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A Vision for a High Performing and Sustainable Health Care System

Keynote speech: A Vision for a High Performing and Sustainable Health Care SystemHeld at the 21st Commonwealth Fund International Symposium, Washington D.C., 15 November 2018

Dear ministers, honorable guests, colleagues/friends.

I am honored to have the opportunity to present the Norwegian governments vision for a High performing and sustainable health care system.

I represent a Centre – Conservative coalition government, in office since 2013. Our current minister of health, Mr. Bent Høie, has held the post since 2013 – a historic record in Norway. I have myself also been in my position as secretary of state these five years. 

I will present our main priorities during our time in office, what we have achieved, current initiatives, and our visions for the future.  But first I will give you a short introduction to Norway and our health and care system. I suppose not everyone here has all the facts totally clear in mind.

For those of you not familiar with Norway, here's some key features:

We're a small country in Northern Europe. Our population is 5,3 Million. We are far north, with a long coastline, and many mountains and fjords. Norway has the lowest population density in continental Europe: 11 persons per square kilometer. In Norway, people live in every part of the country. Therefore, we have a very decentralized service delivery.

Norwegian Municipalities vary a lot in population. Oslo, the capital, has
670 000 inhabitants, whereas the island Utsira, the smallest, has 200.

In general, we're a healthy country. Men can expect to live until 80 and women until 84. Also according to other OECD-indicators, Norwegians are healthy. Still, there are significant social inequalities between and within municipalities, though inequality in life years at birth is among the smallest in Europe.

Our health system is taxation-based, with one national health insurance body covering all citizens living on our territory. We spend 9-10 % of our GDP on health. And 85 % of all health spending is public.

The responsibilities in the field of health is divided between the state and the 422 municipalities. The State is responsible for providing specialized – secondary and tertiary – health services, and the municipalities are responsible for primary health services. This includes emergency services, general practitioners, mother and child services, school health nurses, home-based care and nursing homes, as well as outreach public health work.

Most services are provided by public bodies. The main exceptions are general practitioners and physiotherapists services, which are private, but with permanent contracts with the municipalities and are publicly financed.

Since 2001 we've had a regular General Practitioner scheme where every citizen registers with a GP of choice. The GPs participate in our 24/7 out-of-hour emergency service in the municipalities. Our citizens do not go directly to hospital acute and emergency units if they need help, unless they have a major accident, a heart attack, a stroke or similar.

Central values in Norwegian health policies are accessibility – throughout the country – and affordability. This means systematic efforts to ensure the quality and safety of treatment throughout the health and care services, as well as low out-of-pocket payments with maximum thresholds.

Citizens' access to health care has a strong legal basis in the Patient rights Act and other legislation. These rights include the right to access your medical records, information and to be consulted regarding your treatment.

In general, our health system works well compared to other OECD countries. We do good when it comes to most "hard" outcomes. But we don't do as well when it comes to other aspects, for instance issues the Commonwealth Fund has measured several times, like the involvement of patients in their care.

The vision launched by Minister Bent Høie in 2013 is "The patient as a Partner". We want to create a health care system where the patient is an active partner in managing his or her health. It is different to consider the patient as a partner than patient-centred care. In the centre, you are looked at, you are passive.

To make the patient a partner, it is necessary to involve patients in all important decisions about their own care.  Doctors and nurses, although experts in medicine and care, must understand that the patient is the real expert on his own life and health. We need to ask the patient "what matters to you?". This is the key question.

The purpose of this question is to start a conversation about the things that really matter in people's lives. To turn the focus away from the patient as the sum of disease or diagnosis, and focus on their resources and abilities. Self-management is a medicine that is not used to its  full potential, our patient organisations have told us.

Patients should also be involved in how health services are delivered. Patients are the most important and most radical agents for change.  To design good health care services, patients and professionals must sit around the same table, using service design as a method.

To create the patient's health care system, we need to make the right political choices. But most of all, and hardest of all, we need to change the culture and mind-set of those working in the health care system.  This takes time, but I think we are moving in the right direction.

A main priority for the Health minister has been to strengthen services in mental health and addiction treatment. In this patient group there are many young people. The Minister has done this in several ways. He has set as a target that mental health and abuse must be prioritized higher than the somatic sector by our regional health authorities, and he has made it mandatory for municipalities to have psychologists as part of their health and care services.

He has also focused on public health. Traditionally, public health work has focused mainly on the physical health of the population. In a White Paper on public health from 2015 we presented our plan to include mental health as an equal part of the public health work.

Three weeks ago the 40th anniversary of the Alma Ata declaration was celebrated in Astana, Kazakhstan. Well ahead of that, we started our work to improve primary health and care services in Norway. For those of you who have heard of our coordination reform of 2012, we saw this as the second step of the reform.

The reform aimed at better coordination between municipalities and hospitals, but also on shifting care from hospitals to municipalities. We support these aims, but we meant that the municipalities was not prepared for the many tasks they received. So when we came into office, we wanted to strengthen the primary health and care sector.

In 2015, for the first time in 30 years, our government presented a White Paper to Parliament on primary health care.  

In addition to strengthen capacity and level of knowledge, a main focus of the White Paper was better coordination of care inside the municipalities. In Norway, the municipalities are legally and financially responsible for both health and social care as well as public health. Our organization thereby gives a fundament for coordination in primary care.

Unfortunately, that does not mean that it always works well. Patients tell us that care is fragmented. There are organizational silos and different cultures in health and social care.

As a follow-up of the White Paper, we are piloting new team-based ways to work in primary care. We have increased both the capacity and the knowledge level in the municipalities, especially among nurses. We also have introduced psychologists in primary care, as already mentioned.

