Meld. St. 23

(2022–2023)
Report to the Storting (white paper)

Escalation Plan for Mental Health (2023–2033)

Meld. St. 23 (2022–2023) Report to the Storting (white paper)

Recommendations of the Ministry of Health and Care Services, 9 June 2023, approved by the Council of State the same day. (Støre Government)

Dokumentet på regjeringen.no

1 Introduction

Figure 1.1

Mental health is one of the Government’s most important priority areas. The overarching goal of the escalation plan is for more people to enjoy good mental health and quality of life, and for those who need mental health services to receive good and easily accessible help.

In this plan, the Government identifies a pathway for developing our mental health policy. A stronger effort is needed to prevent mental health issues and disorders. The threshold for receiving help must be lower. At the same time, those with severe mental illness must receive more holistic treatment and follow-up, and we must pay greater attention to personnel resources moving forward. The distribution of tasks and organisation of services impacts the use of personnel. Services for the mentally ill should be good workplaces with opportunities for professional development, and patient and user involvement in the services must also be strengthened.

The escalation plan is a complete plan to improve mental health in Norway and develop the general services in the years ahead. The Government proposes to increase funding for mental health by MNOK 3 from 2023-2033. As part of its effort, the Government has for the 2023 budget year proposed MNOK 150 for measures linked to the mental health escalation plan, and the substance use prevention and treatment reform. MNOK 150 of the increased basic hospital funding was also earmarked for strengthening inpatient child, adolescent and adult mental health services.

The escalation plan means that the Government prioritises mental health and that its commitment to mental health will be increased through a ten-year plan. In the early stages of the plan period, the Government will prioritise cross-sectoral preventive efforts and accessible low-threshold municipal services in order to further prevent mental health issues developing into mental health disorders. The services offered by the specialist health service must be strengthened to give better help to those in greater need. The Government will return to the Storting in the annual budgets with updated assessments, priorities and proposals for concrete measures. This means that the Government’s escalation plan is a dynamic document steered by the overarching goals of the plan built on the most updated and available knowledge at any time.

The Government has chosen three priority areas for the escalation plan.

Health promotion and preventive mental health work

Good and accessible services where people live

Services for people with long-term and complex needs

Under each priority area there are selected thematic areas with associated measures The three priority areas must be seen in context. For instance, improved and more accessible municipal services will in the longer term contribute to reducing the need for permanent help from the specialist health service. Some of the patients, who currently receive healthcare from the mental health services, would instead receive adapted, accessible, good and effective municipal healthcare.

1.1 Performance measures

The measures in the escalation plan aims to contribute to better mental health and quality of life in the population, and the existence of good and easily accessible help for people with mental health challenges. In order to follow the development and achievement of goals during the plan period, the Government has formulated eight performance measures. The performance measures cover the three priority areas in the plan.

There has been a 25 per cent reduction in the number of self-reported mental health issues from children and adolescents.

There has been a reduction in the percentage of young people who become disabled due to mental health issues and disorders.

Citizens of all municipalities have access to evidence-based low-threshold mental health and substance use services.

Children and adolescents who are referred to the child and adolescent mental health service

(PHBU) are offered a clinical interview to clarify further follow-up from the specialist health service or municipal health and care services.

In the longer term, the average waiting time for mental health care will be reduced to less than 40 days for adult mental health service (PHV), 35 days for child and adolescent mental health service (PHBU) and 30 days for cross-disciplinary specialised treatment for substance use disorders (TSB).

Prevent the reduction of beds and ensure that the inpatient capacity of the mental health service is at a level that satisfies the demand for taking care of children, adolescents and adults with severe mental health disorders who need inpatient treatment.

The life expectancy of people with severe mental illness and/or addiction problems is higher, and the difference in life expectancy between this patient group and the rest of the population has been reduced.

Healthcare personnel have more time for patients, users and professional development.

Existing data sources for observing developments shall primarily be used. Nonetheless, new indicators must be developed for some of the goals. Refer to Chapter 5 for a detailed description of how the goals will be followed up.

1.2 Prioritisation and execution

At the beginning of the plan period, cross-sectoral health promotion and preventive efforts will be central. The foundation for good mental health and quality of life is formed throughout life and in many arenas. The measures must therefore be developed and implemented in multiple sectors. The Government will further prioritise increased access to low-threshold services in the municipalities that do not require a referral or diagnosis. The performance measure of providing access to evidence-based low-threshold services will be operationalised through further investigative work. The Government will follow the development and implementation of such services, inter alia, to ensure that the development of low-threshold services does not accidently have a distorted effect on access to personnel, existing services or the flexibility of the municipalities for local adaptation of their services and what they offer.

The goal of directing the effort at health promotion and preventive measures, and local accessible services in the municipalities and specialist health service, is to help reduce the prevalence of mental health issues and disorders in the population. This will also contribute to resources not being used to treat issues and disorders that could have been prevented or remedied earlier. The Government will particularly pay attention to the health, education and labour sectors—and cooperation between them—with the aim of reducing the percentage of young people who become disabled due to mental health issues and disorders.

At the same time, the Government will work to ensure that those who need help from the specialist health service receive it and that the waiting time for mental healthcare is reduced. In addition, children and adolescents, who are referred to the mental health service, are offered a clinical interview. During the plan period, the Government also wants to follow up the findings of the regional health authorities’ (RHAs) prognoses regarding the need to strengthen the capacity for people with severe mental health disorders, and children and adolescents. In the early stages of the plan period, the Government wants to strengthen the effort for improved quality of life and life expectancy for those with severe mental illness and/or addiction problems. Another main priority of the Government is that the health and care services are attractive workplaces, and that patients and next of kin are involved in both the help that is given and development of the services, and that they receive good support and follow-up.

This plan identifies a pathway for creating more sustainable and future-orientated services for people with mental health challenges. Several of the proposed measures in the plan require further investigation and will take time to implement. The Government will return to these later in the plan period. Examples are measures for more thematic organisation within the mental health service and forensic psychiatry. Measures in the health and care services cannot exclusively be based on increased access to personnel, but also involve new work methods and changes in organisation. All measures shall be assessed according to the current personnel situation.

1.3 Background

The majority of people in Norway consider themselves to be in good health[1] and the mean quality of life in Norway is high. Nonetheless, the quality of life is disproportionate and some groups have severe mental health challenges. A person’s perceived quality of life largely follows the traditional socioeconomic dividing lines. People with a stable job, secure income, good health and rewarding social relationships score higher on indicators for subjective quality of life.[2] A society with minor inequalities, security and equal opportunities is an investment in good mental health for everyone.

Textbox 1.1 Key concepts

Mental health is used as a general concept and includes everything from good mental health and quality of life to mental issues and disorders. Measures within this field are all-encompassing, ranging from health promotion and prevention to treatment and rehabilitation.

Good mental health accentuates wellbeing and the perception of good quality of life, meaning in life and the ability to cope with the challenges of day-to-day living, in addition to the absence of severe mental health issues and disorders.

Quality of life can vary from good to poor. Good quality of life involves the feeling of wellness and being able to function adequately, for instance, the feeling of happiness, vitality and satisfaction, security and belongingness, interests, coping, meaning, engagement and autonomy.

Mental health issues are ailments that may cause distress, but which can be considered normal variations in behaviour and a person’s emotional life. Such ailments can produce varying degrees of distress (from minor to severe) without them necessarily being classified as a disorder.

Mental health disorder is used when the distress is severe, lasts over time and is of such a nature that the criteria for a clinical diagnosis are satisfied.

Mental healthcare means the investigation and treatment of mental health disorders conducted by the specialist health service, i.e., at hospitals or a Child and Adolescent Psychiatric Outpatient Clinic (BUP)/District Psychiatric Centre (DPS).

Substance use problems is a collective term for all use of substances that leads to negative consequences for the user, regardless of the diagnostic level.

Source: The Norwegian Institute of Public Health, 2018.

At the same time, anyone can develop a mental issue and disorder for a shorter or longer period of their life. It is well documented that mental issues and disorders can lead to exclusion, which is an important risk factor for somatic symptom disorder. No illness group leads to more loss of health or increased disability benefit costs than mental disorders.[3] Therefore, we must make a greater effort to enable more people to enjoy good mental health and quality of life, and those who need mental health services to receive good and easily accessible help.

To promote good health and quality of life in the population, systematic cooperation between the public authorities, civil society and the private sector is necessary. Sustainable structures and services that contribute to the prevention of mental issues, disorders and problems with substance use that ensure good services moving forward, must be established. The solutions must be evidence-based and adapted to the needs of users. Moreover, they must be sustainable. We cannot plan unrealistic exploitation of healthcare personnel. The Healthcare Personnel Commission believes there is great potential in intensifying the structured work with correct task distribution and good organisation of the work. This will contribute to maintaining the quality of the services, reduction of the use of resources, increased efficiency, attention to the core tasks, and increased motivation and wellbeing among employees. (refer also to Figure 1.2). Greater effort must be targeted towards prevention and health promotion across more sectors, as we simultaneously improve and strengthen the services in municipalities and the specialist health service.

Figure 1.2 Schematic presentation of top-down task distribution

Source: Official Norwegian Report NOU 2023: 4 Time to Act. The Personnel in a Sustainable Health and Care Service.

A health promotion effort is greatly needed to strengthen mental health and prevent mental issues and disorders in the population, particularly among children and adolescents, where there has been a substantial increase in the number of self-reported mental issues. Approximately half of all mental health issues make their debut during childhood and adolescence.[4] It is therefore crucial to address these early and target the effort at arenas where one meets children and adolescents. Health promotion and preventive measures often assume long-term cross-sectoral efforts. It is essential to increase each person’s knowledge of how to best safeguard and strengthen one’s own mental health in order to strengthen public mental health.

Norway has well-developed health and care services. For many years the development of outpatient and ambulatory services within the mental health service and treatment for substance use has been high-priority, whilst at the same time a great effort has been made to expand municipal mental health and substance use services. Following the last Escalation Plan for Mental Health (1998–2008), the conversion to more open and outward-looking services has been continued in the form of strengthened ambulatory and outpatient services in District Psychiatric Centres (DPS) and Child and Adolescent Psychiatric Outpatient Clinics (BUP). There are now more man-years in municipal mental health and substance use work[5] , and the cooperation between municipalities and the specialist health service has been strengthened through new cooperation solutions.

In both Norway and other countries, it has become more common to organise programmes for people with mental illness and substance use problems in cross-disciplinary teams. Examples of this are ACT (Assertive Community Treatment) and FACT (Flexible Assertive Community Treatment) teams, rehabilitation teams, early intervention teams, substance use teams and habilitation teams. In order to act early in crises, ambulatory emergency teams (crisis teams) have been established at the District Psychiatric Centres (DPS) and user-controlled bed places have been introduced. The purpose is to contribute to early intervention and prevent unnecessary hospital admissions.

The Coordination Reform and Follow-up Plan for Work and Mental Health (2013–2016) set out key guidelines for the desired development and prioritisation in the services aimed at users with mental health problems. One objective of the Coordination Reform, beyond improved coordination and continuity in and between the services, was that the municipalities would provide more healthcare and treatment instead of the specialist health service. The reform also emphasised the need for increased commitment to prevention and early intervention.

The protection of human rights has been a fundamental driving force in the development of legislation and services for people with mental health issues and disorders. Most countries have endorsed binding supranational strategies under the auspices of the WHO and EU, which set out clear guidelines for the development of the countries within this field. This shall contribute to better rights, more resources for prevention, treatment and rehabilitation, and more transparency and knowledge.

More accessible treatment has contributed to many people receiving effective help when they need it. At the same time, surveys show that access to the services still varies, and that in some health regions the public receives more treatment for mental health issues and disorders than in others.

In recent years, there has also been an increase in the number of people requesting both mental healthcare from municipalities and the mental health services, particularly among children and adolescents. With corrections for the growth in population, there was a significant increase (around 15 per cent from 2019 to 2021) in the number of children and adolescents accepted by the specialist health service. The growth for adults was three per cent, but in the oldest age group (65 and older), there was a six-per-cent drop. More people are now referred with more severe conditions than earlier.[6] In 2022, 38 per cent of the municipalities reported a large increase in the number of enquiries from children and adolescents, whilst 37 per cent reported a large increase in enquiries for adults with mental health problems.[7] Figure 1.3 shows the trend in relation to the number of referrals to Children and Adolescent Psychiatric Outpatient Clinics from 2011 to 2022. The number of referrals has significantly increased since 2019.

Figure 1.3 Number of new referrals to the Child and Adolescent Psychiatric Outpatient Clinics (BUP) from January-May per year per 100,000 citizens under the age of 18 across the health regions.

Source: South-Eastern Norway Regional Health Authority, 2022.

services offered by the specialist health service must be strengthened in order to give better help to those who need it the most. It must also be a priority to develop accessible services in municipalities where there is a low threshold for seeking help, so that more people can receive help early at the lowest possible level of effective care. Further, the distribution of work must be clearer, and better coordination is needed between the municipalities and the specialist health service. Better coordination is also necessary between the healthcare sector and other sectors to ensure good holistic patient pathways, and to develop good and adapted housing services. Further development of cooperation with the municipalities and specialist health service is needed in connection with clinical interviews upon referral to a Child and Adolescent Psychiatric Clinic (BUP), and future integrated services at one level needs to be considered.

Significant recruitment problems and turnover of personnel have been reported, particularly specialists in the mental health service. Personnel problems will increase moving forward. The problems must be met with a holistic and structured approach to competence and human resources with the goal of offering good treatment, and contribute to obtaining a sufficient number of professionals with the correct competence. This type of structured approach involves, inter alia, proper and correct task distribution and efficient organisation, correct use of personnel-saving technology and treatment methods, a good working environment and better use of research-based knowledge.

The challenges faced by the services create the need for innovative thinking in relation to how we can develop the services and work together. Each municipality and hospital trust, and every health and social care employee must have sufficient freedom and trust to develop and adapt assistance and services in encounters with each single user and patient. Patients shall own their own treatment. Patients, users and next of kin shall have the opportunity to participate in research, innovation and development work to ensure that the solutions correspond to the needs of the population. Professional environments within mental health shall facilitate user involvement in the development of the services, however, there is still a continuing need for more systematic involvement of users and next of kin in both developing and executing the services. Furthermore, it must be ensured that next of kin are better cared for and supported.

It is important that health and social care personnel, users and next of kin exploit the possibilities the technology provides. Digital assistance and services that are easy to use, accessible and adapted to the digital competency in the population may lead to both better quality and accessibility.

The Government will create a strong public health service that is accessible to everyone. It is important that the public health service takes care of a population with varying degrees of healthcare expertise, language proficiency and digital skills to provide a well-adapted health service for everyone. Equitable health and care services shall be offered to the whole population and the services shall be adapted to the individual, so that access to and the quality of the services are equally as good, regardless of the user’s Norwegian language skills, functional ability, cultural affiliation, healthcare expertise and socioeconomic background. All social groups shall be taken care of in the ordinary services. This requires healthcare personnel to have the necessary competence in order to deal with the diverse population.

The plan is aimed at the population as a whole and people who are at risk of developing or have developed mental health problems or disorders, and their next of kin. It is considered that assistance and measures will be aimed at all users and patients, regardless of age, background, sex, gender identity, sexual orientation, functional ability and cultural affiliation.

1.4 Input for the plan

In the work on the escalation plan, the Government has facilitated a widespread input process. Several national input meetings have been held with children and youth organisations, professional organisations, user and next of kin organisations, and student organisations. Regional input meetings have also been held. The option to submit written input for the escalation plan has been possible. Relevant and comprehensive knowledge for work on the escalation plan has been gathered from the Norwegian Directorate of Health, the Norwegian Institute of Public Health, the regional health trusts and resource centres for mental health, substance use and violence.

Adapted options for children and adolescents to participate have been facilitated. A selected number of children and adolescents have been involved through a national input meeting between the Minister of Health and Care Services, the Prime Minister and invited children and youth organisations. In addition, the Ministry of Health and Care Services’ political leadership has held meetings with youth from local youth councils in connection with the regional input meetings. At the input meetings, children and youth were particularly concerned with accessible adults where young people are, for instance, at school, in terms of both milieu workers/therapists accessible in the environment, and an increased number of more accessible health nurses or other healthcare personnel. They describe a need for more knowledge about mental health. Children and youth are also concerned with accessible and safe and sound help when they need it, continuity in the help, sufficient information and the services having the competence to communicate with children. Many are concerned with the fact that mental and somatic health must be seen to a greater extent in relationship to each other. The need for good leisure activities, low-threshold meeting places, particularly youth clubs, were also highlighted by several of the contributors.

Input that is frequently echoed by other groups is accessible municipal low-threshold services and more options to get help without a referral. Several have pointed out the lack of coordination in the healthcare sector and transversely with other sectors. Many would like inpatient beds in the specialist health service to be prioritised. In addition, several highlight recruitment problems attached to the services, and the need to strengthen the GP service for more holistic and well-functioning health and care services.

1.5 Ongoing and future work

The Government has implemented various efforts that will impact the field of mental health during the plan period.

The most central work for this escalation plan is:

Textbox 1.2 Work on plans in the Nordic countries

In 2022, Denmark published a ten-year mental health care plan: Better Mental Health and a Strengthened Effort for People with Mental Illness. The plan has five priority areas:

1. Building up an easily accessible municipal service for children and adolescents with mental ‘unwellness’ and symptoms of a mental health disorder

2. Strengthen the effort for people with severe mental illness

3. Non-stigmatisation of mental health disorders

4. Strengthened cross-disciplinary evidence-based environments

5. Research and development

The efforts will be prioritised where it is considered needed the most. They will be executed through the establishment of easily accessible services in municipalities for children and adolescents, and increased commitment to people with severe mental illness/those who need comprehensive help. At the same time, better frameworks will be created in both the primary and specialist health services by, inter alia, prioritising quality, development and research in order to offer people with a mental health disorder the most beneficial treatment, and to recruit and maintain personnel.

Finland has recently launched The National Mental Health Strategy and Programme for Suicide Prevention 2020-2030 The strategy recognises the importance of mental health in a changing world.

The strategy builds on long-term preparation and broad-based cooperation, and has five priority areas:

1. Mental health as capital

2. Mental health for children and adolescents

3. Mental health rights

4. Adapted broad-based mental health services

5. Mental health management/control

The strategy will initially be implemented by increasing the accessibility of basic preventive services and therapies, and improving the cooperation structures that are necessary to maintain these services. Other measures aim to improve work-orientated mental health services, enhance mental health literacy in municipalities and increase suicide prevention efforts.

Source: The Danish Health Authority 2022; Ministry of Social Affairs and Health, 2020.

The Government’s Trust Reform aims to increase the autonomy of the State and local government’s first line to give them more professional freedom, so the public sector can provide more welfare and improved services to citizens at the right time.

Meld. St. 15 (2022–2023) Public Health Report (white paper) – National Strategy to Reduce Social Inequalities in Health, which was presented to the Storting in spring 2023. The white paper is structured on the premises that health promotion work and prevention must take place in all areas of society.

The National Health and Coordination Plan will as intended be presented to the Storting in autumn 2023. The white paper will cover both municipal health and care services, and the specialist health service. Coordination to create good patient pathways and equal services, digitalisation and healthcare personnel will be some key themes that are particularly relevant to the field of mental health.

The substance use prevention and treatment reform will be presented as a white paper in 2024 as intended. The purpose of the reform is to prevent and reduce negative consequences of substance use, addictive medicines and doping substances for individual people and society. Through the reform, the Government will better prevent substance use and addiction problems, and intervene earlier with adequate help and follow-up.

The white paper for the Storting on the ‘Safe at Home Reform’ will be presented to the Storting in 2023, and shall help the elderly to live longer in their own homes if they can and wish to do so. Solutions that enable as many people as possible to experience that they can cope, and allow them to live good and independent lives, will be critical to the mental health of the elderly.

The escalation plan against violence and abuse against children and violence in close relationships

will be presented to the Storting in autumn 2023 as intended. The plan will strengthen the commitment to prevent and combat violence and abuse, and to take care of those exposed to violence. Measures for preventing violence and helping those exposed to violence could help prevent mental health issues.

The Action Plan against Problem Gaming (2022–2025) shall ensure that work on the prevention of gaming problems in the Norwegian population is long-term, systematic and targeted. Many with gaming problems have concurrent mental and somatic health issues, in addition to serious financial problems.[8] It is therefore necessary to draw attention to the health problems of people addicted to gambling and computer games with regard to prevention, early intervention, treatment and follow-up.

The Government’s Long-Term Plan for Research and Higher Education (2023–2030) was presented by the Ministry of Education and Research, but was jointly drafted by the ministries. Health is now one of the plan’s thematic priorities. The need for more research on prevention and effective treatment within mental health is discussed in the plan. With the long-term plan, the Government launched a targeted social mission to include children and adolescents in education, the labour market and civic life.

The Government’s Action Plan for Gender and Sexual Diversity (2023–2026) aims to contribute to improving queer people’s quality of life, safeguard their rights and contribute to greater acceptance of gender and sexual diversity.

Strengthening the GP service shall contribute to more doctors choosing to become general practitioners and support GPs in spending more time following up patients with serious complex needs. This is important for many patients with mental health challenges and addiction problems.

The National Quality of Life Strategy, anchored by the Government in the white paper on public health, shall contribute to more knowledge about the population’s quality of life, the development of measures that create a more health-promoting and fair society, and equitable social and geographical differences in the quality of life. The strategy will, as intended, be presented in 2024.

1.6 Sufficient access to healthcare professionals and competences

The most important resource for giving good and safe services to people with mental health challenges is the personnel. There is a shortage of personnel and this will continue to be the case moving forward. In order to safeguard personnel and ensure correct use of competence, various measures must be taken simultaneously. An important part of building up capacity must, inter alia, be done through improved task distribution and the use of available personnel. In the services for people with mental illness, there are significant health problems related to recruitment and loss of employees. Recruitment problems in the specialist health service particularly applies to specialists in psychology and psychiatrists. Municipalities report problems with recruiting psychologists, nurses, including health nurses, social educators and social workers.[9] Many decide to work for private sector services and some leave altogether. The Government wants healthcare personnel to have enough time for patients, but also time to become engaged and involved in the professional development of the services. The following performance measure has therefore been set for the escalation plan: Healthcare personnel have more time for patients, users and professional development. This is also in line with the goals of the Trust Reform which, inter alia, entails less detail management and increased autonomy for employees. Measures to ensure sufficient personnel and competence will be further developed through the plan period and in the Government’s upcoming National Health and Collaboration Plan.

In order to safeguard the population’s needs, good services for people with mental health challenges throughout Norway are fundamental. The Government will take active steps to commit to a safe and good working life for all employees in the health and care services.

Textbox 1.3 The government will:

contribute to ensuring sufficient personnel with the correct competence in the health and care services, including

consider recommendations from the regional health trusts about measures to retain and recruit personnel in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB);

investigate a public specialist approval scheme for selected groups of clinical psychologists;

assess measures for improving gender balance in health nurse education, including the assessment of gender points or quotas.

Through the Trust Reform, the Government will contribute to authorised employees being able to arrange services in dialogue with the user and next of kin. The Trust Reform shall form the basis for the development of services for people with mental health challenges to give a top-down approach. It is about supporting municipalities and health trusts with the right instruments and tools, whilst giving employees time and trust to give users and patients improved services.

The Government wants the services to work in a more health-promoting and preventive manner in general, particularly within the fields of mental health and substance use. Innovative thinking is necessary in relation to how we cooperate and solve tasks, so the correct competence is put in place at the right time and contributes to the best possible use of available personnel.

Figures from Statistics Norway’s demand forecast for healthcare personnel (HELSEMOD) indicates there will be a 33 per cent increase in the need for health and care personnel at national level, i.e., approx. 310,000 in 2017 to approx. 411,000 in 2035. The highest increase will be seen in home services and nursing homes.[10] However, as the Healthcare Personnel Commission describes, the staffing trend cannot continue in line with demographic growth, since there will be a greater shortage of personnel moving forward. It is necessary to find new ways to solve tasks, including correct task distribution, changed work methods and personnel-saving technologies.

Textbox 1.4 Healthcare Personnel Commission’s Assessment of Needed Health and Care Services Personnel in the Future

In 2023, the Healthcare Personnel Commission presented its Time to Act Report. The Personnel in a Sustainable Health and Care Service (Official Norwegian Report, NOU 2023: 4).

The growth of the working age population will soon stop and the number of people in the 16-66 year age group will fall in a few years. At the same time, the number of people over the age of 80 will almost double over the next twenty years. This trend also depicts a greater demand for health and care services for the whole population. The Commission states that the need for personnel in the municipalities will increase, particularly in the care services, and that efforts must therefore be steered towards municipal care in the future to handle the increasing number of elderly people. The Commission concludes that there will be fewer employees per patient in the years ahead.

The Healthcare Personnel Commission believes that the main priority of health politicians should be the development of measures and investment in solutions that give the lowest possible personnel growth in the health and care services at the same time as the population across the whole country receives good high-quality health and care services.

Figure 1.4 Schematic presentation of top-down task distribution

In order to develop health and care services that can offer good services in the years ahead, the Healthcare Personnel Commission proposes measures within seven priority areas: task distribution; organisation and coordination; employment conditions and working hours; education and competence development; prioritisation and reduction of overtreatment; and digitalisation and technological development. The Commission considers that the measures may collectively contribute to a reduction in the supply and demand of health and care services. It may also result in better and more efficient use of personnel which at the same time leads to increased individual wellbeing and competence development. Particular emphasis is placed on enhancing the career opportunities for skilled workers in the health and care services that may lead to more applications for vocational education programmes across Norway.

The Healthcare Personnel Commission believes there is more potential in intensifying the structured work on correct task distribution and good organisation of the work. This will contribute to maintaining the quality of the services, reduction of the use of resources, increased efficiency and attention to the core tasks, and increased motivation and wellbeing among employees. With the shortage of healthcare personnel, it is important to be aware of what the personnel shall do and safeguard during the course of the working day. The requirement of responsible conduct shall always form the basis for correct task distribution. This also entails distributing tasks to other personnel when healthcare expertise is not necessary for performing the task.

The Healthcare Personnel Commission’s Report was sent for consultation on 2 May 2023 and will form a knowledge base for, inter alia, the National Health and Coordination Plan, which is planned to be presented at the end of 2023.

Source: Official Norwegian Report, NOU 2023: 4 Time to Act. The Personnel in a Sustainable Health and Care Service; Jia, Z. et al., 2023.

1.6.1 Education of healthcare professionals

The Government is concerned with quality and capacity in the education programmes aimed at health and care services in general and more particularly services for people with mental health challenges.

The programmes of professional study are important for ensuring that the services of the welfare state have adequate access to competent workers. The education programmes must have the right content so that students receive up-to-date and relevant knowledge. It is also important that the education programmes are inclusive, as this contributes to increased representation in the labour market. Competence that can deal with a diverse population is also important for reaching the goal of equitable services for people with mental health challenges. In spring 2024, the Government will present a report to the Storting regarding the programmes of professional study. The report will primarily focus on health and social care programmes, teacher education and engineering programmes.

The authorities and higher education institutions have a collective responsibility for dimensioning the education offered. Central authorities are responsible for the overall education capacity, inter alia, by awarding new places on study programmes. Universities and university colleges are responsible for dimensioning their study programme portfolios consistent with the number of applications for study programmes and needs of the labour market. The education institutions must educate candidates in harmony with the needs of society for competence.

Health and social sciences is highly prioritised when awarding new places on study programmes that have many applicants. Since 2015, the authorities have awarded grants to more than 1,500 new places on health and social care programmes with around half of the places being allocated to bachelor degrees in nursing.

In Meld. St. 14 (2022–2023) Report to the Storting (white paper) Overview of Competency Needs in Norway, the Government looks in more detail at which competency needs will be most important moving forward. In order to handle the demographic trend and increase in the number of elderly people, and to have good nationwide welfare services, more qualified health and care workers will be needed. In the white paper, the Government sets out an expectancy that universities and university colleges shall in their portfolios prioritise resources for the health sciences, IT and areas that are important for the green shift. From this perspective, it will be relevant to prioritise study programmes that may contribute to improving mental health.

National curriculum regulations for health and welfare education are developed through the National Curriculum Regulations for Norwegian Health and Welfare Education (RETHOS). The objective is that the education programmes are adapted to the needs of patients, users and the services. The aim of RETHOS is that the education programmes are future-orientated and that both the services and users have increased influence over the professional content of the programmes.

The clinical degree in psychology is included in RETHOS. The National Curriculum Regulations for Norwegian Health and Welfare Education were adopted for psychology training in 2020. Two new national curriculum regulations for continuing education within mental health and substance use have also been adopted. These are a master’s degree in nursing mental health nursing, substance use and dependence (2022), and cross-disciplinary continuing education in work on mental health, substance use and dependence (2022). Many vocational colleges offer education programmes within mental health for skilled workers.

Psychiatrists undergo in-service training in separate posts for specialty registrars (ST3) with an education pathway in accordance with a plan for each single doctor. The Norwegian Directorate of Health is responsible for setting learning objectives and recommendations for associated learning activities. The health trusts are responsible for enabling each specialty registrar to reach the learning objectives. Government authorisation as a specialist in psychiatry is awarded once the learning objectives have been satisfied. To improve recruitment to the specialties in psychiatry and child and adolescent psychiatry, 31 ST1 posts in autumn 2023 were linked to further specialisation in these specialties.

Specialist education for psychologists is currently taken care of by the Norwegian Psychological Association, and specialists in psychology are not awarded government authorisation as a specialist since the learning objectives are not set by the authorities. The Government will investigate a public specialist approval scheme for selected groups of clinical psychologists. Improved adapted education for specialists in psychology can lead to better recruitment and career development. The possibility to offer specialisation locally is particularly important for recruitment in the districts. The investigation of a scheme must be conducted in cooperation with relevant actors including the Norwegian Psychological Association and expert psychological environments. The Ministry considers that the investigation should be based on medical specialty training, but in an adapted and simpler form.

1.6.2 Retaining and recruiting healthcare professionals

In order to contribute to the development of more accessible and adapted services for people with mental health challenges, the Government will assist municipalities and health trusts in ensuring that there are enough personnel with the required competence. In addition to concrete recruitment measures, measures related to management, work and expert environments, and competence development may have a positive effect on recruitment and retaining personnel in the services. The regional health trusts have been commissioned to carry out further work on measures for recruiting, retaining and developing personnel in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). The regional health authorities will submit their recommendations for restructuring measures in September 2023, and the need for national measures will be concretised later in the plan period and the National Health and Collaboration Plan.

The all-round needs of users and their next of kin form the basis for the development of the services offered. Their needs will vary. It should therefore be encouraged to recruit beyond the traditional mental health education groups. Increased emphasis on health promotion measures means that greater professional breadth and cross-disciplinary cooperation is required. It may also require competence in mental health in other services, particularly the child welfare service.

Recruitment problems have been reported, particularly specialists in psychology and psychiatrists, in the specialist health service. There is a high turnover of psychologists. They leave public-sector services to work in private-sector services or walk away from the health service. The Office of the Auditor General of Norway found in its survey on mental health services that more than 60 per cent of outpatient mental health clinics had vacant posts due to recruitment problems and many did not have specialists.[11] North Norway struggles the most. At the same time, a significant shortage of personnel in municipal health and care services is reported, and many municipalities have problems recruiting and retaining personnel.[12] Increased difficulties with recruitment and retaining qualified persons may lead to diminishment of the professional community. When a service facilitates the professional development of each employee and safeguards a professional environment, it is also an attractive workplace.

The Employer Monitor of the Norwegian Association of Local and Regional Authorities for 2021 revealed that almost all municipalities are struggling to recruit nurses and that the majority are also struggling to recruit doctors, psychologists, social educators, skilled health workers and other relevant skilled groups. Approximately half of the municipalities in Norway are struggling to recruit physiotherapists, occupational therapists, social workers and child and youth workers. Many factors impact recruitment and the causes of the recruitment challenges are complex. Some important reasons are a lack of full-time posts and opportunity for professional development due to small expert environments. In terms of doctors, there are additional reasons, inter alia, increased workloads in general. The out-of-hours medical service in small municipalities is highly overworked.[13] When it comes to the recruitment of psychologists in the municipalities, good expert environments, guidance and possibility for specialisation within the municipality were highlighted as important in the evaluation of grants to psychologists in municipalities.[14]

Violence and threats against employees are a problem in both the municipal health and social care sector[15] and the specialist health service. The Norwegian Directorate of Health’s mapping from 2017 shows that there was an increase in the number of reported cases of violence and threats in the health trusts in the period from 2012-2016.[16] There is much to indicate that the increase has continued after 2016.[17] Threats of violence is a factor that must also be taken into consideration when recruiting to some professional areas such as acute and forensic psychiatry. Another challenge is racism, discrimination and harassment in the workplace. Research has shown that many health and care workers with an immigrant background experience racism, discrimination and harassment when carrying out their work. The Government will present a new action plan against racism and discrimination.

In the Office of the Auditor General of Norway’s survey on mental health services it emerges that 70 per cent of practitioners within mental health do not have enough time for professional development and that every fourth practitioner has difficulty getting updated knowledge on the effect of treatment methods. With a view to implementing effective treatment, and to recruit and retain personnel, it is important to safeguard professional development and competence enhancement as part of day-to-day operations. Systems that guarantee professionals access to research, knowledge and new treatment methods will be important moving forward.

Textbox 1.5 ‘Kompetansebroen’ Online Portal

‘Kompetansebroen’ is an online portal for competence sharing and coordination in the health service. Healthcare personnel can find information and useful learning resources in the portal. The purpose of ‘Kompetansebroen’ is mutual and efficient information and competence sharing between education institutions, municipalities/boroughs and hospitals.

Source: ‘Kompetansebroen’ Online Portal, 2023.

Many professionals report time pressure and little capacity for core tasks. Among other things, it is pointed out that reporting requirements hinder the performing of core tasks. One of the goals is to reduce and streamline reporting in mental health care. This is also in line with the Trust Reform which, inter alia, aims to reduce detail management and give the workers in the services more autonomy.[18] In 2023, the regional health authorities have been commissioned to review reporting requirements in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). At the same time, the Norwegian Directorate of Health is working on the further development and simplification of national patient pathways, and will look at the reporting requirements that are not currently used for national quality indicators, which therefore may potentially be removed. The Norwegian Directorate of Health will also observe which changes and measures the regional health authorities will recommend during their assignment, and which time to event data the new national quality registers for both adult mental health, and child and adolescent mental health, plan to use. The revised patient pathways will be sent for consultation in autumn 2023 and will be ready for implementation in the services in 2024.

Most healthcare personnel groups have competence within mental health. For instance, general practitioners, nurses and skilled health workers also take care of this aspect of patients’ health as part of their work in all health and care services. Skilled health workers and assistant occupational therapists with special training within mental health are important to the work on building fundamental services in the municipalities. The professional education programmes are offered nationwide as continuing education, and there is a large and unrealised potential for better usage and development of the competence of skilled workers throughout their working life. In order to ensure better use of available personnel, the Healthcare Personnel Commission proposes to establish a principle where staffing of the services starts from the bottom (see Figure 1.4), so the competence and capacity of the personnel is exploited as best as possible. A concrete example is to expand the use of skilled health workers in both the municipalities and specialist health service.

Nurses represent the largest personnel group in the mental health service. A new master’s degree programme has been created for specialist nurses within mental health and substance use.[19] Other large personnel groups working in mental health care are social educators and social workers. It is reported that the highest shortage of personnel and most difficult groups to recruit are doctors/psychiatrists and psychologists/specialists in psychology.

A structured approach to correct task distribution between the personnel groups will be important in order to better use personnel resources and free up time for more patient contact. Task distribution between personnel groups, and in cooperation between teams internally and across specialist and municipal health and care services, may also contribute to a lighter workload and simultaneous building of a professional community. Other professional groups such as social workers play a vital role in taking care of, inter alia, psychosocial problems in the health and social care services and schools.

Gender balance among personnel

From 2016 to 2020, there has been a steady increase in the employment of men in municipal health and care services. At the same time, men still only accounted for 15.2 per cent of all employees in municipal health and care services in 2020.[20] Few men in the services is challenging for many reasons. For instance, it is challenging when users and patients want to deal with a male employee. Few men in the services will also have an impact on the employees’ working environment.

The Government wants to increase the percentage of men working in health and care services. For instance, very few men study to be health nurses. This is challenging for those who may want to deal with a male health nurse at health centres or in the school health service. The Government will consider measures for improving gender balance in health nurse education, including the assessment of gender points or quotas. Additionally, refer to Chapter 3.2.2 on the health centre and school health service.

Textbox 1.6 Men in Healthcare

Men in healthcare is a recruitment initiative which aims to increase the percentage of men in the services through a compressed education pathway towards a trade certificate as a skilled health worker. The initiative is aimed at male jobseekers between the ages of 25 and 55. In addition to increased recruitment to the health and social care sector, Men in Healthcare contributes to increased diversity among employees in the services and re-entering the labour market, which may also be crucial for good mental health.

2 Mental health prevention and promotion

Figure 2.1

The basis for good mental health and quality of life is formed throughout life and in many arenas: in families, kindergartens, school and education institutions, working life, the local environment, among friends and through participation in leisure and cultural activities. The commitment must therefore be aimed at these forums where the possibilities for conducting effective prevention and mental health promotion are considerable. Through this escalation plan the Government will illuminate various health promotion and preventive measures that may increase the quality of life and improve health throughout the human lifecycle. A specific goal is to reduce mental issues in children and adolescents and the percentage of young people who become disabled due to mental health issues and disorders. The Government will also work on increasing knowledge about mental health and implement measures to prevent loneliness.

2.1 Basis for the priority area

The work on health promotion is characterised by strengthening mental health through measures that increase the quality of life, coping skills, self-image, knowledge about making good choices for one’s own health, and the ability to handle adversity and stress in life. The purpose of the preventive work is to reduce known risk factors and strengthen protection factors. The work on health promotion and prevention can be directed at the whole population, groups and individuals.

