Penger

Penger, politikk og tjenester

Mange får for lite tjenester. Den bakenforliggende årsaken er stort sett alltid penger. Noen kommunener kan ha for lite penger, andre kommuner prioriterer tjenetene for lavt og noen prioriterer pengebruken i sektoren feil. Få politikere forstår seg på feltet og færre vet hva de bør gjøre.

Tjenester koster, omfattende tjenester koster mye

I Samfunn for alle, nr. 5/2018, ble saken om Tian Thrane Sørgård omtalt. Foreldrene til Tian ønsker at han skal ha brukerstyrt personlig assistanse (BPA). Kværfjord kommune sier nei. Fylkesmannen sa ja, det samme sa tingretten. Kvæfjord kommune anket saken. I januar kommer saken opp for Hålogaland lagmannsrett.

Det er vanskelig å forstå at det kan være noe som helst lovgrunnlag for å nekte Tian BPA. Han er avhengig av oppfølging hele døgnet. I tillegg er det tvangsvedtak som krever to tjenesteytere tilstede når tvangstiltakene utøves. Det å etablere en BPA-ordning for Tian vil være kostbart for kommunen. Kommunen kan spare mye dersom Tian plasseres i et bofellesskap. I bofellesskapet vil det kunne være andre tjenesteytere som kan trø til når den får behov for bruk av tvang. Slik kan en spare inn en tjenesteyter til enhver tid. I tillegg vet vi at vedtakstimene ofte brukes litt om hverandre i bofellesskapene. En skal ikke se bort i fra at Kværfjord kommune kan spare 50-70 prosent av kostnadene, dersom Tian blir plassert i et kommunalt bofellesskap.

Får kommunen viljen sin, så vil Tian bli dømt til et liv i bofellesskapet. I og med at han ikke har en ekstra person knyttet til gjennomføringen av tvangsvedtakene, så kan han heller ikke forlate bofellesskapet uten at de andre beboerne mister den bistanden som de har krav på. I tillegg har Tian en uheldig erfaring med de kommunale tjenestene. Tian er avhengig av få tjenesteytere å forholde seg til. Til nå, har det kommunale tilbudet bestått av et hav av ulike tjenesteytere.

Det etiske spørsmålet i Tian-saken dreier seg om Tian skal få et rimelig leververdig liv eller om kommunen skal kunne spare relativt store beløp.

Effektiv drift

Når en hører argumentasjon om effektiv drift eller synergieffekter, så ligger besparelsen å ikke gi de nødvendige tjenestene. Når personer med utviklingshemming plasseres i bofellesskap, så er det mye enklere å ikke gi de tjenestene som en har krav på. Fra kirken hører jeg at mennesker med utviklingshemming som er opptatt av kirke- og meninghetsarbeid, verken kommer seg til gudstjeneste eller til menighetsaktivitet. Fra idrettsbevegelsen hører jeg at personer med utviklingshemming verken kommer seg til trening, konkurranser eller turneringer. Når NFU arrangerer juletrefester, pizza-kvelder og andre sosiale treff, så kommer en mengde bofellesskap i samlet flokk. Bofellesskapene forlater samlingene først, rundt 19.30, på grunn av vaktskifte.

Manglende og mangelfulle individuelle tjenester var en gjenganger i rapportene fra Nasjonalt tilsyn med helse- og omsorgstjenestene til mennesker med utviklingshemming i 2016. I rapporten fra Trondheim kommune, kan en f.eks. lese:

  • Det fremkommer at grunnbemanningen i flere av boligene er lav, særlig på helg.
  • Det fremkommer at det er liten hensikt i å fremme behov for ytterligere tjenester på grunn av lav bemanning og stram økonomi.
  • Det er lite spor av individuelle vurderinger av den enkeltes behov ved tildeling av tjenesten personlig assistanse. Tildelingen er i stor grad styrt av fastsatt norm.

