2 Summary – Care Plan 2020
“Everyone should be concerned about the future. That is where we will be spending the rest of our lives.”
Source Norwegian proverb
The Care Plan 2020 is a plan for addressing the needs of today as well as the challenges of tomorrow. The efforts to develop and incorporate new, future-oriented solutions have been launched concurrently with the implementation of the Care Plan 2015. To ensure continuity and cohesiveness, the measures set out in this white paper will be included as new elements in the current care plan and will be overlapping features up through 2015. This will provide a foundation for coordinated activity and a common platform for progression. The current plan will gradually be replaced by the new measures, which will steer the plan in a more innovative direction:
Caregiving of tomorrow – an innovation programme towards 2020;
Future users of the care services – with a resource-oriented perspective;
Caregiving community of tomorrow – with a programme for family members, a national volunteer strategy and policy for idealistic, cooperative-based and private service providers;
The care services of tomorrow – with restructuring of professional activities and greater focus on early intervention, rehabilitation for daily life, and networking activities;
The caregiving environment of tomorrow – with a programme for developing and introducing welfare technology and measures to promote renewal, construction and development of future nursing care facilities and residential care homes.
The Government will revert to the funding for various programmes and measures in the individual national budgets for the years to come, with implementation deferred until sufficient funding is made available in the budgets.
Activities relating to the implementation of the measures set out in the plan will be administered under the systems established in the Norwegian Directorate of Health, the Norwegian State Housing Bank and the regional government administration for execution of the current care plan. In its efforts to promote innovation, the Norwegian Directorate of Health is expected to focus on:
strengthening the InnoMed national competence network and employing it actively in the efforts to promote innovation in the health and care services;
contributing to and utilising the knowledge centre and the measures to be established in the Government’s municipal innovation strategy.
In addition, there are plans to strengthen the regional centres for care research in order to assist the municipalities with follow-up research and make documentation from innovation projects available at the municipal level. The county development centres for nursing homes and home care service are to take part in disseminating results and information. At the same time, the funding instruments at the disposal of central research and innovation institutions will be targeted towards enhancing the municipalities’ innovation capacity within the health and care services.
2.1 Caregiving of tomorrow
The health and care services will be facing major challenges in the years to come. The age composition of the population is changing, and the tasks that need solving are becoming increasingly complex. Rather than raising the requirements to qualify for assistance, more services that support prevention, early intervention and rehabilitation must be developed. In order to make the best use of resources across and outside of the municipal organisation, it will be important to take a fresh look at what a service should be and who should help to create it. The care services of tomorrow are to create a framework that enables users to become more of a resource in their own lives, that mobilises residents of local communities in new ways and allows them to become resources for each other, that employs welfare technology as a resource for users who thus will become better equipped to manage their daily lives, and that develops and utilises the resources of idealistic and volunteer organisations in new ways. These resources in and of themselves are not new, but when we systematically include the various actors in the design and production of the services, new solutions will emerge.
2.1.1 Innovation programme 2020 – for the care services of the tomorrow
In recent decades the role of the municipalities in innovation efforts has been primarily to facilitate industrial development and innovation in the private sector. In the face of tomorrow’s challenges, however, the innovation system will need to be targeted towards the municipalities themselves, with the design and production of the services as a focal point. But innovation processes do not launch themselves. Innovation always entails an element of uncertainty and thus presumes a willingness to take risks. While research institutions and trade and industry have their own public innovation and research funding agencies, there are few innovation instruments specifically designed for the care services sector and the municipalities. There is a need to establish a framework and funding instruments that legitimise innovation efforts in the municipal sector and that will better enable the municipalities to test new solutions for dealing with complex challenges.
This is a national task in which the most important efforts must take place in the individual municipality in cooperation between locally elected public officials, experts in the field, users, family members, organisations, and trade and industry. However, action must also be taken at the national level to coordinate, support and provide direction to local efforts, in addition to enhancing competence-building, research and knowledge development, dissemination, motivation, advisory services, documentation and the proliferation of new, tested solutions.
Caregiving of tomorrow is an innovation programme that will design new solutions for tomorrow’s care services together with users, family members, municipalities, idealistic organisations, research institutions, and trade and industry. The innovation programme will promote the development and application of welfare technology, new work methods, new organisational solutions and living arrangements that are adapted for the future. At the same time, the activities will lay the foundation for state and municipal planning, including special instruments designed to support and facilitate municipal research, innovation and development activities in the health and care services for the period up to 2020, including the following components:
strengthening the regional research and development structure of the care services;
ensuring involvement of established innovation and research institutions at the national level;
enhancing the focus on research, innovation and development activities in the municipalities and relevant programmes under the Research Council of Norway.