Textbox 2.1 The government will:

Strengthen the population’s mental health throughout the course of life, inter alia, by

reducing the prevalence of mental issues in children and adolescents, including

the assessment of preventive measures in conformity with the results of analyses of the trend in Ungdata national data collection scheme and the student health and wellbeing ‘SHoT’ study

Contribute to more systematic and evidence-based parental support, including

the assessment of measures for parental support during and after pregnancy

investigation of the need for measures to prevent and treat depression during pregnancy or postpartum depression

Assess measures to strengthen kindergartens as forums for the promotion of mental health. The measures should be founded on a broad knowledge base for quality in kindergartens.

Target and strengthen the work of schools on mental health, including

facilitation of funding for the ‘Mental Health in Schools’ grant scheme to further contribute to supporting the schools’ work on the cross-disciplinary theme public health and life skills, including mental health, through

a competence package on public health and life skills where mental health is included

grants for teaching resources.

research and evaluation of work on mental health in schools

Review existing national measures and assess the competence needs of schools in order to build inclusive, safe and good school environments

Support leisure and cultural arenas that promote mental health

Increase awareness about correlations between using social media and mental health, including

the establishment of a committee to look at children and adolescent’s screen usage

the presentation of white paper on a safe digital upbringing

Contribute to improved health and quality of life among students, including

the performance of analyses based on accessible data material (incl. the student health and wellbeing ‘SHoT’ study) to uncover potential causes of mental issues, loneliness and suicidal thoughts among students

continuing to target the «Students Mental Health and Substance Use’ grant scheme

Help improve the mental health of and prevent mental issues and loneliness among the elderly, inter alia, by

mapping the mental health and quality of life among the elderly;

implementing the ‘Safe at Home’ Reform

potentially setting up the ABC public health campaign to draw more attention to the elderly

Get more people in work, activities and education, inter alia, by

introducing a young person’s guarantee to enable young people under the age of 30, who need help from the Norwegian Labour and Welfare Administration (NAV) to get a job, shall have a fixed contact person and early, close and individually adapted follow-up for as long as necessary

further development of the cooperation between the Norwegian Labour and Welfare Service, health services and education sector

strengthening the knowledge base in relation to which measures and instruments are effective for the transition to working life for various groups, and the coordination and use of instruments across the sectors

further development and implementation of social mandates for including more young people in education, the labour market and community life

continuing the strategy for the field of employment and health

Contribute to good living conditions, inter alia, by

presenting a white paper on a holistic housing policy

Increase the population’s knowledge about mental, inter alia, by

assessing how a national public health campaign based on ABC can be implemented at the population level and for various social groups

Prevent and reduce loneliness in the population, inter alia, by

potentially adding loneliness to the Public Health Act when it is revised

preparing a guide against loneliness

considering an action plan against loneliness

Contribute to knowledge of social psychology being used in the municipalities, inter alia, by

assessing how the municipalities can best exploit social psychology knowledge to promote health and quality of life in the whole population through local community-based measures and measures at system level. This will be considered when the Public Health Act is revised.

Mental health disorders largely contribute to the overall disease burden in Norway. The disease burden is caused by loss of health (measured in YLD – years lived with disability) and is largely accentuated by mental health disorders and muscle and skeletal diseases.[21] Most age groups are affected by these conditions, but mental health disorders represent a particularly large percentage of health loss among young people and those of working age, and parts of the immigrant population. Mental health disorders are an important cause of health loss from as early as the age of ten.[22]

Whilst the prevalence of mental health disorders among adults has been relatively stable over time, the percentage of children and adolescents registered with diagnosis codes in the primary health service has increased. There has also been an increase in the percentage of young girls treated by the specialist health service for mental health disorders. Moreover, there has been a significant increase in self-reported mental issues among children and adolescents, particularly girls. The Norwegian Institute of Public Health points out that the most important potential factors that may have contributed to the increase are social media and screen use, endured stress and pressure, and sleep and sleep problems.[23]

Research shows that mental health disorders are socially skewed.[24] Mental health disorders are three to four times more prevalent in children whose parents are on a low income. These differences continue over the course of life and are also found again when the children become adults.

It is frequently pointed out that programmes offered by health and care services must be increased in order to solve the challenges of increased mental issues. It is uncertain how many people, who report mental illness, actually need health care services, and how many are expressing general and transient mental illness. Such issues may be connected to coping with day-to-day living, which again may be due to or intensified by, inter alia, sleep problems, increased use of social media or pressure at school. The causes of the trends in self-reported mental health issues and contact with the health service must be seen in relation to each other. Experienced severe mental health issues impact help-seeking behaviour, which in turn triggers the use of health services. The Norwegian Institute of Public Health has established a national professional network for research on the mental health of children and adolescents, and is further developing the cooperation with expert environments in Norway. Analyses will be performed on the causes and consequences of the increase in mental health issues in children and adolescents as a basis for assessing relevant measures to increase their mental health and quality of life. A corresponding network and cooperation with the expert environments will be built up around the mental health of adults.

Textbox 2.2 SLT Model

The SLT model aids the coordination of drug and crime prevention measures for children and adolescents. In a municipality, many individuals and public agencies put a lot of effort into providing children and adolescents with better growing up conditions. SLT is about making this effort more effective by coordinating the good forces in every municipality. The model contributes to coordinating information, knowledge and resources between municipal actors and the police, business community and voluntary organisations when natural to do so. Around 190 municipalities use SLT.

The National Mediation Service, n.d.

2.1.1 Cross-sectoral ownership of mental health and quality of life

Good mental health and quality of life are primarily created outside the health and care services. Cross-sectoral ownership is crucial in order to strengthen the population’s mental health and prevent mental health issues. In order to succeed, all departments and sectors with instruments to foster good mental health and quality of life must participate in this work. Not least, this applies to the work aimed at children and adolescents. The commitment must be directed at forums that provide good opportunities for conducting effective prevention and mental health promotion efforts, such as in families, kindergartens, schools, workplaces and various leisure arenas. These are important arenas because this is where one can meet most children, adolescents and young adults, and it is crucial to intervene early: approximately half of all mental health issues make their debut during childhood and adolescence.[25]

In order to develop health promotion measures, good cooperation between the voluntary and public sectors is important. For children and adolescents with mental health challenges, good cooperation between services in different sectors is also important. The Ministry of Children and Families, the Ministry of Labour and Social Inclusion, the Ministry of Health and Care Services, the Ministry of Justice and Security, the Ministry of Local Government and Regional Development, the Ministry of Culture and Equality, and the Ministry of Education and Research have established a core group for cooperation pertaining to children and adolescents. Among other things, the core group will contribute to ensuring that the goals of sector policies, activities and resources are seen in context and initiate common efforts that may lead to better goal achievement across the sectors.

The municipalities have reported for many years that mental health is one of their major public health challenges. This emerges in both the Office of the Auditor General of Norway’s review of public health work[26] , and in the Norwegian Directorate of Health’s sector report 2021,[27] where more than 60 per cent of the municipalities point out mental health and quality of life as two major challenges in public health. Better systems and methods for assessing how various measures impact mental health in the population with a view to, for instance, social and geographic differences is needed.

2.2 Strengthen the population’s mental health throughout the course of life

The Government will implement measures in arenas where mental health and quality of life can be promoted for the whole population, particularly among children and adolescents. One goal is to reduce the number of self-reported mental health issues in children and adolescents. Health promotion and preventive measures can be difficult to prioritise, and they are often conditional upon long-term cross-sectoral efforts and cooperation between public and voluntary actors. The Government will work on a safe and good childhood for all children and adolescents, contribute to increased mental health skills in the population and good mental health in old age. This involves the implementation of measures during the course of life, including more systematic and evidence-based parental support, targeted efforts in kindergartens, schools and various leisure arenas, and stimulation of participation in education, the labour market and activities, which may contribute to school dropout prevention and reduce the risk of developing mental health issues and disorders. The Government wants to strengthen the commitment to getting more people, particularly young people, in work and activities, and aims to reduce the percentage of young people who become disabled due to mental health issues and disorders during the course of the plan period. The Government will also strengthen the mental health of students and the elderly through targeted measures.

2.2.1 Reduce the prevalence of mental issues in children and adolescents

Most children and adolescents report good quality of life and satisfaction with life. Nonetheless, numerous surveys show a significant increase in the number of self-reported mental health issues among children, adolescents and young adults over time. This has gradually been increasing since the 1990s, particularly among girls. Just since 2011 there has been a 30 per cent increase in the number of self-reported mental health issues in the Ungdata national data collection scheme. There has been a 44 per cent increase for girls and 14 per cent for boys.

Figures 2.2 and 2.3 show the trend for girls and boys, respectively.

Figure 2.2 The trend for self-reported mental health issues in girls in various surveys between 1992-2018.

Source: The Norwegian Institute of Public Health, 2023.

Figure 2.3 The trend for self-reported mental health issues in boys in various surveys between 1992-2019.

Source: The Norwegian Institute of Public Health, 2023.

Despite all the surveys showing an increase in mental health issues, particularly among girls, the surveys have different findings. These differences are most probably caused by variations in the definition of mental health issues that are used. Different definitions in the surveys do not however explain the increase that is shown in each survey.

The prevalence of mental health issues is higher in families with fewer socioeconomic resources than in families with many socioeconomic resources. It is currently uncertain whether mental health issues are more widespread among children and adolescents with an immigrant background than otherwise in the population. Different studies give different results.[28]

The Government wants the prevalence of mental health issues to be reduced by approximately 25 per cent during the course of the plan period. In order to gain more knowledge about the increase in mental health issues, the Government will review the trend both in Ungdata and the student health and wellbeing study (SHoT) from the point in time when they started up in 2010 up to the present day to investigate whether changes, for instance, in the use of social media, schools, local environments, leisure time or violence and harassment can help explain the increase in mental health issues. The Norwegian Institute of Public Health will submit the results of the initial analyses of data from Ungdata and SHoT during the course of 2023. On the basis of this new knowledge, more targeted measures can be implemented.

2.2.2 The importance of family for mental health

The strengthening of health promotion and preventive work for children, young people and their families is one of the Government’s main goals. The family unit is an important factor for fostering good mental health in children. This is where the foundations are laid for trust, security, cohesion and coping. The Government will consider measures for parental support during and after pregnancy, and investigate measures for preventing and treating depression during pregnancy and postpartum depression.

The term ‘1,000 days’ is applied to the most important period from conception of a child up until the age of two and includes, for instance, mental health during pregnancy and the first year after birth. Work on children’s health and quality of life must start from as early as conception.

The Government has therefore started work on looking at how the best start in life can be facilitated for all children through adequate care of both prospective and new parents and their children. The theme ‘1,000 days’ is included in the white paper on public health launched in March 2023. It will also be referred to in the National Health and Coordination Plan and the upcoming white paper on social mobility and equality, which together will demonstrate the Government’s all-encompassing work in this area.

Textbox 2.3 Oslohjelpa

‘Oslohjelpa’ is a free low-threshold service that enables children, adolescents and their families to swiftly receive the right help when needed. Anyone can contact the service without a referral. Oslohjelpa has employees with various professional backgrounds who cooperate well with other services in the borough. They work in a cross-disciplinary manner and help with finding other relevant services when needed.

Source: City of Oslo

Correlations exist between low-threshold income and mental health problems in children and adolescents. Financial strain can lead to more mental health problems in caregivers, which in turn may affect parenting strategies and have adverse effects on children’s mental health.[29] Universal schemes in the form of health services before, during and after pregnancy, kindergarten services and financial support schemes for families with children, are all components that give every child the possibility to have a good start in life. GPs and the health centre and school health service are particularly important health services for monitoring pregnancies, and in the postnatal period, childhood and adolescence. National professional guidelines for the health centre and school health service recommend that families should be offered extra follow-up if the parent/guardian shows signs of minor depression or other mental health problems or disorders with concern/problems related to, for instance, breastfeeding, diet, sleep, weight, wellbeing and interaction, and for families who for various reasons need extra support or counselling.

The Government’s strengthening of the GP service and the health centre and school health service also strengthens services for this target group. The family counselling service, crisis centres and child welfare service are other actors who can assist vulnerable families needing extra follow-up.

Parental support varies in form and content ranging from support from one’s own family and informal network to advice, counselling and evidence-based programmes under the auspices of public authorities, charities and private actors. Parental support is offered to most parents and to parents who due to various reasons have special challenges. Municipalities have overall responsibility for making sure that available parental support services can be accessed at all prevention levels. One goal is that evidence-based parental support is available in all municipalities. The grant scheme for parental support work in municipalities, which is managed by the Norwegian Directorate for Children, Youth and Family Affairs (Bufdir), aims to strengthen parents in their role as parents, and help them become good caregivers, and prevent violence, abuse and neglect. The grant scheme stipulates that the measures should be evidence-based and professionally established. Through the grant scheme and Bufdir’s digital professional support for employees and managers in municipalities, evidence-based work on parental support in the municipalities is facilitated. The scheme supports the child protection reform, strengthening prevention and early intervention as well, and reach all social groups. Further, Bufdir has an online resource offering professional support to employees and managers in municipalities who would like to strengthen work on parental support in various services. The objective of the website is to make it easier to choose the right measure(s).

Foreldrehverdag.no is a government resource run by Bufdir, which aims to give all parents easy access to good advice, help and support during parenthood. Bufdir also manages a specialised program specifically aimed at first-time pregnant women. ‘Sammen på vei’ – Nurse Family Partnership (formerly named ‘Familie for første gang’ (Family for the First Time)) is a specialised service for vulnerable families in a difficult life situation. The programme will be tested up until 2027 with the goal of, inter alia, improving the health and development of children, strengthening parental skills and preventing children from being taken into care, contributing to financial independence, and increased trust and contact with support services.

Several studies have been implemented which may contribute to new knowledge about parenthood and safeguarding the mental health of parents. The University of South-Eastern Norway is conducting research on the health of children and families with special focus on prevention and skewed development in children, young people and families at risk. The FamilieForSK study conducted at the Norwegian Institute of Public Health is a study on cohesion and conflicts in families in Norway. An evidence syntheses from Sweden reviewed 45 studies and looked at the correlations between mental health and parental leave.[30] Norway is also included in the data material. The conclusion is that parental leave can prevent poor mental health both in mothers and fathers.

2.2.3 Kindergartens as arenas for mental health promotion

At the end of 2021, approximately 93 per cent of all children aged 1-5 attended kindergarten.[31] Kindergartens are therefore one of the most important arenas for fostering good mental health and coping skills for each and every child. Kindergartens shall safeguard the need of children for care and play, and promote learning and formation in cooperation and understanding with the home.

Children need stable relationships with competent, supportive and caring employees who notice their needs and respond to their signals. It is therefore important to have good relational competence in kindergartens as well. A report from the Norwegian Institute of Public Health[32] based on the findings of the MoBaKinder study shows that in the case of most children there is a correlation between positive and negative relationships with adults in kindergartens and schools, and the academic skills and mental health of children when they reach compulsory school age. Earlier findings have shown that relationships with staff at kindergartens correlate with the mental health of children whilst attending kindergarten. It is important that kindergarten staff are knowledgeable about various types of risk and differences in children, as this may be significant in relation to how kindergartens affect the mental health and development of children. Therefore, it is crucial that staff have the right educational and relational competencies in order for children to develop into confident children.

In addition to competence, it is crucial to have a sufficient number of staff at kindergartens. Around half of all kindergartens report having full staffing levels for 4-5 hours per day, but only 13 per cent report having full staffing levels for six hours or more.[33] It is therefore necessary to strengthen both staffing levels and competence. Improved staffing levels with relevant competence can prevent mental health issues and contribute to social equalisation. The Government has pointed out that one of the biggest problems in the Norwegian education system is that we have the least competence around children in the period that is most important for their development. The Ministry of Education and Research has prepared a new national kindergarten strategy: Kindergarten for a New Era.[34] The strategy aims to contribute to strengthening kindergartens as a forum for fostering mental health, and it contains plans for how competence in kindergartens will be strengthened. The strategy proposes that 60 per cent of the staff must be kindergarten teachers and at least 25 per must be skilled workers by 2030.

A better knowledge base for quality in kindergartens is important for developing measures to strengthen kindergartens as arenas for fostering mental health. Among other things, a research project commissioned by the Norwegian Directorate for Education and Training is currently being conducted at Fafo on effective ways to organise day-to-day life at kindergartens. The project aims to develop typologies for various ways to organise kindergartens and will continue up until 2025. In the MoBaKinder project at the Norwegian Institute of Public Health, the researchers are investigating which key factors attached to the quality of kindergartens can foster good mental health, quality of life and academic performance in children. The goal is to strengthen Norwegian kindergartens as promoters of health, and contribute to reducing adverse effects linked to social inequality and other vulnerabilities. The project ends in 2025.

The Government wants to strengthen kindergartens as arenas for fostering mental health, and put forward proposals for measures based on a broad knowledge base for quality in kindergartens.

2.2.4 Mental health in schools

Schools play a key role in the lives of children and adolescents, who are entitled to a safe and good school environment that promotes health, wellbeing and learning. Schools also have a responsibility to ensure that pupils develop knowledge and skills that promote good mental health, both here and now and from a lifelong perspective.

The school environment is important for the mental health of pupils. A poor school environment where the pupils, for instance, encounter bullying, stress or exclusion, may intrinsically lead to mental health challenges. A good school environment where pupils thrive, experience mastery and develop seems to promote health and is preventive.

The pupil survey shows that pupils are satisfied with the learning environment. The majority thrive well and have good relationships with teachers. They are challenged academically and experience mastery. Most children and adolescents today say they have friends to socialise with.[35]

At the same time, there are signs that more pupils than before experience a poor learning environment. Figures from Ungdata 2022 show that fewer and fewer thrive at school. There is also an increase in the percentage that dread going to school and play truant. The pupil survey shows a decline in wellbeing and motivation in Year 7.

Bullying is a significant risk factor for developing mental health issues and disorders, and for dropping out from school. The pupil survey from 2022 shows an increase in bullying in all year levels. Schools must have zero tolerance for violations (refer to the Education Act, Section 9 A-3) such as bullying, violence, discrimination and harassment. The work on creating an inclusive, safe and good school environment, and to prevent, detect and stop bullying, is high priority in schools.

The Government will continue its commitment to the pupils’ school environment. The Ministry of Education and Research has commissioned the Norwegian Directorate for Education and Training to review existing national services that support the work of schools and kindergartens on building inclusive, safe and good school and kindergarten environments. The Norwegian Directorate for Education and Training shall also assess the competence that the schools now need to become better at building safe and good school environments. Work has started on investigating whether the violations of the Education Act, Chapter 9A, are systematic in order to investigate whether there is a need for more competence measures aimed at precisely these areas.

Quite a large proportion of children and adolescents find schoolwork stressful. More than half of the pupils who responded to Ungdata 2022 said that schoolwork frequently or very frequently stressed them out. Performance-related stress in schools appears to have become an important risk factor for mental health issues among young girls over time. In surveys, adolescents link symptoms of mental health issues to school stress themselves.

An evidence synthesis from the Knowledge Centre for Education[36] has identified four areas that are important for countering stress in schools:

Lessons must be engaging, the pupils must feel challenged, active, happy and competent.

The pupils must experience a social and safe learning environment where they can work in an exploratory manner.

Workloads must be consistent, and schools must show pupils how to sort and prioritise tasks.

School heads and teachers can help prevent a stress culture from developing by consciously being aware of how expected performance is communicated.

In 2024, a white paper will be submitted to the Storting regarding Years 5-10. The objective of the white paper is to create a school that to a larger degree safeguards and strengthens the pupils’ motivation, coping skills, learning and development. The white paper will address themes that are relevant to the mental health of children and adolescents.

The committee’s survey ‘Questions for schools in Norway’ in spring 2022 shows that many school owners and school heads request more competence in mental health.[37] Pupils also request more knowledge on mental health. Knowledge of normal reactions towards stress, normal fluctuations in mood and how emotions affect thoughts and behaviour may better equip pupils to handle problems. Knowledge of how, for instance, social media and lifestyle habits affect mental health can be useful. In the long-term, better and more knowledge about mental health may contribute to preventing mental health issues in children and adolescents.

The new curricula (LK20/LK20S), which the schools started using in 2020, clearly state that pupils must develop competence in mental health in a range of subjects and in different year levels. Public health and life skills are prioritised as one of three cross-disciplinary themes in the curricula. Public health and life skills as a cross-disciplinary theme in schools shall give pupils competence that fosters good mental and physical health, and enables them to make responsible life choices.

Experience from earlier curriculum reforms shows that the introduction of new curricula takes time. Additionally, introduction of the renewal of subjects has been delayed due to the COVID-19 pandemic. It is important that schools have time and the autonomy to start using the new curricula. The new curricula will be evaluated up until 2025.

The grant scheme ‘Psykisk helse i skolen’ (Mental Health in Schools) was implemented as part of the ‘Escalation Plan for Mental Health 1999-2008’, but it is hardly designed for the new curricula. The funds in today’s grant scheme should to a greater degree contribute to supporting the work of schools on the cross-disciplinary theme public health and life skills, and mental health. The Government will support schools in taking the new curricula into use by developing a competence package on public health and life skills, where mental health is incorporated. For instance, this could be designed, among other things, to give teachers and other school staff more support and insight into an evidence-based approach towards mental health and how to convey it in line with the curricula.

The package aims to contribute to reflection on the part of teachers and others in support services around pupils regarding the work on public health and life skills in and across subjects and what it may involve in practice based on the curricula. According to the general part of the curricula, public health and life skills shall contribute to giving pupils competence that fosters good mental and physical health, and enables them to make responsible life choices. Life skills is about being able to understand and influence factors that are important for mastering one’s own life. The theme shall contribute to pupils learning to handle highs and lows, and personal and practical problems in the best possible way. Relevant areas are physical and mental health, lifestyle habits, sexuality and gender, intoxicants, media usage, consumption and personal finances. Choice of values and the importance of meaning in life, interpersonal relationships, the ability to set boundaries and respect those of others. The ability to handle thoughts, emotions and relationships also belongs to this theme. The Government will also stimulate the development of mental health teaching resources, and guarantee research and evaluation of the schools’ work on mental health.

2.2.5 Leisure and cultural arenas that promote mental health

Leisure and cultural arenas such as youth clubs, sport arenas and cultural events are important for promoting mental health and quality of life in the population at large, particularly for children and adolescents. All types of leisure activities can have a positive effect on the mental and physical health of children and adolescents, in addition to preventing exclusion. These arenas contribute to social support and coping skills, participation and belongingness. During the COVID-19 pandemic, encroaching restrictions in the form of, inter alia, highly reduced leisure services and less contact with friends and peers led to increased mental health issues and reduced quality of life. The restrictions on social contact were particularly perceived as stressful.[38]

The Government signed a renewed Declaration of leisure time in autumn 2022 along with the Norwegian Association of Local and Regional Authorities and NGOs. The declaration of leisure time states that all children shall have the possibility to regularly participate in at least one leisure activity with others. The declaration builds on the United Nations Convention on the Rights of the Child, particularly Article 31, which concerns the right of the child to rest and leisure time, and engage in play, leisure activities appropriate for their age and to participate in cultural life and the arts. The solutions must be found together, and the parties will cooperate nationally and locally to ensure that all children and adolescents regularly participate in at least one organised leisure activity with others.

The sense of mastery and social support help to promote mental health and quality of life, and protect against risk factors that may contribute to mental health issues later in life.[39] Both organised and non-organised leisure activities can therefore be considered part of the work on health promotion and preventive public health.[40] The benefits of such measures are attached to improved health and quality of life, the prevention of exclusion and mental health challenges, and socioeconomic profitability in the form of getting more people in work and activities.

A report from the Centre for Research on Civil Society and Voluntary Sector shows clear social differences when it comes to participation in leisure activities.[41] Adolescents form the most resourceful homes are also the ones who participate most in organised leisure activities and the differences are substantial. Adolescents from homes with the highest socioeconomic status are likely to participate in organised leisure activities twice as much as those from homes with the lowest socioeconomic status.

The local community can be a source for good mental health and quality of life. Libraries have become an important meeting place in many local communities by arranging, inter alia, lectures, debates, concerts and courses. Many have long opening hours and services for multiple generations.

Cultural institutions and cultural actors with government support are particularly responsible for including more people to enable everyone to experience art and culture. Arts and Culture Norway is a national coordinator for the work on promoting increased diversity, inclusion and participation in the culture sector, and has implemented several measures to break down barriers for participation, inter alia, for minority groups and people with disabilities.

Youth clubs as health-promoting arenas

Youth clubs are one the largest leisure arenas for children and adolescents, and therefore play a vital role in their leisure services.[42] The clubs are meeting places where youth can socialise with peers, and where they can participate in various cultural and leisure activities under the supervision of safe adults. Youth clubs are often a contact point for the police, child welfare service and substance use or outreach contacts.

Youth clubs are a low-threshold and substance-free leisure service, which often has a free of charge principle, and as such are available to all youths, regardless of their socioeconomic background. Figures from Norwegian Social Research (NOVA)[43] indicate that the service to a slightly higher degree attracts low-income families, and adolescents who are more frequently involved in violence, bullying and break rules. Research also indicates that young people in low-income families participate less in organised leisure activities compared to peers.[44] NOVA’s report Fritidsklubber i et folkehelseperspektiv (Youth Clubs from a Public Health Perspective) shows that youth clubs may be suitable for meeting youths it is relevant to reach out to, as part of the work on public health. Youth clubs are therefore an important public health measure for youths who do not feel at home in or interested in organised or performance-orientated leisure activities.[45] Many youth clubs are included in open municipal recreational services for youth, such as community centres and cultural, music and dance workshops.

To follow-up the Cooperation Strategy for Children and Youth in Low-Income Families 2020-2023, Equal opportunities when growing up, the Ministry of Children and Families called for a report on open meeting places, of which, youth clubs are an example. The Government wishes to gain more knowledge on how youth clubs are financed and regulated, how they are anchored in the municipalities, and what competence and working conditions the employees have. The purpose is to develop the Government’s basic knowledge of today’s situation, strengths and weakness of today’s organisation, and how various measures can impact this youth service.

Good framework conditions for health-promoting voluntary organisations

The voluntary sector contributes to local engagement, community, integration, and cultural and demographic awareness. Giving children and adolescents the opportunity to participate in a variety of leisure arenas in the local community is immensely important for a good upbringing. It also contributes to preparing children and adolescents for social participation in more formal settings later in life. Voluntary organisations are also immensely important for integration, and immigrants’ participation and belongingness in society. Services under the auspices of voluntary organisations are an important supplement to the integration work of the authorities. Voluntary organisations offer a range of activities and function as a meeting place for new and old citizens. The voluntary sector carries out a range of important societal tasks and also supports public services. This is expressed, for instance, in the Public Health Act were municipalities are ordered to facilitate cooperation with the voluntary sector.

Historically, voluntary and non-profit organisations have been important supplements to public services in the field of mental health, and they continue to play a key role both for users and next of kin as well as in preventive work. The Government recognises the social role of voluntary organisations and will create good framework conditions, so the voluntary sector is perceived as inclusive and representative with equal opportunities for participation. It is important that the public authorities are aware of and respect the uniqueness and independence of the voluntary sector. Good framework conditions involve, for instance, predictable and fair funding, uncomplicated regulations and grant schemes, and transparency on how funding is distributed.

In general, it is important that municipalities and other service providers have intentional and systematic work connected to the cooperation with the voluntary sector. In order to recruit, retain and cooperate well with voluntary actors, municipalities must have an active voluntary policy, and prioritise resources for systematic and professional follow-up.

2.2.6 Social media and mental health

Ninety per cent of Norwegian 9-18-year-olds use one or more social media platforms. There is not enough knowledge about how the use of screens and social media impacts the mental health and wellbeing of young people.[46] The Government therefore wants to direct more attention to social media and mental health and, inter alia, establish a committee to summarise the knowledge base and propose new measures attached to the screen use, sleep, mental health and learning difficulties of children and adolescents. The committee will build on the knowledge of earlier committees, for instance, the Medieskadelighetsutvalget (social media harms committee), which delivered its report in 2021.

The Government will consider additional measures during the course of the plan period when new knowledge is presented about the effect of social media on mental health.

Surveys from the USA indicate a coincidence in time between the introduction of social media on smartphones and an increase in mental health issues and disorders in young people. The Ungdata survey shows that 57 per cent of all adolescents in lower and upper secondary schools use social media two-three hours or more every day. Social media, including online gaming, are important social arenas for adolescents.

In 2022, the Government decided that a white paper on a safe digital upbringing would be presented to the Storting. The Ministry of Children and Families is coordinating this work. The white paper for the Storting follows up the National Strategy for a Safe Digital Upbringing (Rett på nett – Nasjonal strategi for trygg digital oppvekst), and will look at the problems and objectives in the strategy in more detail. The Norwegian Media Authority is the coordinator at directorate level, and will launch an action plan to follow-up the strategy.

The Government has implemented a review of children’s consumer protection in digital media Several ministries are involved in this work. Marketing that may adversely affect children and lead to mental health problems and body image pressures are some of the topics that will be looked at in more detail.

In recent years, more attention has been drawn to the potential harmful effects of social media on the mental health of children and adolescents. The Commission for Freedom of Expression however points out that it is difficult to give a clear answer and that some studies pull in different directions. Further, they point out that the studies on these phenomena are far more uncertain than what the debates indicate. Medieskadelighetsutvalget (social media harms committee) points out that most children have positive experiences when using social media and are not harmed, and it provides many possibilities for development and entertainment.

Textbox 2.4 Key Areas in Correlations between Social Media and Mental Health

Knowledge summaries provide no strong correlation between the time spent on social media and mental health and quality of life. Any negative effects on mental health largely appear to concern how adolescents use social media. It seems that exposure to social media during development only seems significant in relation to the most vulnerable youngest adolescents. Some areas appear to be particularly important:

Problematic/addictive use of social media signifies that a person is overly concerned with social media and unable to limit their usage. It affects their health and other important areas of life such as relationships or school/work.

Digital stress. With permanent access to copious amounts of content in different shapes and forms through social media, some people experience digital stress. For instance, it might be fear of missing something, confirmation bias or digital guilt. Higher levels of digital stress are associated with poor mental health.

Negative experiences and incidents. In 2019, approximately one third of European adolescents reported that they had experienced bad incidents online that had upset them, made them frightened or uncomfortable. Depending on the type, frequency and severity, such incidents may be connected to poor mental health. A Norwegian study found that it is likely that a social gradient exists in relation to who experiences such incidents.

Digital bullying. Digital bullying is relatively widespread. The pupil survey from 2021 found that three to four per cent of pupils in year levels 5-7 were digitally bullied at least two to three times per month. Several earlier studies found clear correlations between digital bullying and poor mental health. It seems that those who experience digital bullying are also more prone to experiencing other types of bullying.

Social comparison and self-presentation. Social media provides good conditions for social comparison and increased awareness of how one appears to others, inter alia, through quantification of social acceptance (number of likes, friends, comments, etc.). It has been found that social comparison and being extremely concerned with how one appears on social media is linked to several symptoms of anxiety and depression, and lower quality of life among Norwegian adolescents. Girls were more concerned with self-presentation on social media than boys, and the correlation between self-presentation and symptoms of depression and reduced quality of life was stronger among girls.

Source: The Norwegian Institute of Public Health, 2023b.

The findings from a study conducted by the Norwegian Institute of Public Health[47] show that social media may be a platform for seeking and receiving support. Many young people share difficult topics with friends. The findings show that most adolescents who shared something difficult on social media were socially supported afterwards. Further, the adolescents, who experienced social support, reported improved mental health after sharing compared to those who were not socially supported.

The findings also indicate that social media may function as a social arena and supportive environment for adolescents, and provide opportunities for sharing difficult emotions and incidents. Receiving support and help through social media may have positive effects on mental health and wellbeing.

Social media and the correlation with mental health is a new research field and at the present time little is known about how social media should be understood as a factor in adolescents’ lives. It is paramount to obtain more knowledge about the aspects of using social media that adversely affect the mental health of youth, and those which have a positive effect on mental health and quality of life. In 2020, the Norwegian Institute of Public Health initiated the Social Media Use and Mental Health and Wellbeing among Adolescents Project (Sosiale medier – psykisk helse og trivsel blant ungdom). The purpose of the project is increased knowledge about the use of social media and how the use is linked to health-related factors.

2.2.7 Mental health and quality of life of students

The majority of students are happy, but the student health and wellbeing study (SHoT) (Studentenes helse- og trivselsundersøkelse (SHoT)) shows that the percentage who report poor and extremely poor quality of life has increased substantially, and there has also been a steady increase in mental health issues.[48]

The Government will contribute to improved health and quality of life among students. It involves counteracting loneliness and isolation, and the facilitation of good meeting places and inclusive communities. Measures aimed at students may also reduce the number of self-reported mental health issues from young people.

Mental health has become an increasingly important problem in student welfare. The SHoT study shows a steady increase in the number of students who report severe mental health issues: In 2010, 18 per cent of students said they had severe mental health issues compared to 35 per cent in 2022. The SHoT surveys are carried out by the Norwegian Institute of Public Health and student organisations. The survey response rate was 35.1. There was also a larger share of women in the sample. This impacts generalisability.

The prevalence and level of mental health issues is still much higher among female students than male students. There are no clear age differences in the prevalence of mental health issues even though the level is somewhat lower among the oldest students. The percentage of students with severe mental health issues is much higher than the percentage in the same age group otherwise in the population.

We know little about the reasons why students report such high prevalence of mental health issues, loneliness and suicidal thoughts. In the SHoT survey, a large percentage of students reported risky or harmful alcohol use (41 per cent). More male students reported this than females. The percentage of students with risky/harmful alcohol use was highest in the 21-22 age bracket (46 per cent). Students with a high level of alcohol consumption are more at risk of reduced quality of life and increased mental health problems than students who do not have such a high consumption. The researchers conclude that it is important that education institutions and student organisations increase awareness about mental health problems and responsible alcohol use.[49]

Students with financial problems had more mental health problems and health issues, and failed examinations more often than students who rarely experienced financial difficulty. A higher percentage also reported experiences of self-harm and suicide attempts. The researchers underpin boosting the financial situation of students and student health services as potential measures.[50]

SHoT data also showed a significant increase in loneliness over time. The youngest and oldest students were relatively the most lonely, but also single students and those who lived alone reported more loneliness. This underscores the importance of being concerned with inclusion and belongingness for students, and demonstrates the need for good preventive measures. The public health campaign ‘ABC for Good Mental Health’ includes measures particularly aimed at students.

The host municipalities have the primary responsibility for the students in their municipality with treatment being offered by the ordinary health services. Student organisations are responsible for student welfare services. This service should include health, housing, kindergartens, training services and cultural services. Several student organisations have low-threshold services for students who need advice or someone to talk to. Studentsamskipnaden SiO has been changing its services since 2015, which has led to a significant increase in capacity and completion of treatment with a psychologist, counselling and course participation. At the same time, in spring 2023, it has a long waiting time, i.e., up to five months before the start of treatment with a psychologist.[51] This is a clear increase in the waiting time compared to previous years.

Additional analyses from the SHoT surveys are needed to acquire more knowledge about the reasons, so targeted measures can be implemented. The Norwegian Institute of Public Health will use SHoT data to investigate the significance of potential explanatory variables, such as body image, sleep problems, screen use/social media, perfectionism and loneliness. Results from the first analyses will be available in 2023.

The ‘Studenter – psykisk helse og rusmiddelbruk’ (Students’ Mental Health and Substance Use) grant scheme aims to promote good health and wellbeing among students and prevent problems attached to substance use. The scheme shall also cover the SHoT surveys. Study institutions, students, student organisations and the authorities must come together to put in place measures that give students adequate tools to cope with student life and the psychosocial conditions. The Government will assess whether the grant scheme functions optimally and consider new measures during the course of the plan period.

2.2.8 Strengthen the mental health of the elderly

The population is living longer and for many people old age lasts for several decades. The work on promoting good mental health and quality of life must therefore continue throughout the course of life. We have limited knowledge on the mental health of the elderly. The Government will increase the commitment to improve the mental health and quality of life of the elderly.

Most of the elderly are satisfied with life and the youngest of the elderly are more satisfied than younger age groups.[52] However, from the age of 75-80 the quality of life declines, and the prevalence of depressive disorders and loneliness increases. Many also find that their coping and social skills are reduced. We have least knowledge of the quality of life and mental health of the oldest over the age of 80. As part of Meld. St. 15 (2022–2023) White Paper on Public Health – National Strategy to Reduce Inequalities in Social Health and this escalation plan, the Government will map the mental health and quality of life of the elderly.

The prevalence of loneliness has slightly increased among the elderly. At the turn of the year 2020-2021, 34.4 per cent of all those aged 67 and older living in private households lived alone.[53] Since the number of elderly persons is constantly increasing, we must also expect the prevalence of loneliness to increase. evidence-based measures to prevent loneliness in the elderly are greatly needed (refer to the continued discussion on loneliness under Chapter 2.7, which also explains that the Government will consider including loneliness in the Public health Act when it is revised, and consider an action plan in 2025 to counteract loneliness).

