Imamo tehnologijo – nimamo pa stroja (tri osi razvoja socialnega varstva 6)

V vseh teh letih smo izumili, uvozili in prilagodili, uvajali in preskusili številne metode in oblike dela oz. oskrbe (glej spisek zgoraj). Znamo delati v skupnosti, poznamo osnovne oblike oskrbe – tako vmesne strukture kakor osebne storitve, a imamo vedno znova težave, kako jih uveljaviti v praksi. Srečujemo se z vrsto ovir zakonskega značaja, v zvezi s pretokom sredstev, financiranjem sprememb, kulturnega značaja (skrbniška kultura, aksiomi izključevanja, …),  fragmentacije sistema in pa tudi povsem managerskega, organizacijskega registra (uvajanje demokratičnega vodenja, uporabniško soupravljanje). Za vsako od teh ovir posebej vemo, kako jo premagati, a se vse (povezane v medsebojnem delovanju) pogosto postavijo kot zid, ki ga je težko prebiti.

Dezinstitucionalizacija je pogoj demokratičnega občestva

Totalne ustanove so pravzaprav dediščina razsvetljenega absolutizma. Vzpostavljajo aksiomatiko oblasti, ki izhajajo iz osnovnih predpostavk podrejanja, lastnine, pogodbenih razmerij in človekove identitete.

Na tem registru je dezinstitucionalizacija upor zoper tako logiko obvladovanja življenja. Ne izhaja iz postulatov obvladovanja prebivalstva, temveč iz etičnega imperativa osvobajanja.

Dezinstitucionalizacija kot praksa osvobajanja na praktični ravni pomeni več stvari. V prvi vrsti je cilj tega emancipatornega projekta rekonstrukcija pogodbene moči uporabnikov oz. stanovalcev – da znova postanejo državljani, občani. To hkrati pomeni prehod od pretežno skrbniškega razmerja med pomočniki in uporabniki v pretežno zagovorniškega; na ravni metod pa uporabo takih, ki postavijo uporabnika na prestol in upoštevajo njegovo oz. njeno perspektivo. Naravo postopkov je treba preoblikovati iz ceremonij ponižanja v proslavljanje napredka. Materialna podlaga za metodični in postopkovni premik te sorte financiranje storitev na način, da denar spremlja uporabnika (ne ustanove) – npr. neposredno financiranje. Na organizacijski ravni mora takšne spremembe podpirati demokratizacija odnosov v organizacijah, demokratično vodenje in soupravljanje (uporabnikov in zaposlenih). Demokratizacija razmerij se mora poznati tudi v povezovanje med (inter) službami, ustanovami, sektorji in strokami tako, da bodo v službi uporabnika, določene skupine uporabnikov in skupnosti. Zdaj se namreč postavlja vprašanje: »Čigav je uporabnik?«, kar je odraz skrbniškega lastninjenja uporabnikov. V resnici pa smo mi uporabnikovi izvajalci in bi se vprašanje moralo glasiti: »Kako bomo stopili skupaj, da bomo potegnili voz, na katerem sedi uporabnik«, kar je bistveno počelo timskega dela (»team« → »vprega«), resnično timsko delo pa je gonilo sprememb in garant zveznosti in kakovosti storitev. Za resnično demokracijo in okrepitev uporabnikov (kakor tudi izvajalcev storitev in služb, ki jih izvajajo) je treba uvajati – ne le svetov uporabnikov, temveč skupščin, zborov, kot organa odločanja v organizacijah oskrbe. Da bi vse našteto dosegli je nujno ustvarjanje širokih koalicij v prid emancipacije uporabnikov in za spremembe v sistemih oskrbe.[i]

Gre torej na eni strani za spreminjanje pogleda, pristopa, načina delovanja – torej usmerjenosti, naravnanosti, na drugi pa za spreminjanje naravnav – ureditev, organizacijskih obrazcev in strukture. Zato je potreben domišljen, dialoški in dinamičen management sprememb (ki ga moramo šele razviti). Zagate pri uveljavljanju dezinstitucionalizacije na terenu, kažejo na splošni problem v sociali (ki smo ga naslovili tudi v zvezi s centri za socialno delo).

Management, upravljanje, vodenje v sociali mora biti socialno. Vzpostaviti je treba management, ki izhaja iz stroke (ne pa stroko podrejati managementu) in uporabnikov. Zaradi etičnih in praktičnih razlogov (razpršenost, avtonomija odločanja, boljši učinki …) mora biti vodenje demokratično in dialoško. Izhajati mora iz potreb na terenu (HOPS) ne pa iz političnih, stroškovnih, kvazi-strorilnostnih postulatov.

