When standards fall short: The use of discretion and just allocation of long-term care services in Norway

Care administrators in long-term care (LTC) are 'gatekeepers' to the services and handle applications, investigate care needs, and decide if, what and how much services applicants are entitled to receive. Various models of service allocation have been in operation in the Nordic countries since the inception of LTC services in the 1970s. The main drivers of the development of allocation models have been concerns about service inequality among users, quality of care, patient safety, and the overall efficiency within healthcare settings. While care administrators have several laws and guidelines to aid their decision-making, the use of professional discretion is known to be widespread but less investigated. In the context of Norway, this article seeks to explore: What guides care administrators in reaching decisions? How and in which circumstances is the use of discretion needed in making decisions?

Qualitative in-depth interviews with 5 managers in care administration and 13 care administrators in 5 Norwegian municipalities. The material was analysed using thematic analysis.

Two main themes were identified. These are Negotiating standards with discretion and collegial discussion, and Complexities in deciding needs and services.

Care administrators hold significant responsibility in ensuring fair service allocation. Discretion is a necessary and valuable tool that can strengthen the integrity and trustworthiness of care services. However, increased reforms and standardisation place heavy pressure on administrators, limiting their discretion through stricter allocation criteria. This may reduce their ability to act in the best interests of service applicants in line with the fiduciary principle.