And - we are creating a new clinical master in general practice for our nurses. To meet the needs of our patients, we think nurses, as well as others, need increased and broader knowledge in their field of work. They need to be able to see the whole patient.

Another measure we have prioritized, to improve coordination, predictability and reduce unwanted variation, has been the introduction of clinical pathways. We started with cancer. The feedback from patients is that the clinical pathways have been of great significance for their sense of security.

We are now developing pathways for mental health and substance abuse, and for stroke treatment. And we prolong the pathways from hospitals into the municipalities and into the patient's home.  

Given the good feedback we have received from patients with cancer, I have great expectations for the new clinical pathways for mental health and substance abuse. What is the point of being dismissed from long treatment with not place to live, no activity or work and no money? What a waste of possibilities – it is a bad investment.

The challenges in these areas are significant. Many patients find the services fragmented, uncoordinated and not sufficiently predictable.

We know that patients with severe mental health issues – which often correlate with substance abuse – have a life expectancy 20 years lower than the rest of the population, often because their somatic illnesses are not recognized and taken care of. If we can improve this situation, we will have made a significant impact for those with the greatest needs in our society.

We have implemented acute stroke clinical pathways and will implement stroke rehabilitation pathways in 2019. Stroke management in Norway is among the top in Europe. However, we know that stroke rehabilitation varies, so we still need to improve in this area.

The discussion today has demonstrated that not only new models of care are needed. To meet tomorrow's needs, we need to prioritize. We can't do everything. Here Norway has an advantage. We have worked systematically with priority setting in the secondary care since the eighties.

Priority setting is a key factor for the population to achieve equal access to high quality services all over our wide-spread country. Priority setting is also important to keep cost control. We have a broad consensus on a set of principles for priority setting in the specialist health care sector.

New technologies are assessed on the basis of three priority-setting criteria: the severity of the condition, the benefit of the treatment, the resources involved. The more severe the condition or the more extensive the benefit of the intervention, the more acceptable higher resource use will be. The other way round: conditions with low severity and  treatment with limited benefit can only be justified if resource use is low.

As part of the decision-making processes for introducing new health technologies, all new pharmaceuticals and many other new technologies undergo health technology assessments.

Now we are planning to expand the system to also include primary care. In the years to come, a bigger share of total services will be delivered locally. Our municipalities, with their large degree of autonomy, already prioritize every day, based on local needs and priorities. This is the way it has to be. But they will need help in the difficult decisions they will have to make in the future.

So we need more knowledge about how they prioritize today, and to discuss principles of these decisions as well. They will probably be somehow different from the principles in the specialized sector. People live their lives in the municipalities. Luckily the don't live in hospitals.

But good mechanisms for priority setting is not enough. The ageing of Norwegians means that we may need 30 percent more health personnel in 2030. The solution for us, and other countries in similar situations, can not only be to employ more people. More than half of the new work force cohorts will in that case be needed!

This is not realistic, nor wanted. We have to make major changes in order to run a sustainable health service. We have to work in new ways, and find new technological and organizational solutions to work more effectively.

eHealth and new technologies can be main enablers of a patient-centred health care system and sustainability as well. The 'e' in eHealth is becoming an increasingly important factor addressing the society's and patients' requirements, with respect to improve efficiency and quality of health care. In several areas, electronic solutions enhance the quality of care and patient safety, while reducing costs.

As many countries experience, Norway has challenges in establishing robust systems to have patient medical information available when needed and entitled. Even though we have a high degree of digitalisation, we struggle to build a good infrastructure across the different services.

This is an important element in our plans: how to use technology to ensure that health personnel, patients and decision makers get access to the information they need when they need it, in a safe and secure manner.  

Norway has previously been in the forefront when it comes to the use of new technologies. We have a stringent legislation governing privacy protection, and tough interoperability requirements from publicly funded health platforms.

But we are now facing the price of legacy and being early adaptors. We need to make substantial changes both in our technical solutions and in the way that we make data available to those who need it.

"One Patient – One Health Record" is our national long-term strategy to leverage the potential of ICT to create data availability and increased functionality for GPs, municipality health care and hospitals. This development will be of utmost importance in order to create our future health care system.  

As our patients often travel long distances to receive healthcare, it is a challenge to deliver a high quality, functional and safe system. In this respect, our personnel-connected care program and various e-consultation formats are important to explore further. You will have the opportunity to learn more about that tomorrow.

However, we are already well underway with providing digital services to citizens. Today, patients have online access via the national health portal to their prescriptions and summary of care record, exemption card information, vaccines and main contacts in the health service. Several more services are to be added.

The concept of eHealth is not only a technical development, but even more a way of thinking. We believe it is an attitude and global correction to improve healthcare both locally and globally – from the doctor, the hospital director, nurse, manager, social security worker, patients, relatives and more. There is important work to be done for better connectivity across the healthcare services. So we are just at the beginning of this journey.

As you understand, we have started working on many of the challenging issues already, but we are of course not done. We still have work to do, and at the moment we are preparing our second National plan for our specialized sector.

Not surprisingly, the main topics for the plan are mental health, competence/personnel, technology and coordination of care. We hope, through this plan, to take an important step towards securing a sustainable health and care system, that meets the needs of our population.

Ladies and Gentlemen.

I hope the points I've made tonight illustrate that Norway's health challenges don't differ from those of other countries represented here. We all need to think in new ways to find new solutions. And meeting in a setting as this allows us to share experience and novel ideas on the delivery of health care to our citizens.

The work of Commonwealth Fund has provided important insights to my thinking when working to fulfil Minister Høie's vision of "The Patient as a Partner". Your research has illustrated for instance our need to communicate better with patients. I thank you for this. I look forward to the Breakout Session tomorrow, where I hope we all will receive new ideas on how we can transform and improve our healthcare.

Thank you.

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