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To be in‐between: The road to disability pension with reference to the Swedish social insurance system
Linköping University, Department of Medicine and Health Sciences, Work and Rehabilitation . Linköping University, Faculty of Health Sciences.
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The Social Insurance is part of the Swedish welfare system that is intended to create economic security for citizens in the event of unemployment, sickness, functional disability, and old age. The Swedish sickness‐benefit insurance is based on the standard insurance principle meaning that sickness benefits are related to level of lost income. The increasing number of sick listed people and people with disability pension (DPs) in Sweden may lead to marginalisation of individuals as they are not part of the labour market. The government has decided that the number of sick‐listed people should be halved by 2008, which means a tougher judgment of the applications for sick leave compensation. To be qualified for sickness benefit the disease has to impair the work ability in relation to the specific demands of the work of that person. The evaluation of the work ability in a percentage is an important element with regard to the policy on disability. The social insurance officers (SIOs) who are assessing the work ability are dependent on judgments from the physicians as expertise, and the guidelines in the social insurance act. The eligibility criteria for DP and the process of dealing with applications for DP is scarcely studied.

Objectives: The overall aim of the thesis was to explore demographic and health differences between those, who were granted and those, who were not granted disability pension. The second aim was to study how the process from applications to decisions on disability pensions were executed and perceived by the social insurance offices and to elucidate their working conditions during the decision process. Material and methods: The first two studies explored differences between those granted DP and those not granted DP. Study I was a register‐based retrospective case‐control study carried out in the area of a county in Sweden. The cases were all individuals rejected a full disability pension 1999‐2000, in all 99 cases. Controls were every tenth person who was granted a full DP during the same period, 198 controls. Determinants were recorded from the Social Insurance (SI). In study II demographic data and medical diagnoses were obtained from the SI records. Data concerning self‐reported health, HRQoL, social networks and use of health care were collected by a postal questionnaire. The study objects were the same as in study I. In study III and IV indepth interviews were carried through to study the social insurance officers’ perspective on the process from application to decision on disabilitypensions as well as their experiences of prerequisites and hindrances in their work with DP applications. The transcribed data were analysed by an inductive content analysis.

Results: Unemployment, living in the main municipality and age below 50 years were determinants for rejection of DP. Medical status as described in the Social Insurance records had less association with the outcome. There are variations in praxis of rejection of applicants between social insurance boards in different geographical areas due to other reasons than medical. The nDP group had more often multiple diagnoses, and lower self‐reported health and HRQoL compared to those granted DP. Those not granted DP also had significantly smaller social networks.

The SIOs perceived that they had to make rapid decisions within a limited time frame, based on limited information, mainly on the basis of incomplete medical certificates, and with no firm criteria for the regulations on the individual case level. Communication among the various authorities as employment offices and social services suffered from lack of common goaldirected strategy. In study IV the SIOs described their working conditions when executing the applications for DP. The SIOs perceived recurrent changes in rules and regulations as frustrating as they at the same time had to face the client. The large number of clients prevented them from being able to offer clients activities and support them in the way they were supposed to do. The SIOs powerful position and how their discretion was implemented made them feel responsible for performing their work well. SIOs are to be considered as typical street‐level bureaucrats as they have to perform their work between the policy, rules and clients.

Conclusions: The individuals had an increased risk to be rejected DP if they were younger than 50 years, unemployed, and lived in the main city. No evident differences in medical diagnoses were found between the groups. The results indicate that there may be other reasons than medical in praxis. Contrary to expectations, those not granted DP do not seem to have better health, but rather to suffer from more sickness than those, who were granted DP. Unemployment leads to inability to qualify for compensation and benefits that are associated with participation on the labour market. The group not granted disability pension appears to be a disadvantaged group in need for a co‐ordination between different parts of the social welfare system.

The different perspectives were perceived as obvious obstacles in the communication between professionals in the welfare system as they had other goals and demands. Clients, that have comprehensive problems and are in need of coordinated measures from many authorities to get entrance to the labour market still suffer from lack of coordination. One question is how the different public officers use their discretion when handling clients and how the cooperation can be improved.