Action point 1
At the regional level, the currently existing structure with five care research centres and a development centre for nursing homes and home care services in each county will be expanded. These centres are linked together in a network, and the Centre for Care Research at Gjøvik University College has been given responsibility for coordination and will play a leading role in terms of follow-up research and as a documentation centre. Together with the regional government administration and in cooperation with the Norwegian Association of Local and Regional Authorities (KS), the centres will serve as central, municipally-oriented partners for research, development and innovation activities in the health and care services sector.
Action point 2
At the national level, established innovation and research institutions will be involved, and some of the instruments at their disposal will be strengthened and targeted to stimulate innovation efforts in the municipal health and care services. In keeping with the Government’s innovation strategy, a separate knowledge centre will be established to serve as a locomotive for the entire municipal sector. The Norwegian Directorate of Health has established the InnoMed national network for needs-driven innovation in the health care sector, which will be extended to encompass municipal health and care services in addition to the specialist health care services, and to support innovation activity across all levels of health care services administration as well.
Action point 3
The most critical need is to stimulate the municipalities’ ability and power to innovate. The innovation programme will therefore strengthen municipal innovation efforts in the health and care services at the local level by:
testing new solutions (professional methods, technology, housing arrangements, organisation, etc.) in cooperation between municipalities, the research community, and trade and industry or idealistic/volunteer organisations;
ensuring documentation and research as the basis for dissemination and implementation;
improving the knowledge base used for planning, development and innovation through relevant programmes under the Research Council of Norway.
Initially the structure at the regional and national levels will be expanded to assist the municipalities. The care services comprise almost one-third of the municipalities’ overall activities and must be viewed in connection with the needs and resources in the entire municipal sector. Innovation efforts in the care services must therefore be carried out as part of an integrated innovation initiative in the municipal sector. The Government will develop and support the national and regional innovation groups.
2.2 Future users of the care services
Most development trends and projections indicate that there will be more users in all age groups with more complex care needs in the future.
The number of elderly users has not risen in the past 20 years. The greatest increase has taken place among people under 67 years old, especially those with long-term, chronic illnesses, reduced functionality and mental health and social problems.
The number of users in the 67–79 age group is expected to show the largest increase in the near future, while the dramatic growth in the age group over 80 years old will not occur for another 10 to 15 years. At that time the challenges related to dementia will show a corresponding increase.
While women currently comprise the vast majority of users, especially in nursing homes, this will even out over time since life expectancy for men is increasing faster than for women.
By the same token, future users will have other resources with which to face illness, reduced functionality and other problems. It is not enough just to predict the problems. It is also important to make predictions about the resources and determine how the users’ own resources can be utilised. This applies in particular to the new generations of elderly who will live longer and enter old age with a better financial situation, higher level of education, better health and completely different material circumstances than the previous generation. Thus, an 80-year-old in 2000 will not be the same as an 80-year-old in 2030.
A holistic view of tomorrow’s user lies at the core of all the measures and programmes set out in this white paper. These users have more than just illnesses and problems; they also have resources they can employ to master their own daily lives and participate in society at large. Each individual will have something valuable to contribute all the way up to the end of his or her life.
New organisational forms will encourage this. New forms of communication and work methods will lay the foundation for this. New technology and more universal design of housing and surroundings will create better opportunities for this.
This white paper incorporates terms such as responsible citizenry, co-creation, peer support and user control, and it invites users and their representatives to take active part in the caregiving community of tomorrow.
2.3 The caregiving community of tomorrow
When addressing future challenges in the care services, it will be necessary to mobilise all of society’s care resources and examine how tasks are distributed among the actors in the care services sector. Public care services have undergone continual growth over the past several decades. In light of the demographic challenges that are expected to hit full force in 10–15 years, this growth must be organised so that it supports and stimulates the resources found among the users themselves, their families and social networks, neighbourhoods and local communities, idealistic organisations and trade and industry that assume their share of social responsibility. Professional activities will need to be restructured with a greater emphasis on networking, interdisciplinary cooperation, prevention, early intervention and rehabilitation. Furthermore, people will have to take responsibility for ensuring optimum adaptation of their own homes and we as a community must adapt the physical surroundings to ensure they are accessible to everyone and to all generations.