Lifestyle habits are important throughout the course of life. A good diet and physical activity can increase resistance against illness, accidents, fragility and functional disability in old age, but also contribute to improved mental health and quality of life. There is considerable potential in preventing mild mental health disorders in the elderly. Social interaction and good meeting places in the local community has a positive effect on mental health and the quality of life. Participation in meaningful socialisation and activities strengthens the ability to cope with one’s own life situation. Becoming engaged with the quality of life of others in one’s network, the local community or through voluntary work can be a good way to make connections, experience self-worth and meaning, and to prevent physical and mental health issues.[54]

In spring 2023, the Government will submit a report to the Storting (white paper) about the Safe at Home Reform, which aims to contribute to a vibrant, age-friendly, inclusive local community. In order to reach the Government’s goal for the elderly to live at home longer, it is important to enable them to maintain good mental health through health promotion and preventive measures, preferably well in advance before services are needed. It has been proven that low-threshold services for physical activity in the local community (for instance, senior centres) have a good effect on the mental health of the elderly, Systematic preventive home visits in the municipalities is a measure that can take care of many aspects of prevention, also related to loneliness and mental health, and recruitment to voluntary activity and work. In addition, feeling safe in one’s own home might contribute to less anxiety and restlessness as well. GPs are important actors in detecting and following up mental health issues and disorders in the elderly. More municipalities have also established designated health centres for the elderly. Health centres are a municipal low-threshold service to supplement other services and give useful information about measures that may prevent loneliness and isolation, and therefore mental health issues and disorders.

Textbox 2.5 Health Centres for the Elderly

Health centres for the elderly are a low-threshold service with the purpose of working in a health-promoting and preventive manner helping the elderly to live at home longer and cope with their own daily lives. The service is partly organised so that all elderly persons over a specific age actively receive an offer of a conversation, but they must book an appointment.

Source: Fredrikstad Municipality – Health Centres for the Elderly

The public health campaign ‘ABC for Good Mental Health’ is an initiative directed at activity, meaningfulness and community. Several municipalities cooperate with voluntary organisations working within mental health and quality of life of the elderly, inter alia, the Norwegian Women’s Public Health Association, Norwegian Public Health Association, Norwegian Pensioners Association in Trondheim and Norwegian Foundation Livsglede for Eldre (Joy of life for the Elderly). All work in accordance with the principles of the ABC model for the prevention of loneliness and mental health issues in the elderly. The Government wants to harvest experiences in connection with how the campaign can best be aligned with the elderly in the population. The ABC campaign is described in more detail in Chapter 2.6.

In the elderly population, depression and anxiety are most common mental health disorders. Many of the elderly experience loneliness and social isolation as risk factors for developing mental health conditions. During investigation and treatment, aging, cognitive function, cultural background, concurrent diseases and use of medicines must be taken into consideration. Elderly persons often have complex problems and less capacity to handle them. The Norwegian Directorate of Health has prepared national professional recommendations for mental health disorders in the elderly.

2.3 Getting more people to work, activities and education

Participation in education, work and activities is important to promote coping skills and prevent mental health issues. In many cases, participation in work promotes health, also for people with mental health issues and disorders. Studies clearly indicate that loss of employment leads to poorer mental health but returning to work has a positive effect on mental health.[55] The commitment to increasing the number of pupils who complete upper secondary education and training is intrinsically important, and also contributes to more people being qualified for employment. The Government will therefore strengthen the commitment to get more people, particularly young people, in work, activities and education. Statistics from the Norwegian Labour and Welfare Administration show that the number of young people (aged 18-29) receiving disability pensions has significantly increased in recent years. As a percentage of the population in the same age group, this group has doubled in the last few decades. Among new recipients, those with various types of mental health disorders continually represent a larger percentage compared to other diagnosis groups. Of young people under the age of 30 receiving the work assessment allowance, more than 70 per cent have mental health disorders.[56]

Through measures in, for instance, the health, employment and education sectors, and intersectoral cooperation, it is aimed to reduce the percentage of young people, who become disabled due to mental health issues and disorders, during the plan period. Efforts aimed at young people should be put in place early and incrementally before life on disability benefit becomes a reality.

The Government clearly states in the Hurdal Platform that everyone, who can and wants to work, shall have the opportunity to do so. The Government will strengthen the commitment to young people who are not in education or employment. A new youth guarantee will be introduced from July 2023. The guarantee aims to counteract long passive periods of not being in education or employment, and contribute to more young people completing education and getting jobs. Young people aged 16-30, who need supported employment, will receive early intervention services, a permanent contact person and close individually adapted follow-up from the Norwegian Labour and Welfare Administration for as long as necessary. This will help to build trust, clarify expectations and needs, and find potential solutions in dialogue with the young person, employer and other relevant actors. Better coordination with the health and care services and education authorities are key components in the follow-up.

The exclusion of young people is a major and complex social problem involving massive costs for both the individual and society. Meld. St. 5 (2022–2023) Report to the Storting (white paper) Long-Term Plan for Research and Higher Education (2023–2032) includes a social mission to reduce the percentage of young people not in education or employment and those outside of society through cross-sectoral and targeted efforts aimed at impact factors for a good upbringing. The Ministry of Children and Families coordinates the work on cooperation with other affected ministries.

The Government will present a report to the Storting on social mobility and social equalisation. The report aims to draw attention to children, young people and their families, and what is required to prevent poor living conditions being passed down the generations. The work on the report is a cooperation between the Ministry of Labour and Social Inclusion, the Ministry of Children and Families, the Ministry of Health and Care Services and the Ministry of Education and Research. The report will provide an overall presentation of the knowledge base for this field, and cover important phases and arenas in the lives of children and adolescents, in addition to the transition from childhood to adolescence and adulthood, including measures aimed at young adults.

Many with various health problems not in employment, including people with mental health issues and disorders, need concurrent assistance from both the Norwegian Labour and Welfare Administration and the health and care services to get a job and to improve their health. This means that the health and care services and the Norwegian Labour and Welfare Administration must cooperate in order to meet the needs of users for services. The Norwegian Directorate of Health and Directorate of Labour and Welfare play a key role in further developing the labour and health fields. Among other things, the Directorates have got together to form a strategy for the fields.[57] The strategy emphasises components, such as early intervention, greater commitment to local actors, collaboration, coordinated efforts between the health services and the Norwegian Labour and Welfare Administration (NAV), and cross-sectoral knowledge and competence building. The Directorates are cooperating on following up the strategy. As part of the follow-up, the Directorates have been jointly commissioned in 2023 to follow up the need to coordinate and strengthen competence and quality within labour and health. The Directorates and regional health authorities find that it is necessary to strengthen and coordinate competence and quality within labour and health at the local, regional and national level, and that the goal should be to establish a competence unit anchored in the respective sectors. This will be investigated and concretised in more detail (refer also to the discussion on labour and health in Chapter 3.5).

The Norwegian Labour and Welfare Administration shall assist people struggling to get a job on their own. The agency should be in close contact with the labour market and have a good overview of what companies need in relation to labour. For people with a need for supported employment, various labour market measures contribute to strengthening opportunities in the labour market. Measures such as work training, follow-up, wage subsidies, training, subsidies for inclusion and use of a mentor can be offered depending on individual needs and situation of the labour market. Several evaluations of the use of instruments in labour market policies have been conducted At the same time, there is a continued need for more knowledge about the effects of labour market measures, and how different measures work for different groups. There is also a need for knowledge on coordination and the use of instruments across the sectors.

Many of those not in employment have only completed primary and lower secondary school education. For a substantial number of these, the completion of upper secondary education and training will be critical in order to get a job. The Storting adopted a new Education Act in spring 2023. With the new Education Act, both youth and adults have a stronger right to education and training. This includes, among other things, giving all pupils the right to upper secondary education and training up until they have completed and achieved the Higher Education Entrance Qualification or vocational competence, and a vocational re-qualification right, which gives everyone who has achieved the Higher Education Entrance Qualification or vocational competence the possibility to obtain other vocational competence.

Closer cooperation between the Norwegian Labour and Welfare Administration and regional county councils shall contribute to more people not in employment having the possibility to complete professional and vocational training. The agency also cooperates with county council follow-up services to get young people who dropout of upper secondary education and training back to school or working.

The Act relating to integration through training, education and work (Integration Act), which entered into force on 1 January 2021, largely focuses on formal qualification by, inter alia, facilitating the completion of special subjects and vocational training within the framework of the introduction programme. The changes introduced with the new Integration Act were founded on a solid knowledge base, which indicates that education is a key instrument for success with early integration of newly arrived immigrants into Norwegian society and permanent attachment to the labour market.

It is important to follow-up young people early to prevent them from being passive over time in order to reduce the risk of mental health issues and disorders and permanent exclusion. Increased commitment to getting more people, particularly young people, in work, activities and education is therefore important to the Government, and will result in substantial human and socioeconomic benefits. Different activity and coping skills programmes may also be relevant in this context. This is described in more detail in Chapters 3.3.2 and 3.5.

For a more detailed discussion on the importance of job participation for health, reference is made to the White Paper on Public Health.

2.4 Good living conditions

Housing covers one of our most fundamental needs and the World Health Organisation considers housing as one of the most import impact factors for health. Living conditions impact both physical and mental health.[58] Housing contributes to belongingness, it provides physical security, creates identity and is an important social arena. Conversely, living in poor conditions or homelessness can have serious negative consequences. Poor living conditions make it more difficult to accept and benefit from health, care and welfare services, to complete education and participate in the labour market.Research shows that living conditions particularly impact vulnerable groups such as children, low-income families, immigrants and people in poor health.[59]

Government’s social housing policy

The national strategy We all need a safe place to call home (2021–2024) contains three priority areas for the social housing policy. No one shall be homeless, children and adolescents shall have good living conditions, and the disabled should be able to choose where and how they live as equally as anyone else. The Norwegian State Housing Bank plays an important role in supporting the work of municipalities on preventing people becoming disadvantaged in the housing market and helping the disadvantaged to acquire and retain a suitable dwelling. The Norwegian State Housing Bank manages the housing allowance scheme, start-up loan scheme and rental property loan scheme. Loans for rental properties shall contribute to the acquisition of more rental properties in safe residential areas. The housing must be of a good standard and be functional, and the location must suit the residents’ needs. The owners must enter into a long-term agreement with the municipality giving it the right to refer applicants to at least 40 per cent of the homes in the project for at least 20 years. In addition, the Norwegian State Housing Bank in cooperation with the Norwegian Association of Local and Regional Authorities and selected municipalities, KOBO, is developing a digital system for municipal rental properties. The system simplifies the application process, allocates and administers municipal rental properties, follows up residents and provides better management information.

The Government wants everyone to live in good safe conditions. In 2024, the Government will present a report to the Storting (white paper) on a holistic housing policy. It will address the role of municipalities in reducing social and geographic inequalities, and place emphasis on the value of good local environments in cities/towns and villages. The report will also look at how the Norwegian State Housing Bank can have a renewed role in the housing policy.

New Act relating to the responsibility of municipalities in the housing for welfare field

The municipalities have an overarching responsibility for assisting people, who cannot safeguard their own interests in the housing market, and therefore need assistance in acquiring or retaining a suitable dwelling. This responsibility is reinforced and emphasised in a new Act relating to the responsibility of municipalities in the housing for welfare field, which enters into force on 1 July 2023. The purpose of the Act is to obtain clearer and more comprehensive rules in the field. It may contribute to more disadvantaged persons receiving essential help and the municipalities having more equal levels of housing for welfare stock.

Among other things, the Act contains an obligation for the municipalities to have an overview of the need for ordinary and adapted housing for the disadvantaged in the housing market, which must be included in the basis for municipal planning strategies. Adapted housing means housing with assistive and protective measures for those who need them due to age, disability, substance use and/or mental health disorders or other reasons. This includes, inter alia, housing that due to its design, furnishing and location is particularly suitable for people with substance use and/or mental health disorders. Holistic socio-spatial planning in municipalities, which includes housing for welfare considerations, will enable municipalities to create safe and health-promoting cities/towns and residential areas that prevent problems caused by living conditions and contribute to the reduction of social inequalities. The Act emphasises that municipalities shall ensure cooperation across the sectors and coordination of their services in the housing for welfare field. Municipalities shall also cooperate with other public actors that can contribute to the work for the disadvantaged in the housing market.

In order to help those who are unable to acquire or keep a suitable dwelling, the Act contains a provision emphasising that municipalities shall provide individually adapted assistance to the disadvantaged in the housing market. The Act provides the municipalities with the freedom to act and decide how to set up the assistance in each single case. At the same time, it is important that the disadvantaged in the housing market can be involved in the offer, as such, the principle of user involvement is therefore continued in the new Act. Emphasis on the responsibility of municipalities to give individually adapted assistance may, inter alia, prevent exacerbation of individual living conditions.

2.5 Increased knowledge about mental health in the whole population

For many years, we have delivered successful campaigns focusing on lifestyle habits and physical health. Nowadays, the vast majority of people know that smoking is harmful, exercise is good for them and that eating fruit and vegetables is healthy. When it comes to the field of mental health, there has been no equivalent ongoing work on giving such defined and transparent information. The Government will therefore increase knowledge about mental health and the factors and activities that may have a protective effect and counteract the development of mental health issues giving increased quality of life.

The ‘ABC for Good Mental Health’ public health campaign contains components that might both promote health and have a preventive effect. ABC stands for Act, Belong, Commit. Its goal is to increase public knowledge about mental health, promote good mental health and prevent mental disorders. Trøndelag County Council will run a pilot study in 2023-2024 which will form the basis for recommendations on a nationwide public health campaign. Founded on the results, the Government will assess how a national public health campaign based on ABC can be implemented at population level and for various social groups

Research shows that the components in the ABC campaign significantly impact quality of life even for those who struggle with mental health issues.[60] Concurrently, these activities may seem protective and prevent the development of mental health issues.

One important aspect of ABC for Good Mental Health is that it is suitable to use in kindergartens, schools, workplaces, universities and university colleges. A national information campaign will contribute to increasing the whole population’s knowledge about what strengthens mental health. A public health campaign based on ABC will benefit from solid foundations in the form of extensive mental health research, experiences in Australia and Denmark, and measures in Norway and the Trøndelag Public Health Alliance.

Experiences from other campaigns, for instance, in the field of alcohol and tobacco, show good results in relation to changes in habits and behaviour patterns thus leading to improved health. For instance, the Norwegian Directorate of Health has implemented the communication effort ‘LEV’, which communicates lifestyle habits, i.e., tobacco, diet, physical activity and alcohol in relation to mental health, and mental health and physical health being closely linked. Measurements from before and after the campaign started show an increase in awareness and trust in the Norwegian Directorate of Health’s advice in all five lifestyle habits.

In 2023, it will be 30 years since the United Nations created the World Mental Health Day to promote worldwide awareness about mental health. The goal of the World Mental Health Day is to contribute to knowledge, transparency and engagement around mental health by mobilising the instigation of measures that can strengthen public mental health, reduce stigmatisation and increase awareness of what contributes to strengthening or reducing mental health.

Health literacy is the ability of a person to understand, assess and apply healthcare information to make evidence-based decisions concerning their own health. This applies equally to decisions related to lifestyle choices, measures for preventing illness, coping with illness, and use of health and care services.[61] The health literacy of low-income groups or those with a shorter education is usually lower than that of higher-income groups or those with a longer education.[62] Additionally, the health literacy of some of the immigrant population is lower than the population at large. Low health literacy is associated with poorer health and follow-up of one’s own illness, higher prevalence of illness and more frequent admission to hospital. Strengthening the health literacy of the population may contribute to improved public health.

The Norwegian Directorate of Health’s survey on the population’s health literacy highlights that many people struggle to find information on how to manage mental health issues.[63] Information on how to manage mental health issues should be more readily available in different languages and at such a level that the population—regardless of country of origin—can use the information to take care of their mental health. The ABC pilot study in Trøndelag is planning how the message and measures can be adapted to various groups according to language and culture as well.

The strategy to increase the health literacy of the population expires in 2023. In the work on the National Health and Coordination Plan, the Government will assess the need to prepare a new strategy to increase health literacy of a diverse population, and assess the responsibility of the services to adapt to the varying levels of health literacy.

2.6 Prevent and reduce loneliness in the population

Loneliness and social isolation is one of the major challenges in public health. A high degree of loneliness is associated with significant loss of quality of life. There is a great need for evidence-based measures to prevent and reduce loneliness in various groups in the population. The municipalities should have an overview of the scope of loneliness in their populations and initiate measures to reduce and prevent it. The Government will therefore consider including loneliness in the Public health Act when it is revised, and prepare a guide for public health measures against loneliness and consider an action plan in 2025 to counteract it. The ‘ABC for Good Mental Health’ public health campaign is also an important measure for combating loneliness.

Loneliness concerns having no or insufficient social relationships, but also the need or wish to have better or more social relationships. Loneliness is often associated with stigmatisation and higher risk of a number of physical and mental disorders, and premature mortality. Loneliness can also be a cause and consequence of a mental health disorder. Multiple studies have shown that loneliness and social isolation may be risk factors for heart and vascular diseases, and dementia, in line with known risk factors such as smoking, physical inactivity and poor diet. Poor health and financial hardship are also risk factors for loneliness. It is therefore important to both prevent and reduce involuntary loneliness.

Around 15 per cent of the population state that they often feel lonely, and loneliness has increased the last 10-15 years among adolescents and young adults alike.[64] Immigrants experience loneliness and exclusion from society to a greater degree than the rest of the population.[65] Loneliness and social isolation have a negative impact on the individual, people around them, the local community and society. Despite the prevalence of loneliness remaining relatively stable for many years in Norway, it has increased in some groups, i.e., among people under the age of 35 and the elderly. Since the number of elderly persons is constantly increasing, we must also expect the prevalence of loneliness to increase. During the COVID-19 pandemic with infection control measures that caused more social isolation, loneliness increased among students and the elderly.[66]

The quality of life of lonely people is poorer than the quality of life of those who have a partner, and lonely people in all age groups report more loneliness, concern and low mood than those who have a partner.[67]

As commissioned by the Ministry of Health and Care Services, the Norwegian Institute of Public Health prepared an evidence synthesis in 2022 assessing the effects of various loneliness prevention measures. The conclusion is that there are few documented measures and many of the studies are low-quality. Notwithstanding this indicates that social measures can be effective for reducing social isolation and psychological measures can reduce loneliness. The Government will prepare a guide with public health measures against loneliness and consider creating an action plan.

State and municipal authorities, and decision-makers, cannot eradicate loneliness, but facilitate prevention and reduce it. The mental health promotion arenas referred to above can all contribute to exactly this. Increased commitment to getting more people in work and activities, especially young people, will presumably prevent and reduce loneliness as well. Participation in voluntary work can also reduce loneliness and social isolation. This applies to all age groups. In addition, multiple studies have shown that animal-assisted therapy in elderly care is effective in reducing the feeling of loneliness.[68] [69] The ‘Safe at Home Reform’ initiative aims to contribute to preventing and reducing loneliness in the elderly.

Loneliness is one of the factors that leads to the highest quality of life loss. Good quality of life is unequally distributed between different groups in the population, and one of the goals is for as many people as possible to have good quality of life. The Government has therefore decided to put forward a national quality of life strategy in 2024. The main goal of the strategy is to ensure that society develops in a manner that equalises social differences in quality of life and reflects what the population believes is important for a good life. The Government has decided to include quality of life and will consider incorporating loneliness into the Public Health Act when it is revised.

2.7 Using social psychology knowledge in municipalities

Social psychology knowledge relates to how psychological, social, socioeconomic, societal and physical factors work together in preventing and promoting people’s health and quality of life through the course of life, and is therefore important in the planning and development of local health-promoting measures and measures at system level. Many municipalities have employed both clinical and social psychologists. Social psychology knowledge can be used when planning and designing low-threshold interventions within mental health at various levels. Social psychology knowledge also includes knowledge about health and welfare policy guidelines important for health promotion and prevention work.

It must be ensured that municipalities use their expertise on mental health and public health to promote mental health at the population level as well. The Government will assess how the municipalities can best exploit social psychology knowledge to promote health and quality of life in the whole population through local community-based measures and measures at the system level, and will consider this when the Public Health Act is revised.

The Norwegian Institute of Public Health annually publishes public health and childhood profiles for Norway’s counties and municipalities. The profiles provide updated information and an overview of how the population in each municipality and county are distributed across indicators for living conditions; kindergartens and schools; leisure time and the local community; the environment; injuries and accidents, and health and health behaviours. The overview of public health challenges will be incorporated as a foundation for the work on planning strategies. Social psychological knowledge should be used to plan how the information from the profiles can be incorporated into planning strategies, and used to promote mental health and quality of life in local communities.

3 Access to good quality care close to where people live

Figure 3.1

People with mental health challenges need good and easily accessible help. At the same time, a number of surveys show great variation in the services across Norway. Through the escalation plan, the Government wants to contribute to strengthening the quality and improving the accessibility of services for people with mental health issues and disorders. This entails the facilitation of more low-threshold services in the municipalities, strengthening the services in the mental health service, reducing waiting times, and offering children and adolescents clinical interviews within the mental health service for children and adolescents to clarify the need for further treatment. It also entails working systematically on quality improvement. Good cooperation with users and next of kin is an important prerequisite for developing good services. Further, the facilitation of new ways of working, more effective organisation, correct task distribution and good use of available resources (refer to Chapter 1.6 for a detailed discussion on personnel).

Textbox 3.1 The government will:

Improve the accessibility and capacity of the services for people with mental health challenges, inter alia, by

Facilitating available services in the municipalities, including:

The facilitation of improved low-threshold services within mental health and substance use in the municipalities

Investigation of the advantages and disadvantages of various alternatives in order to contribute to equal municipal low-threshold services within mental health and substance use for all age groups. Legislative enactment of low-threshold services in the municipalities is one of the alternatives that will be investigated

Investigation of the possibility to extend the target group who receives help from Prompt Mental Health Care

The strengthening of the health centre and school health service both professionally and financially

Assessment of setting up potential referral rights for health nurses

Assess measures for improving gender balance in health nurse education, including the assessment of gender points or quotas

Facilitation of good and predictable frameworks for guidance, support and counselling services within mental health, substance use and violence

Strengthening the capacity of and recruitment to the GP service, including:

Assessment of measures for facilitating cross-disciplinary GP surgeries

Enabling regional health authorities to increase their capacity for treating and following-up mental health services for children, adolescents and adults based on analyses and projections, including:

Strengthening the capacity to treat and follow-up children and adolescents with mental health disorders

Ensuring enough capacity for inpatient care and beds in the mental health service for children and adolescents in all health regions for treating and following-up children and adolescents with severe mental illness and need for inpatient care, including children and adolescents in care

Asking regional health authorities for an annual account of how they are positioned in relation to their own projections

Investigation into how a joint referral unit can include cooperation with the municipalities so patients receive essential healthcare at the right treatment level

Contributing to digital programmes and services within the mental health field, inter alia, by

Testing user-controlled outpatient clinics at District Psychiatric Centres with digital monitoring

Further development and implementation of digital self-help tools and guided online treatment

Further development of DigiUng and ung.no

Investigating whether and how all the services from the municipalities can be communicated to the citizens through a joint digital gateway at the municipal level

Strengthening services for children and adolescents with mental health issues and disorders, inter alia, by

Further developing models for cooperation between municipalities and the special health service around children and adolescents, including

The introduction of clinical interviews for children and adolescents

The investigation and piloting of integrated youth services at one level for young people with mental illness and/or addiction problems, which also include cooperation between the child welfare service and the Norwegian Labour and Welfare Administration

Potential abolishment of the user fee for patients up to and including the age of 25 for treatment from the mental health service

Assessment of how state grants can be better used than today to achieve the goal of improved, more holistic and coordinated services for children and young people

Strengthening of the work on prevention, early detection, intervention and treatment of eating disorders, including:

The development of programmes to strengthen knowledge, competence and models for municipal services and coordination measures

Potential organisation of services within the specialist health service

Helping to ensure that work and activities play a bigger role in the treatment and follow-up of people with mental health challenges, inter alia, by

Preparing joint national professional recommendations for service providers within the field of employment and health

Continuing and expanding the Individual Placement and Support (IPS)

Developing and testing models for coordination between the Norwegian Labour and Welfare Administration and municipal health and care services, including Prompt Mental Health Care

Facilitating activities and meeting places for people with mental illness and addiction problems

Preventing violence and abuse, and helping and supporting those who are exposed to violence and trauma, inter alia, by

Putting forward an escalation plan against violence and abuse against children and violence in close relationships

Continuing to test and research trauma therapy in municipalities through further development of Trinnvis sammen (Stepped Care Together)

Supporting the municipalities in the work on psychosocial preparedness and follow-up

Working towards suicide prevention and self-harm, inter alia, by

Following up the Action Plan for Suicide Prevention 2020-2025 – No one to lose, and consider new measures if needed

Continuing the development work on prevention and self-harm

Improving the quality of the services for people with mental health challenges, inter alia, by

Facilitating user and next of kin involvement, including:

The development of several forms of patient-facing decision support in the field of mental health

Preparing next of kin agreements

Working towards equal services and adapted help for a diverse population

Contributing to good management, quality improvement and patient and user safety, including:

The strengthening av national management education for primary care

Further development of the Norwegian Registry for Primary Health Care (KPR) to include data on mental health and the field of substance use

Assessment of measures for improved patient, user and personnel safety in the mental health service

Facilitation of research and innovation, including:

Better use of health data

More research-based quality improvement projects

Clinical research as an integral part of patient treatment

Facilitation of research relevant to the municipalities’ need for knowledge

Contribute with evidence-based services, including

Increased use and better coordination of the assessments in ‘Nye metoder’ (New Methods) and the Norwegian Directorate of Health’s work on standardisation products

Investigation of how the municipalities can receive better support and guidance in their work connected to mental health and substance use

Assessment of the regional health authorities’ recommendation for restructuring measures to increase the capacity of prioritised areas within mental health including programmes at District Psychiatric Centres

Assessment of stronger thematic organisation of the mental health service based on the recommendations of expert committees

Investigation of the organisation of the resource centres outside the specialist health service in a more unified manner

Preparation of a national professional guide on setting priorities in municipal health and care services

3.1 Basis for the priority area

The public shall have equal access to health and care services. In Norway, the services for people with mental health issues and disorders are well-developed. Nonetheless, many people do not receive the help they need.

Several reports show that access to services in municipalities for people with mental health issues and disorders vary, and that the public receives more treatment in some health regions for such conditions than in others. The Office of the Auditor General of Norway also points out that patients who live in areas with a high number of rejections and long waiting times or in municipalities that have not established, for instance, outreach and emergency services, do not have the same access to health services as others.[70] The Health and Social Services Ombudsman reports on a shortage of inpatient beds and insufficient capacity at outpatient clinics, long waiting times and the perception that one has to be more seriously ill to get help from the specialist health service than before.[71]

There is a need to strengthen services for children and adolescents with mental health challenges both in municipalities and the specialist health service. Many found it difficult during the COVID-19 pandemic[72] , and more than 20 per cent more children and adolescents received healthcare from the mental health service in 2021 than in 2020. Increased waiting times and projections show that the demand is higher than the capacity. Those who are referred also have more severe conditions than before. There has been an increase in the number of young people being admitted to hospital for eating disorders[73] , and many are not detected and do not receive help early enough. There has also been an increase in consultations in primary health care related to mental health issues in children and adolescents. The number of beds in the mental health service has been reduced the last 20-30 years at the same time as ambulatory and decentralised services have expanded.

Projections show that continued strengthening of municipal health and care services is an important prerequisite for improving capacity in all the services. Many with mental health issues and disorders are in contact with a GP, which is an important low-threshold service in municipalities. The health centre and school health service takes on this role for children and adolescents, pregnant women and families in the postnatal phase. In addition, there are separate low-threshold mental health services. According to the Office of the Auditor General of Norway, 75 per cent of the municipalities have a separate low-threshold mental health service for treating children and adolescents, whilst other municipalities state that other municipal services such as health centres and the school health service, the Educational Psychological Counselling Service (PPT) and/or the child welfare service treat children and adolescents. Approximately one of ten municipalities do not offer low-threshold services or other services for children and adolescents with mental health issues and disorders other than the GP service. During the COVID-19 pandemic, several municipalities established various low-threshold services and group services to deal with the increased demand.[74] Geographic variation in municipal services and lack of services in municipalities for those who do not receive help from the specialist health service is confirmed in the Health and Social Services Ombudsman’s Annual Report for 2022. The annual report also points out that patients report insufficient follow-up from GPs combined with poorly developed services in municipalities.

Mental illness is one of the diagnoses that most often leads to sick leave and people receiving disability benefit.[75] People with these types of ailments are therefore an important target group for the Norwegian Labour and Welfare Administration. Measures to promote participation in employment along with concurrent medical follow-up are important to prevent permanent disability and reduce the need for health-related benefits. Further, the facilitation of activities and meeting places for people with mental illness and addiction problems is needed.

There is a need for more extensive use of knowledge about the treatment of mental health issues and disorders, and systematic work on quality improvement and patient and user safety. User involvement and next of kin involvement in the services both in municipalities and the specialist health service must be ensured. According to the Health and Social Services Ombudsman, the rights of next of kin are not adequately safeguarded.[76] Next of kin, who frequently perform demanding care tasks over time, must receive better support.

3.2 Good accessibility and capacity

Many who struggle with mental health problems or problems with substance use will experience improvement if they use their own resources or receive help from people in their own network. At the same time, everyone must be confident that help is available when the need arises. Several of the ordinary services such as health centres, the school health service and GPs take care of people with mental health challenges. Concurrently, many municipalities report an increased demand for more services within the mental health and substance use fields. These are services that can function parallel to, as part of, or in cooperation with other ordinary services. The Government will work to improve the accessibility and capacity of the offered services for people with mental health challenges, and to ensure that the threshold for receiving help is low. One goal is for the citizens of all municipalities to have access to evidence-based, low-threshold mental health and substance use services. At the same time, the Government will contribute to providing enough capacity and adequate help to those who need more comprehensive treatment both in the municipal health and care services and the specialist health service. One goal is to reduce the average waiting time in the mental health service both for children and adolescents, adults and specialised cross-disciplinary substance use treatment. An important part of building up capacity must, inter alia, be done through changed prioritisation, more effective organisation, improved task distribution and the use of available personnel. Fewer reports and the further development of digital services and new solutions that will increase accessibility will also be important.

3.2.1 Mental healthcare provided at the municipal level

The Health Care Act orders municipalities to provide necessary health and care services for everyone staying in the municipality. The responsibility of the municipalities covers all patient and user groups, including people with mental health challenges and addiction problems. In order to fulfil this responsibility, the municipality must, among other things, offer health-promotion and preventive services, investigations, diagnostics and treatment, and social, psychosocial and medical habilitation and rehabilitation. An assessment of each single patient or user’s needs is the deciding factor in terms of which services the municipalities have a duty to offer the individual. It is important that the municipalities organise their services in a manner so they reach everyone who needs them and safeguards each person’s rights. In the municipalities, health and care services are given to people with mental illness and addiction problems from general health and care services as well as more targeted services in the form of various services attached to mental health and addiction

The Government will contribute to supporting the municipalities to enable them to provide good services for people with mental health challenges in line with local needs and the problems their citizens have.

Some municipalities co-localise services, for instance, in ‘Familiens hus’ (Family House), where various services aimed at children and families are gathered together. Some services are given in cooperation with the specialist health service. In recent years, more people have received better help through new services in across municipalities. The services cover a wide spectrum from low-threshold services, which anyone can contact, to services for people with more complex and long-term needs. Some services, such as health services at home and practical assistance, are allocated through administrative decisions pursuant to the Health Care Act.

Reported figures from the municipalities indicate that the number of people working in municipal services for mental health and substance use has increased in recent years.[77] At the same time, the Healthcare Personnel Commission’s report shows that the same increase cannot be used as a basis moving forward. The Government therefore wants to see how the resources within the mental health and substance use fields can be used more efficiently, for instance, in the form of new working methods, correct task distribution, appropriate use of technology and other ways to organise the services. The Government will commit to wide-reaching low-threshold services and methods of helping. Reference is made to Chapter 1.6 for a discussion on personnel and competence.

3.2.2 Evidence-based low-threshold programs within mental health and substance use

The threshold for seeking help when suffering from mental health problems should be low. Many, particularly children and adolescents, seek easily accessible help that does not require a referral without a long waiting time. Low-threshold services may contribute to preventing various problems attached to coping with life, life crises, and mild and moderate issues and disorders developing into more severe conditions. Such services may, for instance, include support conversations, help in finding one’s way around the support services, stress-coping courses, work on sleep problems or short-term treatment of mild forms of anxiety and depression. One of the Government’s goals is that the citizens of all municipalities have access to evidence-based low-threshold mental health and substance use services

Textbox 3.2 Ung Arena

Ung Arena is a low threshold service for young people between the ages of 12-25 that they can access when needed. They can telephone if they want to chat or to arrange a time to meet. A landline is staffed during opening hours. They can talk about whatever they wish. Support conversations, practical help, and assistance with a seamless transition to the specialist health service are offered, in addition to other relevant services. Professionals, peer support workers and volunteers work together at Ung Arena to help young people. Cooperation agreements with various public services enable young people to meet professionals: nurses; psychologists; social workers’; substance use consultants; student advisers; and representatives from the Norwegian Labour and Welfare Administration (NAV). It is owned by the municipalities who have mandatory methodological cooperation with Ung Arena, who owns the model. The service is free and low-threshold with no waiting time and long opening hours. It is easily accessible and it is possible to remain anonymous. Ung Arena is structured on a universal preventive public health perspective with the possibility of prompt and seamless entry into the support services.

‘Low-threshold services’ are not defined in health legislation, but is one way to set up services and it expresses the characteristics of the service’s availability. This often means that it is not necessary to have a referral to contact the services or participate in the activities that are offered. In general, help is promptly available. Low-threshold services may include prevention, early intervention, treatment and harm reduction. They can be set up for different user groups and include a wide range of support services such as advice, conversations and counselling, employment and activity services, investigation and treatment or be a meeting place for social community. For substance use, there are also various low-threshold services offering other types of health services, for instance, cleaning and dressing wounds, infection monitoring, issuance of user equipment, etc. The services can be both stationary and ambulatory.

Through different types of low-threshold services, more people can get help early. Prompt access to help and treatment could be of great importance to some people’s quality of life and coping skills. It might also contribute to reducing the influx of people wanting to access the services in the specialist health service.

By using coping skills courses, psychoeducation interventions and group therapy, it will be possible to help more people without increasing employee workloads. This better exploits the shortage of personnel resources. Digital services and services have the potential to reach an extensive number of people. The development and increased use of these will improve the capacity of the services (refer to Chapter 3.2.4.). Such services may include self-help and coping tools, and digital treatment such as guided online treatment and digital consultations.

Many municipalities have established good low-threshold services for their citizens based on local resources and needs. Prompt Mental Health Care (refer to the discussion below) and Ung Arena (refer to Box 3.2) are examples of services that have been established in several places.

Textbox 3.3 Low-threshold team in Tromsø

In Tromsø, a cooperation (low-threshold team) has been established between the municipality and the mental health service for children and adolescents for assessing and following up children and adolescents (up to 18 years old) with mild to moderate problems such as depression, anxiety, behavioural problems, and problems with concentrating/restlessness, and their families. The goal is to ensure that children and adolescents encounter professionally sound and coordinated services.

The team, which has a cross-disciplinary composition (municipal psychologist, specialist in psychology, child welfare officer) with employees from Tromsø Child and Adolescent Psychiatric Clinic (BUP), the University Hospital of North Norway and Tromsø Municipality, has two main functions: rapid clarification of the need for support services, and short-term treatment and follow-up of children, adolescents and families, who presumably do not need long-term services. A referral is not required. Anyone who is concerned about the mental health of a child or adolescent can contact the team directly. The team participates in meetings with adolescents, children, parents/guardians, teachers or other professionals, and arranges cooperation with other municipal health services if needed. The service is particularly used by school health nurses.

The team has started using Feedback-Informed Treatment (FIT) and uses the Outcome Rating Scale (ORS) and Session Rating Scale (SSRS) forms. With the aid of the ORS, the user gives regular feedback on how they are feeling. Through the SRS, the user gives feedback on their perception of the therapeutic relationship. The feedback is used to adjust further treatment.

Textbox 3.4 Short-term mental healthcare in Porsgrunn

Short-term mental healthcare in Porsgrunn Municipality helps people who are struggling with worries, low mood, sleep problems, stress and strain. The department helps people to find their way out of deadlocked situations. Among other things, the service consists of guided self-help (structured self-treatment), courses and group services, individual conversations and systematic follow-up of those left behind after suicide.

The department has established an efficient admission process by using NORSE (a dynamic feedback tool) as a self-referral tool. Administrative personnel take care of admissions. This enables practitioners to concentrate on meeting the users. NORSE is used to evaluate the effect of each single conversation and the effect of treatment six weeks after follow-up ends. The municipality’s peer support worker carries out evaluations and conversations with all users after completion. Continuous work on development using the experiences of users as a starting point is one of the main goals of the service. Psychologists, social educators with special competence and psychiatric nurses work in the team.

Source: Porsgrunn Municipality

The municipality’s self-reporting and diverse input for the escalation plan shows, however, that access to the low-threshold services varies across Norway, and that there is a high demand for easily accessible support services for people with mental health challenges. It has also been pointed out that it is necessary to clarify what a low-threshold mental health service is and to highlight what municipalities are responsible for in relation to follow-up and the treatment of mental health issues.[78] During the plan period, the Government will therefore investigate the advantages and disadvantages of various alternatives in order to contribute to equal municipal low-threshold services within mental health and substance use for all age groups. evidence-based means that the service is based on knowledge from research, the experiences of professionals and the users themselves. Knowledge-based also means that municipal autonomy is taken into consideration in that the municipalities can have more flexibility and take into account their experiences and local frameworks and prerequisites.

Good and accessible low-threshold services in municipalities provide many benefits. They can detect and help people with mental health issues, mental health disorders and addiction problems at an early stage, and prevent worsening of mental health and addiction problems and admissions to the special health service. In addition, the help will be moved nearer to where people live their lives. Low-threshold services will be able to use a wider range of professions in municipalities. Health and social care personnel, people with experiential competence and employees of other sectors, for instance, the child welfare service, the Norwegian Labour and Welfare Administration (NAV), and culture and recreation may be relevant to or in connection with such programmes. It is also important to facilitate formalised cross-sectoral cooperation. The Healthcare Commission points out that in the face of a shortage of some occupational groups, particularly the more specialised groups, it will be important to set up services so that more occupational groups can contribute. For instance, by offering group and online-based services, where there is a knowledge base for such services, it will also be possible to exploit available personnel resources more efficiently.

