The ageing population is increasing pressure on resources in long-term care services; thus, restructuring long-term care for older adults is on the political agenda in many countries [
1,
2]. Consequently, there has been an increased focus on using care resources effectively and efficiently to improve the likelihood of desired health outcomes [
3]. However, this focus has resulted in a range of challenges in long-term care service allocation, such as failure to meet citizens’ actual needs [
4,
5], expanding budgets, rationing of care services, poorer quality of services and higher thresholds in service allocation [
6]. To meet these challenges, priority setting and more effective care strategies, such as reorganisation of services and more efficient resource utilisation, have been foci of health and care services reforms in recent decades [
6]. The aim of this study is to explore how national principles for priority setting are expressed in long-term care service allocation to older adults.
Universalism is a central feature of the Norwegian welfare model and gives all citizens the right to receive health and care services adapted to their needs. This means that municipalities are obliged to provide long-term care services that cover citizens’ needs for longer or shorter periods in situations that may threaten their welfare [
6]. An increasing number of municipalities have in recent years adopted a purchaser-provider model for long-term care service allocation where those who decide on the scope of services given (allocators) are separate from those providing the services (providers). This means that needs assessment and allocation is carried out by municipal service allocators, who typically assess whether long-term care services should be provided, what service(s) should be offered, and, in the event of resource shortages, who should be prioritised [
7].
For many years, in line with political aims in several countries, effort has been made to reduce the use of specialist care, decreasing the length of somatic hospital stays [
8,
9]. In Norway, changes with reducing the length of hospital stays started in the late 1980s and have been expedited after the implementation of The Norwegian Coordination Reform in January 2012. This reform made the local municipalities responsible for parts of the citizens’ health care that were previously the responsibility of the hospitals [
10]. Consequently, the local long-term care services are expected to deliver care to more service users and care recipients with more severe medical needs than previously [
11]. These changes, in addition to the ageing population, increase demands for long-term care services and challenge the sustainability of universalism in the developed welfare state [
12].
Norway’s National Insurance Scheme ensures free or highly subsidised health care and long-term care regardless of age [
13]. Similar to most other Organization for Economic Cooperation and Development (OECD) countries, long-term care services are mainly publicly financed through general taxation and granted according to individual persons’ needs [
14]. Citizens in need of long-term care can apply for several types of services and facilities, such as home care, sheltered housing, nursing homes, day-care facilities, personal assistance, and social alarms. Home care consists of various services, but in this study, we focused specifically on home nursing and home help (practical assistance). Sheltered housing is assisted housing that is allocated to older adults so that they can have easier-to-care-for housing and better access to facilities [
15]. Some sheltered housing has staff on duty 24 h a day, while in others, residents must call for assistance when they need it [
16]. Nursing homes are designed for older adults who require a high degree of medical care and assistance with activities of daily living. Short-term stays in nursing homes are provided to older adults who need health care at a higher level than home care for a shorter period [
17], for example, as respite care, for observation to identify the level of care needed, or while waiting for a long-term placement. Additionally, short-term stays are used for preventive, treatment or rehabilitation purposes for older adults living at home [
6,
18].
All Norwegian residents with illnesses or disabilities can apply for long-term care services in the municipality they live in [
15]. The service allocators process applications, assess needs and make individual decisions regarding service delivery. A study including a sample of 804 service allocators from 261 municipalities indicates that the vast majority of municipal service allocators are nurses (> 80%), while the remaining are from other health professions or other (such as physiotherapists, occupational therapists or social workers) [
19]. In effect, nearly all municipal service allocators are health professionals. Prior to service allocation, the service allocators obtain information about applicants by visiting their homes, sometimes with the next of kin present. At these home visits, the service allocators fill out assessment papers regarding the recipients’ needs and health condition and take notes about the recipients’ wishes, living situation, social situation, and family. If the applicants are already receiving long-term care services, the service allocators obtain the relevant information from service providers, relatives and the care recipient. In the assessment process, the service allocators can discuss with colleagues or long-term care staff before granting or refusing services. According to the Public Administration Act [
20], applicants for long-term care services are entitled to a written reply with an individual decision provided by the municipality within 30 days of submitting the application for services. The individual decision letters contain the municipality’s arguments and reasons for granting or refusing long-term care services, as well as information about the right to appeal [
20]. The applicants can send a new request for an assessment of their needs at any time. The content of the individual decision letters serves as the basis for the planning and provision of long-term care services in collaboration with the individuals who receive them [
15].
In Norway, the needs assessment and the allocation of long-term care services is often based on the principle of the ‘lowest effective level of care’, where services at lower levels (such as social alarms, level 1) should be tried before services at the higher levels (nursing home stays, levels 5 and 6) [
17] (see Fig.
1). Home care services typically require fewer economic resources and serve less severe needs than institutional services [
6] and therefore, in most cases, are offered before nursing home stays.