If informal care is to continue at the current level, a new policy of informal care will be needed that makes it easier to combine work and caregiving duties, that is based on equality between the genders, that acknowledges and values the competency and effort of family members, and that is supported with professional training and guidance.
There are many possibilities for involving more people in volunteer caregiving. This will not happen by itself, however, but will require concentrated effort and systematic follow-up with recruitment, organisation, coordination, training, motivation and guidance. Dedicating professional workers or cooperating with idealistic and volunteer organisations on this is an investment that will yield enormous benefits.
There is also great potential within the care services sector to encourage the idealistic organisations to continue to take the lead and forge new paths, actively involve new generations of volunteers, and develop new forms of idealistic measures and cooperative solutions in which the users and their organisations are more active owners.
At the same time, companies in the private sector will subcontract with the municipalities for a number of services, such as in the areas of construction, technology and housing.
This will make it possible to distribute the care tasks to more actors in the future within the framework of the welfare state’s community-based solutions.
2.3.1 Programme for an active, future-oriented informal care policy 2014–2020
In keeping with the recommendations in Official Norwegian Report 2011:11 Innovation in the Care Services and Official Norwegian Report 2011: 17 Når sant skal sies om pårørendeomsorg (“The Truth Be Told About Informal Care”), the Government will formulate a policy that helps to ensure that family members are valued and seen and that improves gender equality and affords greater flexibility. In this white paper the Government presents a programme for an active, future-oriented informal care policy that:
draws attention to, acknowledges and supports family members who perform demanding caregiving tasks;
improves coordination between the public care services and informal care, and enhances the quality of the overall services available;
creates a framework to ensure that the current level of informal care is maintained and that makes it easier to combine work with caring for children and adolescents, adults and elderly with serious illness, reduced functionality or mental health and social problems.
The first phase of the programme will focus on measures that support family members and enhance cooperation between the health and care services and family members through:
flexible schemes that provide relief to caregivers;
support for family members, information, training and guidance;
coordination and cooperation;
improvement of the pay for family caregivers scheme;
research and development.
The next phase will explore the issue of changes in financial compensation schemes and provisions on leave of absence in cooperation with the Ministry of Labour.
2.3.2 National strategy for volunteerism in the health and care services
The Government wishes to promote a dynamic civil society that generates a sense of belonging, solidarity and community, and will in this light develop a national strategy for volunteerism in the health and care services. The strategy will set out measures for recruiting and retaining volunteers in the care services, facilitate more volunteer activity and reduce loneliness by re-establishing or expanding the individual’s social network. The strategy will take its point of departure in the following five components:
Mobilisation, organisation and coordination
Enhancing expertise in recruiting, mobilising, coordinating, training, motivating, following up and guiding volunteers, with greater focus on training volunteer coordinators under the auspices of the Dignity Centre in Bergen.
Developing networking and neighbourhood activities as a means of promoting volunteerism in the care services and creating nurturing, collaboration-oriented local communities.
Arenas for volunteerism
Making use of the arenas for volunteerism in the care services sectors:
idealistic organisations in the health and care services
municipal volunteer coordination centres
open nursing homes.
“Joy of life” nursing homes
A national certification scheme for “joy of life” nursing homes under the auspices of the foundation Livsglede for eldre (“Joy of life for the elderly”) that aims to enhance active caregiving and focuses on the social and cultural needs of users.
Knowledge and research
Conducting research and knowledge development activity on volunteerism in the health and care services in order to create a framework for long-term planning and systematic cooperation.
The strategy will be finalised and specified in more detail in dialogue with the municipal sector and in cooperation with the Association of NGOs in Norway.
2.3.3 Idealistic service providers as innovators
Idealistic organisations have historically been the vanguard of the welfare state. They have expanded services for disadvantaged groups which have later been subsumed under public services, and they have developed new work methods, often with great emphasis on user influence and participation by the local community.
The need for such pioneers is just as great today. Idealistic organisations will continue to be important teammates in addressing the challenges and opportunities arising from an ageing population, increasing cultural diversity and rapid technological development.
For the Government, cooperation with the idealistic sector has been crucial for the development of the welfare state. The Government has high expectations of the idealistic actors’ innovative approach to the health and care services sector, and it views this cooperation as one of several opportunities to mobilise volunteers and local communities.
