Three themes could be identified in the social insurance officers' descriptions of difficulty in assessing the applications for disability pensions towards a decision on whether the applicant's symptoms or illness qualified them for a disability pension. These are: 1. Clients are heterogeneous. 2. Ineffective and time-consuming waiting for medical certificates impedes the decision process. 3. Perspectives on the issue of work capacity differed among different stakeholders. Each of these themes will be described separately below.
Clients are Heterogeneous
The typical applicant for a disability pension is an individual who has been on long-term sick leave. This application does not cause the social insurance officer any problems. Neither are re-assessing applicants with a temporary disability pension problematic. Those two kinds of applications represent about 80 percent of all applications. Applications from those who have neuro-psychiatric diagnoses such as ADHD (Attention Deficit Hyperactivity Disorder), Asperger's syndrome or autism are however more difficult to handle, as these assessments are more time-consuming and often demand an extended assessment to obtain clarification of medical status. The client may for example have studied at a special school for some years and the reasons for the applicant's problems in the ordinary school system may not have been made clear. The necessary clarification is obtained in different ways, depending on the individual.
And then you ask yourself: how is it possible that this person has gone through more or less his entire education without anyone really getting to the bottom of what the problems are (R5).
Several social insurance officers also talked about unemployed younger people, less than 30 years of age, as a problematic group of applicants to judge, especially after the regulations had become stricter. These clients may have participated in several activities leading to better health and when they are ready for practical experience at a workplace, the employment office should provide this. In these cases the social insurance officers had to encourage the clients to contact the employment office. Often the social insurance officers experienced problems, as the employment officers tend to be overloaded with ordinary unemployed people and have little time for clients with special needs. The implications are that some clients who are motivated to work risk having to wait passively for employment activities.
They [Employment Officers] are overloaded right now and can't handle any more. But then you've got to look at the way it's organized. I mean, in that case there must be something wrong with it (R5).
Another group of applicants that cause the social insurance officer problems are immigrants and refugees, as some of them suffer from unspecified disorders. This group has also increased in number during the last decade, i.e. during the same period as a tightening-up on public economy in society has occurred. Immigrants and refugees may sometimes 'somatise' their mental symptoms, as interpreted by the social insurance officers. Vague symptoms or health problems are more difficult for the physicians to fit into the diagnosis coding system and it is also more difficult for them to make prognoses about future work capacity. Some social insurance officers also said they felt uncomfortable in encounters with immigrants. One social insurance officer said 'we social insurance officers have to become better at dealing with and understanding other cultures' (R3). Social insurance officers also said they were uncertain about the quality of medical certificates as they do not know if possible difficulties in the client's background, for example torture or experiences of war, have been brought to light in the encounter with the physician.
Then of course there are often psychological problems that haven't been assessed (in the medical certificate). For example they may have been tortured when they perhaps come from a war-torn region (R9).
Social insurance officers also emphasize how difficult it is to judge applications from young, female single parents suffering from stress-related symptoms such as headaches; diffuse neck-shoulder pain and tiredness. There are complexities in these clients' problems, as they often have a low education, several children, and work in low-paid jobs.
I mean, it's a complex picture. It's linked to work, the social situation, and, yes, everything (R4).
The social insurance officers consequently find it understandable that these women with great responsibility and 'strenuous work' develop long-lasting disorders but they have difficulty getting through their applications.
Ineffective and time-consuming waiting for the medical certificates impedes the decision process
Social insurance officers often have problems in receiving the medical certificate that is required by law as a basis for the disability pension assessment, in reasonable time. It is more difficult for the applicant to be referred to specialists for medical examinations than it is to obtain an examination by a general practitioner at a primary health care centre. This difficulty affects in particular those vulnerable groups described in the previous theme. The social insurance officers say that they often have to remind the physicians to send the certificate, especially specialist certificates.
But this business of getting them to send in a medical certificate can be really, can take a really long time nowadays (R8).
Another problem mentioned by the social insurance officers is that of 'temporary physicians' employed in the primary health care system. The social insurance officers reported a shortage of permanent general practitioners in the informants' region. 'The temporary physicians' do not have the same time to form a deeper relation with the patients compared with the permanent general practitioner, as 'the temporary physician' meets almost every patient only once. This problem of filling medical positions in the primary health care organization causes further delays with the certificates.