During the investigation, the advantages and disadvantages of various alternatives that may contribute to equal services across the whole of Norway must be addressed. Many with addiction problems have mental health issues, for instance, in the form of anxiety and depression, and it will not be sustainable or professionally moral to establish separate low-threshold services in the municipalities for this group. Any other problems that can be included in the services must be part of the investigation. The investigation shall also in line with the recommendations of the Healthcare Commission assess the consequences of using personnel in health and care services overall. In addition, the consequences for the entire personnel situation in municipalities should be assessed. Low-threshold services should, where possible, build on existing services and structures, and should not lead to further fragmentation for personnel or users. Tight cooperation between users and professionals is also significant, so that the needs of users are included in defining the content of the help.

Enactment is one of the alternatives that will be investigated. Elucidation in health legislation may clarify the frameworks for the service for both the municipalities and citizens. It will also improve cooperation between the mental health service in that it will be clearer for the specialist health service with regard to what they can expect from the municipalities. At the same time, section 2-2 of the Local Government Act states that self-government should not be limited more than what is necessary. Many municipalities have difficulty getting enough personnel to solve the tasks that they have and a new obligation could exacerbate the problem. A potential obligation to provide low-threshold services may tie up resources that could alternatively be used for other measures to increase the quality in the same field. The advantages and disadvantages of enactment must be weighed up against each other during the investigation. The Government wants to investigate enactment of low-threshold services in municipalities early in the plan period.

The Government will ensure that the municipalities have financial autonomy to prioritise low-threshold services, and give them good and adapted professional support and guidance. The Government will assess how evidence-based practices can be spread and adopted by municipal low-threshold services, for instance, through service support, guidance, etc. For a more detailed discussion on research and evidence-based services refer to Chapters 3.8.4 and 3.8.5, and to Chapter 3.8.5 for development of the resource centres.

Prompt Mental Health Care

Prompt Mental Health Care (PMHC) is a municipal service offering short-term treatment without a referral for people over the age of 16 with mild to moderate anxiety, depression, emerging addiction problems and/or sleep problems. Follow-up is given by a cross-disciplinary team. The service is based on cognitive therapy and is given in the form of guided self-help, courses, individual conversations and group therapy. PMHC is an evidence-based method organised according to a mixed care model where the person seeking help, along with a therapist, agree on which service they will start with based on the principle of right treatment at the right level at both the beginning and during the course of treatment.

Prompt Mental Health Care was established in Norway as a pilot experiment in 2012 following inspiration from England where a national commitment was made to make evidence-based treatment of anxiety and depression better available. The Norwegian Institute of Public Health evaluated the pilot experiment, which showed that PMHC works in accordance with the goal of being a low-threshold service that increases access to evidence-based treatment. The evaluation, and a later randomised control study, showed a strong reduction in symptoms of anxiety and depression after treatment.[79]

Today, there are more than 70 PMHC teams spread across the whole of Norway.

The benefits and effects of PMHC are linked to more people gaining access to effective treatment with reduced symptoms of anxiety and depression, and the socioeconomic benefit of more people getting help at the lowest effective level of care. During the plan period, the Government will investigate the possibility of extending the target group who receives help from PMHC.

The Norwegian Labour and Welfare Administration and the Norwegian Directorate of Health are working on developing models for coordinated services aimed at people with mild to moderate mental illness and/or addiction problems with emphasis on cooperation with municipal health and care services. Among other things, this involves cooperation between the Norwegian Labour and Welfare Administration and Prompt Mental Health Care. For a more detailed discussion, refer to Chapter 3.5 on work and activities as part of treatment.

Health centres and the school health service

Health centres and the school health service are the most important preventive and health-promoting services aimed at children, adolescents and their families, in addition to pregnant women and families in the postnatal phase. These services carry out planned health checks on children and pregnant women, and are low-threshold services in municipalities. The services are extremely popular with the public and reach almost everyone in their target group.

Health centres and the school health service are important for the municipalities’ work on giving everyone a good start in life. The services shall contribute to disease prevention and promotion of good physical and mental health in children, adolescents and their parents, the levelling up of health inequalities, and prevent, detect and avert violence, abuse and neglect. Good follow-up after childbirth can help prevent postnatal depression and contribute to uncovering the need for help at an early stage. The services shall also promote health literacy in children, adolescents and parents to enable them to make good choices later in life, and also promote self-coping skills when faced with life’s challenges.

The main challenges for health centres and the school health service are primarily accessibility and capacity. For children and adolescents, this means that the services should be accessible through adapted opening hours and digital platforms, and the capacity should be good enough to enable them to get an appointment at short notice or with no waiting time. Among other things, this requires health nurses to be more present at schools. Through the digital health centre ‘DigiHelsestasjon’ (refer to Box 3.5), which is part of DigiUng, solutions are being developed for digital accessibility at health centres and in the school health service. Digihelsestasjon enables digital dialogue with a health nurse.

Textbox 3.5 DigiHelsestasjon

DigiHelsestasjon is a national cooperation project between the municipalities of Oslo, Bergen, Stavanger and Haugesund, the Norwegian Association of Local and Regional Authorities, The Norwegian Directorate of Health, Norsk Helsenett and the Directorate of e-health. In addition, the three suppliers of electronic patient record solutions for such services are participating. The overarching goal of the project is to establish digital citizen services for health centres and the school health service including Health Clinics for Adolescents (HFU) on a national platform (Helsenorge).

The earmarked grant for health centres and the school health service was expanded in 2023. From 2024, the grant will no longer be limited to specific professions, but municipalities will be able to apply for support to cover the cost of full-time posts in the professions the municipalities consider they need.

Additional competence, professional development and research is needed on the work of health centres and the school health service. The Government has therefore allocated funds for the establishment of a national cross-disciplinary advisory unit for health centres and the school health services. The advisory unit is rooted in the Norwegian Institute of Public Health and is located in Levanger.

Health nurse and midwifery education programmes are included in the National Curriculum Regulations for Norwegian Health and Welfare Education (RETHOS). This ensures that the education programmes are up to date and in line with the needs of patients, users and the services.

There are some challenges in relation to recruitment, particularly health nurses. This impacts the capacity of the services. Innovative thinking is therefore necessary when it comes to problem solving, and efficient and appropriate work methods. An additional challenge in public health nursing in that there is a shortage of men. This may prevent boys from approaching health centres and the school health service. The Government will consider measures for improving gender balance in health nurse education, including the assessment of gender points or quotas.

Good and accessible health centres and school health service can promote health literacy and level up social inequalities. Furthermore, they will uncover and follow-up mental health issues and disorders, and prevent the development of mental ill-health. The health centre and school health service are vital low-threshold services for children and adolescents with mental health challenges. In some cases, children and adolescents who contact the services need to be referred to, for instance, a Child and Adolescent Psychiatric Outpatient Clinic (BUP). The Government will therefore consider piloting referral rights for health nurses to make referrals to BUP. The purpose is improve routines for early clarification of what help children and adolescents need to ensure that those with mental health issues/disorders receive the correct and prompt healthcare at the right level. Health centres and the school health service are in contact with many children and adolescents before and after they have been referred to BUP. Such referral rights will be considered in relation to further development of models for cooperation between municipalities and the specialist health service around children and adolescents including the introduction of clinical interviews. Cooperation with health centres and the school health service will also be considered in more detail when piloting integrated services at one level (refer to 3.4.1).

In order to help children and adolescents to get necessary help and cope with their own lives, health centres and the school health service should cooperate with other relevant actors in the health sector, and across the sectors and services, for instance, coordinating units for habilitation and rehabilitation, the child welfare service, GPs, district medical officer, psychologists and other healthcare services offered by the municipality, the Norwegian Labour and Welfare Administration, the public dental service and educational psychological counselling service.

Educational Psychological Counselling Service

Every municipality and county council should have an Educational Psychological Counselling Service (PPT). This could be organised as a municipal service or cooperation with other municipalities and/or county council.

The Educational Psychological Counselling Service shall help kindergartens and schools to develop competence and their organisations, so the education for pupils who need special adaptation is the best as possible. In addition, the service shall ensure that expert assessments are carried out on the special needs of children and pupils.

The Educational Psychological Counselling Service shall work in a cross-disciplinary fashion when necessary at the local level, for instance, with healthcare services or child welfare service, and at the state level with, for instance, Statped or the specialist health service.

The Storting adopted a new Education Act in spring 2023, which clearly states that the Educational Psychological Counselling Service shall help schools with the work on prevention and early intervention. The new Education Act will come into force in autumn 2024.

Healthy life/teaching and coping services

Health life/teaching and coping services are offered in different ways in the municipalities. Healthy Life Centres are health promotion and preventive municipal health services. The target group is people who have an illness or higher risk of illness, and need support to change lifestyle habits and to cope with health problems. A referral or administrative decision is not required to use their services. In addition to having lifestyle counselling, many Healthy Life Centres have services for people with mild mental health issues, sleep problems and/or risky alcohol consumption. According to the guide for establishing Healthy Life Centres, the services must be adapted, so that everyone in the target group can participate.[80] In many municipalities, there is tight cooperation between the Healthy Life Centre and Prompt Mental Health Care (PMHC). Health Life Centres offer services arranged by themselves and/or in cooperation with other actors. Emphasis is placed on a holistic approach and strengthening the users’ physical, mental and social resources for health, change and coping skills. The healthy life services are fundamentally general and diagnosis independent. Mapping carried out by Statistics Norway (SSB) shows that around 20 per cent of the municipalities had courses for coping with depression (KID) and courses for coping with stress (KIB).[81] More and more municipalities are offering courses in everyday wellbeing. Around 66 per cent of municipalities have a Healthy Life Centre under their own auspices or through intermunicipal cooperation. Accordingly, the Healthy Life Centres reach approx. 85 per cent of the population.

Helplines and online services

There are numerous helplines, online services and support groups providing good help and contributing with information, counselling and support services for people in difficult life situations and their next of kin. These services are primarily offered by non-profit and voluntary organisations, and they are an important supplement to public authority services. Helplines and online services receive a high number of enquiries, and the services report an increase in the number of people contacting them, and there are more serious enquiries now than before the COVID-19 pandemic.

It is important to have quality assured training for those who work in the support services. Work has therefore started on preparing a common training module for mental health helplines. The initiative follows up both the Quality of Life, Mental Health and Substance Use during the COVID-19 Pandemic Report from the expert group, which has assessed the implications of the pandemic on the population’s mental health and substance use, and the Action Plan for Suicide Prevention 2020-2025 – No one to lose. The coordination of relevant helplines within the field of mental health and other relevant helplines via a joint national number and the possibility of establishing an emergency button will also be considered.

In the National Budget for 2023, the Government has facilitated the strengthening of a fairer grant scheme for guidance, support and counselling services within mental health, substance use and violence. The goal is that good and effective services shall encounter predictable frameworks, at the same time as grant administration is transparent and fair. The Government will consider additional strengthening of guidance, support and counselling services within mental health, substance use and violence during the plan period.

3.2.3 Access to general practitioners

Patients with mental health challenges represent a large portion of the work at GP surgeries. Out of more than 16 million GP consultations, every fourth consultation concerns mental health symptoms, and mental illness is the main diagnosis in more than every tenth.[82] For many, a long relationship with their GP makes them a natural first point of contact, which also applies to patients with mental health issues. The majority of those who contact their GP are treated and followed up without a referral to the specialist health service. GPs are an important low-threshold service for citizens and are available in all municipalities in Norway. At the same time, GPs are important contributors in guiding patients to other municipal services for mental health and coping. For patients with severe mental illness, GPs are often coordinators in following up municipal healthcare services and specialist health services.

Somatic disease may be an underlying cause of mental health issues. Investigation of somatic causes is therefore an important part of a GP’s follow-up of mental health issues. People with anxiety, depression and stress-related diagnoses contact their GP more often and have more somatic ailments than others.[83] GPs have the competence to look at mental health and somatic ailments in relation to each other and make good diagnostic and treatment-related assessments.

Capacity problems in the GP service reduces availability and continuity in the therapeutic relationship for patients with mental health challenges as well. In addition, there are challenges attached to coordination between the GP service, other municipal mental health services and the specialist health service. A lack of insight into municipal services among GPs may lead to unnecessary referrals to the specialist health service and subsequently healthcare not being as good or as resource-efficient as possible. Challenges with coordination between the GP service and other municipal services may lead to somatic causes of mental health challenges, or somatic diseases resulting from mental illness, not being detected.

The Government is carrying out ongoing work on increasing the capacity and recruitment to the GP service. Such strengthening is essential to ensure equal and accessible services for patients with mental health challenges, and to improve the internal coordination in the municipal health and care services and with the specialist health service. Trials with several occupational groups at GP surgeries have shown that the patients and healthcare personnel perceive the services as better coordinated with better collaboration. During the trial, one of the GP surgery’s employees was a psychiatric nurse and another had a psychologist in its team. The findings correspond with findings of other work studying experiences with psychologists at GP surgeries.[84] In the work on strengthening the GP service, the Government wishes to facilitate multidisciplinary GP surgeries.

In 2023, the Government proposed a historical commitment to the GP service. The funding is used to strengthen and make the basic grant patient-adapted to specialty training in general practice agreements (ALIS agreements) to increase recruitment and for research. An ALIS agreement is an agreement between a municipality and doctor undergoing speciality training in general practice. Changes to the basic grant will give GPs more support for patients who it is assumed will have more need for services. It shall enable GPs to spend more of their time on follow-up and coordination in respect of patients with serious complex needs, which applies to many patients with mental health challenges. Patient-adapted basic grants are based on selected indicators that shall predict the estimated need for GP services for citizens on GP lists. The indicators are sex, age, use of GP services, education level in the municipality or borough and centrality. The model was introduced in May 2023. The Government has an ambition to further develop the model to better establish the health condition of patients, inter alia, for patients with mental health challenges and addiction problems.

24-hour out-of-hours medical service and immediate assistance

Much of the work that is carried out by the out-of-hours medical service is related to acute mental health challenges, particularly late in the evening and during the night. A large portion of the consultations carried by the out-of-hours medical service are for severe mental illness and surpass those at GP surgeries. One major challenge is that the out-of-hours medical centres are less integrated with other municipal health and care services, and information flow between the centres and other services in municipalities is severely lacking.

The obligation of the municipalities to provide 24-hour immediate assistance was extended to apply to patients with mental illness and/or addiction problems from 2017. The introduction of immediate assistance for mental health and substance use shall contribute to strengthening the general services in the municipalities. Patients relevant for inclusion in this service are those with mild or moderate mental health problems and/or addiction problems, often in combination with somatic diseases/ailments. This may be patients with a clarified condition or known diagnosis who relapse or whose mental health disorder and/or addiction problem becomes worse. In such cases, hospitalisation may remedy or relieve a difficult life situation.

The Government has announced that there will be a separate white paper on emergency medical services to review the chain of assistance that is given from the point in time that a patient needs emergency healthcare up to and including admission to the emergency department at a hospital.

3.2.4 Mental health care provided by specialist health services

Since the last escalation plan, treatment services in the mental health service have undergone a major overhaul with more emphasis on outpatient and ambulatory care than inpatient care. This development has contributed to more patients receiving help and help being given closer to where people live. At the same time, the need for inpatient care has increased, including those committed to compulsory psychiatric care. There has also been a significant increase in the number of referrals, particularly during and after the COVID-19 pandemic, and waiting times have increased. Regional health authorities observe that there is a need to increase the capacity of the mental health service in terms of both outpatient and inpatient services, and have consequently revised the national projection model. Application of the new model will contribute to reducing undesired geographic variation and strengthen treatment services for patient groups with a greater need for treatment from the specialist health service moving forward, particularly those with severe mental illness and children and adolescents. The Government wants the average waiting times to be reduced and will proceed with the goal of the average waiting time in the longer term being less than 40 days for mental healthcare for adults, 35 days for mental healthcare for children and adolescents and 30 days for cross-disciplinary specialised treatment for substance use disorders.

The Government will enable the regional health authorities to increase the capacity for treatment and follow-up in the mental health service. based on projections and what is feasible and realistic to accomplish within the framework of hospital finances. An investigation will also be conducted on how a joint referral unit can include cooperation with the municipalities to ensure better prioritisation and task distribution so patients receive essential healthcare at the right treatment level. The Government will assess recommendations from the Expert Committee on Thematic Organisation of Mental Health Care, proposals for reorganisation measures from the regional health authorities and review of reporting requirements in the mental health service. Further, the Government will assess recommendations in a report on forensic psychiatry and other measures for those committed to treatment. The Government will also assess recommendations from the Committee, which will investigate how inmates with mental health disorders can be taken care of and evaluate the special penal sanctions referred to in Chapter 4: services for people with long-term and complex needs.

Trends in the use of mental health services

After several years with a stable patients rate in the mental health service, there was an increase in the number of patients from 2020 to 2021. The increase was particularly large in the services for children and adolescents. In the same period, there was an increase in both the activity and capacity of outpatient clinics (including ambulatory) measured in the number of consultations and man-years. This applied to services for children, adolescents and adults alike. For adult inpatient services, there was a reduction in the number of beds and inpatient stays from 2012 to 2021 (refer to Figures 3.2 and 3.3). There was only a minor change in the inpatient services for children and adolescents during the period.

Figure 3.2 Trends in activity in the child and adolescent mental health service (PHV-BU) and adult mental health service (PHV-V), 2012-2021. Per 1000 inhabitants in the target group (0-17 years, 18 years and older).

Source: The figure is based on the statistics from SAMDATA Specialist Health Service, Department of Comparative Statistics and administration information at the Norwegian Directorate of Health. Data are collected by the Department of Health Registries and the Norwegian Directorate of Health.

In the child and adolescent mental health service, the contact/consultation rate was relatively stable from 2012 to 2017 (refer to Figure 3.2). From 2017-2018, the consultation rate dropped due to, inter alia, the introduction of a new patient data system in Central Norway Regional Health Authority (RHA). The drop must also be seen in connection with the introduction of activity-based funding (ABF) in 2017, which may have resulted in changes to reporting practices.[85]

From 2019 to 2020, there was a clear increase in the number of contacts with patients in the child and adolescent mental health service linked to telephone and video consultations in connection with the COVID-19 pandemic. There was a slight decline in these types of contacts from 2020 to 2021, but institutional outpatient clinic contacts increased. Overall, the rate for inpatient care in the child and adolescent mental health service increased slightly.

When looking at the period from 2012-2021 as a whole, the rate for outpatient contacts/consultations in the adult mental health service also increased (refer to Figure 3.2). There was also a decline in the consultation rate in this sector from 2017 to 2018 followed by an increase in the last three years.

In the adult mental health service, the inpatient rate decreased in the whole period from 2012 to 2021. There was a higher decrease in the volume of inpatient stays from 2019 to 2020 compared to previous years. This is connected to the fact that emergency preparedness represented a large portion of the treatment offered during the pandemic. On the whole, the duration of immediate help/admissions is shorter than other admissions and leads to a reduction in the volume of inpatient stays.

In the services for adults, the inpatient rate decreased for the whole period up to 2021, whilst the inpatient rate for services for children and adolescents was relatively stable (refer to Figure 3.3).

Figure 3.3 Trends in inpatient beds in the child and adolescent mental health service (PHV-BU) and adult mental health service (PHV-V), 2012-2021. Per 10,000 inhabitants in the target group (0-17 years, 18 years and older).

Source: The figure is based on the statistics from SAMDATA Specialist Health Service, Department of Comparative Statistics and administration information at the Norwegian Directorate of Health. Statistics Norway (SSB) collects data on inpatient beds in the mental health service.

Projection of the need for services

Mental health service be of high quality and correctly dimensioned in line with the population’s needs. The regional health authorities are responsible for dimensioning the services, and the work on projections is strategically important to enable the regional health authorities to plan for enough capacity in the longer and shorter term.

The regional health authorities have recently assessed what the demand will be for mental health services and cross-disciplinary specialised treatment for substance use disorders (TSB) in the years to come. This applies to the demand for inpatient beds, outpatient clinic services and ambulatory treatment, and whether there are any groups that will need more health services in the future. Based on the analyses, they have revised the national projection model for the need for services, personnel and competence in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB).

A new projection model will facilitate good professional solutions and sustainable development of health services up until 2040, contribute to reducing undesired variation and strengthen the services for groups who will have a greater need for health services in the future, improve quality and increase the use of technology. The model shall form the basis for planning education and recruitment of personnel, planning of new buildings, procurement of health services, establishment of technological infrastructure, and the organisation and setting up of health services.

The analyses on which the projections are founded show that there was a significant increase in the number of referrals and activity within child and adolescent health care from 2019 to 2021. Scoring of the patients’ level of functioning shows a slightly lower level compared to earlier. This indicates that these patients are considered to need healthcare from the specialist health service and do not have mild disorders that could be taken care of by municipal health and care services. Eating disorders are one of the most severe mental health disorders suffered by children and adolescents. and a higher increase than the previous year has been observed. In 2021, the number of patients with eating disorders amounted to 30 per cent of the total national consumption of inpatient admission days.

There was also an increase in referrals to the adult mental health service from 2019 to 2021, particularly in the 18-25-year age group, but the increase in the total volume was lower. This shows that the highest increase in the special health service from 2018/2019 to 2021 were those between the ages of 12 and 25. The waiting time in the adult mental health service increased from 46 days in 2021 to 50 days in 2022. In the child and adolescent mental health service, the waiting time increased from 50 days in 2021 to 53 days in 2022.

There is currently little indication that the burden on the child and adolescent mental health service will be reduced, and facilitation of a general increase in the capacity of the child and adolescent health service is needed, particularly a strengthening of outpatient services in general and more specifically services for patients with eating disorders. It is also necessary to strengthen the service for children and adolescents under the care of the child welfare service with mental health problems and disorders.

Both inpatient care and outpatient clinic services for patients with severe disorders need strengthening. The analyses also show that there has been a significant increase in the number of people committed to treatment in recent years. At the same time, there has been a general increase in the number of inpatient days for patients referred for some form of compulsory treatment. There are also indications of comorbidity changes in some patient groups. In this case, patients with concurrent addiction disorders and mental health disorders (COD patients) particularly stand out. The projections show there are problems with capacity throughout the treatment pathway for people with severe mental health problems. A well-developed day and outpatient service may reduce the need for inpatient admissions provided there are time-intensive treatment programmes and strengthened outreach efforts at outpatient clinics. services for patients with severe mental illness are discussed in more detail in Chapter 4.

In 2023, the Government has increased the National Budget with earmarked funding for mental health. MNOK 150 of the increased basic hospital funding in 2023 will go towards strengthening inpatient child, adolescent and adult mental health care. In the revised National Budget for 2023, the Government has proposed that the framework for hospitals will be permanently increased by BNOK 2.5 above the adjustment for prices and wage growth. Mental health has been singled out as an important prioritisation for the funding.

A projection shows that a key prerequisite for improving capacity in all the services is continued strengthening of municipal health and care services with services for patients with mild and moderate conditions. The projection has not investigated how a measure for building up municipal health and care services with services for patients with mild and moderate conditions will impact the municipalities or whether the municipalities will have the capacity or competence to do this. New tasks for municipalities must be authorised by law and investigated in line with the principles and guidelines for state management of municipalities (refer to Chapter 3.2.2 for a discussion on developing low-threshold services in municipalities). The Government will facilitate the strengthening of low-threshold services in the municipalities early in the plan period.

Health and care services are continuously changing. This is necessary in order to improve investigation and treatment, safeguard sustainability and to exploit joint resources as best as possible. For improved sustainability, the use of effective treatment, increased use of technology and better coordination across the service levels is paramount. It is expected that new treatment methods, building designs and better use of technology will impact several aspects of the health services offered. They can increase the accessibility of health and care services, shorten the duration of treatment, reduce the need for inpatient admissions and contribute to reducing the implications of geographic distances.

The regional health authorities have been commissioned to work further on measures to increase the capacity of priority areas within mental health care and cross-disciplinary treatment for substance use disorders where necessary in the longer and shorter term, and measures to retain and recruit personnel within mental health care and cross-disciplinary treatment for substance use disorders to cover the need for staffing and competence. The regional health authorities will submit their recommendations and reorganisation measures in early autumn 2023.

Demand projections are first and foremost a tool that enables the health regions to plan and dimension the services, and the regional health authorities recommend that the projections for what is needed are revised every four years. The updated projections form the foundation for the regional development plans up until 2040.

On the basis of the analyses from the projection, the Government will within the frameworks of hospital finances enable the regional health authorities to strengthen the general capacity to treat and follow-up children and adolescents with mental health disorders in the specialist health to reduce the waiting time, and to have special focus on treatment pathways for patients with severe mental illness. One of the Government’s defined performance measures is to prevent the reduction of today’s total number of beds and ensure that the inpatient capacity of the mental health service is at a level that satisfies the demand for taking care of children, adolescents and adults with severe mental health disorders who need inpatient treatment. The goal will be evaluated every four years in line with the projection revision. The Government will further assess how inpatient care can be arranged in the best possible way based on the projection and recommendation of the Expert Committee on Thematic Organisation of Mental Health Care.

Moreover, additional measures to strengthen the cooperation and to assess the distribution of responsibility between the child welfare service and health services for children with mental health challenges and addiction problems will be considered following submission of the Expert Commission on Child Welfare’s report in autumn 2023. It is important that these two sectors are viewed in relation to each other and that the treatment needs of children under the care of the child welfare service are covered by the right sector.

The new and more detailed projection model for the mental health service forms a good foundation for the regional health authorities to strengthen the service for those who will have more need for health services moving forward. In addition, this model will contribute to reducing undesired variation in the services offered. The regional health authorities will be asked to provide information about how they are doing compared to their own projections annually.

Joint referral unit

Today, patients who are referred to a contracting specialist, specialist doctor or specialist in psychology, who have an operating agreement with regional health authorities, do not have the same rights as patients who are referred to a District Psychiatric Centre (DPS). Their rights are not assessed in accordance with the Patient and User Rights Act This means that the patients do not have the right to have their referrals assessed within ten days. Additionally, the patients do not have a legally binding deadline for when healthcare must start at the latest.

The regional health authorities have been commissioned to establish a joint referral unit where GPs/referring parties can refer all patients who need investigating and treatment within the mental health service to one place. This is where referrals will be assessed, and those who have the right to healthcare will receive it from a contracting specialist or District Psychiatric Centre (DPS).

The establishment of a joint referral unit will in all likelihood lead to a change in referral practices and prioritisation in the mental health service. The change will lead to more equal and appropriate prioritisation of referrals to the specialist health service, whilst at the same time provide a better overview and better exploitation of the total capacity. By establishing a one-way-in referral system, patient rights will be maintained at the same time as it will be easier for GPs to refer patients to the specialist health service.

A joint referral unit will also provide the opportunity for further developing the cooperation between the specialist health service and municipal health and care services in connection with the assessment of referrals. During the plan period, the Government will investigate how a joint referral unit can include cooperation with the municipalities to ensure better prioritisation and task distribution so patients receive essential healthcare at the right treatment level.

3.3 Further development of digital programmes and services

Correct use of technology and digital solutions are fundamental to the development of services, and are important for ensuring sustainable health and care services. The introduction of technology and digitalisation may contribute to correct disposal of available resources in new and better ways. Digital programmes and services can make health and care services more accessible, improve capacity and enable flexible pathways and early assistance. In turn, this can reduce inequalities in the services offered and good digital tools may make it more attractive to work in the services. At the same time, the use of digital solutions requires awareness of the fact that such measures are not necessarily suitable for all recipients of services or in all phases of a treatment pathway. By encouraging more people with mild mental health issues to use self-help tools and digital programmes, it allows those with specials needs to have more time with healthcare personnel.

More use of digital services and programmes requires citizens and patients to have good digital literacy skills. Digital health and care services is a priority area in the municipalities’ joint e-health plan. A national introduction strategy for Helsenorge is being prepared.

Textbox 3.6 Trigga.no

Trigga.no is a course portal designed to help people who are struggling with substance dependence or are at risk of developing substance dependence.

The courses are aimed at citizens who find that substance use, social media, sugar, exercise, gaming, gambling, etc., adversely affects their quality of life and wish to change their habits. The goal is help more people quicker.

Experience has shown that more young people and the elderly get in touch, despite the shame, because the programme is digital.

The course portal was developed by the Coping Unit in Sandnes Municipality. Cooperation has been entered into with 13 other municipalities regarding the use of courses.

Source: Trigga.no

Conversion to extended use of digital solutions can be resource-demanding during a transition period, as it sets new requirements in relation to employee skills in using, understanding and interacting on new platforms.[86] Additionally, it is necessary to build up a culture for changing and adapting to new digital tools in the health and care sector. At the same time, future healthcare personnel will have knowledge of digital services as part of their education, which may contribute to increased digital awareness of the work tasks that healthcare personnel will meet in their working lives.

The use of digital consultations within mental health care increased massively in Europe due to the COVID-19 pandemic.[87] The Health Policy Barometer 2021 showed that 29 per cent of the population believes it would have been easier to seek help for mental illness if it had been available digitally.[88] At the same time, municipalities report that digital contact during the pandemic functioned poorly for some of those with the most severe disorders. This was due to a lack of equipment, expertise, personal preferences or the illness was not suitable for digital follow-up.[89]

Increased digitalisation of services and programmes provide more opportunities but also lead to a higher risk of digital exclusion. As planned, the Ministry of Local Government and Rural Development will present an action plan in June 2023 for increased inclusion in a digital society. The action plan is primarily aimed at groups who experience digital barriers and digital exclusion. It highlights the fact that one’s health and life situation can stand in the way of digital participation. This must be taken into consideration when designing digital services by taking care of the principles of universal design and assisting with good training and guidance for users with limited or deficient digital skills.

Children and young people have excellent digital skills and many spend a lot of time in digital arenas. Digital arenas give children and young people the possibility to become familiar with support services on their own terms and when it suits them. DigiUng shall offer both self-help tools and individual follow-up at ung.no This is an important effort to give adolescents accessible help. See below for a more detailed discussion on DigiUng.

The Government will continue to build on the national e-health solutions such as Norsk Helsenett SF (The Norwegian Health Network), Summary Care Record, E-prescription and helsenorge.no. This enables the municipalities and hospitals to work better together and put into place technology and new functionality that all the health and care services need. The solutions will contribute to relevant personnel having access to the right information at the right time and place. These digitalisation measures will largely have a positive effect on the services and therefore the services aimed at mental health. The benefits of digital solutions are immense in that they improve availability and give better access to the services. Furthermore, there are socioeconomic benefits in the form of giving help at a lower effective care level. In the National Health and Coordination Plan, the Government will give an overall presentation of digitalisation in health and care services. Additionally, see Chapter 4.3.1 regarding good patient pathways.

From calendar-based to needs-based follow-up

Patients have traditionally experienced a hospital-based and calendar-based specialist health service where patients are called in for outpatient follow-up according to a defined time interval. Digital health services allow patients to alternate between physical and digital meetings as needed, and different types of digital treatments facilitate more expedient dialogue between patient and practitioner.

Remote follow-up and user-controlled outpatient clinics will to a greater extent contribute to patients with long-term conditions and disorders being followed up over time, but the follow-up will be adapted to the patient’s need for help during different illness phases.

The Government wants to test user-controlled outpatient clinics at District Psychiatric Centres with digital monitoring. User-controlled outpatients clinics have barely been used in the Norwegian Health Service, but are discussed in a new model for projections in the mental health service and the effect of digital health services have been added to the model. The regional health authorities have been commissioned to continue working on conversion measures and will submit recommendations in autumn 2023. The need for national measures will be discussed in the National Health and Collaboration Plan.

Guided online treatment

A considerable amount has already happened with digital mental health services. Online treatment allows more people, who need it, to seek help. In 2019, the Beslutningsforum for nye metoder (New Methods Decision Forum) approved the use of therapist-guided online treatment for mental health disorders when it is considered appropriate. Online guided treatment with the eMestring program has been taken into use for treating patients with depression, social anxiety and panic disorder. It is based on a treatment programme developed by Haukeland University Hospital Trust. It will now be used in all regions, and the Government will facilitate further development and implementation of guided online treatment.

Digital self-help tools

More recent evidence syntheses indicate that apps and other digital self-help tools can prevent and contribute to coping with mild to moderate mental health issues and disorders.[90] Apps and other digital self-help tools may give people better support in preventing and coping with various issues and problems, or support self-monitoring during various illness pathways.[91] Many can benefit from learning, training and practising some steps that can help to improve coping with stress, anxiety and apprehension.

The advantage of apps is that they are accessible whenever and wherever a person is, and can be used by the patient/user themselves or via a digital referral. Some people may also find it easier to use an app than to seek physical support services. A variety of good tools developed by Norwegian expert environments already exist. Apps can be good educational tools based on recognised principles in a new and engaging wrapping. Such tools can be used with or without the support of healthcare personnel.

Textbox 3.7 Apps for Preventing and Coping with Mental Health Issues

During the COVID-19 pandemic, the Norwegian Directorate of Health acquired five different tools that might help with prevention and coping with mental health issues. The Thought Virus App was downloaded more than 100,000 time and had 80,000 active users after twelve months. Measured with patient-reported outcome goals, seven of ten users experienced improvement in the burden of symptoms, somatic discomfort and general quality of life in relation to health. The Norwegian Directorate of Health has received extremely good feedback from users, GPs, health nurses and mental health service personnel.

Source: The Norwegian Directorate of Health

Textbox 3.8 Mental health Coping Tools

Several Norwegian municipalities participate in pilot testing of mental health coping tools. The tools are used by citizens of the municipalities along with a practitioner. The main goal is to ensure effective and accessible digital treatment of mild to moderate mental health disorders for the citizens of Norwegian municipalities. The Norwegian Institute of Public Health will evaluate the pilot, and the plan is to carry out a randomised controlled trial of the effect on people who receive digital tools in the pilot and those who receive traditional treatment.

The public can find digital tools and courses for mental health issues at helsenorge.no that may substantially help and benefit them. It is important to make these tools more accessible. The tools may contribute to preventing exacerbation and postponement of more expense and resource-intensive treatment measures, particularly if they are used for early intervention in collaboration with the health service.[92] Infrastructure is in place to enable GPs to send digital referrals to a digital tool to their patient via the ‘Verktøyformidleren’ app. The patient finds a prescribed tool via a text message with a link to the tool catalogue at helsenorge.no.

As part of the escalation plan, the Government will facilitate further development and implementation of digital self-help tools, and increased the grant for this in 2023. The main goal is to ensure effective and accessible digital treatment of mild to moderate mental health disorders for the citizens of Norwegian municipalities.

DigiUng and ung.no

Children and young people need and request quality assured information, advice, guidance and help via digital platforms. They want services that are accessible instantaneously on their own terms. Digital accessibility for both information and services—across the sectors—is necessary in order to reach and help children and young people. The goal is for children and young people to find easily accessible and quality assured information, guidance and services. Digital services are an important part of low-threshold services for children and young people. The Government has concluded that ung.no shall be the state’s primary cross-sectoral channel for digital information, dialogue and digital services for children and young people across the service levels through the realisation of DigiUng. Grants for this will therefore be increased in 2023. Seven ministries and underlying agencies are collaborating on DigiUng. In addition, refer to the discussion on the digital health centre ‘DigiHelsestasjon’ in Chapter 3.2.2. The target group for ung.no is currently young people aged 13-20.

Today, most ten-year-olds in Norway have a smartphone and 56 per cent of them use social media.[93] Most children under the age of 13 are online as much as 15 and 16-year-olds despite the fact that they cannot be expected to have the same ability to exercise digital judgement or source criticism. Nonetheless, very few websites and apps are intended for children. Even though many websites and apps have age limits, they are used by children younger than the specified age limit. The content of the majority of websites and apps is not quality assured and many are operated due to commercial interests. Users are largely exposed to advertisements and, in some case, inappropriate/harmful content and unpleasant interactions (refer to Chapter 2.3.5 for a discussion on social media and mental health).

By offering quality-assured and preventive information and guidance to children under the age of 13 online will fill in a gap in public services for children and young people. This will be an important supplement to information and education given in other arenas. It is estimated that ung.no received more than 5,000 questions from around 100,000 users from children under the age of 13 in 2021 despite the lower age limit of the service being 13 years old. This clearly indicates that ung.no and DigiUng may be services that meet the needs of this age group. User insight, however, shows that different age groups have different needs, expectations and user patterns, and that digital services must be age appropriate. The Ministry of Health and Care Services and the Ministry of Children and Families will therefore give the Norwegian Directorate of Health and the Norwegian Directorate for Children, Youth and Family Affairs the task (in cooperation with other relevant agencies) of further investigating the needs of the under 13s as a basis for further work on developing the service for this group.

Single gateway to information

It is important for both those who need help and those who give help that the information on the services offered is transparent and readily accessible. A digital gateway is needed to all information about relevant services in the municipalities for people with mental health issues and disorders, and addiction problems. The measures that are developed to provide an overview of the services must take care of the need to reach out with information to non-digital citizens. Further, they should include information about services linked to psychosocial follow-up after disasters and crises.

The municipalities benefit from giving their citizens good and adapted information about programmes and services, and should have good websites with easily accessible information. This is also important for the specialist health service. When introducing clinical interviews (refer to Chapter 3.4.1), it is particularly important that the specialist health service has good dialogue with the municipality and an overview of its services.

Textbox 3.9 Child and Adolescent Health Services

Those who need help and those who help children and adolescents must understand the different services and their role and responsibility. This is how we can create better support services. Child and Adolescent Health Services is a tool for helping professionals give children and adolescents cohesive support services, but it also gives information to children, adolescents and parents/guardians on where to get help. The effort consists of seven coordination pathways for the most common mental health issues in children and adolescents. The pathways function as a map of the services, and give both professionals and users a better overview of those who hold responsibility in the services and where one can get help. Child and Adolescent Health Services was started by Fonna Hospital Trust and is being rolled out several places in Norway, among others, in Møre og Romsdal.