EEA regulations set some parameters for procurement of services from idealistic organisations by public authorities. The Government is interested in taking advantage of the latitude for action that exists today for procurement of this type of service. Separate procurement processes for idealistic organisations, long-term agreements and cooperation on development and innovation prior to the procurement are constructive, potential alternatives for the municipalities that want to further develop cooperation of this kind.
In the future, the position of idealistic service providers and their high level of legitimacy in the health and social care sphere will depend on their ability to remain innovative, forge new paths, involve volunteers and step in when the welfare state falls short. They must be able to retain their value-based foundation and distinctive character, and find new forms of ownership and models of operation that involve users and their representatives in other ways than previously.
2.3.4 Cooperatives as a possibility
As a form of business organisation, the cooperative is well suited to the welfare sphere and in cooperation between the municipalities on the development of the care services. It is a form of business organisation that encourages more user influence, ownership and user control. It also invites the recipients of services and residents to be more than users and consumers by encouraging them to take responsibility and to participate in the design and production of the services.
The health and care services of the future must be designed and implemented in cooperation between municipal and non-municipal actors with a strong foothold in civil society. The distinctive features of cooperatives allow for local solutions that address local needs, and give individual residents the role of both consumer and producer through participation, user control and co-production of the services. Local democracy in the municipalities will be strengthened through stronger, more direct user democracy.
Cooperatives are widespread throughout the world. In Norway, the cooperative as a form of ownership and operation has generally been used very little in areas under the purview of the public sector, although it has played a dominant role in the private sector and other parts of society at large. In the care services sector there may be room for cooperatives comprised of users, personnel, tenderers and family members, or a combination of these.
The driving force behind social entrepreneurship is the desire to solve society’s problems and safeguard social value creation. In order to promote entrepreneurship in the educational system, the Government is cooperating with Ungt Entreprenørskap (“Young Enterprise”), an idealistic organisation to encourage creativity, innovativeness and self-confidence among children and adolescents, in which many of the companies established incorporate social entrepreneurship principles.
2.3.5 Cooperation with trade and industry
Expertise from Norwegian trade and industry will also be important in the development of the care services sector. By cooperating on the development of services and products, the public and private sectors can create new solutions. There is significant innovation potential inherent in public procurements. As a strategic instrument for innovation, procurements can be used not only to improve utilisation of society’s resources, but also to generate new and better services that will benefit the users. An active private sector that participates in the design of solutions for municipal development needs will lead to better, safer and more effective services and create positive ripple effects within trade and industry.
The foundation will therefore be laid for a policy that:
develops new services at the interface between the care services sector and trade and industry;
enhances the role of the care services sector as a competent, demanding procurer;
develops care services as an export item;
meets a rapidly growing senior citizens’ market.
The Government is concerned with ensuring that developments do not lead to greater inequality in the population’s access to health and welfare services, but some of the practical, more service-oriented services will be produced by others and delivered via the municipalities and the individual senior citizens’ market. This implies a policy in which the Government believes that the municipalities themselves, together with idealistic organisations, should operate long-term spaces in institutions and provide basic health and care services. At the same time, the private sector will subcontract for a number of services with the municipalities. This may apply to services related to construction, technology and housing.
2.4 The care services of tomorrow
The care services of tomorrow will create services together with the users, cooperate with family members, utilise welfare technology and mobilise local communities in new ways. The totality of new work methods and cooperation with family members and networks will require major changes in competencies and recruitment and entail new ways of organising the services. There is therefore a need for professional restructuring that refines the care services’ nursing activities and utilises broader interdisciplinary expertise on rehabilitation and social networking activities.
The following three areas represent some of the most important challenges and opportunities within the care services:
rehabilitation for daily life
caregiving and death.
2.4.1 Active caregiving
Culture, meals, activity and enjoyment are key aspects of integrated care services. In order to develop high-quality, future-oriented care services, there is a need to put more emphasis on activating users both socially and physically and to bring more attention to users’ social, existential and cultural needs.
Daytime activity programmes are often referred to as the missing link in the care services. The Government has therefore launched a major expansion of daytime activity programmes for people with dementia and has proposed enacting legislation that requires municipalities to offer daytime activity programmes to people with dementia once this service has been made fully available. Daytime activity programmes give meaning to people’s daily lives and provide a good experience for individual users. In many cases they can relieve some of the burden for family members and help to prevent or postpone admission to an institution.
