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Meld. St. 26 (2014–2015)

The primary health and care services of tomorrow – localised and integrated

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Part 1
Introduction, description of challenges and summary

1 Why is there a need for a white paper on the primary health care services of tomorrow?

The Government’s political platform clearly states that the Government has the political will to improve the municipal health and care services. The municipal services are important, and in years to come will play an even more vital role in addressing the overall challenges relating to, and meeting the population’s needs for, health and care services.

The Government seeks to promote patient-centred health care services. The needs of the patient must be the focal point of development and change in the health and care services. “No decisions about me will be taken without me.” Achieving this will require change. The municipalities must be equipped to fulfil the intentions of the Coordination Reform on coordinated, integrated patient pathways, more prevention and early intervention, more services close to where the users live, and a larger proportion of the services provided in the municipalities. The challenges and objectives of the Coordination Reform have broad-based support in the Storting. The reform has given the municipalities a more important role in ensuring that vital health and care services are delivered to the population. This role calls for a different municipal structure from the one we have today. A new municipal structure in which the municipalities are larger and have greater competency will enable the municipalities to deliver high-quality health and care services in keeping with current and future needs. A transfer of responsibility for dental health care services from the county to the municipal level will also pave the way for better integrated municipal services. Thus, this white paper must be viewed in connection with the white paper on local government reform.

Addressing the Coordination Reform’s challenges and objectives will also require changes within the municipal health and care services. While these services maintain a high standard in an international context, there are still problems to cope with. The coalition Government parties identified the challenges in e.g. the Storting’s deliberations on Report No. 47 (2008–2009) to the Storting, The Coordination Reform, (Recommendation 212 S. 2009–2010). The Government’s platform reflects this same message. The overall municipal health and care services have not been reviewed in a white paper for many years. The care field was recently described in general terms in the white paper Future Care (Meld. St. 29 (2012–2013)). As a result, this white paper focuses primarily on the municipal health services. However, there is a need to assess the substance of and interaction between all of the sub-services, to formulate new policy also for the care field, and to establish clear, long-term political guidelines for an integrated policy for the municipal health and care services.

A review of the municipal health and care services is important for the efforts related to the national health and hospital plan. The municipal health and care services are the foundation of the health and care services. The quality and performance of these services will determine the type of hospital structure Norway can maintain as well as the future capacity needs in the specialist health care services.

The white paper must also be viewed in connection with the white paper on public health (Meld. St. 19 (2014–2015)). The health and care services must contribute to health-promotion and prevention efforts. The foundation for good public health is often laid in other sectors. This is described in the white paper on public health.

2 Input from the users

Importance has been attached to dialogue with and input from patients and users in the preparation of this white paper. Two large-scale input meetings were held during the process, and various user groups and special interest organisations were invited to give presentations on the following topics:

  • From your perspective, what are the greatest challenges within the primary health care services and how can we address these challenges?

  • Which three measures should the municipalities implement to better safeguard the needs of the patients/users of the primary health care services?

The organisations invited to give presentations were the Ombudsman for Children, Unge funksjonshemmede (“Young Disabled Persons Organisation”), Mental helse (“Norwegian Mental Health Association”), Norwegian Federation of Organisations of Disabled People, Kontaktforum for brukere av helse- og omsorgstjenester (“Contact Forum for Users of Health and Care Services”), Norwegian Pensioners Association, National Council for Senior Citizens, Pårørende innen psykisk helse (“National Association of Relatives of Psychiatric Patients”), National Centre for Knowledge through Experience in Mental Health, Norsk pasientforening (“Association of Norwegian Patients”), Helse-, sosial- og eldreombudet i Oslo kommune (“Ombudsman for Health, Social and Elderly Services in Oslo municipality”), Norwegian Board of Health Supervision, and Ressurssenter for omstilling i kommunene (“Resource Centre for Municipal Restructuring”).

The input meetings communicated clear views from the users regarding the greatest challenges within the primary health care services:

  • Quality of the services.

  • The services are perceived as fragmented and organised in separate, isolated segments. There is too little coordination between the services.

  • There is too little user involvement.

  • General practitioners are poorly integrated into the rest of municipal health and care services.

The organisations conveyed that patients wish to be taken seriously and treated with respect. They are concerned about feeling safe and secure and having confidence in their treatment. The services must provide assistance when needed. The patients themselves must participate and be trained in their own treatment. The services must be adapted to the individual user, not only to the individual diagnosis. The social situation of the patients has a major impact on the ramifications of illness and on the ability of patients to participate in their own treatment and to cope with illness. General practitioners do not have enough time to conduct an overall assessment during a patient’s visit. Changes in or deterioration of the health of elderly patients are not discovered early enough and are not taken seriously enough. In too many cases it is the symptoms, rather than their cause, that are treated.

In addition, it was noted that the set of services for people with comprehensive assistance needs could be improved in terms of range, content and quality. There is still a lack of coordination between the municipal health and care services and the specialist health care services. Specialist-based activities take place within their individual segments and not at an interdisciplinary and overall level. There is too little use of checklists and service declarations, and there is no scheme for reporting undesired incidents that occur in the municipal health and care services. The schemes involving health coordinators and individual plans do not function as intended.

The users offered many ideas for measures to address the challenges. The most commonly mentioned were:

  • More low-threshold services and better accessibility;

  • More user-driven services;

  • Competence-enhancement in the services;

  • Closer follow-up of patients.

The recommendations for measures were elaborated on at the meetings:

  • In dialogue with the patient, service providers must consider the possibility of reducing the use of pharmaceuticals in treatment and of providing treatment without pharmaceuticals.

  • In dialogue with the patient, the services must put more emphasis on involving family and friends.

  • The services must focus more on the healthy aspects of the person who is ill and on what she or he is able to do and wants to do.