Place, publisher, year, edition, pages
Institutionen för hälsa och samhälle , 2005.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 929
Keyword [en]
Disability pension, social insurance, social insurance officers, clients, practice, work ability, street‐level bureaucracy
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-5545ISBN: 91-85497-63-0 (print)OAI: oai:DiVA.org:liu-5545DiVA: diva2:21365
Public defence
2005-12-19, Wilandersalen, M-huset, Universitetssjukhuset, Örebro, 13:00 (English)
Opponent
Supervisors
Note
The electronic version of the printed dissertation is a corrected version.Available from: 2006-01-24 Created: 2006-01-24 Last updated: 2013-09-03
List of papers
1. Disqualified for disability pension: a case referent study
Open this publication in new window or tab >>Disqualified for disability pension: a case referent study
2004 (English)In: Disability and Rehabilitation, ISSN 0963-8288, Vol. 26, no 16, 1079-1086 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: To analyse medical and other determinants for decisions about rejection or acceptance of applications for disability pension.

Methods: A register-based retrospective case-control study was carried out in the area of a county in mid-Sweden. Cases were all individuals rejected a full disability pension 1999 - 2000, in all 99 cases. Controls were every tenth person granted a full disability pension during the same period, 198 individuals. Determinants were recorded from the protocols at the Social Insurance Office.

Results: Unemployment (OR = 7.1, CI = 3.1 - 16.4), living in the main municipality, (OR = 2.8, CI = 1.4 - 5.8) and age below 50 years (OR = 0.4, CI = 0.2 - 0.8) were determinants for rejection of disability pension. Medical status, as described in the Social Insurance act, had no association with the outcome.

Conclusions: There appear to be variations in praxis of rejection of applicants between Social Insurance boards in different geographical areas due to reasons other than medical. Socio-economic situation of the applicant may have an influence. Established criteria for determining work ability are needed.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-13761 (URN)10.1080/09638280410001704368 (DOI)
Available from: 2006-01-24 Created: 2006-01-24 Last updated: 2013-09-03
2. Health, quality of life, social network and use of public health: A comparison between those granted and those not granted disability pension
Open this publication in new window or tab >>Health, quality of life, social network and use of public health: A comparison between those granted and those not granted disability pension
2006 (English)In: Disability and Rehabilitation, ISSN 0963-8288, Vol. 28, no 1, 25-32 p.Article in journal (Refereed) Published
Abstract [en]

Purpose. The aim was to compare self-rated health, health-related quality of life (HRQoL), social networks and health care utilisation of those granted disability pension (DP) and those not granted disability pension (nDP).

Method. Demographic data and medical diagnoses were obtained from the records of the social insurance office. Data concerning self-reported health, HRQoL social networks, and use of health care were collected by a postal questionnaire. The nDP group included all those not granted full DPs between 1999 and 2000 (n = 99). The DP group were a random sample of those granted full DPs, during the same period (n = 197).

Results. The nDP group had more often multiple diagnoses, and lower self-reported health and HRQoL compared to those granted DP. In particular, their average scores were lower on the SF-36 scales social functioning, role limitations due to physical problems and mental health. The nDP group also had significantly smaller social networks.

Conclusions. Contrary to expectations, those not granted a disability pension do not seem to have better health, but rather to suffer from more sickness than those who were granted a disability pension.

Keyword
Disability pension; self-reported health; social networks; vulnerable group
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13762 (URN)10.1080/09638280500165179 (DOI)
Available from: 2006-01-24 Created: 2006-01-24 Last updated: 2013-09-03
3. From application to decision on disability pensions: Swedish social insurance officers’ practice
Open this publication in new window or tab >>From application to decision on disability pensions: Swedish social insurance officers’ practice
2005 (English)Article in journal (Refereed) Submitted
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-13763 (URN)
Available from: 2006-01-24 Created: 2006-01-24 Last updated: 2013-09-03
4. Executing applications for DPs‐ social insurance officers’ experiences of prerequisites and hindrances in their working conditions
Open this publication in new window or tab >>Executing applications for DPs‐ social insurance officers’ experiences of prerequisites and hindrances in their working conditions
2005 (English)Article in journal (Refereed) Submitted
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-13764 (URN)
Available from: 2006-01-24 Created: 2006-01-24 Last updated: 2013-09-03

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