1 Introduction

“The care services crisis is not created by the elderly boom, but by the notion that care cannot be provided in a different way than it is today.”

Source Kåre Hagen

This document is intended to be a report on the potential found within the care field. The main purpose is to provide users of the health and care services with new opportunities to manage better in their daily lives in spite of illness, problems or reduced functionality. At the same time, the white paper seeks to create a basis for further development of professional activities in the field, both for those with the greatest need for care and relief from their conditions and for those who will require daily assistance throughout their entire lives. It is also designed to provide safeguards to ensure that Norway can continue to focus on the community-based solutions it has developed over time through innovation and renewal. It is our job not only to defend, but also to develop, the welfare state.

1.1 The opportunities

Rather than allowing concerns over economic problems in Europe to get the upper hand, and the demographic challenges facing us to impede our capacity for action, this white paper explores opportunities and looks for new ways of performing caregiving tasks.

Against this background, the white paper has three main objectives:

• To obtain knowledge about, reveal, mobilise and utilise the totality of society’s care resources in new ways.

• To develop new forms of care through new technology, new knowledge, new professional methods and changes in organisational and physical parameters.

• To support and strengthen research, innovation and develop activities in the care services at the municipal level.

1.1.1 The new elderly generation

It is true that the dramatic rise in the number of elderly in a few years’ time will result in a greater number of more demanding tasks for the municipal care services in relation to today. It is also the case, however, that the new elderly generation is living longer because it is healthier and more able to meet old age with far better resources than previous generations. The new elderly have a higher level of education, a better financial situation, better living conditions and more functionality than any previous elderly generation. They are more accustomed to using technology and want to take more of their own decisions. This white paper will explore the significance of these resources for future care needs and the overall ability of society to provide this care.

1.1.2 The entire life course

In the past 20 years, the changes in the municipal care sector have largely been related to the rise in the number of recipients of care services under the age of 67. The care services are no longer for the elderly alone, but encompass the entire life course. New, younger user groups bring with them new resources, demands and coping strategies which gradually make an impact on and contribute to renewal in the health and care services.

1.1.3 A modern policy for informal care

A lack of volunteer care providers and recruitment of more health and social services workers in a competitive labour market may present major challenges to the care sector. A future shortage of workers and volunteers will therefore require solutions that make it easier to combine employment and caregiving by incorporating greater flexibility within both working life and the public services. This white paper looks closely at ways to organise the relationship between employment and caregiving in a more future-oriented manner as well as how to provide support for family members who perform demanding caregiving tasks, either by means of professional support and guidance, the expansion of daytime activities or more comprehensive relief services. Official Norwegian Report 2011: 11 Innovation in the Care Services proposes a new, modern policy for informal care, and Official Norwegian Report 2011: 17 Når sant skal sies om pårørendeomsorg (“The Truth Be Told About Informal Care”) presents specific recommendations for a new focus for economic benefits schemes. Proposals from both of these reports will be assessed in this white paper.

1.1.4 Responsible citizenry and solidarity between generations

A strong welfare society can only be created in cooperation with the citizenry. It must be based on faith in the people’s capacity to assume responsibility and participate actively in the community at large, not only through public schemes but also by being willing to make a difference in the daily lives of others. This form of responsible citizenry is manifested in organised participation in volunteer organisations, cooperatives and user organisations, as well as in more informal efforts within the local community, the family and social networks. It is also built on trust and solidarity between generations. This white paper will examine the potential that lies in involving volunteer organisations, exploring new forms of volunteerism and creating a framework for informal caregiving in modern society.

Society’s community-based solutions require that people also participate in the development and design of the public services and not merely approach them strictly as users and consumers of health and care services. Firstly, by doing so they will not only be part of the problem, but part of the solution as well. Secondly, active co-responsibility helps to ensure that expectations regarding the quality and scope of the services are more realistic. Thirdly, active participation strengthens the ability of individuals to take care of themselves and others so that all the caregiving tasks need not be entrusted to professional practitioners. Thus, greater user influence, responsible citizenry and more direct local democracy will be important factors in the caregiving community of the future.

An active, dynamic civil society and volunteer organisations are vital for establishing trust and networks, and will promote a stronger framework for collective action and effective community-based schemes.

1.1.5 Diversity and equality

Greater diversity will be a hallmark of the society of the future and will also be manifested within the many arenas of the care services: in activities, residential care homes, nursing homes and people’s own homes.

Women comprise the majority of those involved in the care field, both as recipients and as providers of services. Men account for only 10 per cent of the person-hours within the sector. It appears that gender equality has come further within family care than within the public health and care services.