Source: Møre og Romsdal Hospital Trust, n.d.

The Ministry of Health and Care Services has commissioned the Norwegian Directorate of Health to investigate whether and how the overall services from the municipalities can be communicated to the citizens through a single gateway at the municipal level. The commissioned assignment may also be relevant to how one can ensure a single gateway for information for citizens with problems related to mental health and addiction.

3.4 Improve services for children and adolescents

Many children and adolescents with mental health challenges receive good help and support from parents, friends, teachers or others in the local community. Conversations with the health centre and school health service, a GP or own low-threshold service can be useful for children and adolescents in recognising what difficult feelings are and what might be symptoms of a mental health disorder. Some have problems that may be long-term and complex, and need more help from support services. The Government wants children and adolescents, who need them, to receive good treatment services.

The Government will therefore strengthen both accessibility to the health centre and school health service, ensure accessible evidence-based low-threshold services in municipalities, further develop child and adolescent specialist health services and models for cooperation between municipalities and the specialist health service, and ensure better cross-sectoral cooperation through continuing to fund programmes for children and adolescents (refer to Chapter 3.4.2 for a discussion on funding programmes). The Government wants children and adolescents, who are referred to the child and adolescent mental health service, to be offered a clinical interview to clarify further follow-up from the specialist health service or municipal health and care services if needed. This means that a rejection exclusively based on a written referral should not normally occur, and assumes good and systematic cooperation between the mental health service and the municipalities (refer to Chapter 3.2.2 for a discussion on the health centre and school health service and evidence-based low-threshold services in the municipalities).

3.4.1 Cooperation between the child and adolescent mental healthcare services and the municipalities

Several reports indicate problems attached to coordination between municipalities and the child and adolescent mental health service. The report of the Ombudsperson for Children Jeg skulle hatt BUP i en koffert (I should have had the Child and Adolescent Psychiatric Clinic in my Suitcase) points out, among other things, problems with various practices when assessing referrals, that children and adolescents who need prompt help are not taken care of, and that they do not always have access to the right healthcare. The Ombudsperson for Children points out that the services in municipalities and the child and adolescent mental health service must be seen in relation to each other and that mandatory measures are necessary. In the report of the Ombudsperson for Children Hvem skal jeg snakke med nå? (Who should I talk to now? from 2022 on healthcare for children and adolescents in the municipalities recommends a flexible and adapted service with the necessary frameworks for cooperation with Child and Adolescent Psychiatric Clinics (BUP).[94]

The Office of the Auditor General of Norway’s report on mental health services from 2021 shows that youth with concurrent mental health disorders and addiction problems do not receive adequate treatment. Mapping conducted by the Norwegian Healthcare Investigation Board (UKOM) in 2021 on services for children and adolescents in the mental health service shows a gap between health services in the municipalities and those in the specialist health service.[95]

During the plan period, the Government will further develop models for cooperation between municipalities and the special health service around children and adolescents including the introduction of clinical interviews. This should be entrenched in the medical communities. and will be seen in connection with measures in the National Health and Collaboration Plan. Further, integrated youth services at one level will be investigated and piloted (preferably in all regions) for young people with mental illness and/or addiction problems, and will also include cross-sectoral cooperation. The setting up of cross-sectoral cooperation must be assessed in more detail. For instance, it may be relevant to assess stronger cooperation with the child welfare service and Norwegian Labour and Welfare Administration (NAV).

The problems attached to organisation and coordination can also be addressed in other ways. Among other things, the Government has invited municipalities and county municipalities to apply to become pilot municipalities, and thereby have the opportunity to test new ways of solving tasks through exemption from the regulations. For instance, it may be relevant to pilot challenges connected to coordination and transition between sectors and services both within and between the different welfare services, and other measures that promote earlier and more coordinated efforts for children and adolescents.

It is important to reduce the threshold so that adolescents receive mental health assistance, regardless of finances. The Government will consider removing the deductible for young people up to and including the age of 25 for treatment from mental health services as a way to contribute to reducing the threshold for mental health assistance, and to prevent personal finances deciding what kind of help one receives.

Clinical interviews

Many children and adolescents are rejected by the mental health service exclusively based on written referrals. Apart from a rejection being perceived as problematic by the person concerned, experience shows that some of those who are rejected are referred again. In the meantime, the condition may have got worse. Therefore, they do not receive help when they need it.

The Government is working to ensure that more people receive the right mental healthcare more promptly, and one of the goals is for everyone who is referred to the child and adolescent mental health service to be offered a clinical interview where the service meets those who need help. This also applies to children who have an unclarified care situation and need to be followed up by the child welfare service.

Several of the child and adolescent mental health clinics have established cooperation between the specialist health service and municipal health and care services in connection with the assessment of referrals. This type of cooperation contributes to better and more targeted referrals to the specialist health service and better prioritisation and task distribution, so that patients are given essential healthcare at the right treatment level and there are fewer rejections of the right to essential healthcare. An important added value of such cooperation is that patients/next of kin and the referring party find that their need for assistance, investigation and/or treatment are met. In addition, it will be possible to better plan and exploit the resources in the various patient pathways. It is also important that children, who are under the care of the child welfare service and need assessing by the specialist health service, are assessed (refer to the discussion on children and adolescents under the care of the child welfare service in Chapter 4.4.2).

Many hospital trusts have already come a long way in arranging for children and adolescents, who have been referred to the child and adolescent mental health service, to be offered an interview to clarify their further needs. This enables children and young people to receive more prompt help in the right place at the right time, and they can avoid developing even more serious problems. This is done in various ways and different terms are used for the services.

The comprehensiveness of the assessment that is given during the first interview varies. Some health trusts have established half-day investigations and report that the practitioners find it meaningful to be able to offer prompt and thorough assessments. They experience that more children and adolescents are taken care of by the municipal health and care services, and report that they have become better at looking at what they should offer in their services. It has also been observed that the quality of the referrals to the child and adolescent mental health service has improved.

One important prerequisite for offering clinical assessments is that the child’s municipality of domicile can offer services if the specialist health service finds after the assessment that further follow-up from the specialist health service is not needed, but other help is.

An interview for everyone who is referred to the child and adolescent health service can reduce the threshold for making referrals. In order to ensure a sustainable service for children and adolescents, it is essential that the municipalities have good low-threshold services, good coordination and prioritisation of who will be referred to the child and adolescent mental health service, and correct follow-up for those who do not need help from the child and adolescent mental health service.

During the plan period, the Government will assess instruments that can underpin the introduction and implementation of the initiative for everyone who is referred to the child and adolescent mental health service to be offered a clinical interview. For instance, the assessment of how the medical communities and national patient pathways can be used to contribute to more systematic cooperation between municipalities and the specialist health service regarding clinical interviews. The introduction of clinical interviews for everyone means that around 8,500 new patients will be accepted for an interview in the child and adolescent mental health service, but this does not mean that 8,500 more patients will proceed further in the specialist health service patient pathway. Transitory experiences from, for instance, Øvre Romerike Child and Adolescent Psychiatric Centre (BUP) show that some are rejected after the clinical interview, whilst others are considered to need specialist health services, and others are offered further services in the municipality. The introduction of clinical interviews involves increased cooperation with the municipalities to clarify the right support. This is a major change for the services. The introduction will be evaluated afterwards to enable the development of sustainable models that contribute to satisfied patients and next of kin. The Government wants everyone to be offered a clinical interview in the longer term. As part of the evaluation, an analysis will be performed on the financial and administrative consequences of a potential expansion.

Integrated services

In order to prevent, detect and offer early intervention to children and young people who need mental support services, increased cooperation and coordination between the service levels is necessary. It is also necessary to strengthen the services for young people with addiction problems, children and adolescents in the child welfare service, and children and young people completing sentences, and to include schooling/work to a greater extent in the follow-up and treatment of young people. Increases knowledge sharing between levels and sectors is also needed.

Experience and testing have shown better results with concurrent integrated follow-up and treatment. Research shows that integrated health and work-orientated follow-up in workplaces leads to more people with severe mental illness getting jobs.[96] There are multiple ways of giving more cohesive and integrated services.

ACT and FACT are models for assertive outreach and concurrent holistic services for people with severe mental illness and/or addiction problems. The Youth FACT team gives integrated and assertive outreach help to youth with serious complex needs. In the evaluation of Youth FACT pilot projects, the youth described Youth FACT as a service that was adapted to their needs, they were better taken care of in the relationship and they found that the team was more flexible and accessible than other services with which they had experience (refer to Chapter 4.3.2 for a more detailed discussion on ACT, FACT and Youth FACT.

In the projection report, the regional health authorities (RHAs) refer to other countries that organise the service in three parts with services for children, youth/young adults and adults. The RHAs make reference to the fact that a separate youth service, for instance, from the age of 15 to 25 will give better transitions and coherence in the treatment services.

Several initiatives have been implemented to improve the services for children and young people. Among other things, the Government will include more young people in education, the labour market and community life through a cross-sectoral and targeted effort (refer to the social mission in the long-term plan for research and higher education). Cross-ministry work is currently being carried out on following up the BarnUnge21 strategy where the goal was to create a targeted, holistic and coordinated national effort for research, development and innovation for vulnerable children and young people.

The Core Group for Vulnerable Children and Young People was established for, among other things, to facilitate cross-ministry cooperation on children and young people (refer to Chapter 2.1.1 for a more detailed discussion on the core group).

Input for the work on the escalation plan from, among others, the regional health authorities and the Norwegian Directorate of Health indicates a need to investigate and test a model that to a greater degree ties the services together as follow-up for children and young people with mental illness and/or addiction problems. The Government will investigate and test an integrated service model at one level. The Healthcare Personnel Commission also recommends investigating more holistic organisation of the health and care services at one level.

A low-threshold service model and a single gateway to services that are more cross-disciplinary may result in prompter clarification of what help children and young people need by those with the right competence. This may contribute to preventing the need for help and young people being tossed around the sectors. It may also reduce the need for more specialised mapping, investigation and help. The setting up of cross-sectoral cooperation on integrated youth services must be assessed in more detail. For instance, it may be relevant to assess stronger cooperation with the child welfare service and Norwegian Labour and Welfare Administration (NAV).

The age group and which services should be included in a model should be entrenched in the medical communities.

The pilot project will be evaluated afterwards to find out how it should be expanded after implementation, including how any undesired skewed effects should be handled.

3.4.2 Programme funding in municipalities

Financial instruments are vital in making it possible for the state to facilitate cooperation and the coordination of services and initiatives for children and young people. The municipalities receive funds over the municipal framework and through grant schemes. Most grant schemes are aimed at specific services, measures and more defined target groups, and are an instrument for reaching special sector-specific goals. Through programme funding, we want to turn this around so the grant funds are aimed at the target group and not the individual service or/measure/sector area.

Programme funding shall give the municipalities more elbowroom to work holistically and to prioritise measures adapted to local needs that to a greater extent meet each child and youth’s need for help. The ambition is that programme funding—through creating a common understanding between the service areas, changes in the organisation of the cross-disciplinary work and coordination—shall contribute to giving children and young people the best possible lives.

A programme funding pilot study, which ended in summer 2023, has been carried out and reports from the county governors show that most municipalities have made great strides in terms of entrenching, concretising, piloting and implementing a variety of measures and cooperation models. According to the project group, it is reported that services are better coordinated, there is a more common organisation culture and better structures.

The Government will ensure that instruments are used as effectively as possible. Among other things, this involves assessing how state grants can be better used than today to achieve the goal of improved, and more holistic and coordinated services for children and young people. Programme funding is the setting up of state grants that better facilitate cross-sectoral planning and cooperation, and the Government will continue programme funding during the plan period.

3.4.3 Improve care mental health care for children and adolescents

An eating disorder can have a major effect on the life of the person concerned. In the case of children and youth, eating disorders can make it difficult to participate in important arenas, such as school, leisure activities and in social contexts. Family and other next of kin can also be strongly affected at the same time as they are often an important resource and support network for the ill person.

There has been an increase in the number of referrals to the specialist health service and the number of people treated for eating disorders the last few years.[97] The increase started before the COVID-19 pandemic, but was high both before and after the pandemic.

An increase was also seen in the number of eating disorder diagnoses among girls in the primary health service during the pandemic.[98] Eating disorders in many people are still not detected and treated, and many wait a long time before seeking help. The health trusts report that many are more afflicted than before when they are first referred.

The prognosis for many people with an eating disorder is good, however, there is still a group of people who have a long-term pathway and significant somatic complications.[99] International research shows that anorexia is the mental illness with the highest risk of premature mortality.[100]

The Government will strengthen prevention, early detection, early intervention and treatment of eating disorders by developing programmes for increased knowledge and competence, models for municipal services and coordination measures, and to assess the organisation of care offered in the specialist health service.

National professional guidelines have been prepared for early detection, investigation and treatment of eating disorders[101] , and national patient pathways for eating disorders in children and young people up to the age of 23.[102] These include recommendations for the primary health service and specialist health service regarding risk and vulnerability factors, investigation, follow-up and cooperation. The health centre and school health service can help with the early detection of children and young people struggling with symptoms of eating disorders and ensuring that they receive necessary help and monitoring GPs are often one of the first in the health service to meet people with eating disorders. GPs are important in identifying, investigating and potentially treating and referring people to the specialist health service, and following up completed treatment from the latter.

All child, adolescent and adult mental health clinics offer services to people with eating disorders, and the regional health authorities have established regional units for treating particularly severe eating disorders.

The treatment services, both outpatient and inpatient care, have been strengthened to meet the increased demand. In a representative proposal (Document 8:166 S) from 2022, the Storting requested the Government to ensure that «…all mentally ill children and young people under the age of 13, if they need it, have access to inpatient treatment both on weekdays and at weekends in their region.» Status information was collected from all the regional health authorities and the feedback showed that capacity had increased and they all had accessible inpatient services the whole week, but in some health trusts patients were transferred to other departments at weekends. However, waiting times and services vary in the health trusts. The projection shows a need for increased capacity in eating disorder treatment in the specialist health service.

A quality registry for eating disorders (NorSpis) has been established.[103] The registry does not at the present time extensively cover the whole nation. Extensive work is being carried out to improve the degree of coverage in order to contribute to higher quality in the treatment of patients with eating disorders.

The national patient pathway for eating disorders and the national guidelines on eating disorders primarily focus on the specialist health service. More guidance material is needed for the municipal health and care services.

Many prevention methods have been developed for eating disorders, but there is no updated knowledge base indicating the extent to which these methods can be used to reduce the number of people who develop such illnesses.

The Government has in 2023 granted funding to strengthen the work on prevention, early detection, intervention and treatment of eating disorders. This will contribute to insight work that illuminates the challenges, and which form the basis for measures, including an evidence synthesis on preventive measures, the development of a program for improved knowledge and competence, and development of models for municipal services and coordination measures.

3.5 Work and physical activity as part of the treatment

For the majority of people, who are of working age, work and health are important factors in life. Often they are intertwined. In many cases, participation in work promotes health. Norway has a relatively high percentage of recipients of health-related benefits, and many are excluded from the labour market due to health problems. Statistics from the Norwegian Labour and Welfare Administration show that mental illness is one of the most common diagnoses among people who receive health-related benefits.[104] In order to help more people get jobs and to reduce the percentage of young people who become disabled due to mental health issues and disorders, the Government will strengthen the effort for work and activity as part of treatment and follow-up.

In the past, it has been thought that people must be well before they can work. This approach is changing. Many with health problems, including people with mental illness, can and want to work. Work participation can give a sense of acknowledgement, community and personal identity. Inclusion at work has only marginally been used as part of the health and care services’ follow-up. It is paramount that basic awareness of how important activity and work participation potentially is for mental health is prevalent in the services more than what it is today.

An important prerequisite for getting more people in work or activities is still tight cooperation between the health sector and employment sector, and work as a sub-goal must to a larger degree be incorporated into ordinary health and care services. Further, it is important that effective cooperation models between the health, labour and welfare sector are developed, spread and taken into use. The goal is to include more people with mental health issues or disorders in work, activities and education, and reduce non-participation in the labour market through simultaneous or coordinated assistance from both the Norwegian Labour and Welfare Administration and health and care services.

Several models exist for cooperation between the Norwegian Labour and Welfare Administration and health services for different types of users and patient groups. For instance:

The Individual Placement and Support (IPS) is an evidence-based cooperation model which is considered to be an innovative work method in the health and care services. It is a voluntary service for people with moderate to severe mental illness and/or addiction problems receiving treatment from the health and care services. The aim of IPS is to help people, who wish to participate in the labour market, to get a job with ordinary wages through individually adapted treatment and job-orientated follow-up from employment specialists. It has been documented that IPS gives good results for the target group.[105]

IPS assumes mandatory and tight cooperation between the health and care services and the Norwegian Labour and Welfare Administration where IPS employment specialists are an integral part of the permanent treatment team in the health and care services. The prevalence however varies between the different counties, and continuation and expansion of the IPS service is desirable so that more of the target group can benefit from it.

A separate study for individual placement and support for young adults under the age of 30 has been created to help more people get jobs or complete education/apprenticeships. The study is now being evaluated. Further development of individual placement and support for young adults will be considered based on the evaluation.

The section for clinical drug and addiction research ‘RusForsk’ and the C3 – Centre for Connected Care at Oslo University Hospital Trust have cooperated to use the Early HTA simulation method to measure the benefits of IPS for patients undergoing cross-disciplinary specialised treatment for substance use disorders (TSB). This Early HTA shows that IPS for patients with substance and dependence disorders soon gives socioeconomic benefits.[106] At the same time, the evidence synthesis published by the Norwegian Institute of Public Health in 2023 shows that they cannot draw any conclusions on the effect of IPS for those with substance dependence because they did not find enough studies.[107] More studies that examine the effect of IPS on people with substance dependence are therefore needed, in addition to other studies on IPS.[108]

HelseIArbeid is a health promotion and prevention initiative linked to muscle, skeletal and mental health issues. The effort is a cooperation between the health services and Norwegian Labour and Welfare Administration. HelseIArbeid has two main components: a corporate initiative involving the conveyance of health-promoting and preventive knowledge in the workplace, and an individual-based initiative offering cross-disciplinary investigation and work-orientated assessments. In line with the Inclusive Workplace (IA ) Agreement 2019-2024, work is aimed at implementing the measure to a greater extent within the framework of today’s rules and prioritisation regulations. An evaluation of the effects of HelseIArbeid is being carried out and the initial results will be available in 2023.

The Norwegian Directorate of Health and Norwegian Labour and Welfare Administration are preparing joint national professional recommendations for service providers within the field of employment and health. Work is currently being carried out on recommendations for IPS and HelseIArbeid, and the aim is to finished and publish them during the course of 2024.

Many people with mild to moderate mental illness and/or addiction problems will also have the need to combine work-orientated services and treatment. The Norwegian Labour and Welfare Administration and the Norwegian Directorate of Health are working on developing models for coordinated services aimed at this group with emphasis on cooperation with municipal health and care services. More specifically, work is being carried out on developing a model that involves more integrated cooperation between the Norwegian Labour and Welfare Administration and Prompt Mental Health Care teams. The work is built on experience with both well-documented and tested models using existing services, such as Prompt Mental Health Care, as a starting point. The intention is that the model will be tested from 2024. Work is also being carried out on a model for more integrated cooperation between the Norwegian Labour and Welfare Administration and GP surgeries.

Meaningful activities, belongingness and capacity to cope

In addition to work-orientated measures, it is important to facilitate activities and meeting places for people with mental illness and addiction problems. Pursuant to the Act relating to municipal health and care services, etc., municipalities shall ensure that each person has the possibility to have an active and meaningful life in community with others,[109] and implement welfare and activity measures for children, the elderly, the disabled and others who need them.[110] Ensuring good and inclusive activities may contribute to improved quality of life, coping skills, and the possibility for an active and meaningful life.

During the plan period, the Government will work to ensure that people with mental illness and addiction problems have access to meaningful activities, belongingness and capacity to cope. Meeting places and activity measures form part of the low-threshold services of many municipalities. For instance, day centre services, social cafes and drop-in centres, and various group services. These type of services can be an effective and good way of conducting health promotion work. The common denominator for all of them is that they offer activities with meaningful content. Self-chosen activities contribute to making each person stronger by being the most important actor in their own lives. For many people, culture, activities and creativeness are sources of mastery and growth.[111]

In addition to the municipality’s own services, the services from non-profit and voluntary organisations are a good supplement to municipal services for citizens with mental health issues and disorders and/or addiction problems, and contribute to the community’s collective commitment to the group.

Textbox 3.10 Recoveryhjelpa Sandnes Municipality

Recoveryhjelpa offers help to citizens who want to participate more actively in society or the local environment, through various voluntary organisations. The target group is citizens with substance use and/or mental health challenges.

Peer support workers help citizens to find services offered by local organisations, teams and voluntary services based on their interests. The service was started in 2020 and is very popular.

In recent years, many municipalities have established a clubhouse run by non-profit actors in cooperation with municipalities (refer to Box 3.11).

Textbox 3.11 Fountain houses

At fountain houses (clubhouses), members and employees work together in a health-improvement working community based on the fundamental human needs of being seen, heard, contribute, master and belong to a community. The fountain houses have a rehabilitation effect through voluntary work and peer support work. A referral is not necessary and membership is free and not time limited.

The work of the fountain houses is aimed at ensuring that people with mental health challenges receive support on their path to paid work, studying and taking back control of their lives. They operate with work-orientated rehabilitation and provide holistic support to individuals and adapt and prepare for participation in the labour market and studying.

The fountain houses illuminate how everyone who does not have a job to go to can be offered help to fill their daily lives with constructive content. The service uses research on isolation and its potential exacerbation of symptoms of mental health problems, and that work, social contact and a meaningful daily life can both prevent and have a positive effect on mental health problems.

Source: Clubhouse Norway, n.d.

3.6 Prevent violence and abuse, and help and support those exposed to violence and trauma

It is totally naturally to have strong reactions to traumatic incidents, such as violence, abuse, war events, accidents and terror. For many people, the reactions will diminish after a while, but for some the distress will be permanent and lead to mental health issues. The prevention of violence and abuse is an important goal of this Government. The Government will also work on ensuring that those exposed to violence and people who are exposed to other types of traumatic incidents receive adequate help.

3.6.1 Violence and abuse

Violence and abuse is a serious public health and societal problem affecting a significant percentage of the population in Norway. The Government wants more attention to be placed on the prevention of violence and abuse, and following up and helping those exposed to violence. The Government will continue testing and researching trauma treatment in municipalities through the further development of Trinnvis sammen (Stepped Care Together), and present an escalation plan against violence and abuse against children and violence in close relationships.

The definition of violence covers physical, psychological, sexual and financial violence, and neglect. Witnessing domestic violence is considered violence. Actions termed as negative social control, forced marriage and genital mutilation are also included in the definition of violence. It is well-documented that violence, sexual abuse and neglect during childhood are risk factors for developing mental illness and somatic diseases, substance use problems and suicidal behaviour. Exposure to multiple incidents increases the risk of developing health complaints in adulthood.[112] People, who are exposed to violence, report several symptoms of anxiety, depression and post-traumatic stress reactions. Notably, the more types of violence a person is exposed to, the more symptoms of mental health complaints are reported. The burden of symptoms is greatest in people who have been exposed to violence during both childhood and adulthood.[113]

Municipalities, regional health authorities and county municipalities shall facilitate the health and care services and public dental service in preventing, detecting and averting violence and sexual abuse.[114] At the same time, the prevention of mental health issues and disorders is a violence prevention measure. The prevention must be part of a cross-sectoral effort. Violence and abuse occur in all social classes. At the same time, both seem to be more common in people with a low level of education and financial hardship, and those who are divorced or separated. Commitment to reducing issues related to living conditions is therefore an important contribution with regard to preventing and reducing violence and abuse.[115]

In order to prevent violence and abuse, it is important that the perpetrators of violence receive good help. Clinical research shows that up to eight out of ten children and adolescents who display harmful sexual behaviours (HSB) have been exposed to violence, abuse or other form of serious neglect. HSB may be a consequential condition of ongoing or earlier trauma.[116] Experiences with children and adolescents completing sentences show that many of them have been exposed to or have witnessed violence and abuse. Violations, such as violence and sexual violence, committed by children and adolescents affect other children and youth. Several measures have been implemented in recent years to improve services for perpetrators and potential perpetrators. Among other things, all the regional health authorities in Norway have established a counselling and treatment service for children and adolescents with problematic or harmful sexual behaviours (HSB), in addition detfinneshjelp.no has been established. The latter is a low-threshold online chat service and treatment service in all health regions for people who are interested in children sexually – aimed at preventing child abuse.

Considerable resources have been invested in strengthening trauma competencies in the health and care services, and other relevant sectors. The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have a special responsibility for the work on competence development in the field of violence and trauma, and offer a variety of trauma-related competence programmes for the services.

The Government want people suffering from trauma to receive adequate help. Over the course of many years, money has been granted and work has been carried out on the implementation of evidence-based treatment methods for trauma in Child and Adolescent Psychiatric Centres (BUP) and District Psychiatric Centres (DPS) across Norway. It is also important to ensure adequate help for trauma in municipalities. The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) has carried out a study on the Trinnvis sammen (Stepped Care Together) treatment model.

Textbox 3.12 Trinnvis sammen

Trinnvis sammen (formerly Trinnvis TF-CBT (Stepped-Care Trauma-Focused Behavioural Cognitive Therapy)) is a low-threshold trauma treatment for children aged 7-12 struggling with significant symptoms of post-traumatic stress disorder (PTSD) after one or more traumatic incidents. The treatment is led by one of the child’s caregivers with counselling and follow-up from a therapist who has close contact with both the child and caregiver. Trinnvis sammen is initially offered by the municipal health and care services. In the event that more intensive treatment is needed, the child will be offered a referral to the Child and Adolescent Psychiatric Centre (BUP).

The aim is that municipalities obtain competence to offer help to more exposed children, give help earlier and to improve cooperation between municipal services and the specialist health service.

Trinnvis sammen has been tested in ten municipalities with around 70-75 children and their caregivers. The report from the pilot project launched in autumn 2022 showed good treatment results for the children who participated.¹The research project has been continued and will be further developed from 2023.

Source: Ormhaug et al., 2022.

The Government wants to continue testing this model and in 2023 money was therefore granted, as part of the work on this escalation plan, for further testing and research on trauma treatment in the municipalities.

In 2023, the Government will present an escalation plan against violence and abuse against children and violence in close relationships. The Government’s measures for the prevention of violence and abuse, and help for victims and perpetrators, will be included therein. Several investigations and surveys have been carried out in recent years, which point out that the work on violence against and abuse of children and violence in close relationships is challenging, and they also provide recommended measures. This applies to both the Government Committee on Violence against Children’s report from 2017, Svikt og Svik (Failure and Betrayal),[117] the Partner Homicide Committee’s report from 2020 Varslede drap? (Forewarned killings?)[118] and the Office of the Auditor General of Norway’s survey on the authorities’ efforts against violence in close relationships.[119] In addition to these, the GREVIO monitoring committee published its report in autumn 2022 on Norway’s implementation of the Council of Europe Convention on preventing and combating violence against women and domestic violence (Istanbul Convention).[120] The escalation plan will, among other things, use these documents as a starting point. In addition, general measures for preventing mental health issues and disorders, and which strengthen the structure around children, such as a strengthened health centre and school health service, parental support, etc., are also measures that may contribute to preventing the occurrence of violence and abuse. General strengthening of treatment services in the form of low-threshold services in municipalities and increased capacity in the specialist health service should also benefit people who need healthcare due to violence and abuse.

The escalation plan against violence and abuse against children and violence in close relationships shall facilitate the development of a holistic and coordinated policy against violence in close relationships, which involves relevant sectors, agencies, institutions and organisations. Online child abuse, negative social control and honour-based violence will be discussed in the plan. People with substantial care needs dependent on other people in daily life are more exposed to violence than other groups, and therefore have a special need for protection against violence and abuse. Several of the measures in the escalation plan will also be relevant for preventing, detecting and following-up violence in these types of relationships. At the same time, more knowledge is needed about this type of violence, so further measures can be developed. Follow-up of the escalation plan for mental health and the escalation plan against violence and abuse against children and violence in close relationships must be seen in relation to each other.

The Criminal Code does not currently have a designated penalty that explicitly prohibits psychological violence. Among others, psychological violence may fall under the section 282 of the Criminal Code relating to violence in close relationships and section 253 of the said Act relating to forced marriages. Due to this, there is reason to investigate whether people who are affected by psychological violence have adequate legal protection, and whether Norway satisfies the obligation of the Istanbul Convention to criminalise the psychological violence. In 2022, a law commission was formed to investigate the general legal problems in cases concerning negative social control, honour-based violence, forced marriage, genital mutilations and psychological violence.

3.6.2 People with war experiences

Refugees

Some asylum seekers and refugees are traumatised after abuse and violence in prison, during war, when fleeing and in refugee camps. Other conditions, including earlier traumatic experiences, can also lead to or exacerbate mental problems. Post-traumatic stress disorder (PTSD), anxiety and depression occur frequently in these groups. The Norwegian Directorate of Health has prepared a guide for psychosocial measures in the event of a crisis, accident or disaster, in which, asylum seekers, refugees and reunited families are discussed.[121] A guide has also been prepared on healthcare services for asylum seekers, refugees and reunited families with a chapter designated to psychosocial follow-up.

Many of these and other refugees may have various degrees of war trauma, etc. When meeting patients with an immigrant background, it is important that information is adapted to the recipient’s individual prerequisites, including culture and language background. In some cases, communication through a qualified interpreter may be vital in order to give proper healthcare and to give necessary information to patients and next of kin.

As a result of the Ukraine war, Norway has received many refugees. People who have been displaced from Ukraine, and have temporary protection in Norway, have the same right to health services as the rest of the Norwegian population. The same applies to asylum seekers. The health authorities are observing the situation with the increased arrival of people from Ukraine, among other things, to monitor the capacity of the municipal health and care services.

The Government proposed BNOK 6 extra in the revised National Budget for 2023 for work related to Ukrainian refugees.

Veterans

Personnel deployed to serve in international operations risk exposure to various forms of stress. The physical and mental health of most Norwegian veterans is good, but some have a variety of health problems. Surveys show that veterans who have experienced a great deal of stress or traumatic exposure during service tend to have a higher risk of developing health problems.

In the past few years, competence in veteran health has been built up in the municipal health and care services and specialist health service. The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have in cooperation with the Norwegian Armed Forces developed various training services for healthcare personnel and others who come in contact with this group in their jobs. For instance, a diagnostic and treatment course for doctors and psychologists has been created. All regions have a regional professional network for deployment personnel, which contributes to dialogue and collaboration between key actors, therefore strengthening competence in local and regional veteran work. A national professional network with key actors for veterans has also been established.

In 2023, the Government will present a new cross-sectoral plan of measures for following up and acknowledging veterans and their families before, during and after service in international operations.

Personnel deployed for international service, aid workers involved in international work and deployed personnel in Norway are other groups that may encounter exposure to stress and strain or traumatic incidents through their work and develop health problems. Work has been carried out in recent years on enhancing the general competence in the support services about reactions after exposure to traumatic incidents and trauma treatment. This could also be useful for personnel from international operations and other groups with such experiences.

3.6.3 Psychosocial preparedness and follow-up during a crisis or disaster

Psychosocial work is a key part of the municipalities’ services for preventing and remedying the impact of trauma after a crisis or disaster. Pursuant to the Health and Care Services Act, municipalities have a responsibility to offer help in the event of an accident and other emergency situations, including psychosocial preparedness and follow-up. This is part of the municipalities’ responsibility to provide for their own citizens. Municipalities must ensure that the needs of each person for health and care services are covered both in the short and long-term. The need for help must be individually assessed and cannot be standardised based on what role the person had in connection with a traumatising incident.[122] For the affected with severe difficulties, it may be relevant to receive treatment from the specialist health service.

The Norwegian Directorate of Health’s guide on psychosocial measures in the event of a crisis, accident and disaster[123] underscores the importance of a proactive approach to psychosocial follow-up. Proactive follow-up entails municipalities actively and directly approaching the affected person(s), and offering them support and assistance at an early stage. Further, proactivity means that after a period of time the affected person(s) is contacted again immediately after the disaster if they do not want/are not capable of accepting help. As part of the follow-up, it is recommended that the affected person(s) receives a permanent named contact person in the municipality, who can contribute with continuity and holistic follow-up. Even though a proactive approach is an important principle in psychosocial follow-up, it is important that the principle does not contribute to people abstaining from seeking help if they need it. It is therefore important that the municipalities give clear information on their websites about available support during a crisis situation (refer to Chapter 3.3 for a discussion on a single gateway to information.

Several support groups have been created after disasters and major accidents. Support groups can also have an important function by supplementing public and professional measures aimed at individual people. Experience shows that network support is crucial and may fill other needs that are not covered by public crisis work.[124]

The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have cutting-edge competency on psychosocial preparedness and follow-up, and assist municipalities with competence enhancement, guidance and service support on the topic. The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) spreads research-based knowledge and knowledge dissemination regarding psychosocial follow-up in the event of various crises and disasters.

Experiences from, for instance, the quick clay landslide in Gjerdrum, the Ukraine war and other crises show that the ability of the health services to take care of the population’s need for psychosocial support is rapidly overrun in crisis situations. The Government will support the municipalities in the work on psychosocial preparedness and follow-up. In the National Budget for 2023, MNOK 5 was therefore awarded to the creation of a framework agreement regarding psychosocial assistance for municipal health and care services. The purpose is to give individual municipalities assistance in handling the population’s need for help during crises rapidly and efficiently.

The Ministry of Health and Care Services has started work on preparing a white paper on health preparedness. This is the first white paper to the Storting on this topic. The white paper will be overarching and provide guidelines for health preparedness. Psychosocial work will be discussed in the paper.

3.7 Prevention of suicide and self-harm

Suicide is a major public health and societal problem. Many people are affected by suicide and suicide attempts. During the last decades, considerable effort has been made to prevent suicide in Norway and many participate in the work. Despite this, the suicide rate has remained relatively stable the last 25 years. Men are overrepresented in suicide statistics. Approximately two out of three who commit suicide are men.

The Government is focused on suicide prevention and is following up the Action Plan for Suicide Prevention 2020-2025 – No one to lose.[125] Eight ministries are working together on the plan.

With the action plan the vision zero for suicide was introduced. It is a moral value that we, as a society, have no to lose to suicide. All measures in the plan contribute to the work on vision zero. An important measure for following up vision zero is the establishment of a systematic work method where every suicide is reviewed. This will provide new knowledge about how suicide can be prevented – both within and outside the health and care services. Based on the findings of this systematic approach, new measures will be assessed. Initially, the method will be tested through a pilot study.

Many authorities, such as ministries, subordinate agencies, resource centres and regional health authorities are working on the measures in the plan. A new national forum has been established for suicide prevention with representatives from knowledge and resource centres, municipalities, the specialist health service and users, next of kin and suicide bereavement organisations. The forum is headed by the Norwegian Directorate of Health. To coordinate the effort across the sectors, an associated directorate cooperation on suicide prevention has been created.

The causes of suicide and suicide attempts are complex and linked to many different life factors. Work on suicide prevention is conducted in several ways in connection with creating an inclusive society, in general with the field of mental health and specifically with suicide prevention. The action plan has both a public health perspective and service perspective. Measures aimed at next of kin and the bereaved are also included in the plan.

A low threshold for seeking help and good accessibility can prevent suicide. It is well-documented that treatment for mental illness, particularly depression, and good treatment pathways in the health service, have a good suicide prevention effect. An important part of providing good help is therefore to ensure that patients receive the right treatment for their underlying mental illness. The prevention of self-harm and suicide is also an important part of work on public health. In addition to continuing the work on measures in the action plan, efforts in this escalation plan will therefore be significant to the suicide prevention work.

Self-harm among young people is widespread. International surveys show that on average 18 per cent of young people between the ages of 12 and 18 state that they have intentionally harmed themselves. The prevalence is highest among teenage girls, but boys also harm themselves. A Norwegian survey found a prevalence of around 16 per cent.[126] Self-harm most frequently starts between the ages of 12-15, but can also start earlier or later, and the problem may be transient or longer lasting.[127]

There may be many complex reasons why someone harms themselves. Often self-harm starts as a coping strategy in a difficult life situation. Self-harm is an expression of something being wrong, but the underlying reason can vary. Research highlights some risk factors associated with why a person harms themself: underlying mental health problems, physical and sexual abuse, neglect, including psychological neglect, loss and separation, and individual risk factors, such as chaotic and overwhelming negative emotions.[128] Good communication with those closest to the person and individual resilience may have a protective effect against self-harming behaviour. In order give the necessary help, it is important to carry out a broad assessment. Cooperation between services may be important for following up self-harming children and adolescents well.

There is an overlap between some measures for self-harm and suicide prevention, and self-harm is a risk factor for suicide. Self-harm is therefore addressed multiple places in the action plan for suicide prevention. Self-harm is also a topic in Proposition 121 S (2018–2019) Escalation Plan for Child and Adolescent Mental Health (2019–2024). In line with this escalation plan, the Norwegian Directorate of Health has been commissioned to start development work on self-harm prevention.

The Norwegian Directorate of Health has also prepared guiding material for the municipalities on self-harm and suicide prevention.[129] The goal is to contribute to reducing the scope of self-harm and suicide in the population, and improved quality and more unified practices in the services. National guidelines on suicide prevention in the mental health service have been revised and expanded to apply to cross-disciplinary specialised treatment for substance use disorders (TSB) as well. These are undergoing consultation with the time limit being in June 2023.[130]

Textbox 3.13 Dialectic Behaviour Therapy

Dialectic Behaviour Therapy (DBT) is a validated treatment method for people with chronic suicidality, self-harm and emotionally unstable personality disorder.