  • More local services related to training and mastery of the situation for patients and family members must be established.

  • The volunteer sector must be given the chance to contribute to the services, and the services must attach greater importance to well-being in services targeted towards the elderly.

  • Those who provide services must look beyond the diagnosis and view the person as a whole. Communication between the health services and the patient must be enhanced, both with regard to language and to understanding the patient’s situation and possibilities.

  • Service providers must establish a framework for understanding the patient’s situation and, together with the person in need of assistance, determine what kinds of treatment are possible and what is needed to help him or her master a life with illness.

  • Patients must be given the opportunity to choose or reject various forms of measures and assistance. The services must both allow patients to choose the direction and tolerate that they can do so. The services must pay greater mind to the experiences of patients, close family members and others in the network surrounding those who are receiving services.

  • The primary health care services must be developed based on interdisciplinarity as an underlying principle, and more interdisciplinary teams must be established.

  • Relevant, accessible services must be provided at the proper time. The services must be targeted more in accordance with the principle of early intervention.

  • Expertise on geriatrics must be used more effectively in the municipalities, and competency in this field must be increased both among general practitioners and in the care services.

  • The services must be organised so that the entity that registers the onset of reduced functionality in a patient takes responsibility for follow-up of this.

  • The services must establish better routines to ensure that patients and close family members receive good information. Patients should be given copies of all referrals, and all test results should be followed up in writing.

  • The municipalities must establish better routines for gathering information about experiences of users and family members for use in the efforts to develop the services. More collaborative projects involving participation of user organisations must be facilitated.

Textbox 2.1 Statements from users

Some statements from the input meetings gave a good indication of the challenges and needs from the users’ point of view:

  • “The silo mentality cannot continue. An interdisciplinary approach is needed.”

  • “Interdisciplinarity must be the guiding principle.”

  • “Cooperation must be a requirement.”

  • “We need more focus on resources and the healthy aspects of patients, on living with illness, and less on symptoms and eliminating them.”

  • “The services are too oriented towards illness. Few think about health.”

  • “People with mental illness may need a break from their home situation. That may be the purpose of providing a bed in a care facility.”

  • “Not everyone needs the child and adolescent psychiatric service (BUP). Children want follow-up where they live.”

  • “Low threshold entails getting help at home – not having to go somewhere to ask for help. Health care personnel must ask: What is important for you, in your life, right now and in the future?”

  • “Someone needs to have society on the list!” “The health care services over treat age and overlook/under treat illness.”

  • “There is a huge over-consumption of pharmaceuticals.”

  • “Remember that living alone has significance.”

  • “A lack of knowledge and impractical organisation are the reason that so many elderly people are in the hospital.”

  • “There is a tendency to overlook all the warning signs until it is too late, and treat the symptoms rather than the cause.”

The input meetings give a clear indication of the challenges we are facing. The various user and special interest organisations also had some overlapping recommendations for measures. Nonetheless, it was evident that different users have different needs. The challenges and recommendations for measures corresponded with the impressions and experiences conveyed by the inspection authorities and the Health and Social Services Ombudsman.

A desire for the submission of written input in connection with the preparation of the white paper has been expressed on several occasions. Input has been received from all levels of the health and care services, organisations and individuals. The amount of input received demonstrates that there is enormous interest in developing the municipal health and care services and broad consensus at higher levels regarding the direction that this development should take.

3 The municipality’s social mission

The concept of municipal self-governance has deep roots in Norway. Municipal autonomy is grounded in the idea that freedom to set local priorities will result in better service quality, more appropriate priorities and more effective resource utilisation. Local democracy also has an inherent value in that people have the opportunity to influence their own living conditions to a greater extent than if decision-making is centralised. Therefore, the central government has far less ability to control the content of the municipal health and care services and ensure equality in the availability and provision of the services than it does in the specialist health care services, which are state owned. However, the central government establishes important parameters for municipal responsibilities and tasks, as set out in the Act relating to municipal health and care services, etc. (Health and Care Services Act). The social mission is also shaped by other factors, and is subject to ongoing change. Changes are brought about by scientific and technological developments that shift tasks between the levels, shifts in demographics and disease patterns, and as a result of policy objectives and measures, such as the Coordination Reform. It is a stated objective for the municipalities to deliver a larger proportion of the overall services and to strengthen public health efforts and preventive services. As described in the paragraph on development trends, these are international trends. Research shows that there is potential to enhance both quality and cost effectiveness by investing in services at the primary level.

To ensure that the services are both future- and patient-oriented, the social mission must emphasise user involvement, prevention, proactive follow-up and good pathways to a greater extent than is the case today. The services must shift from a perspective in which they only respond to individual demand to one where they also take an active role vis-à-vis the population for which they are responsible. The aim is to reach out to individuals who make too little use of the services, and to target the resources towards those with the greatest needs and towards groups for which prevention, closer, structured follow-up, training and rehabilitation can prevent disease progression and hospital stays. It is also an objective to focus more attention on mental health and substance abuse. This will require restructuring within the services.

The public health and care services have been subject to continuous growth for several decades. Given the demographic challenges expected to blossom fully in 10 to 15 years, the services should be organised in a way that supports and elicits all of the resources found among the users themselves, their families and social networks, neighbourhoods and local communities, non-profit organisations, and trade and industry. This is in keeping with the message in the white paper on Future Care (Meld. St. 29 (2012–2013)), which emphasises the importance of enhancing cooperation between the health and care services and society’s overall resources through a programme of an active informal care policy, preparation of a separate volunteer strategy, and expanded cooperation with both non-profit organisations and trade and industry.