Art and cultural activities may be used innovatively to develop new methods and professional approaches to the care services. Cultural activities and caregiving must be coordinated in a close interdisciplinary collaboration that stimulates the body and soul and that activates thought and feelings, such as through memory-enhancing groups and writing projects, dance evenings and music groups or through art and cultural projects based on the abilities, interests and life history of individuals. The Government wishes to further develop the cooperative effort which has been established between the cultural sector and the care services through the Cultural Walking Stick programme and which brings positive cultural experiences to people’s daily lives.
Over time various activity measures have been developed that can be used therapeutically to counteract the anxiety and depression associated with dementia or acting out behaviour when patients are being washed and dressed or carrying out their daily activities. Like the specialist health care services, the care services sector must also develop systems that ensure the application of new knowledge. To ensure that new methods are disseminated and used as a first choice in treatment and nursing, the Government plans to establish a resource centre that can take responsibility for developing and disseminating activity-based therapeutic treatment measures.
2.4.2 Rehabilitation for daily life
It is an objective for individuals and society at large to utilise the resources, abilities and potential of the users themselves as a basis for managing their daily lives. Consequently, habilitation and rehabilitation must be a natural and central part of all care and nursing activity. All effective treatment contains an element of rehabilitation.
A majority of the resources in the care services sector are targeted towards nursing the seriously ill and measures that compensate for reduced functionality. This must continue to be the case in the future as well. The care services must always be grounded in those with the greatest need for assistance and nursing. At the same time, we must remain open to new approaches that assess the potential of rehabilitation and provide the necessary expertise to utilise the resources found in the individual before traditional, compensatory measures are implemented. The Government will therefore facilitate the professional restructuring of the municipal health and care services through greater focus on rehabilitation, prevention and early intervention.
Rehabilitation for daily life is an example of how early intervention and rehabilitation in the care services promotes a better quality of life and greater functionality among users. Rehabilitation for daily life is a type of rehabilitation that can achieve a greater scope by involving the home care services. As a method and professional approach, rehabilitation for daily life takes its point of departure in uncovering the potential of the users themselves to actively assist with re-establishing or increasing their previous level of functionality. The users’ own resources, desires and personal goals will serve as the basis for the services provided.
The method requires the employees to work together with, not for, the individual user. Early interdisciplinary mapping of the user’s rehabilitation potential and corresponding early, intensive training increases the user’s ability to cope and reduces the need for help from the public sector.
When rehabilitation for daily life is introduced in the home care services, it is usually in the form of an interdisciplinary team comprised of occupational therapists, physical therapists, social educators, social workers and nurses specialising in rehabilitation. The team goes in and assesses the individual’s rehabilitation potential and cooperates on training and guiding employees of the home care services so they can be responsible for training in the user’s natural arenas, in the home and in the local community.
The Government wishes to further develop initiatives regarding rehabilitation, activation and achievement of personal goals and to encourage the municipalities to test various models of early intervention and rehabilitation for daily life.
2.4.3 Caregiving and death
Some of the care services’ users require treatment and nursing for shorter durations, while others need assistance and care throughout their entire lives. Seriously or terminally ill or dying patients and users with a great need for care and nursing must have access to safe, high-quality services. This means treating patients with dignity and respect and ensuring that their physical, psychological, social, spiritual and existential needs are met.
Norway is one of the countries in the world with the fewest deaths at home. Creating a framework that allows more people to die at home may better enable us to view death as a natural part of life. Dying at home can reinforce a sense of belonging to and cooperation with the family and civil society, make it easier to direct events according to the wishes of those involved than at the hospital, and help to ensure that death does not become the realm of the professions alone. The number of deaths in nursing homes has risen in recent years, which indicates a need for adequate resources and expertise in nursing homes in order to provide good treatment, nursing and care to patients in the final phase of life.
Caring for dying children is one of the most demanding tasks in the health and care services. There is a need to strengthen palliative treatment and care for children and their family members. National professional guidelines will be drawn up on palliative treatment related especially to children’s needs. To enhance employees’ expertise in this area, several municipalities have been granted funding for competence-building projects in cooperation with volunteer organisations.
Meeting the needs of patients and their family members will require an interdisciplinary approach that utilises personnel and expertise in new and better ways, with more integrated services in the municipalities and health services that support the care services. To enhance quality, knowledge and expertise related to palliative treatment, the Government will establish a framework for greater involvement of family members and develop a training programme for care services employees that provides basic expertise in palliative treatment.