With financial support from the Ministry of Health and Care Services via the Norwegian Directorate of Health, the National Centre for Suicide Research and Prevention (NSSF) carried out a randomised controlled trial (RCT) to investigate the effect of dialectic behaviour on adolescents (DBT-A) with repeated intentional self-harm compared to usual treatment at Child and Adolescent Psychiatric Clinics (BUP) in Norway.¹ It was found that adolescents who received DBT-A had significantly stronger reduction in the number of intentional self-harm incidents, suicidal thoughts and symptoms of depression than youths who received the usual treatment from BUP. This was the first study in the world that could prove that this short version of DBT for adolescents gave a significantly better treatment result than usual treatment, and that it played a major role in the introduction of DBT-A in both Norway and many other countries. More than 40 treatment units across the whole of Norway use the method.

The National Centre for Suicide Research and Prevention offers an education programme in DBT. Through this programme, the centre has trained around 600 DBT therapists and counsellors with 16-18 teams across Norway at any time.

Source: Mehlum et al., 2014.

3.8 Good quality of care

Good quality health services means that the treatment is effective, and safe and sound. Further, it involves the users, is coordinated, accessible and exploits resources in a good way.

In order to create good services for people with mental health challenges and to ensure more equality in the services offered, it is necessary to have systematic user and next of kin involvement, increased focus on management, change work, quality improvement, and patient and user safety. It involves contributing to user and next of kin involvement at the individual, service and system levels, and giving more support and improved next of kin care. Further, it involves managers having the necessary formal managerial competence, good tools and elbowroom to take care of their tasks and responsibility, and that the services work on change and improvement in a systematic fashion.

The Government will strengthen the foundation for evidence-based health and care services. The Government will also facilitate increased use and better coordination of the assessments in ‘Nye metoder’ (New Methods) and the Norwegian Directorate of Health’s work on standardisation products in the mental health and substance use fields.

3.8.1 User and next of kin involvement

Uses of health and care services shall influence the set-up of the services offered. The goal is to contribute to improved health and care services. User involvement has been adopted as both statutory rights at the individual level, and as organisational guidelines at the service and system levels. Users have the right to participate, whilst service providers are obligated to involve them. Users and patients shall participate as equal parties in decisions concerning their own health and own services. Further, the input and overall experience of users, patients and next of kin should be used as a basis for service development and quality improvement. This is executed in cooperation with users and next of kin organisations, and by using user and next of kin surveys and various feedback tools as a basis for improvement work. Language barriers, etc., can lead to lower participation in next of kin organisations, surveys and feedback. It is therefore important that next of kin with an immigrant background are given access to adapted information and knowledge about who they should contact for help.

User and next of kin involvement at the individual level

User and next of kin involvement can be of major value to the individual. Real participation forms the basis for ownership and participation in one’s own treatment, a better adapted and appropriate service, and improves the relationship between patient/user and practitioner.

User experiences have demonstrated that the possibility for routine feedback through tools can make it easier to interact on goals, treatment planning and strengthen user involvement. Through feedback tools, the recipients of help answer routine questions on their own experience with changes and benefits of the help. In this way, the help can be adapted and make it easier to detect whether the person receiving help actually feels better.

Shared decision-making is a form of user involvement at the individual level which is done with healthcare personnel. Shared decision-making tools can be immensely helpful in this decision process. The tools give relevant and reliable information on different conditions and available treatment options for them. A national shared decision-making tool for psychosis been prepared in the mental health service. The regional health authorities have been commissioned to develop more of this type of tool.

Good user involvement at the individual level is also characterised by the services meeting users, patients and their next of kin from a coping and resource perspective. Further, participation also assumes that the services are organised in a way that safeguards the whole of the user and patient’s existence and life. User and next of kin involvement at the individual level do not play a big enough role in the services, and the right to be informed, participate and be involved is not fulfilled for many users and next of kin.

The Norwegian Institute of Public Health has a national function for measuring user-experienced quality in health services, and conducts surveys in both the primary health service and specialist health service. In terms of mental health, continual electronic measurements are carried out among adults in inpatient care in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). From 2022, the Norwegian Institute of Public Health will also be conducting surveys on patient experiences in the child and adolescent mental health service at every outpatient clinic in Norway. In summer 2023, a new major user and patient survey on how users and patients experience outpatient treatment services in the adult mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). The survey is a cooperation between the Norwegian Directorate of Health and Sintef and will provide important knowledge for further development of the service. One-hundred and four-thousand people will receive an invitation to participate in the survey. The results will be available at the beginning of 2024.

Children and adolescents have the right to participate and adapted information. The type of participation should be adapted to the child’s ability to give and receive information. It must be arranged for children to receive information about available and suitable types of services and investigation and treatment methods that exist which they can potentially choose between. Emphasis shall be placed on the child’s view according to the child’s age and maturity. The main rule is that children are responsible for decisions about their own health upon turning the age of 16. The legal position of children in health and care services is specially regulated in the Patient and User Rights Act. These provisions are designed, among other things, based on Article 12 of the Convention on the Rights of the Child.

Assessment of the rights of the child and consequences for the child may ensure safeguarding and highlighting the rights of the child in decision-making processes. Most of the measures the authorities propose will either directly or indirectly have consequences for the child. Assessment of the rights of the child ensures that the consequences for the child are mapped and the child’s best interests are assessed. The Ombudsperson for Children has prepared a practical guide on the Convention on the Rights of the Child, and how the authorities when proposing new measures can map the consequences for the child and assess the child’s best interests, etc.[131]

The Interpreting Act prohibits the use of children as interpreters, Public bodies must not use children for interpreting or other conveyance of information. Exceptions can be made in emergency situations, etc.

The Norwegian Directorate of Health is now developing national professional recommendations for user involvement in the mental health and substance use fields. It is planned that these will be launched in autumn 2023.

User and next of kin involvement at the service and system levels

User involvement at the service level means that user and next of kin representatives are drawn into service development and quality improvement in cooperation with professionals in the health services. The services must ensure that structures for collecting the experiences and views of patients and users are established, and that representatives for users and patients are heard when designing health services.

Further, the services should enable user and next of kin representatives to directly participate with their experiential-based knowledge in processes where service development and quality improvement work is carried out. User and next of kin knowledge should be weighted equally to clinical experience and research in accordance with the principles of practice-based knowledge. It may also be appropriate to employ peer support workers in the services.

Textbox 3.14 Digi Youth Panel

DigiUng actively works on user involvement and a designated youth panel, Digi Youth Panel, has been established. Digi Youth Panel consists of youths who represent the diversity of the youth environment in Norway. There are youths from villages and towns/cities; youths who are politically engaged; youths with experience of being a minority in their environment; youths who like gaming; and youths who prefer to hang out with their friends in their leisure time. They are youths who are focused on contributing to better digital services and daily life for them.

Next of kin

Health and care services shall facilitate good cooperation with next of kin and offer necessary support. The services shall have systems and routines facilitating continuous information, and adapted and close dialogue with next of kin.

A lot is known about the importance of involving and supporting next of kin, particularly if children and adolescents are the next of kin of persons with mental health and/or substance abuse problems. Next of kin are often the patient or user’s most important support persons and in most situations they want to be a resource for the patient or user. The tasks attached to caring and being responsible for their close family member are highly demanding. Next of kin are also important to the services, and can contribute with important information to give the best possible treatment.

The services are not adequately adapted for a whole family perspective when one or more family members have mental health challenges. The knowledge base shows that it is important to direct the effort at families where there are mental health problems and/or addiction problems. This applies to preventive municipal work on public health, early intervention and upbringing, in treatment and in research.

Textbox 3.15 REACT (Relatives Education And Coping Toolkit)

Research has shown that if the patient has a good understanding of the disorder and has specific tools to use in daily life, it can reduce the stress level of all parties involved. Therefore, psychoeducational family involvement (PEF) is recommended in relevant national professional guidelines and guides from the Norwegian Directorate of Health.

The Regional Competence Centre for Early Intervention in Psychosis – South East (TIPS Sør-Øst) is working on expanding REACT (Relatives Education And Coping Toolkit), which is an online self-help tool for families and friends of people with mental health problems, including psychosis. Consent from the patient is not required and the patient does not need to be undergoing treatment. The tool was created by a team at Lancaster University Hospital. The online resource www.reacttoolkit.no is aimed at next of kin in Norway, and has been designed as a digital learning tool. It intends to help next of kin gain a better understanding of what psychosis is.

According to TIPS South East, REACT can be offered instead of family psychoeducational involvement (PEF) or as a supplement to other next-of-kin work when this can/should be supplied as remote follow-up. The goal is make next of kin better equipped to handle situations and stress that can arise when a close relative has a psychotic disorder.

Healthcare personnel shall contribute to taking care of the need for adapted information and follow-up that minors may have when a parent or sibling is a patient suffering from mental illness, substance dependence or a severe somatic disease or injury.[132] Surveys have shown significant shortcomings in taking care of children and adolescents as next of kin.[133]

Textbox 3.16 Sibling and Parent Intervention SIBS

SIBS is a preventive session-based initiative for children between the ages of 8 and 16 who are next of kin. The initiative consists of three child sessions, three parent sessions and two sessions where children and parents focus on talking about how the children feel about their parents’ diagnosis and related problems. SIBS’ goal is to strengthen family communication and thereby improve psychological adaptation and knowledge about the diagnosis. The initiative was developed in close cooperation with user organisations and health services, and a study with 99 families showed improved mental health, family communication and knowledge about the diagnosis among siblings as next of kin after participating in SIBS. The effect of SIBS is being studied in a randomised controlled trial with 291 families, the results of which will be available in 2023/2024. SIBS is now offered in multiple Norwegian municipalities and health trusts by psychologists, health nurses, teachers, family therapists and others who are highly competent in talking to children.

Source: Sibs.no

The Norwegian Directorate of Health has recently carried out a national next of kin survey. The purpose of the survey was to contribute to more insight and knowledge about how young next of kin (aged 16-25) live their lives, how they experience their situation and their needs. Among other things, the survey shows the negative impacts on young next of kin, and that they consider their mental health quite a lot worse than youth in general. Those who are next of kin to someone with mental illness state their own health as worst.

The Women’s Health Commission (NOU 2023: 4) recommends a commitment to increasing the competence of personnel about next of kin and next of kin cooperation.

The Government will contribute to improved cooperation between the services and next of kin. The Government has therefore requested the Norwegian Directorate of Health to prepare a tool in the form of a next of kin agreement, which will form the basis for good routines for such cooperation. The agreement contributes to structuring by clarifying roles and expectations, and gives predictability and sufficient adapted information. The agreement will ensure systematic participation, mutual information exchange, and next of kin experiencing that they are noticed.

The next of kin strategy and action plan Vi – de pårørende 2021-2025 (We – the next of kin) shall contribute to improving the situation of next of kin, and take care of and include them. One of the main measures in the strategy is the grant scheme Helhetlig støtte til pårørende med krevende omsorgsoppgaver (Holistic support for next of kin with demanding care tasks). The scheme shall enable municipalities to develop models for improving the situation of next of kin, and shall contribute to highlighting, recognising and supporting next of kin with demanding care tasks. To contribute to adequate help and follow-up of next of kin for persons with mental health and addiction problems, the grant was increased in 2023.

3.8.2 Equity of care and adapted help

Equal health and care services shall be offered to the whole population. Social categories such as disability, sex, gender identity, ethnicity and sexual orientation may coact and affect living conditions and the mental health of some people. Regardless of these factors, everyone shall have access to services when required. It is important that those who work in the services are familiar with diversity, so they can take care of everyone as best as possible.

A person’s language proficiency shall be irrelevant when it comes to receiving the correct and adequate help. The Act relating to public bodies’ responsibility for the use of interpreters, etc. (Interpreting Act) sets the requirement of using qualified interpreters when needed. The Act shall contribute to ensuring legal protection, and proper help and services for people who cannot adequately communicate with public bodies without an interpreter.

Disabled people

Disabled people have the same right to good quality health and care services as anyone else. The right to health also includes the right to the health and care services one particularly needs due to disability.

In Statistics Norway’s survey on living conditions in 2019, almost 30 per cent of people with a disability between the ages of 20-66 said they had severe mental health issues.[134] There is a clear difference between the population at large where ten per cent stated the same. Disabled people also state that they are less satisfied with their own mental health, suffer from loneliness more, and are more dissatisfied with life than the population on the whole.[135] The Norwegian Federation of Organisations of Disabled People (FFO) point out in the report Koble kropp og sinn – sammenhengen mellom somatisk sykdom og psykisk helse (Somatisation and the Mind-Body Connection) that many people with a disability and chronic disease find that they do not receive the follow-up they are entitled to, that waiting times for talking to someone with psychological expertise are long and that healthcare personnel with psychological expertise lack knowledge on somatic health.[136] Among other things, it is pointed out that increased knowledge of mental health in support services that meet disabled people and the chronically ill is needed, in addition to more interdisciplinarity, increased coordination between services and better mapping of the patients’ need for follow-up.

Adequate competence is a prerequisite for good, efficient and safe services. Personnel, who offer services to disabled people, must have sufficient knowledge and competence to offer services in a professionally sound and good manner. By detecting early signs of developing illness, worsening mental health, loss of functional ability or problems, measures for changing, improving or mitigating potential worsening can be initiated early. This requires the services to meet each individual based on earlier needs and prerequisites with a holistic approach above and beyond the disability or illness. A person-centred approach can contribute to safeguarding mental, social and existential needs, and increased trust and confidence.

Services for the Sami population

The Ministry of Health and Care Services has a special responsibility for facilitating essential health and care services for the Sami population. In order for these services to meet the Sami population’s needs, sufficient knowledge is needed on the risk factors for developing illness, and accessibility and quality of the services. This might be language and cultural issues related to communication between Sami patients, and the health and care services. The contributors to the escalation plan also point out a lack of low-threshold services adapted to the Sami population (refer to Chapter 3.2.2 for a more detailed discussion on evidence-based low-threshold services within mental health and substance use).

Some studies indicate that the prevalence of anxiety, depression and dissatisfaction with life may be higher among the Sami people.[137] In 2020, the Norwegian Institute of Public Health conducted a population survey in cooperation with the counties. An additional model prepared by the Centre for Sami Health Research was included for the northernmost counties regarding, among other things, the Sami people. The survey included questions on health, lifestyle, living conditions and quality of life. The responses from Nordland County show that the majority of the participants reported good or excellent health, however, for Sami women and men fewer stated that their health was good. Women reported mental health issues more than men. This applies regardless of ethnicity.[138] At the same time, young Sami people report high resilience and a relatively strong feeling that life has meaning.[139] Surveys conducted by the Centre for Sami Research have also shown that the prevalence of most forms of violence is higher among the Sami people than non-Sami people in the same geographical area. This particularly applies to Sami women.[140] Mental health challenges was more widespread among those who had experienced domestic violence and violence in childhood, regardless of sex and ethnicity.[141]

Sámi Klinihkka was formally opened in January 2020 offering specialist health services within somatics, mental health, substance abuse and dependence, and is adapted to the language and culture of the Sami population. The clinic comprises a specialist doctor centre and Sami national competency service – Mental Healthcare and Substance Use (SANKS). SANKS is organised as six clinical units consisting of a national team that shall help promote equal and culturally adapted treatment for Sami people across the whole of Norway.

To contribute to building up and improving the quality of the health and care services for users who speak Sami and have a Sami background, a separate grant scheme has been established for professional development and competence enhancement. These measures will be aimed at areas that include citizens with a southern, northern and Lule Sami language and culture. The grant will contribute to acquiring, initiating and disseminating knowledge of the needs of Sami citizens receiving municipal health and care services, and to address how these needs can best be met. It will also help to improve competency among health and care professionals who provide services to Sami users. It will also help to improve competency among health and care professionals providing services to Sami service users.

The Centre for Health Research (SSHF), Sámi dearvvašvuodadutkama guovvdáš, is allocated support for basic funding through the Storting’s annual budget resolution. In addition, the Government has set aside funds for completion of SAMINOR 3. The SAMINOR surveys on health and living conditions is the centre’s most important research project. SAMINOR is one of the most important sources of knowledge about the health and living conditions of the Sami people and population of northern Norway. The purpose is to gain knowledge about the prevalence of illness and risk factors related thereto, prevent disorders and improve health services for everyone.

The Government has decided that the theme for the white paper on Sami language, culture and civic life in 2024 will be public health and living conditions in Sami areas.

LGBT+

The LGBT+ community are one of the groups with the lowest subjective quality of life in Norway.[142] This group also had the highest decline in satisfaction during the COVID-19 pandemic. Compared to the population at large, sexual and gender minorities are more exposed to bullying and social exclusion, hateful comments and violence in public spaces, violence in close relationship and sexual violence. LGBT+ people also have a higher risk of developing health issues and problems, self-harm, suicidal thoughts and suicide attempts compared to the rest of the population.[143] Bisexual women and transgender people report more symptoms of anxiety and depression than other LGBT+ people.[144]

The LGBT+ community is complex, and the level of vulnerability and experienced discrimination varies immensely. At the same time, the interactions between the various vulnerability factors are complex, and health-promotion and prevention efforts must be implemented across the public sectors to ensure good care. Knowledge of and awareness of this complexity is a prerequisite for designing public services, including health and care services, which effectively are equal.

The Government will improve the living conditions of LGBT+ people and therefore launched an action plan for gender and sexual diversity in spring 2023. The action plan will apply up until 2026 and include a special commitment to improving the quality of life of LGBT+ people, secure their rights, and contribute to greater acceptance for gender and sexual diversity. In addition, the Ministry of Health and Care Services has created a new grant scheme with the goal of good mental health and quality of life, and more equal health and care services for groups in the population who break away from the standard genders and sexuality.

People with an immigrant background

As per 2022, immigrants and Norwegian-born people with immigrant parents account for just over one million citizens in Norway. This is a diverse group with, among other things, many different migration stories. length of residency in Norway, experiences and Norwegian language skills. The migration process involves settling in an unknown country and adapting to a new culture, in addition to experiences in the country of origin prior to leaving. All the phases are associated with situations and experiences that may impact health, particularly mental health. The percentage of immigrants with a high level of mental illness is on average slightly higher than in the population otherwise. In some groups, stigmatisation and taboos are also attached to mental ill-health.[145] Further, experienced racism and discrimination can also significantly impact mental health.

The Government has started working on a new action plan against racism and discrimination on the basis of ethnicity and religion, which according to plan will be presented during the course of 2023. The main topics in the plan are climbing the ladder in the labour market, and the experiences of youth related to racism and discrimination in social arenas, such as school, education, the voluntary sector, leisure and social media.

3.8.3 Leadership, quality improvement and patient and user safety

In order to create good and safe services for people with mental health issues and disorders, good management and systematic work on quality improvement and patient and user safety are essential. Quality improvement is a continuous process on improving current practices, testing out innovative ideas and applying research-based knowledge in practice. The regulations on management and quality improvement highlight the responsibility of the enterprises in this work.

The holistic and systematic national work on quality and patient and user safety will be incorporated into the National Health and Collaboration Plan.

Fewer professionals per patient in the future with the attached challenges connected to recruitment and retaining competent personnel indicates an increasing need for the services to work on quality improvement and patient and user safety in an evidence-based and systematic manner. On top of this, there are rapid medical and technological developments that set new competency requirements and create expectations on the part of patients, users and next of kin (refer to Chapter 1.6 for a discussion on personnel and competence).

Management entrenchment is an important prerequisite for systematic work on quality improvement and patient and user safety, a good and safe working environment, and adaptation for professional development and evidence-based practice. The span of control (the number of employees per manager) in the health and care services is extremely high, at the same time as formal managerial competence is low. This has major consequences for the working environment, including sick leave and turnover, staffing and quality of the services. In order to contribute to increased managerial expertise in the health and care services, the Government will continue and strengthen management education for the primary health service and specialist service.

The Ministry of Health and Care Services will also facilitate the development of a short online manager training programme corresponding to the online manager training programme for GPs, and other managers in municipal health and care services. Given the substantial work pressure and numerous managers, a formal manager training programme should be designed to allow as many managers as possible to take the programme and reach a higher level of expertise. In order to enable managers in municipal health and care services to easily gain an overview of various tools and manager competency measures, the Norwegian Directorate of Health has been commissioned, along will relevant actors, to develop the programme. Increased attention on core tasks, innovation, reorganisation and improved work sharing requires good management. The Government will support trust-based governance and management, so the services can to a larger extent develop services and test new work methods.

The Norwegian Directorate of Health points out that continuous work on quality improvement is not given sufficient priority in the services or at the system level. An important reason for this is the lack of time and resources, but also insufficient improvement knowledge and research competence, access to tools, support functions and research infrastructure, and good insight into the effects of such work. Some experience systematic quality improvement as a new area where work methods and processes are unknown. Systematic work on quality improvement, knowledge development and research can with preference be looked upon as an activity that takes place parallel to ordinary operations.

Good data is important for planning, implementation, research, evaluation and, not least, correction of one’s own practices. This means that the whole of the quality improvement cycle, on which regulations on management and quality improvement are built, must be taken into use. The Norwegian Board of Health Supervision has pointed out that the services are quite good at planning and implementing measures, but less so at following up the measures with evaluations and corrections. The Office of the Auditor General of Norway found in its survey on the boards of directors follow-up of quality, that the boards in the specialist health service rarely requested the effect of measures.[146]

For the municipal mental health and substance abuse services, performance data is still lacking. The Norwegian Directorate of Health points out that neither the municipalities, county governors nor the Norwegian Directorate of Health have sufficient data to observe developments in the services. The municipalities need simple adapted statistics to use in planning, managing and quality improvement.

State and municipal reporting (Kostra) and the Norwegian Registry for Primary Health Care (KPR) are statutory reports which take care of the central authorities’ need for data from the municipalities. IS 24/8 is Sintef’s annual mapping commissioned by the Norwegian Directorate of Health in all the municipalities/boroughs in Norway. The goal of the mapping is to observe the trend in resource use in municipal mental health and substance use work over time.

The purpose of the Norwegian Registry for Primary Health Care (KPR) is provide a basis for planning, managing, funding and evaluating municipal health and care services. The KPR does not at the present time contain data on the mental health and substance use fields. The Government will therefore start work on further developing the registry so it also includes data on mental health and substance use. This will contribute to knowledge development and better municipal service data for observing developments in this field. There is also a need to further develop the Norwegian Patient Registry (NPR) to give better and more all-encompassing event history analyses.

3.8.4 Research, development and innovation

The possibilities for knowledge development and participation in research and innovation activities contribute to improving quality and patient safety in the services, a better basis for setting the right priorities, more effective prevention and helpful treatment, in addition to updated and more motivated professionals. In the long-term, it may lead to better use of society’s resources.

The Government wants health data to be better used in research, more research-based quality improvement projects and for clinical research to be an integral part of patient treatment for mental health. More knowledge about the organisation, control and management of the services, work-saving innovations in the face of a short supply of healthcare personnel and implementation research will be important moving forward. The topic will be followed up in the National Health and Collaboration Plan.

Distribution of research funding from national and European sources shows that mental healthis the therapy area that receives the most funding for research followed by cancer and general relevance to health.[147] Mapping carried out in 2019 shows that most research funding was used for research on psychoses and schizophrenia, depression and dependence. In 2021, research on mental healthcare constituted 11.6 per cent of all research efforts.[148] In the European Union’s research and innovation framework programme, Horizon Europe, there has been more calls for proposals related to mental health in the programme’s health priorities. This is partly due to the consequences of the COVID-19 pandemic and partly because the area represents a large and growing disease burden in Europe.

Increased knowledge development must be facilitated in municipal health and care services in line with the Government’s Long-term plan for Research and Higher Education. Results from research must be made available, conveyed and used. The Government will facilitate more research relevant to the municipalities’ need for knowledge, and investigate how the municipalities can receive better support and guidance in their knowledge development work on mental health and substance use.

The National Programme for Clinical Research in the Specialist Health Service (KlinBeForsk) shall accommodate the need for more high quality national clinical trials. The purpose is that more patients across the whole of Norway will be invited to participate in clinical trials. The programme will contribute to coordination of competence, resources and infrastructure. In 2022, research on clinical treatment for child and adolescent mental health was particularly prioritised.

Knowledge about the effect of measures is an important prerequisite for setting the right priorities. This means that measures that have a documented effect should be implemented instead of measures where the effect is more uncertain. As a follow-up of Meld. St. 38 (2020–2021) Health benefit, resources and severity, the Ministry of Health and Care Services has commissioned the Norwegian Directorate of Health to prepare a national professional guide on setting priorities in municipal health and care services. The guide will be an important decision-making support tool when the municipalities set their priorities.

Preventive measures generally take place outside the health and care services, which requires a cross-sectoral research effort (refer to Chapter 2 for a discussion on health promotion and prevention measures).

The Office of the Auditor General of Norway’s survey on mental health services concluded that the work on increasing knowledge about mental health issues and disorders is not good enough. Among other things, it was found that they lacked knowledge about which type of treatment was effective for several mental issues and disorders.[149] A general problem when researching mental health measures is that causation is complex and unknown, and compared to somatics it is more difficult to identify objective and measurable endpoints. Treatment is also more context-dependent, and there is a wider variety of measures and study designs in research on mental health than what is common within somatics.

Activity in research on personalised medicine in mental healthcare has increased.[150]

3.8.5 Evidence-based care

Healthcare personnel shall work in an evidence-based manner. Evidence-based practices involves taking professional decisions based on systematic collection of research-based knowledge, experiential knowledge and the patient’s wishes and needs in a given situation.[151] At the same time, it is important that evidence-based methods are applied. A distinction must be made between the extent to which sufficient documentation of the effect of different treatment methods actually exists and whether the knowledge has been implemented in the services. An Australian review from 2018 shows that we do have knowledge about treatment for most mental illness.[152] At the same time, more research needs to be conducted on patients in Norway and what is needed to increase the use of knowledge in practice. Knowledge is not sufficiently used in the services, and facilitation of local adaptations and the evaluation of effects when implementing and spreading innovations and research results through systematic use of health data, health services and implementation research is required.

In order to offer the best treatment to patients, the services must have access to updated knowledge, and they must have routines for further educating personnel. This applies to the municipal health and care services and specialist health service alike. The national patient pathways provide external frameworks, whilst national professional guidelines provide directions for the organisation and professional content of investigations and treatment of each single condition. To ensure adequate treatment, the professional guides must cover the most common disorders and be updated regularly. The guidelines must also clearly state the distribution of responsibility and tasks between municipalities, the specialist health service and other relevant actors.

The mental health service must have routines for examining the effect of treatment that is given. Good effect goals include both symptoms and level of functioning, and patients must regularly be asked about any experienced benefits from the treatment. New medical quality registries for mental healthcare will provide national infrastructure and data as a basis for systematic work on quality improvement and patient user safety in the services. National guidelines and national patient pathways for mental health and substance use recommend using feedback tools during treatment. With systematic use of feedback tools, continuous feedback is received from the person receiving help about any experienced changes and benefits from the help. The feedback tools can identify and prevent negative outcomes from the treatment and contribute to more adapted help.[153] Several services have started using various feedback tools. At the same time, work still has to be done on assuring patients and users access to such tools.

Healthcare personnel, who are up to date on research, have better ability to critically assess established and diagnostic methods, offered treatment and technologies. In its survey on mental health services, the Officer of the Auditor General of Norway found that the possibilities for participating in research on mental healthcare were worse than for somatics in relation to opportunities for sideline jobs and leave of absence for research. In research on schizophrenia, it has been found, among other things, that clinical research has the greatest impact on subsequent changes to clinical practices and that the largest social and health benefits are achieved through interdisciplinary research teams.[154]

Better knowledge is important for making decisions on the introduction of new methods. It is also important for phasing out methods that are used today, but do not have the desired effect. For instance, the need to strengthen documentation of pharmacological or other treatment methods that the service started using before the establishment of ‘Nye metoder’ (New Methods) (see below for further discussion) and the introduction of guidelines stating that new medicines must be methodologically assessed.

‘Nye metoder’

‘Nye metoder’ (New Methods) is a system in the specialist health service for assessing both the introduction and phasing out of methods based on evidence. ‘Nye metoder’ can basically assess all measures used for prevention, investigation, diagnosing and treating illnesses, including measures for rehabilitating patients and organising health services. ‘Nye metoder’ is not limited to specific professional fields, but an overview of methods that are reported show that methods for treating mental illness are only registered in a very few cases. It relies on the industry, professional environments, service, patient and user organisations, etc., reporting relevant assessment methods and the existence of a documentation basis for assessing the methods either nationally or through mini-method assessments in the health trusts.

If the evidence basis for the measures to be assessed in ‘Nye metoder’ is lacking, it has been arranged for these to be registered in the program for clinical research on treatment in the specialist health service, as a relevant need for evidence. This is part of their adaptation to so-called user-identified research. The user-identified research instrument is characterised by processes where special needs for knowledge are identified and constitute the basis for special calls for proposals for research funding. This instrument can be used within all relevant therapy fields where more certain knowledge is needed.

Several health regions have made adaptations for assessing new methods within mental healthcare and cross-disciplinary specialised treatment for substance use disorders (TSB) through linking professional environments within mental health and substance use to ‘Nye metoder’. ‘Nye metoder’ could be a relevant instrument for building up evidence-based practices in the mental health service in that the basis for knowledge that is presented for the methods is systematically reviewed with a methodological assessment. This knowledge can be disseminated through coordination of the decisions in Nye metoder with normal products, such as treatment guidelines, guides, standardisation products, etc.

Standardisation products

The Office of the Auditor General of Norway demonstrated in its report on mental health services that more than half of the national guidelines and guides on the mental health field had not been updated the past four years.[155] The Norwegian Directorate of Health’s work on reviewing standardisation products in the mental and substance use fields is ongoing. In 2022, the recommendations for using mapping tools were updated.

In 2023, an overview will be prepared of the proposed prioritisation of recommendations that need updating and which can be unpublished. Possibilities for improving the work process when developing standardisation products will also be considered.

National medical quality registries

There has been a great commitment to the development of new medical quality registries in mental healthcare since 2019. In 2022, three new quality registries within mental healthcare received national status (refer to Box 3.17 for an overview of which). The Quality Registry for Child and Adolescent Mental Health Care applied for national status in 2022. The Norwegian Quality Registry for Eating Disorders received national status in 2015.

Medical quality registers contain structured information about investigations, treatment and follow-up, which makes it possible to assess the quality of patient treatment. Knowledge from the quality registers shall contribute to improved quality and patient safety. A national registry makes it considerably easier to assess whether one’s own practices comply with national professional guidelines and whether the treatment has the desired effect. Quality registries also uncover whether there is undesired variation in the treatment offered in Norway. The quality registries are an important source for researching the effect of different treatment initiatives.

Textbox 3.17 New Quality Registers in Mental Health Care

The National Quality Register for Electroconvulsive Therapy (ECT). ECT is a treatment method for some mental illnesses, and the ECT Register shall map the effect, side effects and experiences the patient has from the treatment.

The Quality Register for Old Age Psychiatry (KVALAP). The register was created to contribute to improved investigation and treatment of the elderly with mental illness, research and quality work.

National Quality Register for Adult Patients in Mental Health Care. The register will include all adult patients in mental health care and provide insight into the effect of treatment given in Norwegian hospitals.

National services in the specialist health service

National services a joint term for national treatment services, multiregional treatment services and national competency services in the specialist health service. National and multiregional treatment services include highly specialised treatment that should be centralised in one or two places in Norway. Centralisation of the treatment offered shall contribute to health benefits in the form of better prognoses and quality of life for the patient, improved quality and competency in the treatment, and better national cost effectiveness.

A national advisory unit shall within a period of five or ten years secure national competence building and competence dissemination within its specified area of expertise. The establishment of an advisory unit will not lead to centralisation of patient treatment or competence, but to competence enhancement in the field nationally. The goal is that after the function period of the competence service ends, its areas of expertise will be safeguarded by all the health regions that are part of the ordinary services offered albeit with the possibility of continuation under the auspices of the regional health authorities as a national quality and competence network, centre or by other means.

The system for national advisory units shall be dynamic with the possibility to establish services in areas where competence building and dissemination is needed, including mental healthcare and substance use.

The regional health authorities are responsible for applying for approval to establish new national services. Several of today’s mental health advisory units were established approximately ten years ago. This applies to the Sami National Advisory Unit on Mental Healthcare and Substance Use (SANKS), the Norwegian National Advisory Unit on Concurrent Personality Psychiatry (NAPP) and the Norwegian National Advisory Unit for Concurrent Substance Abuse and Mental Health Disorders (ROP). The frameworks for establishing and creating the national advisory units will be discussed in the National Health and Collaboration Plan. During the plan period, it will be relevant for the regional health authorities to assess the need for advisory units in the areas that underpin the goals in the plan.

National and regional resource centres outside the specialist health service

In addition to the national advisory units in the specialist health service there are a range of national and regional resource centres for mental health, substance use and violence outside the specialist health service. These are important for the development of competence in mental health, substance abuse and violence. In addition, they are key suppliers of knowledge for the services, contributors when implementing knowledge in the services, and professional advisers for public authorities and services. The centres should be a service both for the services, and the preventive and health promotion activities in the municipalities.

The centres shall operate or participate in the summary of research in their own field, participate in practice-orientated and practice-relevant research, and participate in relevant research networks. The Healthcare Personnel Commission considers that the potential of the resource centres and advisory units has not been realised. In the Commission’s view, it is necessary to investigate how they can be developed through linking the centres tighter to the health and care services to help improve the quality of the services offered in the municipalities and special health service.

During the plan period, the Government will investigate how the municipalities can receive better support and guidance in their work connected to mental health and substance use In connection with this, it should be assessed whether resource centres are organised in the most appropriate way. The Ministry of Health and Care Services shall in consultation with the affected ministries investigate more unified organisation of the resource centres outside the specialist health service with the aim of establishing a more holistic system for better and more coordinated support to the municipal sector. The basis for the investigation is a decentralised structure with expert environments in proximity to the services. The Government will return to the Storting about this matter in an appropriate manner.

The BarnUnge21 strategy, which was finalised in 2021, also recommended a review of the role of the advisory units and resource centres in the production of knowledge, knowledge dissemination and the application of knowledge with the aim of highlighting their mandate and role in a holistic and evidence-based childhood policy. It was recommended that the review should look more closely at the extent to which all expert areas are covered and the organisation contributes to children and adolescents receiving equal, safe and effective services, regardless of geography. This recommendation with be assessed in the forewarned investigation on more unified competence centres outside the specialist health service. The Ministry of Health and Care Services cooperates with, among others, the Ministry of Children and Families in relation to how the recommendation will be followed up.

Textbox 3.18 Thematic Organisation

The Government has established an expert committee to investigate stronger thematic organisation of the mental healthcare. The purpose is to ensure good quality services and for patients to receive swift access to the right treatment. The committee will deliver the report by 15 September 2023. The expert committee’s work will concentrate on quality both in treatment and the organisation of services.

People with mental illness tend to have a complex clinical picture and may satisfy criteria for different diagnoses at different times. Thematic organisation that is too tightly linked to specific diagnoses will result in fragmented treatment for patients with complex conditions, which can lead to skewed division of professional expertise. Mental healthcare cannot be organised exclusively as thematic, but such organisation may enable patients to received targeted treatment for their illness.

An intensive treatment service has been developed in Bergen for patients with obsessive-compulsive disorder (OCD) where exposure and response prevention therapy is completed during the course of four days. Flexible outreaching cross-disciplinary teams (FACT) have proven to be effective for patients with severe mental illness with or without a concurrent substance use disorder. Both OCD and FACT teams have now been established around Norway. In child and adolescent mental healthcare, separate teams for investigating autism spectrum disorder have been established, and all health regions have established specialised services for investigating and treating newly diagnosed psychological disorders.

The expert committee will investigate whether there are other clinical areas, conditions or patient groups who might benefit from treatment that is more thematically organised. Since many patients have a long-term pathways involving alternating contact with municipal health and care services and mental health services, it is necessary to establish models for fluid cooperation that give continuity in patient treatment across the administrative levels.

The health trusts report an increasing number of referrals to mental health services. Practitioners report that they spend a disproportionate amount of time on assessing new patients, investigations and reports for national patient pathways. Simplification of routines and investigation well reduce the time practitioners spend on this part of the pathway. Patient admissions can be more differentiated so that patients are sent to a suitable place for further treatment sooner. In order to use treatment resources as best as possible, patients, who no longer need treatment or where it is observed that other services would be more appropriate, must be discharged from mental health services. Differentiated admissions and prioritisation during the course of the pathway can free up personnel resources to give more patients the right treatment for their mental illness. This is something the expert committee will consider further.

4 Services for people with long-term and complex needs

Figure 4.1

People with long-term and complex needs shall receive good and cohesive help. A great deal of effort has been made to ensure this over a prolonged period of time, but further development is still needed to provide good and proper help. The Government will therefore strengthen the whole treatment chain for people with long-term and complex needs and contribute to increasing the life expectancy of people with mental illness and/or addiction problems. This priority area requires measures for people who need long-term and comprehensive help, including services for those with severe mental illness.