Priority setting and resource allocation in long-term care
Priority setting in long-term care services is an underresearched area of study [
17]. In the international scientific literature, there is a lack of clear definition of long-term care services [
21]. This is because the organisation and responsibility for delivering these services differ across countries. Despite different systems, the core of the concept of long-term care is the need for support from a third party to manage activities of daily living (ADL) [
22]. Furthermore, a primary challenge in long-term care service allocation is that citizens’ needs and/or demands often exceed the available resources, which leads to a need for priority setting [
23]. Additionally, sustainable long-term care for older adults should also include the optimal distribution of resources [
24]. To address the challenges and complexities in long-term care services, there is a need for a system for priority setting that is effective and just [
7], that prevents exacerbation of illness and functional failure and ensures that persons in need of care get the right service at the right time. Health authorities are increasingly recognising the need for clearer principles for priority setting to ensure safe, efficient and equitable resource allocation [
25].
Previous research on the topic has shown that constrained resources, health inequalities, and increased complexity in older adults’ health and care needs present challenges to priority setting in long-term care service allocation [
24,
26,
27]. The consequences of these challenges can be marginalised care with ethical implications and less individualised and inclusive care [
5,
28]. Despite service allocators’ desire to comprehensively assess older adults’ needs [
29‐
31], limited resources influence the extent of needs assessed [
30]. Earlier research has shown that in several cases, assessment and service allocation were more supply-led than needs-led [
4,
30,
32,
33] and that service allocators were more loyal to the organisation and available resources than to the needs of service recipients [
4,
30,
34]. A Norwegian study from 2018 showed that service allocators throughout the assessment process actively worked to fit older adults’ needs to services with low resources. As a consequence, certain older adults’ needs were obscured in the assessment process [
34]. Older adults’ psychological and psychosocial needs are especially prone to remain unassessed [
30].
Variations in long-term care assessment and allocation of services occur across regions, municipalities, and city districts both in Norway and internationally [
19,
35‐
41]. Explanations of variations in service allocation are variations among organisations, municipalities’ economy, individual judgements, and the influence of resourceful and strong-willed relatives [
17]. A study conducted by Syse et al. [
19] showed that municipality size could explain some of the variation, as larger municipalities tended to allocate less practical assistance than smaller municipalities. Additionally, the individual service allocator to whom the care recipient was assigned was almost as important for the allocation of long-term care services as the municipality in which they lived. Some variations in service delivery are necessary and unavoidable due to differences in needs, preferences and clinical responses. Studies have shown that unwanted allocation variation occurs in services offered to younger and older service recipients [
39] due to unequal standards in the assessment of care needs, with younger recipients’ needs being assessed relative to normal activities for those in the same age group [
40,
41]. Variations in long-term care service assessment can be considerable in areas where no common priority-setting principles exist [
37]. Principles for priority setting in long-term care service allocation can help establish a common foundation and reduce unwanted allocation variation [
39].
Decisions regarding how health care needs should influence priority setting can draw on different theories of distribution, such as egalitarianism [
42,
43], prioritarianism [
44] and individualism [
45] and on combinations of normative evaluations that underpin the principle of need [
46]. A general normative principle of health care needs is that the larger the need for health care is, the greater the claim for such resources [
46]. However, in the long-term care services, there are a myriad of variables independent of medical diagnoses that play a part in determining what care recipients’ care needs are. Contextual variables such as family networks and physical environment can be part of this. Therefore, the values, principles and criteria that should be the basis for priority setting in long-term care are subjects of debate [
47]. Establishing commonly agreed-upon principles for priority setting is challenging due to values such as equality and fairness on the one hand, and resource constraints on the other [
45]. Additionally, the absence of a common understanding of what long-term care services are and should be among policymakers, managers, service providers and service users as well as suboptimal measures of outcomes, impede formulation of public policy [
21]. A study shows that employees in the Swedish long-term care services experienced national priority-setting principles in health care and nursing as useful [
48]. Nevertheless, there is still a need to specify principles for long-term care services separately to primary and secondary care [
49].
Recently, three principles for priority setting, resource, severity, and benefit, were selected as guiding principles in Norwegian long-term care services. These principles are the same as those in the Norwegian specialist health care, only with moderate changes [
7]. However, there are major differences between the specialist and long-term care services, and therefore, it is not given that the three principles are equally adaptable in both sectors [
50]. The long-term care service is a service that provides older adults early and long-term follow-up. The follow-up is often aimed at several diseases and disorders in addition to the consequences and challenges that the diseases cause (e.g., coping with everyday life, the functions of daily life and basic needs). The specialist health service, on the other hand, often focuses on one disease at a time, they complete the treatment and discharge the patient for further follow-up by the long-term care services [
50]. Addressing these differences, in the principles for the long-term care services, the term “coping” have been incorporated in the severity and benefit principle [
7]. This study explores how these three principles are expressed by municipal service allocators in the allocation of long-term care services to older adults.