Family members will receive support and guidance through informal care schools and discussion groups. The regional centres for palliation in the specialist health care services will develop and disseminate expertise in palliative treatment within the region. Together with the palliative centres at hospitals, they are also responsible for interdisciplinary knowledge networks on palliative treatment and for ensuring the continuity of nursing and care services to palliative patients and bringing expertise to the municipalities.
2.4.4 Professional restructuring and broader expertise
To ensure sustainable, high-quality care services in the future, it will be necessary to restructure the professional activities of the care services. There will be a need for a higher level and different kinds of expertise, new work methods and new professional approaches. The professional restructuring will primarily be related to a greater emphasis on rehabilitation, early intervention, activation, networking, activity therapy, guidance for family members and volunteers, and the implementation of welfare technology. The further development of expertise in palliative treatment and care at the end of life will be encouraged as well. The Government’s competency and recruitment plan, Kompetanseløftet 2015 (“Competency Reform 2015”), will help to ensure adequate, stable and competent staffing of the care services sector.
To promote professional restructuring of the care services, the Government will focus on the following objectives in this white paper:
raising the level of professional expertise in the care services, in part by increasing the proportion of personnel with a university college education and facilitating internal training;
creating a broader professional base with more professional groups and increased focus on interdisciplinary activity;
strengthening the care services’ own knowledge base through research and dissemination of knowledge.
Professional restructuring will also have ramifications for how the services are organised, as well as for cooperative relationships and the interface with society at large. If the services are to develop new work methods and strengthen preventive and rehabilitative activities, they must team up with the overall resources of society. The care services must go out and meet the users and their networks. Thus, proximity and decentralised services are critical. The care services must be an integral part of the local community and not be removed from contexts in which professional and informal care can continue to work together.
New content and new professional approaches to the services will also mean that the municipalities must assess the focus and organisation of their services, both internally in the health and care services and in relation to other municipal services. Consideration must be given to new ways of organising and working that shift the current dividing lines between the professions and between the areas of activity in the municipalities.
The services must be organised in a closely coordinated manner to ensure that individual users experience them as being provided continuously and consistently. New work methods and redirection of municipal services will also require the specialist health care services to support and guide the municipalities. It is essential to establish contact channels and a system for competence development, task solving and interdisciplinary cooperation between the municipalities and the specialist health care services.
2.4.5 Men in the health and care services
Men represent perhaps the greatest unused resource in the care services. It is unrealistic to think that tomorrow’s extensive caregiving tasks can be solved without recruiting more men to the health and care professions or involving them in the caregiving arena.
Trondheim municipality has made one of the most successful attempts to recruit men to the care services sector. Men there are lining up to try out health and care work in the home care services and nursing homes as a future workplace and vocation. The Government wishes to build on the experience of Trondheim municipality and make “Men in the health and care sector” into a nationwide initiative. At the same time, municipalities, educational institutions and organisations are invited to place special focus on the recruitment of men and design measures that promote better gender balance at workplaces within the health and care services sector as part of their innovation activities.
2.5 The caregiving environment of tomorrow
The use of welfare technology and universal design principles will make it more possible for people to receive care services in their own homes. The design of future nursing homes and residential care homes will be crucial as a framework for service provision and cooperation with family members and local communities. The Government will therefore continue the current support scheme under the Norwegian State Housing Bank for nursing homes and residential care homes, and will explore whether the requirements of the scheme can be adapted to allow for the construction of assisted living residences. A scheme that sets aside funding for research, development and innovation with a view to designing and testing new models for future institutional and housing solutions will also be explored.
The Government is launching a national programme for the development and implementation of welfare technology that will promote the full integration of welfare technology into the services by 2020.
2.5.1 A new concept for nursing homes and residential care homes
There is an exciting development taking place in the municipalities in which the rooms in nursing homes are beginning to resemble actual homes and today’s residential care homes are being built together and used both as a supplement and as an alternative to nursing homes. Soon it will not be possible to see the difference between small, modern nursing home units with a high living standard and local living and service centres with separate residences. The municipal care services also cover the entire life course from children’s homes to nursing homes.
The Government wishes to take the best from the two different traditions and build tomorrow’s solutions on the basis of several fundamental principles:
“Small is good.” Small shared flats and units instead of traditional institutional solutions.
