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Kommunale tjenester ute av kontroll

De kommunale tjenestene styres av kommunepolitikere som ikke kjenner feltet. Rådmannen er opptatt av budsjettstyring og kontrollen med tjenestene er svak. Alt ligger tilrette for dårlig styring av tjenestene til mennesker med utviklingshemming.

Dårlige rammer for individuelle tjenester

De fleste voksne med utviklingshemming bor i bofellesskap. Bofellesskapene var små med fire til fem beboere tidlig på 1990-tallet. Små bofellesskap medfører relativt få tjenesteytere og gir gode og oversiktlige rammer for å gi gode og individuelle tjenester. Nyere bofellesskap er sort sett dobbelt så store og omfatter et hav av tjenesteytere, mange med små stillingsbrøker. Antallet tjenesteytere er såpass mange at beboerne knapt kjenner alle tjenesteyterne. Forholdet forverres med høy turnover og mye sykefravær. Selv den enkleste informasjon kan være krevende å formidle i slike systemer.

Styring og målforskyvning

Målsetningen med tjenestene er å sikre at den enkelte får et aktivt og meningsfullt liv sammen med andre. Tjenestene ble etablert for at den enkelte i størst mulig grad skulle kunne ta del i dagliglivets gjøremål, på samme måte som andre innbyggere. Slik er det ikke blitt.

Det kommunale styringssystemet består i at bofellesskapene rapporterer om ressursbruk, dvs. økonomi, avvik fra lov og forskrift og andre uheldige hendelser samt sykefravær. Ingen rapporterer om måloppnåelsen, dvs. i hvilken grad tjenestemottakerne får aktive og meningsfulle liv. Verken rådmann eller kommunepolitikerne får noen som helst informasjon om tilstanden i tjenesten i forhold til den overordnede målsetningen.

Fylkesmannen fører tilsyn, men tilsynene er få og bofellesskapene er mange. Videre er tilsynsmetodikken mer som skriftlig saksbehandling supplert med intervju. Tilsynet ser om de rette dokumentene finnes og at innholdet i dokumentene er slik som det bør være. Finner de feil og mangler, så får kommunen avvik. Da må kommunen skrive et brev til fylkesmannen og fortelle hva de vil gjøre for å få på plass akseptable dokumenter. Ingen sjekker om beboerne får et aktivt og meningsfullt liv.

Kommunene hyrer av og til inn eksterne konsulenter for å sjekke tilstanden i sektoren. Firma som Agenda Kaupang, Rune Devold AS, PWC og flere andre. Felles for konsulentene er at de fokuserer på økonomi, ikke på målsetningen med tjenestene. Fra nettsiden til Rune Devold AS, kan en f.eks. lese: "Rune Devold AS har i mange år utviklet de beste modeller for å planlegge en effektiv og kvalitetssikker omsorgstjeneste i kommunene. Vi bruker IPLOS-data, økonomidata, KOSTRA og annen tilgjengelig informasjon". Hvordan IPLOS-data, økonomidata, KOSTRA og annen tilgjengelig informasjon kan benyttes for å avgjøre om tjenestemottakerne har aktive og meningsfulle liv, har konsulentene aldri fortalt.

Kommunal organisering til besvær

I reformperioden var det en sterk oppmerksomhet rundt det å etablere gode tjenester. Fokuset var dels et resultat av statlig styring, men i større grad et resultat av den kommunale organiseringen hvor kommunens helse- og sosialstyre hadde stor myndighet og besto av kommunepolitikere som ofte ble spesialister på feltet og sektorforsvarere. Helse- og sosialstyret jobbet tett med sosialsjefen, noe som også var lovpålagt. Det var krevende både for rådmannen og kommunestyre å handle på tvers av sektor- og fagkunnskapen til politikerne og etatsjefen.

Med kommuneloven av 1992 ble særlovene som regulerte sektorforvaltningen avskaffet. Lov om kommunalt helse- og sosialstyre m.v. ble opphevet. Det ble sterke skott mellom politikk og forvaltning. Rådmannen var bindeledde mellom politisk- og administrativt nivå. Endringen bidro til å styrke rådmannens stilling på bekostning av etatsjefene. En mistet sektorpolitikerne og fikk generalistpolitikerne. Endringene var trolig positive for de politikkområdene som mange er kjent med. Det ble lettere å prioritere på tvers av sektorene. For tjenestene til mennesker med utviklingshemming, var endringene en tragedie. Politikere og rådmann mistet faktagrunnlaget som kreves for å utøve god styring.

Rådmannsperspektivet er i stor grad juss og økonomi. Kommunen skal drive lovlig og budsjettene skal overholdes. Nettopp dette perspektivet vises igjen i rapporteringsrutinen i sektoren.

Hver høst legger rådmannen frem et forslag til budsjett og hver vår revideres budsjettet. Når verken rådmannen eller kommunepolitikerne har nevneverdig kjennskap til tjenestene til mennesker med utviklingshemming og budsjettdokumentene heller ikke fokuserer på målsetningen med tjenesten, så blir resultatet som i beste fall som beskrevet av Ibsen: "Hvor utgangspunktet er galest, blir titt resultatet originalest".