The distribution of responsibility between the municipal health and care services and the specialist health care services is critical for delimiting the boundaries of the municipal social mission. It is currently unclear what is expected of the municipalities in several areas, especially within mental health, substance abuse, patient training and rehabilitation. Larger municipalities with a broader range of competency will be able to do more than municipalities today. The white paper on local government reform (Meld. St. 14 (2014–2015)) identifies the tasks that the municipalities are expected to perform and potentially assume responsibility for. By implementing local government reform, the Government will promote the creation of larger, more robust municipalities and strengthen local democracy. Larger, more robust municipalities are necessary for achieving the Coordination Reform’s objective for the municipalities to deliver more of the health and care services. The white paper mentions dental services, care services and mental health services as areas in which the municipalities should assume a greater responsibility. This will be discussed in more detail under the various chapters in this white paper.

Changes in the social mission affect the service providers in the municipalities. It is the service providers that must change their work methods and distribution of tasks, and find new ways to cooperate and interact with the users. To achieve this, there is a need for a common understanding of what the social mission entails, and this must be reflected in e.g. instructional material and guidelines.

Thus, an important objective of the white paper will be to seek a common understanding of what the social mission entails and what it should be in the future. Changes in the statutory framework is only one means of clarifying this mission. The many instruments used by the central government – organisational, financial, legal and educational – and the political message conveyed via white papers, strategies and plans will all be important. Consequently, the white paper on public health (Meld. St. 19 (2014–2015)) and the upcoming national health and hospital plan will also play an important role in defining the municipalities’ overall social mission.

4 Description of the challenges

The municipal health and care services must deal with a vast number of challenges across a wide spectrum. There are challenges related to user information, management, recruitment, competency, organisation and work methods, accessibility and financial schemes, as well as the roles and responsibilities assigned to the various professional groups through educational programmes and the regulatory framework. There are also challenges related to demographic shifts resulting from an increase in the number of elderly and immigrants as well as changes in the overall disease burden. In addition, ICT systems are deficient and there is too little data for use in management, service development, quality-promoting activities and research. Some areas have problems with capacity and poor accessibility. Personnel resources are not being used optimally. There is too little emphasis on prevention. The services are not sufficiently proactive and do not incorporate a population perspective into their planning. There is too little mastery training involving patients and close family members. The services have been organised into a silo structure and are not viewed together as an integrated whole with a need for close coordination. There are also major challenges related to sustainability. The current services are not adequately designed to meet the needs of today and tomorrow. The increase in the need for services may exceed the potential to educate and recruit personnel and society’s ability to pay. Society’s collective resources must be utilised more effectively. Increased internationalisation of the market for personnel, service providers, patients and users will pose great demands for innovation and change in the services in the coming years. The services of the future must therefore be equipped with the necessary flexibility and restructuring capacity. The challenges are described briefly in this chapter and expanded on in the individual chapters. The challenges for skilled nursing facilities and home care services are discussed in more detail in the white paper Future Care (Meld. St. 29 (2012–2013)).

At the same time, it is important to note that the health and care services comprise more than just an expense item in public budgets. The sector contributes widely to value creation, in addition to the population’s health and welfare.

More users with more complex needs

The complexity and breadth of the tasks that the municipalities have been charged with have increased steadily over time. The primary health care services were developed at a time when efforts were focused on the fight against infectious diseases and patient stays in hospitals or other institutions extended over a long period. The distribution of tasks between the specialist health care services and the municipal health and care services, which emerged gradually during the years leading up to the entry into force of the Act relating to the municipal health services (the Municipal Health Services Act) in 1984, was very different from what it is today. Individuals who formerly resided in institutions are now supposed to receive most of their services in the municipalities where they live. This is a result of e.g. the reform of the system of health care in place (HVPU), the desired restructuring in mental health care and the dramatically reduced time of stays in hospitals and other institutions within the specialist health care services in general with a transition to more out-patient and day treatments. With regard to the disease burden, it is now the non-infectious diseases such as COPD, diabetes, cancer, cardiovascular diseases, and musculoskeletal disorders, mental health disorders, substance abuse problems and dementia that comprise the major challenges. As a result, there is a need for other types of interdisciplinary follow-up over time while the patient lives at home.

This development is expanding the demand for capacity and competency in the municipal health and care services. There is a need not only for personnel with a higher level of expertise, but also in part for personnel with different kinds of competency altogether. The new situation also requires greater cooperation, and there is a need for innovation and development of the services in keeping with the changing needs. It is increasingly the case that a single service provider alone cannot deliver the services that users need. Many users have a need for numerous services at the same time and over a long period of time. A wider range of team-based service provision is required, along with an interdisciplinary approach to ensure integration and continuity. By way of example, current users of home care services have more complex conditions than previously, and thus require a wider range of, and more advanced, health care services than in the past. For many users, in-home nursing services are no longer sufficient. They need more medical services and more physiotherapy, and they often require other health and social care expertise in addition to nursing services. The established division between the health and care services in the municipalities is not designed to accommodate this. These services must work in a different way, they must cooperate more effectively, and they need new organisational solutions that better reflect today’s challenges.

Challenges related to sustainability – personnel resources and priorities

The increased need for services in the municipalities creates problems in terms of sustainability. It will be difficult to recruit enough health and social care workers, and it will be costly as well. It is essential to utilise collective resources more effectively. The municipal health care services today are too targeted towards meeting the needs of users with straightforward health conditions, those who seek help of their own volition, who can go to the doctor’s office/institute and who can take on an active role in their own follow-up. These patients must continue to have access to high-quality services. An important characteristic of good primary health care services is good accessibility with a low threshold so that health problems can be prevented and discovered at an early stage. For many user groups, it is important to reduce wait times and improve accessibility. This is the case for users with mild and moderate mental health disorders and users who need rehabilitation. Task distribution and resource utilisation in the future must ensure that services offer an adequate range of services, both to the patients who seek out help themselves and those who have comprehensive, complex needs.