And it's the same thing with people being on the sick list for a long time; I think one of the reasons is that the doctors don't have time to get to grips with the problem, or they think 'I'm only here temporarily, I'll just extend it (the sickness certificate). And then the next one comes along and is also only there temporarily (R6).
Even if the medical certificates are received within a reasonable time they are often incomplete and require supplementary assessments or comments if they are to be usable as a basis for the social insurance officer's investigation before a decision is made at the Social Insurance Board.
Sometimes we sort of don't really get answers to what we need. It may be descriptions of different things and functions and so on. But still not a real sort of prognosis, and how long the condition will last, whether it's something that will disappear in a few months or a year, or never. You don't get, they don't take a stand on it, and then it's sort of very difficult to make a decision (R7).
When certificates are incomplete, the social insurance officers need to ask the physicians employed at the Social Insurance Board, who are advisers and consultants on medical matters, for a statement about the need for additional examinations and rehabilitation. Consulting the social insurance physician is time-consuming and may cause further delays if the social insurance physician refers the client for further assessments by insurance medical specialists such as physiotherapists, behavioural scientists or physicians with specific competence to perform assessments of work capacity. In this way the decision-making procedure is prolonged. Social insurance officers sometimes experience these assessments as a waste of time, as the additional information sometimes does not contribute to the basis for judgement of work capacity.
And then maybe you have to wait for six months to a year for the assessment that anyway is going to say no, it's not possible to do anything about it. And that's a big problem. Yes, you've got to wait a long time whatever it is, I think, a really long time (R10).
This occasionally time-consuming waiting for different assessments frustrates the social insurance officers as they feel responsible for the time the client has to wait. This responsibility is reinforced by social insurance officers' experience of feeling over-burdened by a heavy caseload. As long as they has an unsatisfactory assessment to present to the Social Insurance Board, no decision can be made on whether to grant a disability pension or not. The social insurance officer is aware of the problem this may cause the client; for example, not having enough money to pay their bills. One social insurance officer expresses her empathy with the client in the following way:
I mean, I can't just say I don't care about this today if they've got to have money for something; there are dates when bills have to be paid and all that. So this is the pressure you have on you that you've got to get it done by that day; it's their livelihood after all (R1).
The social insurance officers explained that they are responsible for writing a memorandum as a basis for a decision on a disability pension at the Social Insurance Board, even if there is no medical certificate. Presenting an incomplete memorandum and knowing that the application will be rejected by the Social Insurance Board, is expressed as a problem by the social insurance officers, both for the clients as they have to submit a re-application, and for their own job satisfaction.
Perspectives on the issue of work capacity differed among different stakeholders
The social insurance officers consider that there are difficulties due to the fact that the authorities, such as social insurance offices, employment offices and social services, have different definitions of the concept of work capacity.
Social insurance officers make decisions on work capacity in relation to sickness. Therefore the physicians' certificates are important for the social insurance officers' assessments, but sometimes the physicians avoid judging work capacity.
In the medical certificates they have difficulty formulating what kind of work capacity there is. There's usually a diagnosis and what kind of (medical) problems they have. But how this limits (the individual) in working; they themselves think that's difficult (R9).
Social insurance officers mention that sometimes there may be doubts about which authority is responsible for providing financial support for an individual. In some cases individuals are requested by the employment office to apply for disability pensions, as the employment office regards the client as not healthy enough to be employable. The employment office might also direct clients to apply to the social welfare office for financial support. Here similar problems may occur in the assessment of the individual's health and work ability, i.e. these authorities consider the client too ill to grant unemployment compensation or social welfare. When the applicant comes to the social insurance office he or she may not have been in contact with the health care centre and may be unable to get the necessary medical certificate. When the social insurance officer assesses work capacity in relation to medical status, clients may however be considered healthy enough to be able to work, which eliminates their chance of applying for a disability pension. The fact that social insurance officer and other stakeholders have different interpretations of the concept 'work capacity' is exemplified in the following:
Perhaps we juggle with the applicants, no, but we can say 'then the social welfare office will have to take care of that', and the social welfare office may have thought 'well, but they are rather ill, they haven't got a chance of earning their living'. So of course they're borderline cases everywhere (R10).