Gender equality and non-discrimination will comprise fundamental values in the efforts related to health and care services, and the Government views it as crucial to incorporate a gender equality perspective into the efforts to develop the health and care sector. This means that gender equality will be used as an assessment criterion in many of the proposed measures.

Some users will have special challenges related to e.g. language, cultural background or personal history. The care services of tomorrow must be based on an individual approach and adaptation of the care services to a person’s background, whether this concerns their language, culture, faith, or worldview; their age, gender, and sexual orientation; or their diagnosis, reduced functionality or problem. Dealing with this will require leadership and good ethical practice at all levels, by means of legislation, regulations, and economic and professional priorities.

1.1.6 Life and health

Good health is one of the most important prerequisites for living life to the fullest. This is why the health and care services are so closely linked together. Affording people the opportunity to live a meaningful life will be central to the care services, as many people require services 24-hours a day over many months and years or need assistance throughout their entire lives. One of the key tasks of the care services is to ensure that people can live full lives within these parameters in spite of illness and reduced functionality.

The care services deal with matters of life and death. The objective is therefore not only good health, but life itself. Those who work in this sector must be acquainted with life’s many facets, and will encounter the most basic human needs. They must be able to create a framework that addresses these needs in an integrated manner, whether the needs are of a physical, social, cultural, psychological or existential nature. This requires knowledge and expertise across many professional areas.

There is a difference between receiving services in order to survive and receiving assistance in order to live one’s life.

1.1.7 Close caregiving

Most – and the best – care is provided through “close caregiving”, meaning that the public health and care services function as an integral part of a local community in close cooperation with the users themselves, their families and social networks, volunteer care providers, and local organisations and enterprises. This is one of the most prominent characteristics and distinctive features of the care services which is most clearly displayed in the activities of the home care services in thousands of homes around the country.

In a future perspective, it will be crucial that these services are not reorganised out of this context but that they remain decentralised as part of the local community and retain their strong municipal ties. This will enable the care services to continue to encourage co-responsibility and utilise the resources that the users themselves have and that are found within their environment.

Better adaptation of homes and the surrounding areas, new technology and new professional methods will help people to manage their daily lives for a longer period of time on their own. Therefore, this white paper targets the opportunities inherent in:

• using universal design to make existing homes and surroundings suitable for the elderly and people with reduced functionality;

• utilising new welfare technology that affords greater security, enhanced skills mastering and access to information and advice;

• putting more emphasis on skills mastering and rehabilitation for daily life.

The white paper confirms that the municipalities will continue to have responsibility for the municipal health and care services and that no changes will be made in the distribution of responsibility between the state and the municipalities. The state will work to ensure that good framework conditions are in place for local and regional research, innovation and development activities.

1.2 Innovation

Innovation and development activities in the care services are conducted primarily within the individual municipality and local community. This white paper is therefore intended to inspire and support municipal innovation activities in the care field. By the same token, it gives consideration to establishing state-level instruments that can enhance the innovative capacity of the care sector as part of the unified municipal innovation effort.

The care services constitute almost one-third of all municipal activities and must be viewed in connection with the needs across the entire municipal sector. The municipal health and care sector must work with innovation along two axes. Along the vertical axis, innovation activities take place across administrative levels between the specialist health care services and the municipal health and care services, as described in the Coordination Reform. Innovation activities along the horizontal axis take place in the areas of overlap between municipal spheres of activity, across the sectors, and between the municipality as part of the government administration and the municipality as a local community.

Innovation does not entail searching for best practice, but for what can be a better next practice. The concept of innovation implies change and assumes a willingness to take risks. One way to describe the concept of innovation may be to say that innovation is:

• known or new knowledge combined with a new method or use in a new context;

• ideas converted to better practice that creates added value;

• enterprising, daring and experimental in form;

• a way of approaching tasks – a culture;

• a process whose result is unknown in advance.

Innovation entails creating something new. It provides a means for opening up the future and expanding the latitude for action by identifying multiple options, highlighting alternatives and finding new paths and solutions.

There are powerful drivers for innovation within the municipal sector. In many contexts local democracy has in itself been the foundation of innovation and local societal development. Over the course of history the municipalities have established savings banks and power companies, built roads, operated ferry lines and secured the water supply. In the welfare sphere, the municipalities have in many cases taken the lead in developing new schemes, often in close cooperation with local organisations and men and women who had ground-breaking ideas. Political elections and competition for political leadership positions, development-oriented leaders, skilled workers and a dynamic local community with active citizens, users, organisations and the private sector are still the driving forces behind innovation and development in the municipalities.