In simplified terms, users of the health and care services may be divided into three categories: 1. Users who are healthy and users with a straightforward, uncomplicated illness/condition, 2. Users with a complex illness/condition or multiple, simultaneous disorders/problems, but who are self-sufficient and often employed, and 3. Users with the most complex, complicated needs, often users of home care services/residents of assisted living facilities or care institutions. This latter group is already the recipient of the largest proportion of resources, although these patients comprise a small percentage of the population. Nevertheless, many still do not get the health-related follow-up they need. They do not receive enough medical services, they are often followed up by untrained personnel and others with insufficient expertise, and they receive little rehabilitation. To meet the needs of these users, it will be necessary to dismantle the dividing lines between health and care services, improve coordination, and free up general practitioners so they can use more time on those who need medical services the most. Competency within the in-home nursing services must be increased so that in-home nurses can identify a reduction in a patient’s functionality at an earlier stage. More resources must be allocated to everyday rehabilitation (rehabilitation for home-living people) as a means of preventing reduced functionality. This will help to prevent hospital stays.

In addition, patients with multimorbidity require better services than they are currently receiving. They need closer follow-up in accordance with professional guidelines and better training in order to master a life with illness and prevent their condition from deteriorating. They also have a need for better coordinated services. Coordination should take place in the municipalities, where most of the services will be received. General practitioners are responsible for coordinating medical follow-up. Coordination in relation to this group should be strengthened.

The services must safeguard everyone’s needs, including those at low risk. In many cases, users at low risk do not need traditional consultations to address their problems, but can use simpler services such as patient portals (helsenorge.no), social media and the like. Often they can get treatment and advice from a nurse rather than a doctor or psychologist. One example of this is the expanded right of public health nurses and midwives to prescribe all types of birth control for all women over age 16, regardless of service location. The necessary coordination may be handled through an electronic exchange of information between service providers.

More expedient use of personnel resources will make it possible to enhance accessibility for everyone. Good accessibility is important and necessary if the primary health care services are to fulfil their role. It creates a more secure framework, helps to prevent or clarify problems at an early stage, and reduces superfluous use of more specialised services. Although there has been a general increase in accessibility over time, the situation is still not satisfactory. The population has higher expectations regarding accessibility. Compared with other countries, there are more patients who must wait to get an appointment with their general practitioner. There are also long wait times for physiotherapy in many locations. Adolescents report they do not have adequate access to their general practitioners and school health service.

Sustainable services will not only require different use of personnel resources, but also new forms of cooperation with volunteers, non-profit organisations and close family members. In coming years these voluntary service providers will also become a scarce commodity. It will therefore be important to safeguard the local community’s collective resources and use them more efficiently. User competency can and should be drawn on to a greater extent through peer support. Not least, the users themselves must be empowered, mobilised to take responsibility, and equipped to do so at the same time.

Role of the user

Efforts have been underway in Norway for many years to redefine the role of the user and put the focus on the patient. The title of Official Norwegian Report 1997: 2 on management and organisation of hospitals was “The Patient First!”. In spite of this, not enough progress has been made in this area. The white paper High Quality – Safe Services (Meld. St. 10 (2012–2013)) describes and recommends measures for achieving a more active role for patients and users. The efforts to follow this up are ongoing. This Government has even higher aspirations in this area. It is still the case that many decisions in the health and care services are taken without giving the patient a say in the matter. This applies to everything from decisions about how the services should be designed and targeted to patient-oriented decisions that directly affect the individual’s life. If the users’ views had been collected systematically, a great deal would probably look different.

Training

A new role for the user, in which the user takes part in decision-making and follow-up, means that users must be given sufficient information, guidance and training. Currently this is far too seldom the case. General practitioners do not have time for this during their brief consultations, and in many cases it would be more appropriate for other health care workers to provide such guidance and training, which could be done in groups. The municipalities have established very few services of this type. Many municipalities have gradually introduced programmes that promote healthy living, but only a minority of municipalities have established programmes to provide training for the large user groups with chronic illness.

Fragmented in organisational terms

Up until the 1960s, the primary health care services in many locations consisted only of a district doctor and a public health nurse. Beginning in the 1970s and especially during the 1980s, the responsibilities and tasks of the municipalities have been expanded. Traditionally, the municipalities have organised each new service as a separate, independent entity: child and school health services; general practitioners’ offices; physiotherapy institutes; skilled nursing facilities, etc. Nursing and care tasks in particular have increased, and in most municipalities these services have been organised into their own departments. This trend appears to be continuing. In addition, new services are established separately from existing services: healthy living centres, intermediary departments, 24-hour municipal emergency assistance. As a result, today’s health and care services are fragmented in organisational terms.

This fragmentation is reinforced by the fact that the services are often physically separated from each other in different buildings with few or no formal meeting places. Inter-municipal solutions for some of the services add further complication. Like the specialist health care services, multiple sub-services within the health and care services share responsibility for a majority of the patients, but they have separate journal systems and thus are unable to share information. Moreover, the funding schemes are designed differently for the various service providers.

Fragmentation affects the most vulnerable patient groups, those with serious, complex problems, users with mental health disorders, substance abuse and addiction problems and cognitive impairments, as well as feeble elderly patients with multiple illnesses. Fragmentation also affects all those with chronic diseases who require follow-up by several different services. Many of the patients in this latter group end up with responsibility for coordinating everything themselves. For users with a need for long-term, coordinated services, the municipality has an obligation to provide a coordinator, and furthermore, these users have a legal right to an individual health and care plan. Many municipalities (and hospitals) are having trouble complying with the patient’s legal right to an individual plan (IP).

Innovation and technology

Developments within information technology offer new opportunities that have not been sufficiently exploited. The various sub-services in the municipalities make too little use of electronic channels to communicate with each other and with the specialist health care services. The functionality of the journal systems is inadequate. There are many reasons for this, but one of the most important is the lack of decision-making regimes for ensuring a coordinated, functional ICT system within the health and care services. This has many ramifications, but put briefly, it has an effect on coordination, patient safety, quality and efficiency.