A clear distinction between the types of living arrangements and services in which the services and resources are tied to the individual’s needs.
A clear distinction between private, common, public and service areas in all buildings used for health and care purposes.
Housing solutions that are adapted for use of new welfare technology and that have all the necessary amenities (bathroom, toilet, kitchenette, bedroom and living room) within the private area, adapted for both residents and family members.
Care services with living arrangements and offices that are an integral part of the local community in towns and city neighbourhoods in which the public areas are shared with the population at large.
Based on these principles, a space in a nursing home can serve as a person’s home and vice versa.
Very little research has been conducted on the developments in the care services, and there is a great need to document and systematise the experiences and to carry out knowledge development activities in this field. About 45 000 spaces in institutions and residential care homes have been built or renovated in the past 15–20 years. In order to assess which basic requirements should be applied to the design of future solutions, it is essential to evaluate the experience with existing buildings and learn more about how these function in relation to their purpose for the users, for employees, for cooperation with family members and for day-to-day operations. There is also a need to establish test housing for more systematic trials of new technology, fall-friendly materials and surroundings, bathroom solutions and interiors, as well as to establish pilot projects that are followed up by documentation and research. Against this background, the Government will look into the implementation of a scheme for research, development and innovation targeted at the design and testing of new models for future institutional and housing solutions.
Most of the homes and institutions where users will live and receive health and care services in the coming decades have already been built. This applies primarily to ordinary single-family homes, town homes and apartments which in Norway are owned and used mainly by the people living in them. It also applies to the 40 000 spaces in old-age and nursing homes and some 50 000 homes used for nursing and care purposes, which are owned primarily by the municipalities and rented out to residents in need of assistance. An important focus in the next few years will be on renewal and rebuilding so that existing buildings are well adapted and can function optimally to address future needs.
Half of Norway’s residential care homes and nursing homes were either newly constructed or completely renovated under the Action Plan for Elderly Care which ran from 1998–2007. The other half of the approximately 40 000 spaces in institutions and the roughly 50 000 homes used for nursing and care purposes will soon need to be renovated or replaced. The municipalities should concentrate on replacing the old, run-down spaces before the need for greater capacity manifests itself 10 years from now. To ensure an even pace of expansion, the renewal efforts should be completed before the need for greater capacity reaches a critical point in the years leading up to 2025. This will make it possible to distribute the rising costs that the municipalities will face in 10 years from now as a result of rapid demographic changes over a period of several years. Replacing the existing spaces will not necessarily lead to higher operational expenses and may in many cases also enhance the efficiency of operations. A long-term perspective and predictable investment parameters will be important for increasing capacity and renewal, and the rapid demographic changes will require planning and adaption at the national level. Thus, the Government wishes to continue the current scheme under the Norwegian State Housing Bank, after 2015 as well.
In addition, the question of whether the requirements for the scheme can be adapted to allow for expansion of assisted living residences will be explored. Assisted living residences are homes with Smart House technology, reception and hotel services which address the residents’ various needs for practical services, such as housecleaning, laundry, home maintenance, meal service and other services that assist residents in their daily lives. Homes of this kind can preferably be built in connection with daytime activity centres, cultural centres, local community centres, welfare centres or the like with easy access to activities and opportunities to socialise with others.
2.5.2 Financing and user-payment schemes independent of type of living arrangements
The municipalities’ total expenditures on nursing and care services came to approximately NOK 90 billion in 2012. Almost all of the expenses were financed through distributable municipal revenues, while revenues generated by user payments comprised about seven per cent.
The municipalities have the primary responsibility for financing most of the health and care services. However, the state contributes funding for medical services, physical therapy, pharmaceuticals, technical aids and housing allowances for users who live in their own homes. Today users of municipal health and care services pay for the services they receive according to two different sets of regulations depending on whether they receive services inside or outside an institution. People who live in their own homes pay for each service they receive, while people living in institutions pay a fixed percentage of their income for the entire set of services. Thus as a result of regulatory differences, users pay different amounts for the same services depending on whether the municipality provides them with a space in an institution or whether they live in a home that they own or rent.
