Skilt: Kaos

Kaos i kommunale tjenester

Kommunene har ikke maktet å drive forsvarlige tjenester til mennesker med utviklingshemming. Situasjonen blir verre. Det er ingen tegn til bedring, heller motsatt.

Resultatet fra det nasjonale tilsynet med tjenestene til mennesker med utviklingshemming i 2016 var såpass nedslående at Statens helsetilsyn stilte spørsmål med den grunnleggende styringen av feltet:

"De alvorlige forholdene som dette tilsynet har avdekket gir grunn til å stille spørsmål om dagens rammer og ressurser for kommunenes tjenestetilbud er tilstrekkelige til å sikre gode og trygge tjenester til alle brukerne. Har kommunene nødvendige forutsetninger for å etablere og drifte forsvarlige tilbud – også til brukere med store og komplekse tjenestebehov? Gir staten tydelige nok krav, føringer og faglig støtte til kommunenes oppgaveløsning? Prioriterer spesialisthelsetjenesten bistanden til kommunene høyt nok?" (se Det gjelder livet - Oppsummering av landsomfattende tilsyn i 2016 med kommunale helse- og omsorgstjenester til personer med utviklingshemming, side 27)

Fra oppsummeringen til Statens Helsetilsyn (se side 3), finner en følgende:

  • "I mange kommuner var tjenestene preget av svak styring og høyt risikonivå, og det ble avdekket svikt med potensielt alvorlige konsekvenser for brukernes livskvalitet og helse."
  • "I noen kommuner var svakhetene mange og store, og tjenesteytingen framsto tilfeldig."
  • "I mange tilsyn ble det påpekt som en alvorlig styringssvikt at kommunens ledelse ikke følger godt nok med på om brukerne får nødvendige helse- og omsorgstjenester og at de ikke etterspør informasjon om tjenestene fungerer som forutsatt."
  • "Blant hovedfunnene var at tjenestene som inngår i personlig assistanse mange steder var utilstrekkelige og lite individuelt tilpasset."
  • "I mange kommuner påpekte fylkesmannen at tjenesteyterne hadde svak kompetanse og at det manglet planmessig opplæring av de ansatte. Tjenesteytingen var ofte lite systematisk, og dokumentasjonen av personlig assistanse mangelfull og spredt. Resultatet var at mange ansatte er dårlig informert og oppdatert om brukerne de skulle bistå, om oppgavene de skulle utføre og hvordan det skulle gjøres."
  • "Det var også i mange kommuner få spor av at brukerne medvirket i utmåling, utforming og evaluering av eget tjenestetilbud, og pårørende og verger var ofte ikke godt nok informert til å ivareta brukernes interesser."
  • "Opplysninger om brukernes helseforhold kunne være vanskelig tilgjengelige, og mange steder hadde ansatte dårlig kunnskap om den enkelte brukers diagnoser og andre helseforhold, om hva de skulle observere av endringer og om hva de skulle dokumentere."
  • "I flere kommuner avdekket fylkesmannen alvorlig svikt i legemiddelhåndteringen. Det gjaldt blant annet uklare ansvarsforhold, dårlig kontroll med utdeling og utilstrekkelig kompetanse hos dem som gjør i stand og deler ut legemidler."

Fra de siste 13 årene finner en 6 samlerapporter fra nasjonale tilsyn:

De siste 13 årene er det gjennomført 6 nasjonale tilsyn. Leser en rapportene i sammenheng, så kan en konkludere med svikt på alle områder og ingen tegn til bedring.

Hva gjør statlige myndigheter?

Statlige myndigheter har først og fremst redusert den statlige styringen med sektoren og økt det kommunale selvstyret. Prosessen skal fortsette. Husbankens tilskuddsordninger skal overføres kommunenes rammetilskudd. En skulle forventet at når kommunene beviselig ikke makter å styre sektoren selv, så burde staten lagt flere og sterkere føringer på kommunene.

Staten har aldri sett om kommunene har økonomisk rom for å utøve de pliktene som staten har pålagt dem. Staten bestemmer alle kommunens inntekter og plikter. Systemet henger nødvendigvis ikke i hop, men staten har aldri undersøkt om kommunenes inntekter er tilstrekkelige til å dekke kommunens plikter. Kommunal- og moderniseringsdepartementet vurderer jevnlig kommunaløkonomien og overføringssystemet, men de ser på kommunens kostnader og ikke på kommunens plikter.

Det er vanskelig å se at statlige myndigheter gjør noe som helst for å sikre tjenestene til mennesker med utviklingshemming. Svekkelsene av den statlige styringen med sektoren har imidlertid vært flere og godt merkbare.

Hva gjør kommunene?

Kommunene gjør trolig så godt som de kan, noe som er langt i fra godt nok. Kommunestyret er den øverste myndigheten. Kommunestyrene består stort sett av folk som overhode ikke kjenner feltet, de vedtar rådmannens innstilling uten debatt. Rådmannen kjenner heller ikke feltet, så rådmannens kvalitetssikring er av svært tvilsom karakter. Helse- og omsorgsfeltet utgjør ca. 30 prosent av kommunenes utgifter og er det feltet med minst statlige føringer. Skal noe kuttes i budsjettene, så står helse- og omsorgsbudsjettet lagelig til. Ut over budsjettbehandlingen, er det lite kommunestyret involverer seg på feltet. Det er mer enn krevende for styrerne å styre en sektor som de ikke kjenner til og hvor det knapt eksisterer statlige føringer, kun kommunalt selvstyre.

Bofellesskapene blir stadig større og bemanningen stadig mindre. Resultatet er sykefravær blant ansatte, passivitet og mistrivsel blant beboerne.

De første signalene på utviklingen fikk vi fra det nasjonale tilsynet i 2005. Siden den gang har Stortinget ved enkelte anledninger kommet med mellomrom kommet med gode vedtak og merknader. Det er ikke viljen til rikspolitikerne som er problemet, det er gjennomføringsevnen.

Jens Petter Gitlesen

3 januar 2019

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