The ICT challenges are one reason that data are currently lacking from large segments of the health and care services. Data from the services are necessary for administration, management and service development. Data are also crucial for local quality-enhancing efforts, quality measurement and research. Thus, a lack of data has serious consequences.

There are challenges related to dissemination and incorporation of innovations in the services. Furthermore, there are no indicators for or data about the total innovation activity. The Health&Care21 strategy describes the major research and innovation challenges in the municipal health and care services.

Management challenges

There are many signs that management within the municipal health and care services today is not good enough. The Norwegian Board of Health Supervision has stated repeatedly that its inspection findings indicate a lack of quality assurance and control and that efforts to improve quality and patient safety are not given adequate strategic focus by the management. The management challenges have many causes. Through the years the municipal health and care services have evolved into a large, complex activity. Competent leaders are needed at all levels in order for the municipalities to carry out their legally prescribed responsibilities and satisfy the requirements set by governance systems in the form of internal control and ongoing efforts to enhance quality and patient safety. The sector has too few personnel in leadership positions, and too many of these lack leadership training.

Organisational fragmentation is in itself a challenge for the leadership. High-quality professional service and good patient safety mean that all sub-services must have effective routines for collaboration and must also cooperate well with the specialist health care service. In addition to competent leadership skills, there is a need for adequate access to insight into health and social care. However, many municipalities have chosen an administrative structure in which the chief municipal executive level entails only financial administrative management, and does not include professional health and care management .

Another significant management challenge is the contract system for doctors and physiotherapists. The individual contracts work against internal management of the specific doctor’s office/physiotherapist institute because the individual parties are responsible for their services. Even more important, they make municipal regulation and management more difficult since the contracts are lifelong and the services are largely regulated by framework agreements entered into between the Norwegian Association of Local and Regional Authorities (KS) and the trade unions and funded by the state. Evidence suggests that there is wide variation in the degree to which municipalities perceive it to be their responsibility to direct this activity. However, responsibility has clearly been placed with the municipalities, including for these services.

Challenges related to services for special user groups

In addition to the cross-cutting challenges related to fragmentation at the organisational level, management and expertise, there are challenges related to the array of services offered to various user groups.

In several service areas, especially mental health, substance abuse, patient training and rehabilitation, it is currently unclear what is expected of the municipalities. By the same token, the municipalities are expected to perform a large share of the overall tasks in these same areas in the future. There is a need to clarify the distribution of tasks vis-à-vis the specialist health care services and better equip the municipalities to carry out their responsibilities.

Regarding mental health and substance abuse, there is broad political and professional consensus that the municipal services are not sufficiently developed. This applies both to the preventive services for children and adolescents and to services for people with mild to moderate disorders. This also applies to the integrated follow-up of persons with more serious mental disorders or substance abuse problems. There is in addition a lack of emergency medical services for people with mental health disorders and substance abuse problems during the evening and night, in part because very few district psychiatric centres (DPS) and mobile emergency teams are on 24-hour standby. Studies show that many children and adolescents experience stress and mental distress that inhibits them in daily life. Many of those who suffer the most do not find the right help. An alarming number of those who drop out of upper secondary school state the main cause as being emotional and social difficulties. Mental illness and substance abuse problems lie behind a large share of sickness absence and disability pensions. The World Health Organization (WHO) ranks depression as fourth on the list of global burden of disease resulting in the greatest loss of quality of life and years of life. In economic terms, depression is clearly the most costly of the mental disorders. The price for the individual affected is enormous and cannot be measured.

Another area with challenges is habilitation/rehabilitation. There are a variety of views about what rehabilitation entails, and there is ambiguity related to distribution of responsibility between the levels as well as insufficient capacity and expertise in the services. Many users do not receive satisfactory services. An extremely important component of a rehabilitation pathway is training to master one’s own situation. By offering more targeted, intensive services in the municipalities, many users will become more self-sufficient and have a better life. Many municipalities understand this, but report problems with adjusting the content of their services in step with changes in the content of the services offered by the specialist health care services. One problem they point out in this connection is the difficulty of influencing the content and priorities in the contract-based physiotherapist service.

Although children in Norway enjoy relatively good health, there are still challenges related to children and adolescents. Recent reports show a worrisome trend in children’s and adolescents’ mental health. The drop-out rate from upper secondary school and vocational training is high, which has serious ramifications for the individual and society alike. Many children live in a situation with insufficient care, violence and assault. This is often discovered too late, and many do not get the help they are they entitled to, even though most children attend pre-school or school and have regular contact with the health care services from birth. Bullying and exclusion are also problematic within this group. A cross-sectoral effort is needed to address many of these challenges.

The services must adapt to population changes occurring as a result of immigration. Immigrants comprised 13 per cent of the population in Norway as of 1 January 2015, while Norwegians born of immigrant parents comprised 2.6 per cent of all permanent residents in the country (Statistics Norway). These people represent 222 countries and autonomous areas. Immigrants reside in all Norwegian municipalities, but the greatest number live in Oslo, where they comprise 31 per cent of the population. Drammen and Lørenskog have the second largest immigrant populations with 26 per cent and 24 per cent, respectively. The national strategy on immigrants’ health (2013–2017) describes the particular health challenges, as well as cultural and linguistic challenges, that arise when individual patients with an immigrant background encounter the health and care services. There is a lack of knowledge about the health of various immigrant groups and their use of the health care services. However, it appears that certain diseases occur much more frequently in segments of the immigration population than in the population at large. These include diabetes and mental health disorders. Morbidity is much more prevalent in women than in men. Evidence also suggests that some immigrant groups use the services in a different way from the mainstream population. There are major challenges related to the use of interpreters in the services, despite the fact that good communication is essential for safe services. The Government seeks to ensure that differences in health are not a result of systematic under-treatment or incorrect treatment of population groups, and will intensify efforts to develop patient-oriented health care services that take into account the special needs of individual immigrant groups. The municipal health and care services play a vital role in achieving this objective.