Textbox 4.1 The government will:

Contribute to increased life expectancy for people with severe mental illness and/or addiction problems, among other things, by

Preparing a holistic plan for increasing the life expectancy of people with mental illness and/or addiction problems

Facilitating cohesive services and pathways, among other things, by

Continuing and further developing outreach services, such as ACT/FACT and Youth FACT

Preparing various coordination and integrated service models, and assessing how medical communities are better enabled to support desired trends in mental health

Enabling the regional health authorities to strengthen the treatment chain for people with long-term and complex needs, which includes both outpatient follow-up at a district psychiatric centre and inpatient treatment

Contribute to better services for children and adolescents with long-term and complex needs, among other things, by

Continuing, renewing and strengthening health efforts in the child welfare service

Giving children in the child welfare service, who need it, equally good access to healthcare as other children and implementing measures to ensure the needs of these children are met

Investigate measures for increasing competence in recognising early signs and following up neurodevelopment disorders in kindergartens, schools and services in the municipalities and specialist health service, and measures for strengthening cooperation on measures and treatment for this group

Prepare standardisation products related to autism spectrum disorder and Tourette syndrome

Contribute to better services for adults with long-term and complex needs, among other things, by

Further developing specific models for integrated services for patients with concurrent substance abuse and mental health disorders (ROP)

Work towards better enabling the medical communities to support the development of services for patients with concurrent mental illness and addiction problems

Contribute to implementing national expert recommendations for the prevention of force in adult mental healthcare

Work towards better housing and services for people with long-term and complex needs, including

solutions for patients who are subject to involuntary admission pursuant to the Mental Health Care Act and people who are at risk of being violent

investigation of staffed housing and services that better use available resources from both levels

Contribute to promoting correct use of medicines

Work towards good and coordinated services from the health and justice sector, among other things, by

Assessing the services for those committed to compulsory psychiatric care based on investigations and overarching plans from the RHAs concerning forensic psychiatry and other measures for people committed to compulsory psychiatric care

Creating a committee to investigate how inmates with severe mental illness or developmental disability can best be taken care of on remand, when completing a sentence and returning back to society, and the evaluation of sanctions in custody, court-ordered committal to compulsory psychiatric care and court-ordered committal to compulsory treatment

Investigating obstacles and possibilities for cross-sectoral cooperation and participation of the welfare services prior to, during and after completing a sentence for those aged 18-24

Presenting a white paper for emergency medical services

4.1 Basis for the priority area

Textbox 4.2 Severe Mental Illness

The group that is described as ‘severely mentally ill’ is not a uniform group when it comes to diagnosis or level of functioning The Norwegian Directorate of Health’s guide on local mental health and addiction work, Sammen om mestring (Coping Together) provides examples of groups that are covered by the pathway for severe and long-term illness, medication or dependence problems, severe bipolar disorder, severe depression, schizophrenia and severe personality disorder. The same diagnoses are highlighted in the definition of severe mental illness in the Norwegian Directorate of Health’s management data for the medical communities.

Source: The Norwegian Directorate of Health, 2014; Lehn, 2022.

Many with severe mental illness have a good quality of life and live meaningful lives. At the same time, having a severe mental illness may have personal and social consequences for the individual. Mental illness can lead to exclusion, and many still experience stigmatisation attached to their illness. Severe mental illness might be associated with disability, unemployment, sick leave, physical diseases and reduced life expectancy.[156]

Mental health, substance use and somatic health must be seen in relation to each other. The number of people with a somatic disease, who also have psychosocial burdens, is increasing.[157]

Many patients in somatic departments have substance use-related health problems, and some patients referred for cross-disciplinary specialised treatment for substance use disorders (TSB) have levels of co-morbidity[158] .

As a group, people with severe mental illness and addiction problems live significantly shorter than the general population.[159] Inspections have shown that the mapping and follow-up of this group’s somatic discomfort is lacking, and studies show that premature mortality can largely be attributed to somatic diseases. Even though a large percentage of people with mental illness do not have an addiction problem, we know that mental illness and addiction problems or addiction disorders often occur concurrently.[160] There are several challenges attached to services for people with severe mental illness and/or addiction problems. Internal collaboration in the health and care services and between different services and sectors is particularly challenging. The Health and Social Services Ombudsman has several cases showing that collaboration and coordination between the specialist health service and municipalities has failed.[161]

According to the Office of the Auditor General of Norway, some municipalities do not offer outreach services to citizens with addiction and/or mental health problems.[162] The municipalities have problems acquiring adapted housing services for the target group, particularly those with a comprehensive need for services and problems with violence.[163] The number of people committed to compulsory psychiatric care and committed to compulsory treatment has increased considerably in recent years. Reports and inspections show that both the municipalities and specialist health services have problems ensuring good and coordinated services for people who represent a safety risk and simultaneously safeguarding civil protection.[164]

Youths with concurrent mental illness and addiction problems do not receive adequate treatment and follow-up. This is demonstrated in the Office of the Auditor General of Norway’s survey on mental health services and the projections of the regional health authorities. Additionally, there are still, despite many years of efforts, major challenges attached to healthcare for children under the care of the child welfare service. Children with comprehensive challenges experience insufficient cross-sectoral cooperation which prevents holistic follow-up. This also applies to children and youth completing sentences.[165]

Even through many years of commitment to work-orientated measures in combination with medical follow-up and treatment, some municipalities still do not offer evidence-based work-orientated measures, such as individual job support and job-coping follow-up.[166] These measures are important because employment and meaningful activities are key factors for improvement, quality of life and a dignified life. Many with mental health issues and addiction problems may have problems completing education and building up work experience. Work and activities as part of treatment are discussed in more detail in Chapter 3.5.

It is essential to ensure good support for next of kin, including children as next of kin. Many next of kin of people with long-term and comprehensive needs, and children who are next of kin, are highly burdened when it comes to their own health and quality of life. The degree to which next of kin are involved in treatment and follow-up, and whether children in the capacity of next of kin are followed up, varies immensely (refer to Chapter 3.8.1 for a more in-depth discussion on user and next of kin involvement).

4.2 Increased life expectancy

People with severe mental illness and/or addiction problems have poorer physical health and, as a group, have a much shorter life expectancy than the population at large. Life expectancy depends on a range of factors, inter alia, living conditions and type of disorder. Mortality is also particularly high among people with severe mental health disorders and concurrent problems with substance use.[167] Surveys show that the difference in longevity between people with severe mental illness and/or addiction problems, and the general population is at least 15 years.[168] People with mental illness shall have the same possibilities to live a long and good life as the rest of the population. This also applies to children and adolescents with comprehensive needs, including those under the care of the child welfare service. The Government has therefore set a performance measure in the escalation plan stating that people with severe mental illness and/or addiction problems shall have a higher life expectancy, and the difference in life expectancy between this patient group and the rest of the population shall be reduced. In order to contribute to this, a holistic plan to increase the life expectancy of people with mental illness and/or addiction problems will be prepared, and an indicator for premature mortality due to non-communicable diseases among people with severe mental illness and/or addiction problems will be established.

There has been an increase in the prevalence of unnatural deaths among people with mental illness and substance dependence, such as suicides, accidents and overdoses, however, the excess mortality can largely be attributed to somatic disorders for which there is treatment. There can be many explanations for excess mortality, such as genetic vulnerability related to mental illness, lifestyle habits, psychosocial stress and loneliness, cognitive issues, side effects of medicines and poor diagnosis, and delayed or insufficient treatment of somatic disorders. The difference in life expectancy is increasing, and emerges in both national and international studies. The conditions in Norway are equal to those in other Nordic countries.[169]

Analyses performed by the health atlas service provided by Førde Health Trust in 2017/2019 showed that the use of somatic specialist health services systematically varied in different parts of Norway for all examined illnesses. They did not find the expected increase in the use of the somatic specialist health services for people receiving mental healthcare or cross-disciplinary specialised treatment for substance use disorders (TSB) compared to people without such contact. Increased use was expected due to higher risk of somatic diseases in this group compared to the population in general. The finding indicates underuse of somatic specialist health services for this patient group.

Severe mental illness and addiction problems also often lead to reduced oral health, among other things, due to the use of medications and substances. Poor oral health can also impact mental health. The Government has established a public committee to review the dental health field. The committee will carry out a comprehensive review of public health services, including organisation, funding and legislation, including regulation and rights. The committee will deliver its report at the end of June 2024.

Mental illness, somatic diseases, including dental and mouth cavity diseases, and problematic use of substances may be linked. Treatment in the health and care services should therefore be seen in relation to each other. In national patient pathways for mental health and substance use, a separate product has been prepared with summarised recommendations and measures to ensure better safeguarding of somatic health, including dental health, in people with mental illness and/or addiction problems. The prepared recommendations apply regardless of the level of treatment and describes, among other things, the distribution of responsibilities between municipalities and the specialist health service. The goal of the measures is to contribute to improved health, increased quality of life and increased life expectancy for this patient group. The importance of including somatic diseases is also acknowledged in a new and extended national pathway for child protection, where any somatic health issues, dental health and sexual health problems will be mapped in addition to mental health and substance use.

It is still necessary to strengthen the work on better follow-up of somatic health, dental health and lifestyle habits, particularly for those with severe mental illness and substance use disorders.

Along with other healthcare personnel, GPs are important in the work on taking care of the somatic health of patients with mental illness and/or addiction problems. This requires GPs to have good relationships with patients and good cooperation with other parts of the health and care services. GPs must also have time to prioritise this work. For instance, to stimulate this work a separate rate has been introduced which can be used for full annual checks on vulnerable patient groups. This applies to patients with a comprehensive need for help combined with less ability to ask for help, such as patients with long-term psychotic disorders. At the same time, it is necessary to highlight the groups it concerns, and increase the use of GP check-ups for people with severe mental disorders. The Government wants an effort for the GP service (refer to Chapter 3.2.3).

Co-localisation of services within mental healthcare, substance use and somatics contributes to the facilitation of somatic health services to patients with mental illness and addiction problems. Co-localisation of somatics and mental healthcare departments has been on the agenda for several years, since different forms of localisation create challenges for internal coordination in the specialist health service. This particularly applies to people with conditions within old age psychiatry (dementia disorders), psychosis, severe depression, eating disorders and addiction problems in acute phases. Through co-localisation of mental healthcare, substance use and somatics, it is possible, among other things, to facilitate the treatment of multiple conditions that a patient may have in the same place and at the same time, thereby providing a basis for more holistic and coordinated treatment pathways.

Death from overdose is one of the major causes of death among young people worldwide. For the last few years, Norway has had one of the highest registered prevalence of drug-induced deaths per inhabitant in Europe. The National Overdose Strategy 2019-2022 gave directions for the overdose-prevention effort and illuminated measures to face the challenges. In 2023, the Norwegian Directorate of Health has been commissioned to continue the National Overdose Strategy, which will be strengthen the effort against overdose deaths.

Norway has committed to the global targets set by the World Health Organization (WHO) for the period 2010-2025 for reducing premature mortality caused by non-communicable diseases (NCD) by 25 per cent. The goal of reducing premature mortality is continued in the global sustainable development goals with the target of reducing premature mortality by one third by 2030 compared to 2010. Mental illness is included in the disease categories.

In connection with the work on a new national NCD strategy and integration of mental illness in the NCD work, the Norwegian Institute of Public Health prepared a proposal with indicators for morbidity and mortality related to mental illness. The morbidity indicators included a prevalence of 30 days with anxiety and depression, and 30 days of alcohol use disorder. The indicators for mortality included suicide, drug-induced deaths and excess deaths caused by non-communicable diseases among people with severe mental illness. A new comprehensive NCD strategy will be presented.

In January 2023, the Norwegian Medical Association published its report Bedre helse og lengre liv (Better health and longer life) with recommended measures for increasing life expectancy among people with mental illness and/or addiction problems. The report points out that patients with severe mental illness or substance use disorders and dependence need special measures and extra effort in getting health services that are equal to those offered to the general population. In order to actually improve the mental health of these people, it is necessary to implement a range of measures at several levels simultaneously. The Norwegian Medical Association recommends a national effort for improved somatic health and life expectancy with severe mental illness/substance use disorders.[170]

The Government will contribute to increasing the life expectancy of people with mental illness and/or addiction problems by preparing a comprehensive plan with measures. The key measures will be the prevention of somatic health problems, improved investigation and diagnosis of somatic diseases, and better routines for cooperation between the municipal health and care services and the specialist health service. Measures for increased physical activity, improved living conditions and quality of life shall also be included in the plan. The plan must also be viewed in relation to efforts for preventing unnatural deaths in this group. As part of this work, the Norwegian Directorate of Health has been commissioned to draft proposals for measures and instruments for better access to diagnosing, investigation, treatment and follow-up of somatic health problems and disorders for people with concurrent addiction problems and mental illness focusing on the municipalities’ responsibility for the group.

Measures in a holistic plan that aims to improve living conditions and quality of life will also include measures for children and young people with complex needs such as children in care. It will be necessary to prepare several indicators to observe the performance measures of increased life expectancy for people with mental illness and/or addiction problems. An important part of this will be making sure that children under the care of the child welfare service who need treatment for mental health issues or disorders receive mental healthcare (refer to the discussion on children and adolescents, and services for the child welfare service in Chapter 4.4.2).

4.3 Cohesive services and pathways

The Government wants patients to experience holistic patient pathways where the different parts of the services cooperate effectively. This is particularly important for people with long-term and complex needs. Through the escalation plan, it will also be arranged for the services to reach more people who need integrated and outreach services. Among other things, the Government will continue and further develop outreach services, such as ACT/FACT and Youth FACT.

4.3.1 Good patient pathways

Many patients, users and next of kin experience fragmented health and care services. The goal is for patients to experience holistic patient pathways where the different parts of the services cooperate effectively. The Government’s primary measures for collaboration and patient pathways will be discussed in the National Health and Collaboration Plan.

Many municipalities and health trusts already cooperate effectively. Notwithstanding additional efforts and measures are still needed to support collaboration. Collaboration problems exist internally in the municipalities and in the specialist health service, and between municipal services and the specialist health service, and within each single service and across the sectors. Well-coordinated services are important for everyone with mental health challenges, but extra important for people with long-term and complex needs.

Patient groups with complex needs who need both municipal and hospital services are not adequately taken care of. Transitions between the service levels are failing, and municipalities and health trusts do not have enough joint planning. Several attempts have been made to standardise and formalise coordination and collaboration, yet it is still the case that few of these patients are appointed a coordinator or individual plan.[171] The coordination schemes and measures to improve this will be addressed in the National Health and Collaboration Plan.

In order to give the best possible healthcare, it is a prerequisite that relevant and necessary health information follows the patient throughout the patient pathway. This is not always the case today. Health professionals spend valuable time on searching for correct information about medicines or medical histories, and they must often make decisions based on incomplete information.

The State has established within selected areas national e-health solutions (Norsk Helsenett SF (The Norwegian Health Network), Summary Care Record, E-prescription and helsenorge.no). Today, these contribute to collaboration in the services. Experience shows that the solutions provide huge benefits, and contribute to cohesion and unity in that health professionals have easier access to necessary information, and the public has access to easy and secure digital services.

The Government wants to further build on these solutions to reach the goals of holistic and effective collaboration, and development of new functionality that can handle reciprocal needs. In order to cover the need for holistic services moving forward, it is necessary to start using solutions and functionality for collaboration within several fields. Digitalisation in the health and care services will be a central theme in the National Health and Collaboration Plan where the Government will, among other things, present a comprehensive presentation of the e-health policy for the next four years.

The way in which the funding systems for health and care services are set up is important for service development and collaboration between the service levels. Funding schemes that support better cohesion between and efficient use of all resources are needed. Work on the National Health and Collaboration Plan assesses how funding as an instrument can support good patient pathways and collaboration between municipalities and hospitals. In connection with this work, the Norwegian Directorate of Health has been commissioned to investigate how the funding schemes can better support collaboration, cooperation and decentralised services. In the Official Norwegian Report of the Government appointed committee for hospitals NOU 2023: 8 Felleskapets sykehus – Styring, finansiering, samhandling og ledelse (Community hospitals – governance, funding, collaboration and management),[172] a proposal was made to amend the funding schemes for the specialist health service, and the introduction of a collaboration budget for municipalities and health trusts that would only be triggered by the result of plans and processes in the medical communities. The Committee’s report is undergoing public consultation up until 30 June 2023, and it will be considered whether to incorporate the proposals in the National Health and Collaboration Plan.

4.3.2 Integrated services and outreach and outward-looking services

It has long been a goal to change the mental health service’s activities from inpatient treatment into outpatient and ambulatory treatment. Outreach treatment is recommended for patients who the health trusts cannot otherwise reach. At the same time, there has been a significant commitment to expanding municipal services within mental health and substance use. Nonetheless, almost 30 per cent of the municipalities do not offer outreach services for adults with mental health issues and disorders nor with concurrent mental health issues and addiction problems.[173]

The group of patients with concurrent mental health issues and addiction problems often need integrated services. Compared to other patients with no known addiction problem, they are more prone to emergency admissions and re-admissions, and their inpatient stays are shorter. They also tend to need comprehensive and long-term help from multiple actors.[174] The mental health and substance abuse fields were early in offering integrated treatment and there are good examples of models for integrated services.

A primary measure in the National Health and Hospital Plan 2020-2023 was the establishment of 19 medical communities. These consist of health trusts and the municipalities in the catchment area. Representatives from health trusts, adjacent municipalities, local GPs and users will meet to plan and develop the services together. This is an important arena for ensuring more integrated services. People with severe mental illness and/or addiction problems are one of four groups that will be prioritised in the medical communities.

Textbox 4.3 Integrated Treatment of Concurrent Substance Abuse and Mental Health Disorders

Integrated treatment of concurrent substance abuse and mental health disorders/IDDT is a manual-based tool to help health and care services with offering integrated services. The manual was translated into Norwegian in 2022 and many actors find it very helpful in giving more cohesive and holistic help.

For many years, a commitment has been made to ACT (Assertive Community Treatment)- and FACT (Flexible Assertive Community Treatment) teams. These are cross-disciplinary ambulatory teams aimed at people with severe mental illness and/or addiction problems. Evaluations of both the ACT and FACT models in Norway conclude that the teams provide a better service to people in the target group compared to the persons they had earlier.[175] Patients and next of kin are more satisfied and there has been a significant reduction in the number of inpatient days in the specialist health service and use of compulsory treatment. The ACT and FACT teams are an important step in the right direction for giving more holistic and cohesive services. The mandatory cooperation between municipalities and the specialist health service is most important for the success of the model in Norway. It is possible to apply for time-limited support to part-finance the establishment and operation of cross-disciplinary active outreach treatment teams in adherence with the ACT and FACT models. The Norwegian Resource Centre for Community Mental Health (NAPHA) and the Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) are closely cooperating with the county governors, KORUS, the Norwegian Centres for Violence and Traumatic Stress and Suicide Prevention (RVTS), and various user organisations regarding implementation of the ACT and FACT models in Norway. Among other things, a network offering implementation support has been established. The Norwegian Resource Centre for Community Mental Health (NAPHA) and the Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) are working together on further developing and revising both the FACT model description and the establishment handbook (practical guide).

There has been a significant growth in the number of teams, and around 86 ACT/FACT teams have now been established in Norway. Even more teams can be established.

Despite the experiences with ACT and FACT teams being good, there are several challenges related to cooperation barriers, access to experts, long distances and financing of the teams and so forth.

Improvements have been made, but tasks on further development remain to be done.

Textbox 4.4 FACT Lofoten

Vågan, Vestvågøy, Flakstad and Moskenes Municipalities established a FACT team with Lofoten and Vesterålen District Psychiatric Centre in 2019. The team was established as mandatory collaboration between the service levels. As per February 2023, the team is providing services for 68 people.

The target group for the team is equal to what is described in the FACT model description. One of the additional criteria is that previous help has only had a limited effect. The team finds that they come in contact with people who had negative experiences with the previous help they received, and that they manage to offer the users cohesive and holistic services from both levels.

The team has a cross-disciplinary composition with employees from the two largest municipalities and the specialist health service, whilst the two smallest municipalities pay the team to receive services. The various owners finance their posts in the team.

FACT Lofoten has extremely good scores on model fidelity scale even though the team was established in a rural context with long distances.

It is important that children and adolescents with long-term and complex challenges receive help adapted to their needs, and that the services can be in the child and adolescent’s arenas. The Officer of the Auditor General of Norway’s survey on mental health services showed that half of the municipalities do not offer outreach services for children and adolescents with mental health issues and disorders.[176]

In connection with the National Health and Hospital Plan 2020-2023, three pilot teams where established to test Youth FACT in a Norwegian context. The Youth FACT team has a cross-disciplinary composition that provides integrated and long-term treatment to youth aged 12-25 with a functional disability within the areas of mental health, education, network, work, family, substance use, crime, sexuality and dependency, and where it is assumed that long-term and comprehensive efforts from multiple services and levels is needed.

The Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) has evaluated the pilot studies and published the evaluation report in autumn 2022.[177] It shows that in the opinion of the team employees, cooperation partners, next of kin and the youths themselves, Youth FACT should continue and be further developed, and that more youths should be offered Youth FACT (refer to Box 4-5 for an overview of the youths experiences). At the same time, the report showed areas of improvement in conjunction with implementation of the model. In the evaluation report, specific recommendations were given for the further roll-out of Youth FACT. The work on further developing Youth FACT has started. The Norwegian Resource Centre for Community Mental Health (NAPHA) is responsible for the coordination and execution of training, and for giving implementation support to the Youth FACT team. During the course of this work, the centre cooperates with other resource centres and a national implementation team has been created.

It is possible to apply for time-limited support for part-financing of the establishment and operation of a Youth FACT team. There are now around 20 teams, including preliminary projects.

Textbox 4.5 Experiences from the Youth FACT Pilot Studies

On the whole, the youths satisfied with the follow-up from the Youth FACT teams.

Many of the youths state that the Youth FACT team gives better help than the ordinary services (Child and Youth Psychiatric Outpatient Clinics (BUP)).

Most of the youths find they have a good relationship with the employees in the team, and that they are heard and no one gives up on them.

The youths find that the team meets them on their own terms and are solution orientated.

The youths find that the team is accessible, flexible when it comes to arenas and focus on families.

The youths find that they have real co-determination.

On the whole, the youths are satisfied with the cooperation between the team and cooperation partners, and the team and parents. The youths have limited knowledge of the contents of the cooperation.

Several of the youths experience positive changes in their lives: they can cope more, they participate more at school, they have better relationships and communicate better with their families, and they are more content with themselves.

Source: The Norwegian National Advisory Unit on Concurrent Personality Psychiatry, 2022.

The Government will enable the services to better reach people who need integrated outreach services. Among other things, this involves investigating various collaboration models and assessing how the medical communities can be better equipped to support the desired developments within mental health services. Solutions for local adaptations will be looked at in line with the Trust Reform The overall direction for further development of collaboration is put forward in the National Health and Collaboration Plan, and further measures will therefore be concretised over the course of the plan period (refer to Chapter 3.4.1 for a discussion on integrated services for children and adolescents in general).

The Government will continue and further develop outreach and outward-looking services, such as ACT and FACT teams, and Youth FACT teams. In line with this, instruments for supporting integrated treatment will need to be adjusted and assessed on a larger scale, we will facilitate the breakdown of barriers, and look at how the Government can facilitate continuity and predictability in the services.

4.4 Improved care for children and adolescents with long-term and complex needs

Children, adolescents and their families need holistic services adapted to individual needs. Some face complex problems that require coordinated, complex and adapted solutions. As part of the escalation plan, the Government wants to improve services for children and adolescents with complex needs through, among other things, strengthening the work on better coordination of the services offered, continuing and refreshing the health effort for children under the care of the child welfare service, and increasing competence related to recognising/detecting early signs of neurodevelopment disorders and following them up. Children and adolescents completing sentences, and children and adolescents with concurrent mental health issues and addiction problems, must also receive adequate follow-up and help. Services for children and adolescents with concurrent mental health issues and addiction problems will also be followed up in the prevention and treatment reform for the substance abuse field.

Children and adolescents have the right to participate and adapted information. Children’s rights will be maintained in decision-making processes. (refer to Chapter 3.4.1 for a discussion on children’s rights and consequences for children).

4.4.1 Children’s coordinator

The Government is concerned with children and their families experiencing good and holistic help. The Office of the Auditor General of Norway has pinpointed that families of disabled children and adolescents must take a lot of personal responsibility for getting help and coordinating services.[178] Families who have or are expecting a child with a serious disease, injury or disability, and will need long-term and comprehensive or coordinated health and care services, in addition to other welfare services, are entitled to a children’s coordinator. This right was introduced on1 August 2022. From the same date, harmonised and stronger rules on coordination and cooperation between the welfare services were always introduced. Joint regulations on individual plans also entered into force on 1 August 2022. The Norwegian Labour and Welfare Administration, the Norwegian Directorate for Education and Training, the Norwegian Directorate for Children, Youth and Family Affairs and the Norwegian Directorate of Health have prepared a joint guide for the regulation amendments. The children’s coordinator shall make it easier for families who have or are expecting a child with a serious disease, injury or disability. The coordinator shall ensure that the family and child receive coordinated and holistic welfare services and necessary information and guidance.

4.4.2 Children and adolescents under the care of the child welfare service

If a child is ill for a prolonged period of time, it can harm the child’s health and development. In particular, prolonged stress is harmful for children. It may lead to the child being more vulnerable to diseases, both physical and mental. A key goal of the child welfare reform, which entered into force in 2022, is that municipalities shall intervene early to help children and families at risk. The reform underlines the importance of a cross-sectoral approach for both early detection and measures. Early intervention can prevent cases from developing into serious child welfare cases, which in turn will reduce the risk of developing mental illness.

Children with measures, who are under the care of the child welfare service, have a higher number of health problems than other children, and there is a significant overlap between the target groups for the child welfare service and the Child and Adolescent Psychiatric Outpatient Clinics (BUP). National and international studies show that both children who receive assistance measures at home, and children who live in a foster home or institution, have a higher risk of developing mental health problems.[179] As the Norwegian Board of Health Supervision and others have pointed out in the 2019 Care and Frameworks Report, we see some of the most unwell children in child welfare institutions often with problems linked to self-harm, eating disorders or substance use, and more courses of unsuccessful treatment behind them within the healthcare sector.

The child welfare service find that many have problems linked to self-harm, eating disorders or substance use. These children have the same right to essential healthcare as other children, yet for many years problems have been pinpointed at the cross-over point between mental health services and the child welfare service with the consequent risk that children in care do not receive essential mental health services. The ordinary health and care services and goals and measures for strengthening them are fundamental for ensuring that children in care receive access to essential mental health services based on their support and treatment needs, including inpatient child and adolescent mental health services when considered necessary for health reasons. The priority setting guide for child and adolescent mental health services highlights that the specialist health service along with the first line should pay particular attention to vulnerable groups, such as children under the care of the child welfare service. An unclarified care situation or substance use problem should not be reasons for refusing a person mental health services.

Collaboration and competence need to be strengthened to ensure that children with such complex problems receive adequate help. In addition, it has been necessary to implement special measures to detect and take care of the needs of these children on a larger scale. Cooperation between the health and care sector is particularly important, especially for children in child welfare institutions who often need services from both sectors at the same time. Consistent feedback from the child is important, and the child’s wishes and needs for flexible adapted help must be accommodated. Among other things, this requires the services to work together and in parallel to each other, so children do not feel they are being flung around the sectors.

The Ministry of Health and Care Services and the Ministry of Children and Families have cooperated on the health effort in the child welfare service over time to contribute to improved services through the child welfare service, and services for children and adolescents with mental health challenges. One of the implemented measures is a national pathway for the child welfare service, which aims to ensure that children and adolescents in care are mapped and investigated by the health services for any mental health and addiction problems, so they receive the essential healthcare they may need. The pathway has also been extended to include mapping of somatic, sexual and dental health. The national pathway shall form the foundation for the commitment to improved healthcare for children in care, and it describes responsibility, tasks and cooperation between the municipal child welfare service, municipal health and care services and the specialist health service. The pathway also gives recommendations on how the cooperation can be set up, so that the services can jointly ensure early mapping and investigation of children in care.

Children who will be removed from their parental home can be offered cross-disciplinary health mapping through a cross-disciplinary health mapping team, which shall identify the support and health needs of the child. The purpose is to give the child welfare service sufficient knowledge about the strengths and needs of the child, so the child receives adapted care and follow-up in their new home, and essential healthcare.

To strengthen the cooperation, health managers have been introduced in all child welfare institutions, and the regional health trusts have engaged child welfare officers in the child and adolescent mental health service. Two care and treatment institutions have been established in Bodø and Søgne for children between the ages of 13 to 18, who need long-term care outside their parental home and desperately need mental healthcare. The institutions are regulated by the Child Welfare Act and the personnel have both child welfare and healthcare expertise. This institutional service will be evaluated.

In June 2022, the Ministry of Children and Families appointed a committee to investigate child welfare institutions and proposed essential changes to the service. Among other things, the committee shall investigate which frameworks and competencies the institutions must have to give children adequate care and follow-up services. The committee shall also look at what kind of assistance can be demanded from other important services for children and adolescents, such as health services for those with mental illness. The committee will deliver its report at the end of June 2023.

Despite efforts over the course of many years, recent reports and numerous cases in the media, major challenges still exist in this area. The Government will therefore continue, renew and strengthen healthcare efforts in the child welfare service with the following goals and measures, so that children in care receive holistic and cohesive services corresponding to their needs:

Early intervention to detect the need for medical and healthcare services with special emphasis on cross-disciplinary health mapping, national pathways and healthcare expertise in the child welfare service.

Tighter follow-up to ensure that the rights of children in care to receive medical and health services with special emphasis on good cooperation between the child welfare service, health services and other relevant services in a manner that contributes to good access to a GP and other municipal services for children in the child welfare service.

The development of services that are adapted to the needs of children in care for health care services and stability with emphasis on ambulatory services, prevention of relocations, national pathways, digital services, models for better coordination of cooperation and collaboration and increased expertise on children and substance use.

Better coordination of efforts aimed at children who need help from different agencies with emphasis on warnings and cooperation between the health and child welfare sector, so adapted help can be implemented when there is a possibility that children at high risk will no longer receive proper services.

4.4.3 Children and adolescents completing sentences

Children and adolescents, who commit crimes, have a worse upbringing and have been in contact with the child welfare service more often than others in the same age group.[180] The correlation is particularly transparent for those who repeatedly commit crimes. Experiences with those who are completing the special penal sanctions for those aged 15-17—juvenile punishment and juvenile follow-up—is that they have severe and comprehensive challenges, for instance, mental health challenges, addiction problems, violent and aggressive behaviour and harmful sexual behaviour.[181] At the same time, the National Mediation Service experiences that it can be difficult to get the right help for the adolescents. Reports from the City of Oslo and Oslo Police District show that youths, who are registered as repeated offenders over the course of several years, have severe challenges, but have not received the help they need.[182] On the basis of this, and through the Core Group for Vulnerable Children and Young People, the Secretariat of the Mediation Services, the Norwegian Directorate for Children, Youth and Family Affairs and the Norwegian Directorate of Health have been commissioned to investigate obstacles for the cross-sectoral cooperation and the welfare services’ participation during the completion of juvenile punishment and juvenile follow-up. The report will be available in autumn 2023 and will recommend measures and give advice for the further work of the ministries.

4.4.4 Children and adolescents with developmental disorders and other concurrent disorders

Challenged children often have complex difficulties. The symptoms can therefore satisfy several diagnoses in the diagnosis systems. A holistic perspective is particularly important when it comes to children, and it is important to consider somatic and mental health in relation to each other when giving help.[183]

Children and adolescents with neurodevelopment disorders are a complex group. Some have mild problems, whilst others have comprehensive problems that require tight follow-up from a lifespan perspective. The common denominator for these children is vulnerability that can lead to severe consequential mental and somatic problems if they do not receive the right adaptation and help. The complex conditions require cross-disciplinary and cross-sectoral cooperation and coordination. These children and adolescents may need services from many agencies in the municipality at the same time. It is important that schools, the Norwegian Labour and Welfare Administration (NAV) and the culture and leisure sector give good and coordinated help to these children and their families to ensure they have a good life and to prevent exclusion and mental health issues and disorders.

In order to give children and youths with neurodevelopment disorders a good service, early, coordinated, cross-disciplinary and evidence-based help must also be implemented to prevent severe problems. Increased inclusion of children with special needs in ordinary education requires knowledge of frequently occurring conditions, such as neurodevelopmental disorders, in schools and kindergartens.[184]

Mental illness more frequently occurs in people with development disorders than otherwise in the population, particularly the part of the target group who have cognitive impairments.[185] These people are entitled to, on par with everyone else, essential mental health services.

There is a great need to develop expertise and the capacity of treatment for primary and additional disorders in this patient group. Variation in the patient group also leads to a need for many different forms of expertise in the specialist health service to meet the needs of individual patients. Good cooperation between all the involved agencies is important. Cooperation between mental health services, the health and care services in the municipality and habilitation services, is often necessary to give proper mental healthcare to the patients. Increased knowledge about the conditions is also important in other sectors, such as the culture and leisure sector. In order to give these children and adolescents adequate help, the Government will during the plan period investigate measures for increasing competence in recognising early signs and following up neurodevelopment disorders in kindergartens, schools and services in the municipalities and specialist health service, and measures for strengthening cooperation on measures and treatment for this group.

The Ministry of Education and Research has initiated a competence boost in special education and inclusive practices, which shall contribute to municipalities and county municipalities gaining sufficient competence to prevent, detect and follow-up all children and pupils, so they receive an inclusive and well-adapted educational service in kindergartens and schools. The Norwegian Directorate for Education and Training is responsible for the structure of competence boost in cooperation with the Norwegian Association of Local and Regional Authorities and Statped.

In the Official Norwegian Report, NOU 2020: 1 Services for people with autism spectrum disorder and for people with Tourette syndrome, the committee were commissioned to describe the needs and main services from a lifespan perspective for these groups. The committee was also commissioned to assess today’s situation and propose how the services could be improved. The goal for the assignment was to strengthen the overall services for the group and their next of kin. To follow-up the investigation, the Government has commissioned the Norwegian Directorate of Health to draft standardisation products related to autism spectrum disorder and Tourette syndrome. The work on this started in spring 2023.

4.4.5 Children and adolescents with concurrent mental illness and addiction problems

The Government wants children and adolescents with mental illness and addiction problems to receive adequate help. The Office of the Auditor General of Norway pointed out in its survey on mental health services that adolescents with concurrent mental illness/disorders and addiction problems do not in many municipalities receive adequate enough treatment or have not been offered a municipal service.[186] Almost 20 per cent of the municipalities do not have services for adolescents with addiction problems, and almost 40 per cent of the municipalities state that the treatment services for adolescents with concurrent mental illness/disorders and addiction problems are not good enough.

A report from the Norwegian Directorate of Health shows that it is necessary to clarify who is responsible for offering specialised substance abuse treatment to children and adolescents in the specialist health service.[187] According to the report, it is also necessary to investigate the investigation tools and treatment methods adapted to children and adolescents with addiction problems, and any concurrent conditions. The Directorate’s investigation indicates that there are organisational barriers that cause problems for child and adolescent mental health services in working flexibly inside arenas and with the system around these children. Among other things, the Norwegian Directorate of Health points out that it should be assessed whether funding, including activity-based funding, supports the services in working more holistically with this group and their families. The Government will follow-up the report in dialogue with the Norwegian Directorate of Health and regional health authorities. Measures will be discussed in more detail in the prevention and treatment reform for the substance abuse field.

Textbox 4.6 Home-hospital care for children and adolescents

Home-hospital care is a service for children and adolescents who need more help than what they can receive by attending an outpatient clinic. The patients receive treatment in their own home with their families.

Oslo University Hospital has established a cross-disciplinary arena-flexible unit for adolescents, Front Ungdom hjemmesykehus (Front Home-Care Hospital for Adolescents). The goal is give adolescents the right help at the right time. Front Ungdom fills the void between outpatient clinics and inpatient departments by offering adolescents and families customised treatment. Employees travel to give adolescents help at home in known surroundings. Front Ungdom is concerned with strengthening the coping skills of adolescents during a crisis in their natural environment, not least, to strengthen the parents/guardians ability to care for them.

Lovisenberg Diaconal Hospital and the Diakonhjemmet Hospital have established a home-care hospital service for mentally ill children and adolescents. The service is particularly aimed and children and adolescents undergoing an acute crisis with conditions such as psychosis, risk of suicide, serious aggressive behaviour, self-harm or eating disorders, and children aged 0-6 in the risk zone. The hospitals closely cooperate with services in boroughs and municipal services, such as the child welfare service, the Educational Psychological Counselling Service (PPT), schools, kindergartens and respite services, and practitioners at outpatient clinics.

4.5 Improved services for adults with long-term and complex needs

The Government will strengthen services for people with long-term and complex service needs, and facilitate holistic and simultaneous cross-disciplinary services from different levels and sectors. More outreach, cohesive, integrated and flexible services are needed in municipalities and health trusts for people with long-term and complex needs (refer to Chapter 4.3 for a discussion on cohesive services and pathways). As part of the escalation plan, the Government will further develop models for mandatory collaboration and integrated services for people with concurrent substance abuse and mental health disorders (ROP) and support implementation of national professional recommendations on involuntary admissions in adult mental health services. In addition, the Government will aspire to ensure better housing services for people with long-term and complex needs.

4.5.1 Concurrent mental illness and addiction problems

The Government will work towards ensuring that the quality of the services for people with concurrent substance abuse and mental health disorders (ROP) are improved. Patients and users with concurrent substance abuse and mental health disorders (ROP) must receive integrated treatment and follow-up. Those offering the services shall arrange the necessary collaboration. The goal is that the resources of the patients and users are supported and used in such a manner that their health and quality of life improves.

Many patients with severe mental illness receive treatment from the mental health services for their addiction problems. Addiction problems can exacerbate the patient’s challenges and are important in relation to what services and treatment the patients need. It is particularly challenging to get cohesive and integrated services for people who have both severe mental illness and substance use problems. Patients with concurrent mental illness and substance abuse problems are more prone to emergency admissions and re-admissions, and their inpatient stays are shorter compared to patients with known addiction problems.[188] They need comprehensive and long-term help from multiple actors. Follow-up and treatment of somatic conditions are lacking. This is reflected in the group’s higher risk of increased morbidity and premature mortality. Life expectancy is discussed in more detail in Chapter 4.2.