The care services of tomorrow will be dependent on cooperation between the state and the municipalities, cooperation between employees and managers, and cooperation between service providers, users and family members. To succeed in promoting new ways of thinking and innovation, employees must be viewed as teammates and resources. Change processes that are not in alignment with employees’ views are seldom successful. Innovation that is propelled by publicly elected officials and employees may solve many of the future care challenges.

Future services must focus on innovation and expertise. The Government believes that this is the responsibility of the leadership and it recommends that the municipalities include innovation and expertise as specific items in their plans for the health and care sector as part of the overall municipal planning process.

There is a need to better equip the municipalities to conduct innovation activities in a systematic manner if we are to meet the challenges to come. This means increasing expertise in innovation, methodology and innovation management, and enhancing the ability and desire to work across traditional dividing lines, take political risks, give employees greater freedom to act, and involve citizens, users and organisations more actively and directly. Expanded cooperation with trade and industry and research institutions will also be crucial components of municipal innovation activities.

We cannot save our way out of the challenges facing the welfare society. We must develop our way out of them. This white paper will show another path to enhanced efficiency than through traditional savings policy and market-oriented thinking. It emphasises the development of a public administration that promotes diversity and mobilises the many resources found within the local community, that focuses on interaction based on trust rather than on bureaucratic control, that recognises and utilises professional knowledge and experience, and that cooperates across professional areas and administrative levels. A new public administration policy of this nature means that democratic governance must be enhanced both through political leadership at all levels and through direct user influence and participation of the citizenry, and that more focus must be placed on partnership solutions with civil society as well as with the private sector.

1.2.1 The Coordination Reform as the basis for thinking along new lines

The Government has introduced the Coordination Reform to ensure sustainable, integrated and coordinated health and care services that are of high quality and tailored to the individual user. Greater emphasis will be placed on measures to promote health and prevent disease, on habilitation and rehabilitation, on increased user influence, on courses of treatment and on binding agreements between municipalities and hospitals.

The Coordination Reform is designed to generate a change in course and forms the basis for a shift in the content and organisation of the municipal sector. The objectives of the reform are to ensure more coordinated health and care services and to put greater emphasis on measures that prevent and limit disease. The Government is focusing attention on renewal and innovation throughout the entire health and care services sector as a step in the effort to address the coming demographic, social and health-related challenges. In many ways the Coordination Reform also comprises a municipal reform.

One of the main action points of the Coordination Reform is to develop the role of the municipalities so that they are more capable than today of achieving the objectives related to prevention and early intervention to halt the development of disease. More support will be made available for the patient’s own skills mastering, increased focus on preventive and health-promoting measures and the expansion of low-threshold services. This requires new forms of work and cooperation, new services and new ways of carrying out the tasks. Some of the current services will be moved closer to where the users live, and new municipal services are being developed for patients prior to, instead of or following admission to hospital. The established financial incentives are designed to achieve the desired solutions to the tasks and provide the basis for good patient services and cost-effective solutions. To ensure effective implementation of the reform, the Ministry of Health and Care Services and the Norwegian Association of Local and Regional Authorities have entered into a national framework agreement on coordination in the health and care services.

Experience from the first year of the reform shows that both the municipalities and the specialist health care services are well underway with these activities. Efforts related to cooperative agreements, adaptations to make immediate, 24-hour assistance available in the municipalities, and the municipalities’ reception of more patients who are ready to be released from hospital show that both the municipalities and the specialist health care services have begun the process of achieving better coordination between the levels of the health and care services. It appears that the Coordination Reform has helped to chart out a new direction in the efforts to improve the health and care services.

In order to continue and further refine the Coordination Reform, there is a need to think along new, future-oriented lines about the substance, focus and resource utilisation of the municipal health and care services. The services must put more emphasis on active caregiving, prevention and rehabilitation and on encouraging the use of new technology and new work methods. This is in keeping with the recommendations in Official Norwegian Report 2011:11 Innovation in the Care Services, and this white paper will build further on the basis set out in the Coordination Reform.

1.2.2 Challenges for the care services

The few studies conducted on the activities of the care services indicate that their strength lies in the fundamental tasks they perform related to treatment and care. However, services often do not start until late in the game and are not equally effective with regard to preventive measures, training, rehabilitation, and physical, social and cultural activities. There is much evidence to suggest that this situation has been compounded in recent years.

This white paper has chosen to address some of the problems and weaknesses of the care services and to explore the possibility of finding new approaches and solutions that can turn this situation around.

