Specialiserad biståndshandläggning inom den kommunala äldreomsorgen : Genomförandet av en organisationsreform och dess praktik

Sammanfattning: The 1990s was a period characterized by a strong pressure for reform in the Swedish municipalities. The care manager reform, i.e. the initiation of a position within the administration - the care manager - whose work tasks are concentrated around needs-assessment practices only, was one of many reform proposals. Within a fairly short time span a great number of municipalities decided to implement this new model for organizing the care of the elderly. A central research question in this thesis is how the rapid diffusion of this organizational idea could be explained. The diffusion of new ideas of organizing doesn’t come about automatically and doesn’t take place in a social vacuum. Reform proposals encounter different actors and local traditions, opinions and understandings of desirable goals and appropriate means. Eight Swedish municipalities were studied, and the thesis shows that there were differences among them concerning the arguments used when the reform was launched and implemented. A key to understand the impact of the reform is that it over time was ascribed more and new problem solving qualities. Among the early adopters the model was justified by ideological arguments, and the reform was seen as a necessary element in the privatization of the old age care services. The other municipalities in the study were not inclined to adopt the model in connection with marketization rhetoric; in fact, some of them opposed it on precisely these grounds. However, in a discourse about the need for greater rättssäkerhet – legal security in the sense of the individual’s rights in the face of law – the reform eventually became a solution to a new problem. The third discourse that paved the way for the care manager reform is connected with cost-efficiency. In this discourse the reform was associated with the control function of costs and a more restrictive needs-assessment practice. In the last phase of adoption, the reform had reached the status of a fashion prescribing the modern way of organizing old age care. The second part of the dissertation studies care management as occupational practice. The thesis shows that managers supported the reform with arguments echoing the different problem solving functions that had been ascribed to the model over time, but it also shows that support were tied to hopes for increased professionalization. However, the core domain of the care manager’s work – need-assessment – is contested by other occupational groups, e.g. medical professions. As the thesis shows there are signs that indicate that the power of the care managers to protect their new domains is uncertain. The empirical material consists of strategic interviews and documents. Interviews were held with the social actors involved in the implementation such as politicians, public servants at different positions in the local administration, union representatives and care managers. The documents were basically of two kinds; official public documents produced on a yearly basis in the local administration and internal documents produced in the old age care organizations, and secondly, documents referred to in the interviews, such as directives from supervisory authority, local evaluations and reports from consultants.