The municipal health and care services must not only provide health care services in the traditional sense, but must also promote social security, improve living conditions for disadvantaged people, advance fairness and equality, prevent social problems and ensure that individuals have the opportunity to live and reside independently and to have an active, meaningful existence in community with others. There are challenges in this area as well. Not everyone with a need for it is offered activities that give meaning to daily life and that can satisfy the individual’s psychosocial needs.

In the effort to shape patient-centred health services, there are also challenges related to gender. Factors of a biological, physiological, social and cultural nature affect women’s and men’s health and use of the health services, resulting in different challenges. In the case of young women, there is an unfortunate trend towards an increase in mental health disorders, fatigue syndromes, pain disorders, and challenges related to pregnancy and birth. Among the adult population, there are more women on sick leave than men. At the same time, men have a lower survival rate than women for many of the somatic diseases, such as cancer, cardiovascular disease and diabetes. More knowledge is needed to address these gender differences. It is also important that the services first encountered by patients, i.e. the municipal health and care services, are able to organise themselves in a way to meet the full range of needs.

5 Summary

The Government has presented this white paper as a crucial step towards creating health care services centred on the patient. The Government is seeking to establish a framework for future-oriented municipal health and care services. The services must function well, for people in good health in need of straightforward consultations, for those with chronic diseases and a need for more follow-up over time, and for patients with complex needs and reduced functionality who require personalised services. Future-oriented services take decisions in consultation with the users, are concerned about the users’ goals, needs and desires for their own lives, and use this as a basis for determining which services to provide and how they should be designed.

Future-oriented municipal health and care services must be easily accessible in order to prevent and resolve problems before they escalate. They are services that promote mastery by means of thorough training and systematic follow-up in consultation with the users and based on professional guidelines. In this way, people living with disease can also participate actively in school, work and other activities they find meaningful. Future-oriented health and care services must be organised in keeping with developments in the disease burden, professional knowledge, technology and society in general. They must take into account that more users than previously have more diseases simultaneously and that more of the follow-up is carried out in the municipalities, making the tasks in the municipalities more complex. As a result, the services must be organised differently and must work in a different way. This will require expanded competency and good management.

The Government will implement a number of measures, some with a short-term impact and others more long-term in nature, which will help to bring about the necessary changes. Together, the measures clearly indicate the direction in which the Government will develop the municipal health and care services in the coming years. The greatest changes are needed in the areas of organisation, distribution of tasks, work methods, competency and management. The course being charted corresponds with the objectives of the Coordination Reform, and takes them to the next level. The road ahead must be viewed in connection with the local government reform, which will generate new opportunities for the health and care services.

The Government will return to the various measures in the national budget for the individual years. The measures will be implemented provided that sufficient funding is allocated in the national budgets.

Teams

The Government will lay the foundation for more team-based health and care services. Today the services are fragmented, in part due to organisation in a silo structure. Locating the services at the same site is a good first step towards improving cooperation and coordination across today’s sub-services. The Government will therefore encourage same-site location. However, co-location alone does not make a team. The Government wishes to establish two types of teams in particular: primary health care teams and follow-up teams for users with comprehensive, complex needs.

A primary health care team is a team with responsibility for basic health care services for the entire population. Team-based first-line services pave the way for a broader, more coordinated set of services, better accessibility, and more appropriate use of personnel resources. General practitioners will have more time to attend to users with comprehensive, complex needs and complex medical problems. At the same time, users with long-term or chronic conditions who are still self-sufficient will receive better services. This is the group that will benefit in particular from a primary health care team. By involving the users, gaining an overview of their own population’s needs and establishing efficient task distribution, the teams will be able to develop services that entail good training, close follow-up and good accessibility over time. This will enhance safety and quality. The Government will facilitate the establishment of primary health care teams through amendments to regulations governing organisation and funding. Studies will be conducted on relevant amendments.

Users with the most complex needs do not have access to good enough services today. These users often have too little medical services and rehabilitation, and episodes involving a lapse of functionality are often discovered too late to avoid a hospital stay. The establishment of teams will help to improve this situation. Many such teams are already in operation today. However, the current teams are often linked to diagnoses. In the municipal health and care services, where the users have complex needs and relatively few have the same diagnosis, the practice of linking teams to diagnoses alone is neither professionally expedient nor sustainable. The Government is seeking a more structured approach to groups of users based on function and need, independent of diagnosis. A structured approach implies, among other things, a coordinator, use of knowledge-based procedures and checklists, a personalised plan formulated in consultation with the user, and systemic follow-up and evaluation for achieving the objectives set out in the plan. The coordinator leads a team that cooperates with others, preferably across levels, and coordinates the services. The Government will facilitate the establishment of such teams for users with comprehensive, complex needs through the implementation of various measures, such as continuing learning networks, competency measures and professional guidance.

New work methods – proactive efforts and prevention

Establishing teams makes it possible to work in a different way than before. To meet the needs of the entire population, it is no longer enough for the services to follow up when the need arises, with people themselves seeking treatment. It will be necessary to take a more active, population-oriented approach, to have an overview of the needs, and to have a systematic method for distributing resources in keeping with the needs. All the services must focus more of their efforts on prevention, provide follow-up, give training that promotes mastery, and prepare treatment plans in consultation with users. Substantive changes such as these will take time. Changes in expertise, culture and attitudes, and thus in educational programmes, will be required, and these must be sought by the leadership at all levels. The Government will promote a number of measures to achieve this. It must be made clear in legislation that the municipalities are required to provide training to patients and users. Instructions and national professional guidelines will be drawn up. Learning networks that contribute to improvement efforts will be continued. A mandatory professional dialogue between general practitioners/primary health care teams and the specialist health care services will be introduced. Infrastructure, such as modern information and communication technology, must support such a development.