The background for these challenges is described in St. Meld. nr. 25 (2005–2006) Report to the Storting, Long-term care – Future challenges, Care Plan 2015 and in Official Norwegian Report 2011:11 Innovation in the Care Services as follows:

• the growth of new younger user groups;

• more elderly in need of assistance;

• the shortage of volunteer care providers;

• the shortage of health and social services personnel;

• the lack of coordination and medical follow-up;

• the lack of activities and coverage related to psycho-social needs;

• the internationalisation of the market for personnel, service providers, patients and users.

In this context, we cannot avoid addressing the considerable uncertainty in the global economy that has resulted in a high unemployment rate and major financial problems for many Europeans. In times like these, we must take care not to set all of the care services in stone, but ensure that the services we develop have the flexibility and restructuring capacity that may be needed.

As noted in Official Norwegian Report 2011: 11 Innovation in the Care Services, these challenges entail problems as well as opportunities. This white paper will focus on the opportunities.

1.3 Background and basis

In St. Meld. nr. 7 (2008–2009) Report to the Storting, An innovative and sustainable Norway, the Government selected the health and care services as a priority area for innovation and renewal, and appointed a public committee to explore new innovative solutions for meeting future challenges in the care services. The committee submitted its recommendations in Official Norwegian Report 2011: 11 Innovation in the Care Services in summer 2011. The report has generated a great deal of interest and gained broad support across most of the usual dividing lines. There is also considerable impatience in some quarters, especially with regard to issues related to restructuring of the care services with greater emphasis on welfare technology and rehabilitation and the need for new instruments in municipal innovation activities.

Official Norwegian Report 2011: 11

This white paper is based primarily on Official Norwegian Report 2011:11 Innovation in the Care Services, and the extensive input from stakeholders after the document was circulated for review. The white paper is intended to lay the foundation for a future-oriented policy for the municipal care services by establishing the perspectives and contributing to the design of new solutions for the care services as the major demographic challenges facing the care sector in the decades leading up to 2025 begin to intensify. The report identified an active ageing policy, a policy that removes barriers for people with reduced functionality and a modern policy for informal care as the basis for its five recommendations:

• “Close caregiving” – the second Coordination Reform;

• “New rooms” – future housing solutions and neighbourhoods;

• “Technoplan 2015” – technological support for the care services;

• A national programme for municipal innovation in the care services;

• The care services as an industry.

Currently the care services cover the entire life course and have recipients of all ages with a need for a diversity of solutions related to housing options, services and professional approaches. The Coordination Reform reinforces this diversity, assigns the municipalities new tasks and affords them new opportunities.

Official Norwegian Report 2011: 17

This white paper emphasises the importance of enhancing community-based solutions by improving cooperation between the municipal services and civil society and by creating good, motivating framework conditions for the voluntary resources found within families and local communities. In formulating a modern policy for informal care, the white paper is in alignment with Official Norwegian Report 2011: 17 Når sant skal sies om pårørendeomsorg (“The Truth Be Told About Informal Care”), which recommends three main action points:

• an expanded benefit scheme for family caregivers;

• a new, enhanced municipal care benefit that replaces the current supplementary benefit and pay for family caregivers;

• legally established support for family members involving measures that give value to and include family members and ensure the quality of the services.

Welfare technology

In the efforts related to welfare technology, the Norwegian Directorate of Health submitted a report on the implementation of welfare technology in the municipal health and care services up until 2030 to the Ministry of Health and Care Services in 2012. That report has formed part of the basis for this white paper. In the report, the Norwegian Directorate of Health recommends the establishment of a national initiative on welfare technology through a Welfare Technology Innovation Programme (2013–2020).

The potential of information and communication technology (ICT) and welfare technology for the health and care services sector is also addressed in Meld. St. 23 (2012–2013) Digital agenda for Norge – IKT for vekst og verdiskaping, white paper on ICT for growth and value creation, Ministry of Government Administration, Reform and Church Affairs, and must be viewed in connection with Meld. St. 9 (2012–2013) Én innbygger – én journal, Digital tjenester i helse- og omsorgssektoren, white paper on digital services in the health and care services sector, Ministry of Health and Care Services.

Quality

The Government previously submitted Meld. St. 10 (2012–2013) God kvalitet – trygge tjenester, Kvalitet og pasientsikkerhet i helse- og omsorgstjenesten, white paper on quality and patient security in the health and care services, Ministry of Health and Care Services, in part with the aim of promoting more user-oriented health and care services, a more active patient and user role, more systematic testing of new treatment methods and higher quality through knowledge and innovation.