People with concurrent substance abuse and mental health disorders (ROP) have a higher risk of being violence.[189] Mental illness and addiction problems are also risk factors for exposure to violence.[190] KORUS and the regional resource centres for violence, traumatic stress and suicide prevention (RVTS) have been commissioned by the Norwegian Directorate of Health to develop knowledge modules on integrated treatment of substance use and violence. The purpose is to increase competence among employees working in services for people with mental health challenges and addiction problems, so that services of a more holistic nature can be given to people with addiction and violence problems[191] (refer to Chapter 3.8 for a more detailed discussion on violence).

In 2017 and 2018, the Norwegian Board of Health Supervision carried out a nationwide inspection of the services offered to people with concurrent substance abuse and mental health disorders (ROP).[192] The inspection included specialist health services, municipal health and care services and social services, and revealed that people with concurrent substance abuse and mental health disorders (ROP) did not receive the services they need, which could have serious consequences for their health and life situation.

The Government will further develop concrete models for integrated services for patients with concurrent mental illness and addiction problems, and aspire to better enabling the medical communities to support service development for this group. This must be seen in relation to measures that are put forward in the National Health and Collaboration Plan.

The services for people with concurrent substance abuse and mental health disorders (ROP) will also be a theme in the substance use prevention and treatment reform.

4.5.2 Preventing compulsory treatment in mental health services

The main rule is that all healthcare is voluntary, regardless of whether the help is aimed at somatic, mental or substance use/related health challenges. In the mental health services, most people receive help on their own accord and with their own consent. In some situations it is necessary to give care and treatment even if the person does not want help or is not able to assess what help they need. Compulsory treatment can be given if the conditions of the law are satisfied. For instance, it is required that voluntary solutions have been unsuccessful or it must be evident that it is futile to try such solutions. With an imminent and high risk of endangering one’s own health and life, or that of others, compulsory treatment may be enforced, regardless of whether the person has the capacity to give informed consent or not. The obligation of the State to protect the life and health of individuals and the population shall in such cases take precedence over the main rule that healthcare should be voluntary.

Feedback has been received stating that the condition of incapacity to give informed consent may have negative consequences for the patients concerned, next of kin and society at large. Among other things, the concerns relate to the law amendment potentially having caused an overall increase in the use of compulsory treatment, the actual patients being more ill before they receive treatment, and the police increasingly helping the Norwegian Health Service to deal with severely mentally ill people. The Government has therefore appointed an expert committee to evaluate the condition relating to incapacity to give informed consent for compulsory treatment. The committee’s opinion is expected by 15 June 2023. The expert committee will look more closely at the challenges the rule has generated for the services, users and next of kin.

Psychiatric emergency departments, inpatient wards in District Psychiatric Centres (DPS), and local and regional forensic units treat mentally ill patients with various levels of severity. The scope of aggressive behaviour, risk of suicide, self-harm and risk of violence varies between and within the treatment levels. Similarly, the need for compulsory treatment and security measures varies. At the same time, the available local expertise on managing problems with aggression and other boundary-breaking behaviour impacts the institution’s ability to solve difficult situations without using force and preventing compulsory treatment from becoming the only option. Professionally, it is well-documented that compulsory treatment can be significantly reduced with targeted and systematic prevention work. In order to succeed in limiting the use of compulsory treatment, systematic and consistent work is required at multiple organisational levels and between cooperating actors. This entails active leadership and the development of a culture, organisation and expertise that promotes voluntary solutions.

The Norwegian Directorate of Health has prepared national expert recommendations for the prevention of involuntary treatment in adult mental health services, which became effective on 1 March 2022.[193] The expert recommendations are intended to be an instrument for a more uniform understanding of how the use of involuntary treatment can be prevented. A key goal of the recommendations is to reduce undesired variation in the use of involuntary treatment, and to contribute to quality improvement in health and care services.

The Norwegian Directorate of Health cooperates with the regional health authorities regarding use of the new recommendations. It will be necessary in the future to follow-up how the expert recommendations are being used in the health trusts, including whether the health trusts’ own plans for preventing and reducing involuntary treatment have been updated in accordance with the new national guidelines.

4.5.3 Housing services

Good living conditions and the basic needs that housing covers are important for all human beings (ref to Chapter 2.4), including those with long-term and complex needs. During the plan period, the Government will aspire to ensure that this basic need is covered for people with long-term and complex needs. This involves working towards better housing services for people with long-term and complex needs, and assessing which measures should be implemented to achieve this. This work includes solutions for patients who are subject to involuntary treatment pursuant to the Mental Health Care Act and people who are at risk of being violent It should also be seen in relation to measures for people who have been committed to compulsory psychiatric care, and include an investigation on staffed housing services and services that result in improved use of available resources from both levels. The work must be seen in relation to measures under Chapter 4.7 relating to good and coordinated services from the health and justice sector, and it will be carried out in consultation with the Ministry of Local Government and Regional Development, and the Ministry of Justice and Security.

Homelessness

Even though most people live well in Norway, this does not apply to everyone. The homeless are the most vulnerable group in the social housing policy. In Norway, the homeless are defined as people who do not have their own home to live in, and are referred to random and temporary housing services; people who live temporarily with friends, acquaintances or relatives; people who will be discharged from an institution or the Norwegian Correctional Service within two months and do not have a home to go to; and people who sleep on the streets. Temporary accommodation services, for instance, hostels, boarding houses or camping huts. The homeless have been mapped through suitable surveys every four years since 1996.[194] Mapping was last performed in 2020. There were around 3,300 homeless people. One in four of the homeless (749 people) had children under the age 18, and 112 of these were homeless with their children – at least 142 children. The mapping showed that twelve per cent of all the homeless were in institutions and six per cent in the Norwegian Correctional Service. In 2020, there were 798 people with concurrent substance abuse and mental health disorders (ROP). This constitutes 24 per cent of all homeless people. Those with concurrent substance abuse and mental health disorders are more frequently evicted from their homes compared to other homeless people, and they receive treatment more often.[195] Two of three in this group have repeatedly been homeless over the course of several years or for more than six months. The new Social Housing Act (refer to Chapter 2.4) may contribute to more disadvantaged people receiving essential help and the municipalities having more equal levels of housing for welfare stock.

According to the mapping performed by Sintef of municipal work on mental health and substance abuse, 16 per cent of municipalities experience that the housing situation for this mental health group is poor or extremely poor. The most common challenges are stated to be housing for people with concurrent substance abuse and mental health disorders (ROP disorders), insufficient differentiated housing services and lack of housing/shared housing where users have essential access to personnel.[196] . People with substance abuse and mental health disorders may need help to cope with living in their own home, for instance, advice, guidance, practical assistance or training. For people with concurrent substance abuse and mental health disorders (ROP),[197] coordinated services are particularly important (refer to Chapter 4.5.1 for a more detailed discussion on services for these people).

Textbox 4.7 Ljabruveien Residential Treatment Facility

Ljabruveien bo- og behandlingsenhet (Ljabruveien Residential Treatment Facility) consists of ten new builds and specially adapted dwellings for men with substance addiction and severe mental illness, and a long history of challenging behaviour related to violence, threats and vandalism.

The dwellings are attached to a 24-hour staffed personnel base. The initiative offers assistance in cooperation with boroughs and the specialist health service to encourage the individual om their road to recovery and coping with their life situation, in addition to giving them the opportunity to live in their own home over time.

The co-localised dwellings shall provide a good and safe living environment, and safeguard both the private life and safety of each single resident.

The personnel group focuses greatly on wellbeing and safety, and the buildings with a personnel base has been built with this target group in mind.

Source: City of Oslo, 2023.

Adapted housing for people who need care

People with long-term and complex needs should have access to housing adapted to their needs. The work on improved access to adapted housing for people who require care is also addressed in the report to the Storting (white paper) about the ‘Safe at Home Reform’. The reform is limited to the elderly, but several of the measures in the reform will apply to the whole population and be relevant to people with mental health and addiction problems. For some people with long-term and complex problems, the need for housing with 2.hour health and care services might be a solution (refer to the Health and Care Services Act, Section 3-2). The investment grant for 24-hour care places, which is managed by the Norwegian State Housing Bank, aims to stimulate the municipalities to renew and increase offers of nursing home places and residential care homes for people who need 24-hour health and care services, regardless of the resident’s age, diagnosis or disability. The investment grant is arranged so the municipalities, in addition to increasing the number of 24-hours care places, can also replace, renovate and upgrade all existing buildings. The Government will contribute to making the investment grant for 24-hour care places known to Norwegian municipalities to stimulate the provision of more dwellings to people with addiction problems and/or mental health problems.

In connection with work on the substance use prevention and treatment reform , the Norwegian Directorate of Health has been commissioned to map the scope and type of inpatient care that the municipalities offer to people with addiction problems and mental illness, and to assess if it takes care of this group’s needs. The assignment will also be relevant to the work on following up the escalation plan.

Housing services for people with higher violence and safety risk

When giving input for the escalation plan, many municipalities reported challenges linked to obtaining adapted housing particularly for those who need comprehensive services and have a problem with violence, This includes those who have been committed to compulsory psychiatric care. Users and patients with problems related to violence and aggression represent a smaller group that needs specially adapted and simultaneous health and care services. They are often the worst off in the housing market in terms of finding suitable housing and keeping a tenancy over time.[198] Challenges linked to discharge processes for patients with severe mental illness and concurrent serious violence problems have been described in multiple reports in recent years.[199] This patient population has comprehensive challenges and complex needs, and it is increasingly stated that both the specialist health service and the municipalities struggle with providing adequate safety, treatment and care services.

In 2020, mapping was performed of patients and discharge processes from forensic units.[200] The mapping shows that many municipalities receive patients with complex challenges from forensic psychiatry units and that there is an increase in the number of discharges. The findings indicate that these patients have comprehensive and complex needs, and there are challenges in the municipalities that receive them. This concerns legislation, finances, expertise, collaboration culture and the formation of a common understanding of the challenges between everyone involved.

The report highlights which measures are potentially significant to improving the legal protection and quality of life of this patient group. The measures are linked to housing types that take care of this patient group’s treatment and care needs, and legal protection in terms of restricted freedoms and use of force, whilst at the same time ensuring that the community is protected.

In February 2023, Fafo published the report In no man’s land. Social protection and forensic psychiatry from a municipal perspective.[201] The report discusses the challenges of the municipalities to provide proper services to people discharged from mental health services/forensic psychiatry to complete compulsory psychiatric treatment outside inpatient institutions (TUD), and where regard to the protection of society is central.

The report shows that municipalities provide services to a complex group of users with severe mental illness, often with concurrent addiction problems, where it is considered there is a higher risk of violence or safety risk. A range of services in the municipalities are involved in following up this target group. The people in this group often find themselves in no man’s land between the responsibility of the municipal services and the specialist health service. They often have co-occurring needs for the different instruments that the specialist health service and the municipality can offer. Municipalities are responsible for housing services, however, municipal services are based on the citizens wanting to receive them voluntarily. The report shows that municipalities and the specialist health service often understand and assess patients’ needs differently, and have limited knowledge of each other’s context and frameworks. There may be disagreements about the patient’s situation and their needs, what is a suitable and good service, and who is responsible for giving essential services, treatment and follow-up. Limited inpatient capacity in the mental health services puts pressure on discharging patients and a higher threshold for admissions.

The regional health authorities have been commissioned to create an overarching plan for forensic psychiatry. Among other things, the health trusts shall assess the need for long-term strengthened housing services in cooperation with the municipalities and whether it is purposeful to establish cross-disciplinary ambulatory teams to take care of people who represent a safety risk.

4.6 Using medicines correctly

Medicines can have an important place in the treatment of mental illness, particularly for more severe conditions. When psychopharmacology is needed, it should be part of a holistic treatment pathway. The Government will contribute to promoting correct use of medicines.

The use of medicines to treat mental illness is increasing. Figures from the Norwegian Institute of Public Health show that around 390,000 Norwegians were dispensed at least one antidepressant and antipsychotic drug in 2021.[202] Antidepressants are the most used but the use of antipsychotics is also increasing. The number of people taking sleeping pills and sedatives per 1000 inhabitants has on the whole not changed the last few years.

There may be genetic conditions affecting the way the body metabolises the active ingredient in the drugs for several of the most used antidepressants and antipsychotics. Personalised medicines can contribute to optimising the use of pharmaceutical drugs for each patient. The Centre for Psychopharmacology at Diakonhjemmet Hospital has over the last 20 years developed and introduced pharmacogenetic analyses for precision dosing of psychopharmaceuticals. The genetic investigations contribute to increased precision when choosing a drug and dose for individual patients. The vision of the Government’s strategy for personalised medicine (2023–2030) is for personalised medicine to become an integral part of prevention, diagnostics, treatment and follow-up from the healthcare services, where the objective is to improve health and coping skills throughout life. One measure in the strategy is that the Norwegian Directorate of Health will assess the need for recommendations linked to pharmacogenetic analyses. This will particularly contribute to meeting the need for such recommendations in municipal health and care services.

Several studies also indicate an increase in the total use of psychopharmaceuticals in the 0-17 years age group during the last decade in Norway, especially among young girls.[203]

There is limited knowledge about what type of consequences the use of psychopharmaceuticals in children and adolescents will have in the longer and shorter term. The Medicines for Children Network, Norway, aims to ensure that paediatric medicinal treatment is appropriate and safe. The network has been commissioned to establish and operate a national medicines network within child and adolescent psychiatry. The Nasjonalt kompetansenettverk for psykopharma til barn og unge (the Child and Adolescent Psychopharmacology Network) started up in January 2022 and consists of a cross-disciplinary group with pharmacists and specialists in child and adolescent psychiatry from various health trusts.

National professional recommendations for using psychopharmaceuticals for children and adolescents were published in September 2022. Among other things, the recommendations shall help ensure that only children and adolescents with the required indications receive psychopharmaceuticals and that the treatment is followed up systematically and ended if no effect is received or there are serious side effects.

The national patient pathway contains recommendations on how medicine usage should be followed up and specific recommendations for following up the use of antipsychotics.[204] The Norwegian Medical Association has prepared recommendations for tapering and the cessation of antipsychotics.[205]

Non-pharmaceutical treatment

Non-pharmaceutical treatment in the mental health services was first introduced in all regions in 2017 upon commission of the Ministry of Health and Care Services. The basis for the effort was a clearly communicated need from users to have an alternative to the traditional pharmaceutical-based treatment in mental health services. The service helps people to improve their mental health without side effects from pharmaceuticals or to manage with lower doses. It is therefore an important contributor to better coping skills and the reduction of unnecessary use of psychopharmaceuticals.

The evaluations from the Competence Centre for Lived Experiences and Service Development (KBT) show that the service has anything but met the users expectations in terms of assistance with tapering or ending psychopharmacological treatment. Other forms of therapy (for instance, conversation therapy, group therapy, music and art therapy and animal-assisted therapy) and support measures, can help improve functional ability and contribute to less discomfort from pharmaceutical side effects.

KBT’s last report shows considerable variation in implementation non-pharmaceutical services, and that a lot of work still remains to be done to make the services accessible on par with other mental health services.[206] According to the report, the non-pharmaceutical services are considered difficult to access for the users. This is partly due to a lack of information about the availability of the service and what the alternatives to pharmaceuticals involve. Non-pharmaceutical treatment has a natural place in modern, patient-orientated mental health services. Further development of the service should be carried out in dialogue with the expert environments, users and next of kin.

4.7 Good and coordinated services from the health and justice sector

Many inmates or people, who have been committed to treatment or compulsory care, have comprehensive and complex mental illnesses or intellectual disabilities that require adapted conditions for serving the sentence and following up health problems. The Government will facilitate good and coordinated services from the health and justice sector, which will contribute to improving the life situation and health of each single person, whilst at the same time safeguarding society.

4.7.1 Court-ordered committal to compulsory psychiatric care

Court-ordered committal to compulsory psychiatric care and court-ordered committal to compulsory care are special penal sanctions (the Norwegian Criminal Code, Sections 62 to 65). These special penal sanctions replace prison sentences for people who were criminally insane at the time when the offence was committed.

There has been a significant increase in the number of people committed to treatment in recent years, especially from 2020 to date[207] (refer to Figures 4.2 and 4.3). The increase coincides with the amendment to the conditions in the Criminal Code for ordering transferral to compulsory psychiatric care, which entered into force in October 2020. There has been a massive increase in some areas causing capacity problems. According to the regional health authorities’ projections, if the trend continues for the next ten years, there will be 500-600 convicted persons in psychiatric care, which is double the number today. A significant increase in capacity will be needed to treat and follow-up patients, who have been committed to compulsory psychiatric care, if the conditions for using special penal sanctions remain unchanged. The Government will soon appoint a committee to, among other things, evaluate the arrangements involving sentences ordering transferral to compulsory psychiatric care and committed care.

Most people complete court-ordered committal to compulsory psychiatric care in inpatient departments. Some are in forensic units (regional or local) and other in ordinary inpatient departments in hospitals or District Psychiatric Centres (DPS). Notwithstanding many also complete the sentence without inpatient stays.

Reports and inspections show that both municipalities and the specialist health service have problems ensuring good and coordinated services for people who represent a safety risk whilst simultaneously safeguarding society.[208] Challenges exist in relation to capacity, expertise, housing services and cooperation between the police and healthcare services. If the increase in the number of people committed to treatment continues, the current challenges will be exacerbated, and further impact the general capacity and use of personnel in the services.

Holistic and stable services are necessary prerequisites for safeguarding society during completion of court-ordered committal to compulsory psychiatric care without inpatient stays. Adults without legal residency however are only entitled to immediate help and healthcare services that are completely essential and cannot wait. People sentenced to special penal sanctions, but are staying in Norway illegally, therefore risk remaining in a specialist health service inpatient facility longer that what is justified in relation to the person’s need for treatment.

Based on an enquiry from the Parliamentary Ombud, the Norwegian Directorate of Health along with the Norwegian Directorate of Immigration and Norwegian Labour and Welfare Administration were commissioned to propose practical solutions, within the boundaries of today’s regulations and systems, for situations where the attending practitioner in charge at a psychiatric facility is of the opinion that a foreigner, who does not have a resident permit and has been sentenced to special penal sanctions, should be discharged from a psychiatric inpatient facility. The report was delivered in October 2022.

As of October 2022, five specially punished people without legal residency in Norway were still in a psychiatric inpatient facility even though the professional in charge was of the opinion that they were ready to be discharge from the specialist health service. Notably in respect of the progression of treatment, they should have been transferred to compulsory psychiatric care without inpatient stays. The main conclusion of the Norwegian Directorate of Health is that it is not possible within the boundaries of today’s regulations to ensure that specially punished persons without legal residency in Norway can be discharged from an inpatient facility when the professional in charge is of the opinion that it is correct to do so. Nonetheless, solutions have been proposed—within the boundaries of today’s regulations—that can remedy the situation up until they are returned. The Ministry of Health and Care Services will in cooperation with the Ministry of Justice and Security and Ministry of Labour and Social Inclusion consider how the investigation should be followed up.

Measures are needed both in the specialist health service, the municipalities and in the cooperation between the former and latter to meet the increased number of committed people.

In 2022, the Ministry of Health and Care Services commissioned the regional health authorities to prepare an overarching plan for forensic psychiatry and other measures for people committed to compulsory psychiatric care. According to plan, the report will be completed in summer 2023. Among other things, the plan will explain the need for content, organisation and cohesion in the forensic psychiatry service with the purpose of facilitating better patient pathways in psychiatric care. The report will also address capacity needs and guidelines for cooperation between the specialist health service and the municipalities. The report will be directional for the further path to take in forensic psychiatric services.

Figure 4.2 Number of persons committed to compulsory psychiatric care in the period from 2015-2021.

Source: South-Eastern Norway Regional Health Authority, 2022.

4.7.2 Court-ordered committal to compulsory care

Committal to compulsory care is a special criminal punishment that was originally established for people with severe intellectual disabilities who had committed serious crimes against other people’s lives, health or freedom (for instance, sex crimes, arson, gross violence, etc.). A national unit has been created with responsibility for completing this special penal sanction. The Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care) is located at St. Olavs Hospital, Central Norway Regional Health Authority. The specialised unit is responsible for ensuring that all convicted persons are investigated in the unit’s inpatient department. When consideration towards the convicted person and safety considerations do not argue against it, the specialised unit can enter into an agreement stating that the care can be completed outside the specialised unit, for instance, in the convicted person’s own municipality of residence. In addition to responsibility for accepting convicted persons for compulsory care pursuant to sections 63 and 64 of the Criminal Code, the specialised unit is obliged to accept people placed surrogate remand in custody pursuant to section 188 of the Criminal Procedure Act and/or forensic psychiatric observation pursuant to section 167 of the Criminal Procedure Act.

From starting up in 2002 up until 2019, relatively few people were ordered by a court to complete compulsory psychiatric care (up to two persons per year). Since 2020, the number of convicted persons has increased considerably. More people have entered the scheme in the last three years than the total number in the period from 2002-2019.[209] The is primarily due to amended rules in the Criminal Code regarding culpability and conditions for court-ordered compulsory care. The amendment was effectuated in autumn 2020. Following the law amendments, court-ordered compulsory care is no longer reserved for the intellectually disabled. People with mental illnesses involving a high symptom burden, and equivalent organic and somatic conditions affecting the mind (for instance, dementia, Alzheimer’s disease, brain damage and autism disorders) can be sentenced to the scheme if the prosecuting authority and court consider it fitting for the crime. Compared to earlier, it is at the court’s discretion to order special penal sanctions (court-ordered committal to compulsory psychiatric care or committal to compulsory care) based on what the court considers best in each single case. In addition, the guiding IQ threshold for severe intellectual disability in the sense of the Criminal Act has been increased from 55 to 60.

Further, the trend in court-ordered committal to compulsory care has put the scheme under a lot of pressure. The capacity of the ward at Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care) has been exceeded and the Central Norway Regional Health Authority has had no choice but use beds in regional forensic departments. It may be necessary to extend the already newly built forensic building at St. Olavs Hospital to handle the stream of new convicts. The trend in the number of court orders has also caused a substantial increase in costs with repeated overspending of grants awarded to the scheme in the National Budget. The administrative and financial consequences of reducing the threshold and expanding the scope of application for court-ordered committal to compulsory care were not sufficiently investigated prior to the law amendments.

Figure 4.3 Trend in the number of persons sentenced to compulsory care in the period from 2002-2022.

Source: Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care), 2022.

4.7.3 Prisoners

The prevalence of mental illness among prisoners in Norwegian prisons is higher than in the population at large and it is not uncommon for prisoners to have several concurrent mental health disorders. Studies show a high prevalence of comorbidity and that 92 per cent of prisoners have some type of personality disorder or other mental health disorder.[210]

Many prisoners in Norwegian prisons therefore need health care services. Some prisoners already have comprehensive and complex mental illness or intellectual disability prior to imprisonment, which sets higher requirements for prison conditions and adequate follow-up of mental health challenges.

Without good prison conditions and sufficient healthcare, there is a higher risk of prisoners becoming isolated and the possibility for rehabilitation to a life without crime being reduced. This is a joint responsibility of the Norwegian Correctional Service and the health and care services.

Restricting the right of an individual to have social contact with others is a serious invasion of personal integrity and autonomy. Additionally, restrictions on human contact, lack of activities and meaningful community with others—and in many cases total or part isolation—harms both physical and mental health. The extent to which prisons facilitate social contact, community and activities is therefore vital for the physical and mental health of prisoners.

Norwegian authorities have been subjected to special criticism in recent years where it has been pointed out that many prisoners in Norwegian prisons are isolated. In June 2019, the Parliamentary Ombudsman (now Parliamentary Ombud) submitted a special white paper to the Storting on isolation and lack of human contact in Norwegian prisons (Document 4:3 (2018–2019). In its recommendation, Innst. 172 S (2019–2020), the Storting’s Standing Committee on Scrutiny and Constitutional Affairs asked the Government to implement measures and to put forward proposals to the Storting for essential law amendments to follow up the recommendations of the Parliamentary Ombudsman’s special white paper. The Parliamentary Ombudsman recommended improvements, such as enactment of the responsibility of health care services to follow-up isolation and use of solitary confinement or restraint beds, and to ensure that the prison health service is given a joint professional platform. Amendments to the provisions of the Execution of Sentences Act regarding exclusion from community and strengthening of the scrutiny scheme were also among the recommendations. Both the Ministry of Justice and Security and the Ministry of Health and Care Services are working on measures to follow up the Parliamentary Ombudsman’s report.

The use of isolation in the Norwegian Correctional Service has gone down. The Ministry of Justice and Security sent proposed amendments to the Execution of Sentences Act and the Health and Care Services Act (community, exclusion and means of coercion in prisons) for comment in February 2023. The time limit for comments is 1 June 2023. The intention of the proposals was to remedy the problems with isolation in prisons, to take care of consideration for prisoners and employees, and to safeguard society’s need for adequately secure prisons and prisons with a good rehabilitative effect. The Storting has adopted new rules on scrutiny boards for the Norwegian Correctional Service. The amendments concern new rules pertaining to independency, appointment, authority and organisation, in addition to rights and obligations during scrutiny.

The Norwegian Correctional Service’s buildings consist of many relatively small prison units, and several of them are in a poor technical condition minimally fitting for modern prison operations. A major problem is that many prisons and departments do not have suitable space for health and welfare services, and for community and prisoner activities. An overarching goal of the Norwegian Correctional Service is to enable as many prisoners as possible, including the mentally ill, to socialise with others and join activities in adapted common areas (if applicable).

Prisoners have the same right to essential health and care services as the population at large. The municipality in which the prison is located is responsible for providing health and care services and the health trust is responsible for providing specialist health services. The Norwegian Correctional Service is responsible for enabling prisoners to receive essential health care services. National professional guidelines for municipal health and care services for prisoners has been submitted for comments. The time limit for comments is 2 June 2023.

The regional health authorities have been commissioned to establish local specialist services for mental health and cross-disciplinary specialised treatment for substance use disorders (TSB) This shall guarantee regular local services at regular times within both fields in prisons. The regional authorities have also been commissioned to establish strengthened national services for the most debilitated prisoners at Ila Detention and Security Prison for men and at Bredtveit Detention and Security Prison for women. It is important that the local services and strengthened units are allowed to operate over time with the planned and recommended resources.

It is necessary to investigate how prisoners with severe mental illness or intellectual disability can best be taken care of during remand, serving sentences and when returning to society. The Government has decided to create a committee to investigate this matter and evaluate the penal sanctions on remand, court-ordered committal to compulsory psychiatric care and court-ordered committal to compulsory care.

There is a substantial minority of female prisoners and convicts. At the same time, several reports and surveys show that the percentage of women with mental health problems is markedly higher than for men.[211] Female prisoners are a particularly vulnerable group when it comes to exposure to suicide and suicide attempts. In 2022, there were 95 suicide attempts in prison and the majority were carried out by women.[212] The Parliamentary Ombud also pointed out this situation in the Selvmord i fengsel (Suicide in Prison) report in 2023. The Norwegian Correctional Service pays great attention to preventing suicide in prison, and when suicide is indicated. an action plan is prepared. The health care services must be informed when this type of plan is prepared. It may also be relevant to place vulnerable prisoners in separate high-security units in prisons where available.

Insofar as possible, women, shall carry out their stay in prison in separate prisons or in prison facilities adapted for women. It is necessary to assess what special considerations must be applied for women in connection with remand in custody, serving sentences or completing special penal sanctions, and the need for new measures and solutions that may improve the mental health of these women.

The threshold for imprisoning children and adolescents is high, and a prison sentence is only permitted when specifically required. Children who are imposed an unconditional prison sentence, generally serve the sentence at one of the specially adapted juvenile units established under the auspices of the Norwegian Correctional Service. Young prisoners have the same mental health problems as other prisoners. but are also highly vulnerable due to their age. Basic staffing in the juvenile units must be cross-disciplinary with the addition of an interagency team to ensure participation from a variety of agencies. If a child turns 18 whilst serving their sentence, they will normally be transferred from the juvenile unit to an ordinary prison. This can be experienced as a major transition, and there is a risk that good return and rehabilitation pathways come to a halt. Cross-disciplinary youth teams have been established at several prisons to give those aged 18-24 stronger follow-up. Cross-sectoral cooperation and local services are also needed, but the degree to which this works varies. Through the Core Group for Vulnerable Children and Young People, work is therefore being conducted on a joint assignment for the relevant directorates to investigate obstacles and possibilities for cross-sectoral cooperation and participation of the welfare services prior to, during and after the completion of sentences for those aged 18-24.

4.7.4 Responsibility when transporting the mentally ill

In some cases, health care services need assistance from the police when transporting mentally ill people. Such assistance may, for instance, involve taking people to compulsory medical examinations or transferring them to psychiatric care. The requirement is that police assistance during transportation is essential, however, the health care service assesses and decides to request assistance, and the degree to which it is necessary. Several regional and local measures have been implemented in recent years to increase competence and collaboration between the actors who meet the patients during various parts of the pathway, including the police. The cooperation works extremely well in many places. At the same time, experience shows that the police occasionally feel they are called upon too often, and the health care services sometimes have difficulty getting police assistance.

Along with the Norwegian Police, the Norwegian Directorate of Health has been commissioned to revise the circular regarding the responsibility of the health care services and the police for the mentally ill. One goal of the cooperation is to solve the responsibility tasks in the least possible invasive way and for the best of the individuals. The revised version shall, among other things, particularly specify when police assistance is needed, for instance, in connection with transportation and when the health care services cannot safeguard this themselves. The revised circular is expected to be finished in summer 2023. Broad implementation of the revised circular is planned.

The Government will present a white paper to the Storting regarding emergency medical services where it will also be natural to discuss any problems related to the transportation of mentally ill patients.

5 Financial and administrative consequences, and outcome follow-up

Figure 5.1

The Government proposes to increase funding for mental health by MNOK 3 from 2023-2033. This involves permanent strengthening to a new level. Increased grants for individual measures depend on priority setting in the annual budget processes.

As part of the commitment, MNOK 150 has been awarded in the 2023 budget year for new and stronger measures linked to the mental health escalation plan and substance use prevention and treatment reform. MNOK 150 of the increased basic hospital funding was also earmarked for strengthening inpatient child, adolescent and adult mental health services.

The escalation plan is a dynamic plan based on the overarching performance measures. Several of the proposed measures in the plan require further investigation and it will take time to estimate the costs and implement them. The investigations will, among other things, assess the consequences related to the demand for personnel of which there is a shortage. Therefore, the plan can also be adapted to the trend and build on the most updated knowledge about the need for services and public health measures. Measures in the plan will be concretised and put forward in the ordinary budget processes. The Storting can therefore consider concrete measures and how quickly they will be phased-in during the course of the plan period. The status and progression of the plan will be presented annually in Proposition No. 1 S.

The cost of following up the performance measures related to access to evidence-based low-threshold services is estimated to be between MNOK 900-1,100. The calculations are based on experiences with the quotes from Prompt Mental Health Care and Ung Arena. According to Sintef’s report IS 24/8 regarding man-years in municipal health work, 11 per cent of the municipalities do not have low-threshold services for children and young people and 20 per cent state they have a partially adapted service for the target group. In terms of Prompt Mental Health Care, 268 municipalities do not currently offer this service. The cost of establishing new Ung Arena services will range between MNOK 2-3 per service, whilst for Prompt Mental Health Care the estimated cost is around MNOK 6 per team. In order to establish such services, many municipalities will have to join forces or use other models, since the models that are used as a basis require a population of 15,000 to 20,000 inhabitants. The cost assessment is based on a need to establish 15 new services for children and young people, and around 140 new services for adults. In addition, it is necessary to further develop the services for children and adolescents equivalent to 20 new services.

The financial consequences of the goal for children and adolescents to be offered a clinical interview when referred to child and adolescent mental health services is estimated to cost around MNOK 30 (2023 NOK) for children and young people up to the age of 18. The estimate is based on calculations from the regional health authorities. It has been taken into account that the introduction of clinical assessments involves taking in around 8,500 new patients for an interview in the child and adolescent mental health services, and that more cooperation with the municipalities must be expected to clarify which support services are the right ones to use. Nonetheless, it does not mean that 8,500 more patients will proceed further in the specialist health service patient pathway. Transitory experiences from, for instance, Øvre Romerike Child and Adolescent Psychiatric Centre (BUP) show that some are rejected after the clinical interview, whilst others are considered to need specialist health services, and others are offered further services in the municipality. The Ministry estimates that interviewing everyone will require around 30 extra man-years at a cost of around MNOK 1 per man-year. If the target group for clinical interviews is extended to those aged 25, the financial consequences will increase.

Many of the proposed measures will have positive socioeconomic consequences far beyond the health and care services. However, it is difficult to attach figures to these benefits with the knowledge basis we have today. Mental illness contributes to loss of health from the age of ten. No other disease group causes more loss of health or costs attached to disability benefit than mental illness, and even a small reduction in the percentage of young people, who become permanently disabled, will have a significant effect over the course of some people’s lives as well as for society.

It is also difficult to calculate the benefits of increased life expectancy and quality of life for people with severe mental illness. In 2017, the Norwegian Resource Centre for Community Mental health (NAPHA) estimated that around 26,000 users might be in the target group for follow-up from a FACT team[213] , and therefore in need of specialised, long-term and complex help for severe mental health and/or addiction problems. The estimate is built on reports from the municipalities in BrukerPlan, and is the number of users that the municipalities have mapped as having severe mental health and/or addiction problems with a very low or serious functioning level score. This means that at 26,000 people have serious complex mental health and/or addiction problems and difficulties in most areas of life. The Holden Group[214] , in its socioeconomic assessment of the infection control measures during the COVID-19 pandemic, used MNOK 1.4 as an estimate for the value of non-quality adjusted life years. This estimate was based on the Norwegian Directorate of Health’s recommended calculation method. If one takes into consideration a low estimate for lost life years in the group of 26,000 people over the course of ten years, it involves 260,000 expected lost life years. Based on these assumptions, it can be estimated that the value of lost statistical lives and life years for people with severe mental health and/or severe addiction problems will be around BNOK 364.

Experiences from the evaluation of the ACT teams[215] show that more adapted follow-up considerably reduces the use of compulsory inpatient stays and increases quality of life. Nonetheless, it is too early to say whether such measures specifically affect life expectancy. Regardless of this, more holistic and comprehensive help will be critical to improving health-related follow-up in connection with mental illness, addiction problems and somatic ill-health.

The benefits of each single measure are illuminated in the respective paragraphs in the plan. In the work on investigating concrete measures within and outside the health and care sector, we will aspire to illuminate the benefits of the measures, and the Storting will receive the presented proposals for concrete measures in the annual budget processes from 2024.

Instruments in the plan

The Government has taken into account that goals and measures aimed at the municipalities are generally funded through the municipalities’ unrestricted income. Today’s municipal expenditure attached to the field of mental health is primarily covered by the municipal sector’s income system, and any further commitment through the municipalities’ unrestricted income will contribute to elucidation and predictability for the municipalities. Unrestricted income also stimulates efficient exploitation of resources in line with local needs, so the municipalities have a cohesive overview of their welfare tasks, including integration of municipal work on mental health in the ordinary services. Similarly, the specialist health service shall be funded through the annual financial budgets for the health trusts. Some priority areas will, however, require special funding, among other things, to give better knowledge support to the services, develop and disseminate new measures and models, and stimulate collaboration.

Following up results

The Ministry of Health and Care Services will, as the coordinating ministry, continuously follow-up the progress and goal achievement in the escalation plan. To ensure a low report burden, existing data sources should be used insofar as possible to keep up with and watch the plan. To map the efforts of the municipalities, the Norwegian Directorate of Health’s IS-24/8 form must be used. In addition, figures from Brukerplan, Ungdata, etc., will give us valuable information about the situation in the municipalities, and the users and their functioning levels. Likewise, the Norwegian Patient Registry and Samdata will give us information about trends in mental health services. Further, the Norwegian State Housing Bank’s reporting routines will be used to follow up the municipalities’ work on contributing to more people with mental health problems having a good place to live. Established indicators for follow-up already exist for most performance measures. New indicators must, however, be developed for three of the performance measures:

Citizens of all municipalities have access to evidence-based low-threshold mental health and substance use services.

People with severe mental illness and/or addiction problems shall have a higher life expectancy, and the difference in life expectancy between this patient group and the rest of the population shall be reduced.

Healthcare personnel have more time for patients, users and professional development.

During the plan period, it is proposed that the Norwegian Registry for Primary Health Care KPR) is further developed to include municipal services related to mental health and substance use. This will contribute to potential knowledge development and better municipal service data for observing developments in this field. There is also a need to further develop the Norwegian Patient Registry (NPR) to give better and more all-encompassing event history analyses.

Completion and evaluation

A ten-year plan period has been set up, and a separate evaluation program will be established. The evaluation should include follow-up of the plan’s goal achievement in the specific performance measures, in addition to the experiences of users and next of kin during the plan period. The Norwegian Directorate of Health will be commissioned to establish an evaluation program from 2024 to follow the effects of the escalation plan as it is gradually completed. The evaluation will be part of the basis for further follow-up and completion of measures during the plan period, including assessment of the need for changes or adjustments to the use of instruments. Status, goal achievement and the progression of measures must be reported annually to the Ministry of Health and Care Services.

It is important to make the plan known and contribute to the development of local plans in the field of mental health. Therefore, the Norwegian Directorate of Health will in cooperation with the county governors be commissioned to oversee that experiences are exchanged and good examples are spread. Entrenchment of the escalation plan in municipal, administrative and political bodies is essential for its execution and goal achievement. The county governors shall support the municipalities in planning and developing community mental health work during the plan period through recommendations and guidance, and their points of contact in the municipalities.

Advising

The Ministry of Health and Care Services

advises:

That the recommendations of the Ministry of Health and Care Services of 9 June 2023 relating to the Escalation Plan for Mental Health (2023–2033) are sent to the Storting.

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The expert group for socioeconomic assessments in connection with the coronavirus outbreak, 2020.

215)

The Norwegian National Advisory Unit on Concurrent Personality Psychiatry, 2014.