Safeguarding Human Dignity: Sweden’s Personal Ombudsmen System

Safeguarding Human Dignity: Sweden’s Personal Ombudsmen System Guarantee Basic Rights and Responsibilities

Recognised by the Zero Project as an Innovative Policy on Independent Living in 2015, Sweden’s Personal Ombudsmen System, established in 2000, provides a nationwide system of guardians who support decision-making for persons with severe mental or psychosocial disabilities. Personal Ombudsmen (POs) are highly skilled persons who conduct outreach work and establish trusting relationships with individuals in need of support. They assist individuals in taking control of their own situation, identify care needs, and ensure that these individuals receive the necessary help.

Guardianship, hospitalisation, institutionalisation, powerlessness, isolation, drug addiction, homelessness, suicide, and violence are among the negative situations and conditions that the Swedish system of Personal Ombudsman helps to prevent – proving to be a true ‘change-maker’ in the lives of many persons with disabilities.

An internal study conducted by Sweden in 2005, reported that the scheme is highly effective in socioeconomic terms since individuals with PO support require less care and their psychosocial situation improves. As a result, the National Board of Health and Welfare (Socialstyrelsen) have deemed the policy so effective that not only has the position been promoted as a new social profession, but as also in 2013, a new regulation entered into force that established permanent funding for the PO system.

At a Glance
  • The Swedish national system of a Personal Ombudsman provides support in decision-making for persons with severe mental or psychosocial disabilities.
  • Personal Ombudsmen are highly skilled persons who do outreach work and establish trusting relationships with individuals in need of support. They assist individuals in taking control of their own situation, identify care needs, and ensure that these individuals receive the necessary help.
  • POs have no medical responsibility, nor do they make any decisions in the capacity of an authority; they work only to represent the individuals they assist.
  • Personal Ombudsmen are to be ‘independent’ of their principals in terms of organisation, and should preferably not share premises with them.
  • As the pilot project evaluation showed both good qualitative and quantitative outcomes, the Parliament decided in 2000 to expand permanently the PO system to the whole country.


Policy Reference

Government Decision No 16 on State Subsidies to Municipalities for Operations with Personal Representatives of May 18, 2000. [In Swedish]

Regulation 2013: 522 on government grants to municipalities that operate with the personal representative. [In Swedish]


Connected Policies

Act No 387 concerning Support and Service for Persons with Certain Functional Impairments (LSS) of 1993. [In English]


Selection as a Future-Just Policy

In 2000, Sweden established a nationwide system of Personal Ombudsmen to provide support in decision-making for persons with severe mental or psychosocial disabilities. Personal Ombudsmen (POs) are highly skilled persons who conduct outreach work and establish trusting relationships with individuals in need of support. They assist individuals in taking control of their own situation, identify care needs, and ensure that these individuals receive the necessary help.

People with severe mental or psychosocial disabilities belong to the “forgotten” types of disability and all around the world they are subject to serious human rights violations, including guardianship, hospitalisation, institutionalisation and violence, which often result in their powerlessness, isolation, drug addiction, homelessness and suicide. The Swedish system of Personal Ombudsman has proved to be a true ‘changemaker’ in the lives of many persons with such type of disability.

While the PO scheme has drawn on models found in the United States and the United Kingdom, it differs considerably from these. From 1995 to 1998 the government funded ten pilot projects, of which several were run by municipalities, some were set up by civil society, and one (PO-Skåne) was set up by an organisation of persons who formerly used institutional and psychiatric care. As the pilot project evaluation showed both good qualitative and quantitative outcomes, the Parliament decided in 2000 to expand permanently the PO system to the whole country

An internal study conducted by Sweden in 2005, reported that the scheme is highly effective in socioeconomic terms since individuals with PO support require less care and their psychosocial situation improves. As a result, the National Board of Health and Welfare (Socialstyrelsen) have deemed the policy so effective that not only has the position been promoted as a new social profession, but as also in 2013, a new regulation entered into force that established permanent funding for the PO system.