Agreement with the Norwegian Association of Local and Regional Authorities

The Government and the Norwegian Association of Local and Regional Authorities have entered into an agreement on further refining the quality in the municipal health and care services for 2012–2015. The parties have agreed to foster innovation and new ways of thinking in the municipal health and care services with a special focus on mobilising citizens’ responsibility and participation, early intervention, prevention, rehabilitation and the use of new technology.

It has been noted that the municipalities are facing challenges with regard to changes in the age composition of the population, and new, younger user groups that have other needs and preferences. These challenges must be solved by achieving the most effective utilisation of the collective resources and through innovation:

“The parties will ensure sustainable services in the future through research, innovation and solutions that enhance quality in all parts of the services. The parties agree that innovation efforts in the health and care services must be incorporated as part of a cohesive set of municipal innovation activities.

The parties will work together to:

• promote innovation activities at the national, regional and local levels, across sectors and administrative levels, and in cooperation with trade and industry, organisations and civil society;

• cooperate on the development of infrastructure for municipal innovation cooperation;

• use the municipal planning system for innovative thinking, restructuring and implementation of new ways of working;

• work to implement solutions that allow users to live at home as long as possible, if they wish to;

• promote the development of new types of living arrangements and housing solutions, in part through new cooperative projects;

• encourage the use of welfare technology, in part through training, expertise and organisational development;

• promote a future-oriented policy for volunteer care providers;

• promote a policy that supports family members who provide care and make adaptations for volunteer caregiving.

Municipal innovation

Parallel with the activities of the Ministry of Health and Care Services related to the white paper, the Ministry of Local Government and Regional Development has drawn up a municipal innovation strategy designed to stimulate innovation activities throughout the entire municipal sector. This white paper must be viewed in connection with the strategy Nye vegar til framtidas velferd (“New roads to the welfare of the future”), and the general municipal policy instruments that are designed to promote municipal innovation.

The HelseOmsorg21 strategy

The Ministry of Health and Care Services will establish a forum for dialogue between the health and care services, academia, trade and industry, and professional organisations. In 2013, the forum will provide input and propose measures to be included in a broad-based, overall strategy for research and innovation in the health and care services, known as the HelseOmsorg21 strategy. The strategy will form the basis for a targeted, integrated and coordinated national initiative on research, development and innovation in the health and care services.

Innovation in health care

The white paper must also be viewed in connection with the 10-year (2007–2017) initiative from the Ministry of Health and Care Services and the Ministry of Trade and Industry on need- and research-driven innovation and commercialisation in the health and care services sector. The initiative involves innovation within ICT and technical medical equipment, innovation in public procurements, and innovation designed to address major societal challenges such as chronic illnesses, an increasingly ageing population, and better coordination between service levels.

Key participants in the initiative are the regional health authorities, InnoMed, Innovation Norway, the Research Council of Norway and the Norwegian Directorate of Health. The participants have entered into a national cooperative agreement and drawn up a plan outlining measures. The Norwegian Association of Local and Regional Authorities is also taking part in this cooperative effort. The initiative entails strengthening the scheme for public sector R&D contracts for health care purposes and measures designed to promote arenas and meeting places between the supply industry, the health care sector, and public funding and innovation agencies.

Innovation on the international agenda

Innovation in the public sector is now gaining a place on the agenda in international forums in the Nordic countries as well as in the rest of Europe in organisations such as the EU, OECD, UN and WHO. The demographic and economic challenges facing Norway constitute some of the key issues and driving forces behind this development.

“A society for all ages” and “active ageing and solidarity between generations” are two of the most important catch phrases in these efforts. A new picture of elderly inhabitants and their role in working, social and cultural life is emerging. Participation, inclusion, independence and self-sufficiency are key themes. Efforts to combat age discrimination and bridge-building that establishes trust between young and old are seen as vital instruments in a senior citizen’s policy that encompasses all generations and that has significance for all areas of society.

Eight principles for high-quality care services

The Ministry of Health and Care Services established eight principles for good care services in cooperation with the Norwegian Pensioners Association, the Church City Mission, the Norwegian Association of Local and Regional Authorities, the Norwegian Nurses Organisation, Norwegian Union of Municipal and General Employees, and the Norwegian Union of Social Educators and Social Workers. These principles were presented in spring 2012.

The care services are to be:

• developed on the basis of a holistic view of the human being;

• based on user participation, respect and dignity;

• adapted to the users’ individual needs;

• show respect and care for family members;

• comprised of competent managers and employees;

• focused on emphasising health-promoting activity and preventive measures;

• flexible, predictable and offer coordinated, integrated services;

• innovative, pioneering and engaged in promoting learning.

These eight principles also form part of the basis of this white paper.