V tem trenutku na strokovni-politični ravni potrebujemo predvsem strategijo prehoda, ki bo rezultat široke konzultacije – kako uresničiti pravno in moralno obvezujoča 12. in 19. člen konvencije (2006).[ii] Strategiji mora slediti akcijski načrt z določnimi cilji in roki, te pa morajo spremljati lokalni in drugi parcialni akcijski načrti.

Za oblikovanje in uveljavljanje strategije in akcijskih načrtov potrebujemo na nacionalni ravni telesi (posvetovalno in operativno), ki bosta s polnimi pooblastili in konstantno spremljali, podpirali, korigirali in usmerjali dogajanje na terenu.

Za spremembe je potreben kadrovski vložek. Nujno je dobro izbrati in izobraziti kader, ki bo vodil spremembe (odločevalci, uradniki, direktorji itn.). Preobrazbo morajo voditi izpričani borci za pravice uporabnikov (Evropske smernice, str. 27).

[V seriji blogov objavljam besedilo, ki je nastalo ob posvetu Tri osi razvoja socialnega varstva, ki ga je pripravila katedra za duševno zdravje na Fakulteti za socialno delo, 14. junija, 2022. Oblikoval sem ga sam, pri pripravi posveta in nastanku besedila pa so sodelovali še: Janko Cafuta, Vera Grebenc, Andraž Kapus, Vili Lamovšek, Lea Lebar, Juš Škraban, Mojca Urek, Marjan Vončina, Darja Zaviršek, Jelka Zorn in drugi.][iii]

Sklici

Evropska  skupina  strokovnjakov  in  strokovnjakinj  za  prehod  iz  institucionalne  v  skupnostno oskrbo (2021), Skupne evropske smernice za prehod iz institucionalne v skupnostno oskrbo. Ljubljana: Inštitut Republike Slovenije za socialno varstvo. Pridobljeno 18. 8. 2022 s https://di.irssv.si/skupne-evropske-smernice

Flaker, V., Rafaelič, A., Bezjak, S., Ficko, K., Grebenc, V., Mali, J., Ošlaj, A., Ramovš, J., Ratajc, S., Suhadolnik, I., Urek, M., & Žitek, N. v sodelovanju z Dimovskim, V., Kastelicem, A., & Pfeifferjem, J. (2015). Izhodišča dezinstitucionalizacije v Republiki Sloveniji (Končno poročilo, verzija 3.2). Ljubljana: Fakulteta za socialno delo.

Konvencija o pravicah invalidov (2006). Generalna skupščina Združenih narodov, 13. december 2006. Ur. L. RS 37/2008.

Rafaelič, A. & Flaker, V. (2021). Dezinstitucionalizacija I: neskončna. Ljubljana: Fakulteta za socialno delo.

 

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[i] Dezinstitucionalizacija ne more biti omejena le na sektor socialnega varstva. Potrebne so analogne spremembe v ustanovah, ki so v sektorjih zdravstva, šolstva in pravosodja.

[ii] Poleg neupoštevanja konvencije zoper družbeno onemogočanje, z nameščanjem v takšne strukture kršimo še

konvencijo o pravicah otrok, CEDAW, Ženevsko konvencijo in mnoge druge listine, ki jih je Slovenija podpisala (Flaker idr., 2015; Rafaelič in Flaker, 2021).

[iii] Lahko štejemo, da je besedilo nastalo tudi v okviru raziskovalnega programa »Socialno delo kot nosilec procesov družbenega vključevanja in socialne pravičnosti v Sloveniji – teoretske podlage, metodološke in metodične usmeritve in zgodovinski razvoj« (številka: P5-0058) pa tudi raziskovalnega projekta »Dolgotrajna oskrba ljudi z demenco v teoriji in praksi socialnega dela« (številka: J5-2567), ki ju financira ARRS.

Lack of autonomy and plentitude of rigidity - organisation and management of residential institutions in Macedonia

The organisation scheme in the long-stay institutions is usually very simple one. In Demir Kapija, the structure of organisation (organigram) divides the institution into general service (administrative and technical) and residential services, these are then divided into the wards. The ‘ward organisation’ coincides with spatial organisation (each service is ‘housed’ in a special building or in a part of it). In Topansko Pole and Banja Bansko the services are divided into the general (administration), residential[1] and educational (occupational) services[2] – the residential in Banja Bansko being divided according to age groups of residents (dept. for nursing and care of up to 6 years old, 7–14, 15–26 and above 26 years).