Better accessibility

New ways of working will increase the accessibility of services for those who are basically in good health, but who develop a health problem. The most common problems are musculoskeletal disorders and mild mental health conditions. In these cases, it is critical to address the problem quickly so that it does not escalate. A brief intervention, e.g. in the form of several consultations with a health care professional, may be sufficient. It may prevent illness as well as employment disability. Primary health care teams will improve accessibility for all. In addition, the Government will consider introducing direct access to physiotherapy without a referral from a doctor or other entity, and require that all municipalities have psychologist expertise. Until this requirement takes effect, the Government will introduce a new funding scheme for psychologists in the municipalities in order to put this expertise in place.

More and wider competencies

More users with comprehensive and more complex needs from a professional perspective have an impact on the competency needs across the municipal health and care services. There is a need for more workers with competency in health and social welfare, more workers with a higher level of health care expertise, and not least, for a greater interdisciplinary range than previously, adapted to the challenges that the users are facing. There is a need for leaders with greater managerial skills as well as expertise in the services they manage. Moreover, there is a need for training for workers who do not have professional education, recruitment to professional education in health and social welfare, and continuing and further education.

The Government had previously announced that it would draw up an action plan for recruitment, competence and professional development in the care services. The Government is now proposing to expand these efforts to include long-term strategies and specific measures for competence-building and professional development throughout the entire municipal health and care sector. The objective is to foster a high level of professional expertise in the health and care services and ensure that the sector has adequate, competent staffing. The action plan is planned to be submitted in the proposal to the national budget for 2016.

The Government plans to introduce competency requirements into the Act relating to Municipal Health and Care Services, etc. (Health and Care Services Act).

Management

The municipal health and care services have become a large, complex organisation that claims a major share of society’s resources. There is a great need for innovation and development in the years to come. This places great demands on management as a whole and on the individual managers. There is a need to boost managerial skills in general, and stronger leadership at all levels is called for. The number of managers must be increased, but even more importantly, these must be equipped with high-quality managerial skills and access to in-depth understanding of health and social welfare issues. The Government will facilitate this in several ways, e.g. by clarifying the duty of the municipalities to conduct internal controls and by increasing access to relevant management training programmes. The Government will establish cooperation with the specialist health care services on an educational programme for top-level managers. The Government will also prepare guidelines for municipal control of private actors with service contracts. It is also important that the Government, through the white paper, identifies a different way of organising the services that involves more and clearer leadership roles. This opens up opportunities both for the municipalities and for health and social welfare personnel who have a vision and the desire to participate in the development of the future services.

Data for administration and service development

Good leadership, governance, administration and development of the municipal health and care services at all levels, from the ministry via municipal councils to administrative directors and organisational leaders, are dependent on data about the services’ content, activities and results. There is currently a considerable lack of data about segments of the municipal health and care services. To lay the foundation for knowledge-based development in the future, the Government will establish a municipal health and care registry. The registry will also facilitate local quality-enhancing efforts and research on and in these services.

More research on and in the municipal health and care services is essential for better leadership, governance, administration and development of the services. It is also important for competence and quality in the services. The Government will create a framework for strengthening research through the follow-up of the Health&Care 21 strategy.

New technology

Technology will be one of the pillars of the future health and care services. Information technology (ICT) may enhance quality and patient safety in the municipal health and care services. New online digital services will give residents and patients more opportunities to make active choices regarding their own health and to influence what kind of health services are available. Access to their own health information and self-service options may simplify the daily lives of patients and promote more bona fide participation in their own treatment. Further effort must be made to provide the municipal health and care services with the ICT equipment needed to support their work tasks in an effective manner. The Government will modernise the ICT platform so that important health information can follow the patient throughout the entire patient pathway. The municipalities and the specialist health care services are now cooperating with the Norwegian Directorate of Health on a number of development measures which facilitate better electronic coordination in various ways.

Many of the measures in the white paper will have significance across sub-services and user groups. This applies, for example, to measures related to competence, management, organisation, distribution of tasks, and work methods. In addition, the Government will promote measures targeted specifically towards individual sub-services.

Children and adolescents

It is critical that children and adolescents have easy access to the services. Problems in children and adolescents must be discovered at an early stage to ensure that they do not escalate. Although children and adolescents in Norway are very healthy in an international perspective, we know that many of them have mental health challenges. To uncover these problems and help the children, adolescents and their families as quickly as possible, many actors must cooperate and coordinate their efforts. The Government has already launched efforts to ensure even better conditions for children growing up in Norway as well as access to competent, coordinated services with sufficient capacity. Measures for moving ahead with these efforts are described in this white paper. The Government will continue the efforts to strengthen child and school health services, and adapt their content and work methods to today’s issues. A health strategy for adolescents and a new strategy for sexual health will be drawn up. The Government will combat childhood poverty, and submit a strategy on childhood poverty in spring 2015. A plan for the Government’s efforts vis-à-vis children and adolescents will also be submitted in autumn 2015. The inter-ministerial cooperation on at-risk children and youth between ages 0–24 will be continued. The efforts will seek to improve the completion rate of pupils in upper secondary education and training and prevent them from falling by the wayside.