Future-just Policy Scorecard

Our “Best Policies” are those that meet the Future Just Lawmaking Principles and recognise the interconnected challenges we face today. The goal of principled policy work is to ensure that important universal standards of sustainability and equity, human rights and freedoms, and respect for the environment are taken into account. It also helps to increase policy coherence between different sectors.

    Sustainable use of resources

  • The nationwide system of Personal Ombudsmen helps all actors to work more efficiently.

    Equity and poverty eradication

  • Personal Ombudsmen serve people with severe mental or psychosocial disabilities, one of the most neglected types of disability.
  • Personal Ombudsmen reach out to those people who often live in complete isolation and poverty, receiving no help or benefits.
  • Cases are assessed on an individual basis, however, children and the young are given general priority in many areas of the country.

    Precautionary approach

  • Personal Ombudsmen help to avoid forced psychiatric treatment and the negative impacts of medicine, as well as preventing the loss of hope and the belief that an illness is chronic.

    Public participation, access to information and justice

  • NGOs of ex-psychiatric users and survivors, and of family members were involved and consulted when the first ten pilot projects were set up by Socialstyrelsen (the Swedish National Board of Health and Welfare).
  • Socialstyrelsen assisted municipalities with implementation and provided education for the heads of the municipalities, with Personal Ombudsmen, and conducted evaluation with a high level of transparency.
  • Complaints are effectively handled by the county board of social services or the court.
  • Personal Ombudsmen are to be ‘independent’ of their principals in terms of organisation, and should preferably not share premises with them.

    Good governance and human security

  • The county board of the social services is monitoring the Personal Ombudsmen system and its implementation.
  • Certain Personal Ombudsmen (PO) services, such as PO-Skåne, have set up a code of ethical conduct, which, for example, states that POs should not accept gifts or money, and prohibits their talking to clients when they have drunk alcohol (note that POs can be reached 24 hours a day).
  • Many of those concerned have conflicts with their neighbours, family, the State, etc.; POs contribute to peacefully solving such conflicts. POs can, for example, complain against authoritative decisions such as forced treatment and take a conflict to court, whereby costs are covered by the State.

    Integration and interrelationship

  • By raising awareness and reaching out to people who are in need to receive help, Personal Ombudsmen promote social justice in the communities and their decision-making takes social impact into account.
  • By preventing stays in psychiatric hospitals and forced treatment, Personal Ombudsmen contribute to saving money in health and social services budgets as well as increasing economic benefit.

     Common but differentiated responsibilities

  • Personal Ombudsmen strengthen the individual’s position vis-à-vis the social services and are provided as a free service.
  • The PO system is a flexible model that can be applied to any context.
  • Sweden recognised recently Personal Ombudsmen as a new profession and established permanent funding in 2013 by regulation.


Context

The Swedish Psychiatric Reform of 1995 completely changed the way in which people with severe mental or psychosocial disabilities were viewed and treated. In 1995, the Swedish Parliament enacted Fundamental Act No. 387 concerning Support and Service for Persons with Certain Functional Impairments (LSS) of 1993, which establishes an entitlement to 10 different measures of support for persons with severe intellectual and physical impairments.

With regards to entitlements under LSS, Act No. 940602 of 1994 included provisions for the start of an experimental programme of personal representatives, the so-named Personal Ombudsmen (PO). From 1995 to 1998, in order to find the arrangement most appropriate to Sweden, the government funded ten pilot projects, of which several were run by municipalities, some were set up by civil society, and one, PO-Skane, was set up by an organisation of ex-users and survivors of psychiatry.

As the pilot project evaluation showed both very good qualitative and quantitative outcomes, the government decided in 2000 to expand the PO system to the whole country in order to establish permanent operations. A report submitted to the government in 2005, pointed to positive trends as a result of the work of Personal Ombudsmen – the scheme is profitable in socioeconomic terms, the psychosocial situation of individuals has improved and their position has been strengthened in society.

As a result of the policy’s success, the National Board of Health and Welfare (Socialstyrelsen) began to promote the Personal Ombudsmen as a new social profession. In 2013 a new regulation entered into force that established permanent funding for the PO system.


Objectives

The Personal Ombudsman (PO) is a model for supported decision-making which is independent from all authorities. The primary goal is to support individuals with a complex need of care who, because of their psychiatric disability, have a substantial and long-term social impairment, and who are thus hard to reach, isolated or left without support.