In Topansko Pole, the activities of their units are coordinated by a series of managing bodies. Professional collegium, consisting of director, deputy director, secretary, dept. leaders, social worker, psychologist, doctor and others meets weekly (every Monday) and deals with current affairs. Professional council consists of deputy director (chairs), special educators, educators, instructors and members of professional team (doctor, psychologist, social worker) and they manage professional issues. Professional team consists of deputy director, doctor, social worker and psychologist. The task of the team is observation and new admissions, suggestions on users; it also undertakes field visits to assess the situations of applicants. The managing committee is the main organ of the institution that is overseeing the management; accept the annual reports and programmes. In Demir Kapija, such organs and meetings do not seem to be functioning, probably due to recent frequent changes in management and atmosphere of demotivation of the leading workers.

The majority of managers tends to be from the ranks of professional workers (special educators, social workers, psychologists), sometimes the managers are imported from political ranks or are recruited from the institution’s administrative staff (jurists, economists). In the case of professional workers as managers, they lack knowledge and training in management and organisation (use of such profiles can sometimes be seen as a waste of professional knowledge and skills, which are badly needed on the ground); while in case of managers from the outside they lack the knowledge of disabilities issues and the social care system. One of the best solutions seems to be embodied in the present director of Demir Kapija, who has been employed in the administration of the institution, finished the degree of management (in tourism, albeit), so she has a good knowledge of the institution and also about management. The directors of the institutions were and have been in most cases exposed to the ideas of deinstitutionalisation, but have never had a systematic training on this topic, especially from the point of managing the change and transformation. Neither have they received support on these issues.

In addition to the issue of management skills issues and the problem of coordination, we have observed two major problems in management of the institutions. One is lack of stability of management due to political recruiting of directors; another is the lack of authority and autonomy in management. In the case of Demir Kapija, we have only in four months witnessed four different managers, which is probably an extreme case. However, some of the change can be attributed to the political changes.

Directors of care institutions feel and actually are constrained in their decisions and resources management. Actually, they are more like administrators of public resources and ministerial decisions rather than managers of public institutions. They seem to be compelled to consult with the responsible civil servants and seek their permission in the ministry regarding the financial decisions, handling the resources, minor maintenance works and deals with firms performing them, speaking to the press etc. The perception on the side of the ministry sometimes seems to be that the directors lack initiative and are asking them permissions in the matters that they have full authority to act.

Intervention of foreign and domestic external agencies and experts (like us) make the lack of autonomy and authority of management even worse. Dependence on donation, power delegated to the ‘intruders’ and absence of vision and strategy make managers an easy prey and subvert their autonomous position.

Due to lack of training, organisational culture both in the institutions as well as in Macedonia at large, the level and quality of management and management support is low. The recruitment practices are subject to political and clan affiliations, clear job descriptions are in deficit as well as clear assessment procedures of staff (staff performance plans), promotion prospects and training of staff  are neglected (especially with the staff with lower qualification, which often have led to the demotivation and poor performance of the staff.

Professional groups or specialist activities are seldom formed as formally distinct services, or any kind of formal units (e.g. psychosocial service, health or medical service – sometimes some units are called educational or rehabilitation units). However, the division of labour along the professional lines is very strong and there is, in some institutions little collaboration across the specialities. In Demir Kapija, which is probably an extreme case, the division is rigid. The special educators undertake ‘defectology treatment’, nurses distribute medicines and take care of health issues, while the care staff feeds, dresses, washes residents and keeps them warm. The social worker is seen more as a part of administration – due to location in the administrative building, but also because a major bulk of her work is concerned with sorting administrative matters and relationships with relatives and external authorities. Even when there is a group distribution of tasks, they are distributed by the type of work and not shared by all professions. A care worker said: “I never saw a defectologist change a diaper.”

Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008–2018, which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector. For this blog, Vlado Krstovski and Andreja Rafaelič are considered to be co-authors.

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[1] In Banja Bansko named ‘Service for rehabilitation and socialisation’, in Topansko Pole ' Department for health with accommodation (internat) and kitchen'.

[2] In Banja Bansko named ‘Education service', in Topansko Pole 'Department of education, work training and training for production work and day centre for adults’. In the latter case, deputy director is the leader of educational unit.