Farlig forsvarlighet

Begrepet faglig forsvarlighet har i økends grad kommet inn i tjenestene. Stort sett får begrepet sitt innhold fra helsesektoren. Faglig forsvarlighet synes å gjelde medisinutdeling, personlig hygiene og andre forhold knyttet til liv og helse. Det er selvsagt positivet å holde fokus på både på medisinutdeling og personlig hygiene. Problemet er at ingen holder fokus på tjenestenes overordnede målsetning, nemlig det å sikre individuelle tjenester slik at enhver i størst mulig grad kan leve gode og aktive liv.

Den faglige forsvarligheten i omsorgstjenesten lider av den samme svakheten som kjennetegner de fleste målstyringssystemene. En måler, registrerer og rapportere forhold som er enkelt å måle, registrere og rapportere, uavhengig av de overordnede målsetningene på feltet.

Hva bør gjøres?

Når kommunene ikke makter å styre sektoren selv, så må staten hjelpe til med klarere føringer, kontroll og informasjon.

  1. Etablering av bofellesskap bør reguleres. Statlige myndigheter bør børste støvet av de tidligere reguleringene som Husbanken hadde overfor tilskudd og finansiering av bofellesskap, dvs. rundskrivene HB-1212 og HB-1255. På den måten kan reinstitusjonaliseringen stoppes.
  2. Fylkesmannen bør få sanksjonsmuligheter overfor kommunene når det gjelder grove lovbrudd og lovbrudd som ikke rettes opp. Staten bør kunne kreve inn kostnadene som kommunen sparer på å begå lovbrudd, slik som i Sverige.
  3. Rettsikkerheten til tjenestemottaker bør styrkes. Pasient- og brukerrettighetslovens § 7-6 sier at "Fylkesmannen skal ved prøving av kommunale vedtak om helsetjenester legge vekt på hensynet til det kommunale selvstyret ved prøving av det frie skjønn. For øvrige kommunale vedtak skal klageinstansen legge stor vekt på hensynet til det kommunale selvstyre ved prøving av det frie skjønn". I lys av den veldokumentert svake tilstanden i tjenestene til mennesker med utviklingshemming, burde fylkesmannens overprøvingskompetanse styrkes og minst være på nivå med overprøvingskompetansen som gjelder helsetjenester.

    Rettsikkerheten ble ytterligere svekket ved overgangen fra sosialtjenesteloven til helse- og omsorgstjenesteloven. I forarbeidene til Helse- og omsorgstjenesteloven ble det presisert at fylkesmannen bare i helt spesielle unntak skulle omgjøre kommunale vedtak: "Ved prøving av «det frie skjønn», bør Fylkesmannen som hovedregel ikke benytte kompetansen til å fatte nytt vedtak når det gjelder vedtak om tjenester som i dag reguleres av sosialtjenesteloven" (se Prop. 91 L (2010–2011), avsnitt 34.7.9). Rettstilstanden tilsier at Fylkesmannen absolutt bør kunne omgjøre urimelige kommunale vedtak, ikke bare oppheve dem.
  4. Tilsynet med kommunene bør styrkes og endres. Tilsynet bør først og fremst sjekke om tjenestene er individuelle og bidrar til at den enkelte får et aktivt og meningsfullt liv i samsvar med egne preferanser og verdier. Fokuset på dokumenter bør reduseres og fokuset på levekårene bør styrkes.
  5. Kommunens rapporteringssystemer må endres og utvikles. Målstyringssystemer som ikke fanger opp de overordnede målsetningene bidrar til målforskyvning og hindrer realisering av overordnede målsetninger. Det finnes ingen indekser eller indikatorer som fanger opp innholdet i de overordnede målsetningene. En må derfor redusere målstyringen og i større grad satse på tillitsbasert ledelse hvor det gis tilstrekkelige rammer for å yte gode og individuelle tjenester i samsvar med den overordnede målsetningen. Rapporteringsrutiner vil en måtte ha, men rapporteringen med hensyn til overordnede målsetninger må være kvalitativ og ta utgangspunkt i tjenestemottakers preferanser og behov.
  6. Etatsledernes posisjon må styrkes i forhold til rådmannen. Ingen enkeltperson kan ha oversikt og innsikt i all kommunal virksomhet. Rådmannen har en viktig funksjon med hensyn til budsjettstyring, men budsjettstyringen må ikke kneble den faglige styringen, slik som i dag. Spesielt på felter som få kjenner til og som i liten grad egner seg for målstyring, bør de faglige perspektivene være overordnet de budsjettperspektivet. På noen felt bør kommunen gå i den retningen en hadde før den nye kommuneloven kom i 1992.
  7. Politikerne må sikres innsikt og kompetanse på feltene som de skal styre. I tillegg til budsjett, må det også komme politiske saker som forteller om tilstanden i tjenestene og i hvilken grad tjenestemottakerne får individuelt tilmålte tjenester som bidrar til at de kan ha aktive liv og delta i samfunnet. Uten informasjon av denne typen, mangler politikerne grunnlag for å fatte budsjettvedtak eller styre feltet på andre måter.

Jens Petter Gitlesen

14 april 2019

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