Methods of Implementation

The overall coordination of the system is mandated to the National Board of Health and Welfare (Socialstyrelsen), which should support and evaluate the activities, inform and stimulate further development and develop training and skills development for Personal Ombudsmen.

To establish a Personal Ombudsman service, municipalities can apply for grants to the county board of social services. The framework in which the Personal Ombudsmen work, may then vary: usually, one municipality functions as the principal actor and has operative responsibility. In some places, however, a number of municipalities have merged their organisations, while in others the activity is a county-wide organisation. The service may also be offered by foundations, voluntary associations, care associations or other coordinating bodies.

Personal Ombudsmen are to be ‘independent’ of their principals in terms of organisation, and should preferably not share premises with them. . This means that although POs are usually formally employed by the municipality, the activity should be kept separate from the municipality’s social services. This independence means that POs are better placed to make demands on public agencies, and this also makes it easier to work across departments and achieve more ‘unconventional’ solutions.

Personal Ombudsmen support the individual in pursuing his or her personal development. They have five essential duties:

1. To coordinate the efforts of the individual.
2. To assist in liaising with various agencies.
3. To assist with establishing an individual care and service plan
4. To identify care and service needs.
5. To do outreach work, and to ensure that the individual receives the care to which she or he is entitled.

As many individuals are very suspicious of state services, the Personal Ombudsman communicates with them directly and step-by-step by: making contact, developing communications, establishing a trusting relationship, starting a dialogue, and obtaining commissions. This also enables the PO to be 100% on the side of the client if the client’s interests should run counter to the opinions of other professionals.


Impact

Evaluations by Prof. Klars Hansson and Dr. Tommy Björkman, of Lund University, have shown that the Personal Ombudsmen service is important for both the persons who received the support, and the economy. They reported that clients have a better social, psychological and psychiatric situation after 18 months of representative activities, that their use of psychiatric hospital and psychiatric day care had decreased and that the Personal Ombudsmen have been successful in 80% of the cases in helping their clients to receive benefits (without PO only 5-10% succeeded).

In 2005, their 6-year follow-up study reported that the ten pilot projects involving 176 clients showed a clear positive change for the people in need, including functional capacity and reduced need for outpatient and inpatient psychiatric care and that Personal Ombudsmen operations reduced costs by approximately €80,000 per assisted person over a five-year period.

In 2014, 310 Personal Ombudsmen provided support to more than 6,000 individuals in Sweden. In the same year, 245 municipalities (84 percent) included Personal Ombudsmen in their social service system and Swedish local governments stated that the system is a natural part of the services that are expected to be offered in a municipality.

Legal capacity was one of the most controversial issues in the drafting works for the Convention on the Rights of Persons with Disabilities (UN CRPD). The Swedish Personal Ombudsmen system served as a practical solution illustrating how people with severe psycho-social problems can be supported in their decision-making and is enshrined as “supported decision-making” in UN CRPD Article 12.


Potential as a Transferable Model

The Personal Ombudsmen service is a practical model that can be applied to different contexts.

Recently, two other Scandinavian countries have undertaken steps for introducing a similar Personal Ombudsman service: On August 1, 2010, a personal support system was started in Oslo and several local Personal Ombudsmen (Palveluohjaus) operate in Finland.  In addition, different cities such as San Francisco, Vancouver, Sydney, Budapest and Riga have shown interest to set up a similar Personal Ombudsman service.


Additional Resources

Zero Project Website: Sweden: Personal Ombudsmen

WHO/WB, World Report on Disability, 2011, p. 138

Swedish user-run service for Personal Ombudsmans, PO-Skåne

A New Profession is Born, Personligt Ombud, PO, Socialstyrelsen, 2008

Mental Health Europe, Paving the Way to Recovery – the Personal Ombudsman system, video. [In English]

Amnesty International, Supported Decision-Making in Theory and Practice. Ireland’s Capacity Bill –Maths Jesperson on Sweden’s Personal Ombudsman System as an Example of Supported Decision-Making, video. [In English]

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