Mental health and substance abuse

The Government wishes to enhance the range of services for people with substance abuse problems and mental health challenges. The white paper describes how the Government will follow up on its promise to use legislation, planning and financing to establish low-threshold mental health services, including more psychologists in the municipalities. By introducing the requirement that the municipal health and care services must include mental health expertise, the Government will raise the level of competency in the municipalities’ mental health and substance abuse services, and at the same time give the municipalities an important tool for promoting public health. The white paper describes the road ahead with regard to requirements for 24-hour emergency assistance and the municipalities’ payment obligation for patients ready to be released from the mental health services and specialised, interdisciplinary substance abuse treatment. The Coordination Reform states that the municipalities must assume a greater responsibility for the treatment and follow-up of patients, including in the areas of mental health and substance abuse. The Government will clarify the municipalities’ responsibility for providing high-quality, robust services for people with mental health disorders and substance abuse problems. The Government will introduce a municipal payment obligation for patients ready to be released from the mental health services and specialised, interdisciplinary substance abuse treatment, and take steps to ensure that the municipalities’ obligation to provide 24-hour emergency assistance also includes users with mental health disorders and substance abuse problems. The Government will implement the local government reform to create municipalities that have the capacity and competence to deliver a wide array of services, which will also benefit people with mental health disorders and substance abuse problems.

Users with mental health challenges have a need for follow-up that also addresses their somatic problems in a satisfactory manner, as well as for training and help with making lifestyle changes, mastering their lives, and following up their own health challenges. Thus, primary health care teams and better training will be extremely important for them. For those with extensive, complex needs due to mental health disorders and/or substance abuse problems, however, primary health care teams will not be sufficient. The benefit of out-reach treatment teams in this context has been documented. The Government will work to establish more such teams by considering a new, permanent funding scheme.

Training and rehabilitation

Many patients currently do not receive the rehabilitation they need. The need for rehabilitation is often not reviewed and assessed. This is related to the competency, management, attitudes and culture in the services. When users are asked what is important to them, they often respond that they want to master daily tasks. The follow-up must reflect this, and this is why the Government has announced it will prepare an escalation plan. In this white paper, the Government recommends clarifying the municipalities’ obligation to provide training for patients and their close family members. Training is a critical component in the set of rehabilitation services and necessary to enable patients to master their own lives. In addition, the Government recommends measures for more appropriate use of the physiotherapy resources and for giving the municipalities more opportunity to control the content of their services. Furthermore, the Government recommends a closer evaluation of how a transfer of responsibility for habilitation and rehabilitation from the specialist health care services to the municipalities can be implemented as part of the future local government reform effort. Also important are measures related to competence and management. Rehabilitation is a mode of thinking that must pervade all levels and sub-services in the municipal health and care services.

Emergency assistance

Good access to emergency assistance is crucial for people’s safety. It has long been noted that emergency wards are the weak link in the chain of emergency medical services. The Government has therefore revised the regulations on emergency medicine. The effects of this will be followed closely. Many municipalities, especially in the outlying districts, have a problem acquiring the expertise needed for this service. Good solutions require close cooperation between the health trusts and the municipalities, regionally and locally. The Government will encourage local cooperation through its governance of the regional health authorities and by giving the municipalities the framework needed for good solutions. The local government reform is an important step in improving the framework conditions. In addition, the Government will promote a higher level of professionalism in the home-based health and care services. This may be an important supplement to emergency wards and 24-hour emergency assistance. Good cooperation between the services will make it possible to establish an alternative to hospital admission or municipal 24-hour emergency assistance.

Violence and assault

Violence and sexual assault are a serious public health problem. Far too many children and adults live with violence for years without it being exposed. Everyone has a responsibility to bring to light violence and sexual assault, but personnel who work with and see children on a daily basis have a special responsibility in this regard. This includes health care workers in the municipal health and care services. The Government will therefore strengthen the efforts to develop the services in this area, clarify responsibility in legislation, increase expertise, and better equip the municipal health and care services, including general practitioners and emergency wards, to discover and combat such assault. Beginning in 2016, the specialist health care services will have the primary responsibility for providing services to children and adults who are victims of sexual assault, while at the same time existing, robust municipal centres for sexual assault victims will be continued. Emergency wards will continue to deal with most of the people who experience violence in close relationships.

Care services

The white paper describes the Government’s new measures for strengthening capacity, quality and competency in skilled nursing facilities, home care services and daytime activity programmes. The Government has already increased the investment grant for 24-hour care spaces and allocated more funding for competence development. In addition, the Government will work with the Norwegian Association of Local and Regional Authorities (KS) to draw up a plan based on presumed net growth in 24-hour care spaces in skilled nursing facilities and residential care homes, establish a trial scheme with state funding of the care services, help to expand preventive home visits for the elderly, establish 24-hour nursing and care as a legal right, develop a new Dementia Plan 2020 together with users and close family members, and establish a programme of quality development for skilled nursing facilities.

To give a complete picture, the Government’s plan for the care field for 2015–2020, Care 2020, is being presented along with this white paper. Care 2020 encompasses previously approved policies for strengthening capacity, quality and competency in skilled nursing facilities, home care services and daytime activity programmes, and it follows up the white paper Future Care (Meld. St. 29 (2012–2013)), which received broad-based political support in deliberations by the Storting, cf. Recommendation 447 (2012–2103).

Integrated services – patient-centred health care services

Individual measures are important, but it is even more critical that the white paper lays a foundation for viewing instruments for all of the municipal health and care services in relation to each other. It will be important in the future to dismantle organisational and other divisions between various types of health services and between health and care services in the municipalities. The divisions do not reflect the users’ needs. As described both here and in the white paper on local government reform, the health and care services will also encompass dental health care services in a few years from now. This makes it possible to build an integrated, future-oriented municipal health and care service that serves as the foundation for patient-centred health services.

Download the complete text, including the bibliography, of this white paper (Meld. St. 26 (2014–2015) Fremtidens primærhelsetjeneste – nærhet og helhet) in Norwegian: https://www.regjeringen.no/contentassets/d30685b2829b41bf99edf3e3a7e95d97/no/pdfs/stm201420150026000dddpdfs.pdf

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