Trondheim kommune er ikke enestående. Forholdene i Haram kommune synes å være vel så tragiske:

  • Vedtak om praktisk bistand og opplæring er lite presise og/eller av gammal dato
  • I intervju kom det fram at tilsette, brukarar og pårørande opplever av og til at det er for lite tid til å hjelpe den enkelte brukar.
  • I intervju og av dokumentasjon kom det fram at enkelte brukarar ikkje har fått innvilga tilstrekkeleg praktisk bistand
  • I intervju og av dokumentasjon kom det fram at enkelte brukarar ikkje får hjelp i det omfang som går fram av enkeltvedtaket
  • I intervju og av dokumentasjon går det fram at ikkje alle brukarane bur i bustad som er egna for deira behov.
  • Tiltaksplanane til enkelte brukarar som har spesielle utfordringar er mangelfulle og inneheld ikkje konkrete tiltak for kommunikasjon og samhandling med brukar, samt korleis målretta miljøarbeid skal ytast. Tilrådingar frå habiliteringstenesta er ikkje alltid følgt, utan at det ligg føre dokumentasjon på faglege vurderingar for kvifor dette ikkje er gjort.
  • Enkelte brukarar har svært mange ulike tenesteytarar.

Tilsvarende funn ble gjort i en rekke  kommuner.

Effektiv drift, tvang og medisinering mot mistrivsel

I Samfunn for alle nr.5/2018, forteller et foreldrepar hvordan behovet for tvangstiltak forsvant da sønnenflyttet fra bofellesskapet til sitt eget hjem og fikk en BPA-ordning i stedet for kommunale tjenester. Det å motta for lite tjenester, være bundet til bofellesskapet, ikke kunne ha aktive liv og dyrke egen interesser, måtte bo sammen med noen som en ikke trives sammen med og å måtte forholde seg til 20-30 eller 40 ulike tjenesteytere og andre konsekvenser av den effektive driften, gir ikke grunnlag for lykkelige liv. Utagerende atferd og depresjon er to naturlige konsekvenser av slike livsforhold. Vanlige løsninger på slike problemer er tvangsvedtak og medikasjon.

"Me kan sjå at mistrivsel blir feiltolka som psykiatrisk sjukdom", sa nåværende helsedirektør Bjørn Guldvog til NRK i 2011. Siden den gang, er det ikke blitt gjort noe med den saken.

Kostnadene med gode liv

Hvis Tian skal få BPA og leve et aktivt og meningsfullt liv, så vil Kværfjord kommune få en langt større regning enn om Tian stues bort i et bofellesskap. Får Tian et aktivt og meningsfullt liv, så er det fare for at flere kan komme etter. Slik er problemets kjærne. Det gjelder ikke bare Tian, men alle de rundt 25.000 personene med utviklingshemming som mottar omsorgstjenester.

Få kommunepolitikere er klar over situasjonen og den er aldri på det polistiske sakskartet. Budsjettet er imidlertid på sakskartet hver høst. Budsjettdokumentene verken viser eller forsøker å koble kommunens utgifter med kommunens plikter og individets rettigheter på omsorgsfeltet. Derimot er det vanlig å finne argumenter om effektivitetsgevinster, synergieffekter og mange andre fine ord på det å skape umenneskelige og ulovlige livsbetingelser for mennesker med utviklingshemming.

Slik vil det trolig fortsette til levekårene til mennesker med utviklingshemming blir like godt behandlet av kommunestyrene som budsjettet.

