consider. Obviously then, the public officials do not follow the guidelines that clearly state that the applicants are to be heard. Is this a use of discretion implemented by staff in order to abide by the national governmental intentions to cut costs on personal assistance? This needs to be further investigated.

Organisational logic – fragmentation

The organisational logic applied by the SSIA also provides some strategies. The strategies used involve fragmentation of (1) the organisational protocol for assessment, (2) the support needs, (3) the data underpinning the decision, and (4) the process of performing the assessment.

First, the organisational protocol for assessments that is built on mostly boxes to tick allows for excluding living conditions of importance for the applicant and does not require all needs to be described. Second, the assessment is then further divided with a fragmentised view on support needs that splits an activity into many parts where only one small part is eligible for the applied support. Third, the information collected is not assessed in connection with the intention of the law when writing up the decision. This procedure could be viewed as a strategy that facilitates taking decisions without really weighing in the substance of the information in the case.

Finally, the fragmentation of the work tasks between the assessment and decision-making contributes to alienating the street-level bureaucrats from the consequences for the citizen applying for help, as well as awareness of their ethical professional responsibility. The decision-making is divided among several bureaucrats in a hierarchal structure with the consequence that there is no connection or relationship built between the bureaucrats responsible and the applicant. In keeping with Bauman (1989), the highly rational and hierarchal structure of the responsibility for decision-making divided among bureaucrats in the SSIA makes it possible for the bureaucrats to refrain from acknowledging their ethical responsibility. Overall, little attention is paid in the records to the material aspect of practice complying with the rule of law. Of major concern is the absence of consideration over the applicant’s unique situation and the consequences of the decision for the person.

Consequences for social policy

Social policy becomes reality when put into practice. The example of needs assessments used in this article shows how austerity measures have been implemented in practice by street-level bureaucrats in the applications for personal assistance. The right to personal assistance in Sweden is becoming increasingly circumscribed due to governmental cost-cutting goals and political rhetoric that questions the legitimacy of the right to personal assistance (Altermark, 2018). The goals to cut spending are turned into practice by street-level bureaucrats, making up a reality in which now only 15% of first-time applicants are granted personal assistance from the SSIA (SSIA, 2018). During the time period from 2008 to 2017, the personal assistance granted by the municipalities increased from 3500 to 4900 persons (National Board of Health and Welfare, 2018). This is difficult to interpret since there should be an increase due to a growing national population, though it may point at some shift in responsibility towards the municipality from the state. Still, people whose applications are rejected or who lose the personal assistance, both children and adults, increasingly need to rely on care from family members, get by with restricted home-care or apply for a place in a group home.

The goal of austere spending in welfare systems is obviously not only to be interpreted as a fiscal reduction strategy. Using Hayes (2017) interpretation of austerity, the issue is to be understood as an ethical scheme in which the debt is transferred from the wealthy to the poor and is ‘conducted against the most socially and economically vulnerable sections of the population’ (Hayes, 2017). Austerity in this sense is above all a directed exclusion of vulnerable groups from the right to participation in society. This study describes how a fifty-year era of valuing good living conditions and equal participation in society has been traded for a trend toward austerity values.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by Försäkringskassan [grant number 070576–2016].

Notes on contributors

Ulrika Järkestig Berggren

Ulrika Järkestig Berggren is an Associate Professor, Department of Social Work at Linnaeus University, where she teaches Social Work and Disability Studies. She has a background in social work practice with persons with disabilities and family support services. Her research interests include professional social work, child and family support and particularly in relation to disability.

Ulla Melin Emilsson

Ulla Melin Emilsson is a Professor at Linneaus University, Department of Social Work and at the School of Social Work, Lund University. She is a Psychologist, qualified as a Social Worker, graduated in Supervision and in Psychotherapy and she holds a PhD in Social Work. Melin Emilsson’s research areas are mainly social work, care of older people from various psychological and socio-political perspectives.

Ann-Sofie Bergman

Ann-Sofie Bergman is an Associate Professor in Social Work at Uppsala University, Sweden. She has a background in social work practice with children and families. Her research interests are mainly focused on children in foster care, children with parents in custody disputes, and support for children and parents in vulnerable situations.