Jens Petter Gitlesen

10 desember 2018

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Disse tjenestene gis etter enkeltvedtak og kan ikke endres i negativ retning uten at tjenestemottaker har hatt en betydelig positiv utvikling. Formål med habilitering og et tydelig lovverk «Formålet er at den enkelte pasient og bruker, som har eller står i fare for å få begrensninger i sin fysiske, psykiske, kognitive eller sosiale funksjonsevne, skal gis mulighet til å oppnå best mulig funksjons- og mestringsevne, selvstendighet og deltakelse i utdanning og arbeidsliv, sosialt og i samfunnet» Ifølge lovverket skal kommunen «yte et egnet tjenestetilbud til de som ikke kan dra omsorg for seg selv eller som er helt avhengig av praktisk eller personlig hjelp til å greie dagliglivets gjøremål. Begrepet dagliglivets gjøremål må i denne sammenheng forstås som mer enn rene omsorgsoppgaver. Dette gjelder også muligheten til i så stor grad som mulig å ta del i hverdagslivets opplevelser og aktiviteter, opprettholde kontakt med familie og sosialt nettverk, være i fysisk aktivitet, holde seg orientert og være aktiv med utgangspunkt i egne engasjement og interesser. Tilbud om dagaktiviteter er derfor også en del av det kommunale omsorgstjenestetilbudet.» Tilsyn med kommunale tjenester Det er fylkesmennene og helsetilsynet som foretar slike tilsyn. I rapporten «Det gjelder livet. Oppsummering av landsomfattende tilsyn i 2016 med kommunale helse- og omsorgstjenester til personer med utviklingshemming» heter det bl.a.: «... Det var tilsyn i 57.kommuner; 12 kommuner hadde ingen lovbrudd, i de øvrige 45 fant fylkesmennene til dels alvorlig svikt. Fylkesmennene intervjuet mer enn 200 brukere og ca. 70 representanter for brukere som ikke selv kunne formidle sine erfaringer.» 45 kommuner med til dels alvorlig svikt! Det overfor mennesker uten egen stemme! Helt uakseptabelt! Vil en redusering med 16 årsverk medføre at slike avvik vil bli å finne her også?! Fylkesmennene fant videre at tjenesten personlig assistanse mange steder var utilstrekkelig og lite individuelt tilpasset. Fylkesmannen påpekte mange steder at de ansatte hadde svak kompetanse og at det manglet planmessig opplæring. Tjenesteytingen kunne være lite systematisk, og dokumentasjonen mangelfull og spredt. Ansatte kunne være dårlig informert om brukerne de skulle bistå og om oppgaver de skulle utføre. Mange steder var det få spor av brukermedvirkning, og pårørende og verger var ofte ikke godt nok informert til å ivareta brukernes interesser. Hva risikerer Kristiansund kommune ved å skjære med tilbudet med 16 årsverk? En drøss med avvik? Som først og fremst skader de mest sårbare innbyggerne, men som også vil gå utover slitne pårørende, tjenesteytere og kommunens renomme. Sett landet i gjennomsnitt avdekker tilsyn 90 % avvik på området, der 70 % er ift. lovpålagte oppgaver. Vi må på den bakgrunn anta at det er mange som i dag ikke mottar lovpålagte tjenester i Kristiansund. Dette er også en reell situasjon ut ifra erfaringer i vårt miljø, inkludert egne erfaringer selvfølgelig. Tjenestenes kvalitet «Forskrift om ledelse og kvalitetsforbedring i helse- og omsorgstjenesten» sier noe om en annen viktig side om tilbudene; for det dreier seg jo ikke bare om kvantitet, men også om tilbudets kvalitet. Selvfølgelig. «§ 1. Formålet med forskriften er å bidra til faglig forsvarlige helse- og omsorgstjenester, kvalitetsforbedring og pasient- og brukersikkerhet, og at øvrige krav i helse- og omsorgslovgivningen etterleves.» Kvalitet handler også om at menneskerettigheter skal ivaretas. I etterkant av NOU 2016: 17; «På lik linje – Åtte løft for å realisere grunnleggende rettigheter for personer med utviklingshemminger», har bl.a. disse vedtakene blitt gjort enstemmig på Stortinget: «Vedtak 894 Stortinget ber regjeringen legge frem en Stortingsmelding med forslag til tiltak for at utviklingshemmede skal få oppfylt sine menneskerettigheter på lik linje med andre. Vedtak 902 Stortinget ber regjeringen legge frem en Stortingsmelding om sikring av utviklingshemmedes menneskerettigheter der det legges vekt på å sikre at tjenesteapparatet for mennesker med utviklingshemming innehar tilstrekkelig kompetanse til at utviklingshemmede får likeverdige tjenester innenfor ulike samfunnsområder, på linje med alle andre.» Mine spørsmål blir videre Vil Kristiansund kommunens visjon «I medvind uansett vær», med «levering av gode tjenester» bety at utviklingshemmede får de tjenester de har krav på iht. lovverket hvis budsjettforslaget blir vedtatt? Hvordan skal dette i så fall ivaretas når 16 årsverk er foreslått fjernet? Hvordan vil dette innvirke på kvantitet? Kvalitet? Er fjerning av 16 årsverk i bo- og habilitering, dvs. tjenester til mennesker som selv er uten stemme og som er de mest sårbare blant oss, i samsvar med å være en varm, klok, smart og modig kommune? Jeg leser at årsverk bl.a. skal fjernes ved naturlig avgang, hvor stor naturlig avgang er kalkulert inn av tjenestemottakere? Er det slik at noen av våre skal dø og slik medføre mindre utgifter? Ei kald dyne! Jeg vil avslutte med en lettere omskriving av Hellbillies strofe fra sangen Det finaste eg veit fra «Det e jaggu me rart koss det kan gå te.» til «Det e jaggu me lovbrudd hvess d her slår t» – dyna blir kaldere for dei finaste vi har! Grete Reitan

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