It is becoming more and more difficult to see any difference between nursing homes and residential care homes other than in the way in which they are financed. Several municipalities are now referring to their residential care home facilities as nursing homes, while others are discontinuing their nursing homes spaces and calling them residential care homes, living and service centres and the like. Official Norwegian Report 2011: 11 Innovation in the Care Services therefore recommends introducing the use of the same financing and user-payment schemes and the same rights to pharmaceuticals, technical aids and housing allowances for everyone, regardless of the type of living arrangements. The same conclusion is presented in a research report that describes the tendency of the municipalities to place high-income groups in nursing homes and allot residential care homes to pensioners who receive the minimum state pension and who are eligible for housing allowances. The financing system can create economic incentives for the municipalities with unintentional effects that may change the development pattern.
The framework conditions for the municipalities and users must be designed to ensure that services are primarily assessed on the basis of the needs of individuals and on the most effective course of action from a socioeconomic perspective.
The Government will launch a study of the financing and user-payment schemes used for various types of living arrangements. The purpose of the study will be to create a framework for a fair, predictable payment system for users and to clarify the spheres of responsibility between the state and the municipal sector.
2.5.3 Welfare technology programme
The use of welfare technology opens up many opportunities. Such technology can help people to cope with their daily lives and health issues, allow more people to live longer in their own homes despite reduced functionality, and help to prevent or postpone admission to an institution.
Technology can never replace human caregiving and physical proximity, but it can help to strengthen social networks and facilitate greater cooperation with the services, local communities, families and volunteers. Thus it can also free up resources in the care services that can then be used in direct user-oriented activities.
The development of welfare technology must be placed in a framework. It must be aimed at solving specific problems and addressing users’ needs. Welfare technology should therefore be implemented in the health and care services alongside changes in the organisation and focus of the services.
In order to fully exploit the potential of welfare technology, a framework must be created that encourages the municipalities to make greater use of such solutions. To facilitate this, a national programme for the development and implementation of welfare technology in the municipal health and care services will be launched. The main objective of the programme will be to make welfare technology an integral part of the care services by 2020.
Greater implementation of welfare technology in the health and care services will:
enhance the ability of users to manage their own daily lives;
increase the sense of safety and security for users and their family members and relieve some of the concerns of family members;
increase the participation of users and their family members in user networks and enhance the ability to maintain ongoing contact with each other and the support system.
The programme will be based on the objectives set out in the Coordination Reform regarding health-promoting activities, preventive services, early intervention and the delivery of services where people live. The programme will also build on the local conditions in the municipalities and address the need to view welfare technology solutions and service innovation in relation to each other. The programme will lay the foundation for new work methods and forms of cooperation between municipalities, users, family members, local communities, volunteers, the specialist health care services and the private sector.
The Norwegian Directorate of Health will have the primary responsibility for implementing the technology programme as part of the Care Plan 2020. The Norwegian Directorate of Health will be expected to implement the programme in cooperation with InnoMed and the knowledge centre to be established as part of the overall municipal innovation strategy.
The programme will consist of the following measures:
Introduction of open standards for welfare technology
Strong national steering of the development of ICT in the health and care services sector will be necessary. The standardisation efforts in the area of welfare technology will help to promote integrated welfare technology solutions independent of suppliers across the public and private sectors so that the users receive high-quality, coordinated, predictable services. The Norwegian Directorate of Health has been assigned responsibility for the overall standardisation efforts in this area. Close cooperation with the KommIT programme, a programme for ICT coordination in the municipal sector under the Norwegian Association of Local and Regional Authorities (KS), as well as with Standards Norway, suppliers and industry associations, and the Norwegian Health Network – Norsk Helsenett SF, will be critical. The efforts must be viewed in connection with the standardisation efforts on electronic coordination of the health and care services. Standardisation in the welfare technology area will be given priority in the national strategies for standardisation.
Development and testing of welfare technology solutions in the municipalities
The municipalities must participate in the development and testing of welfare technology solutions in a three-way cooperation with the private sector and research, development and innovation circles. Top priority should be given to the development of safety packages, in keeping with the recommendation in Official Norwegian Report 2011: 11 Innovation in the Care Services and the Norwegian Board of Technology. A safety package is an expanded form of the safety alarm which may also include a self-triggering alarm, fall sensors, smoke detectors, electronic door openers, mobile phones, tracking solutions (GPS), etc.
Knowledge production and dissemination of welfare technology solutions
The programme will promote new research-based practice. To document the impact and benefits of employing various welfare technology solutions, priority will be given to knowledge production and dissemination of good welfare solutions to the municipalities. Top priority will be given to follow-up research and the establishment of knowledge-based practice. The regional centres for care research will be assigned a key role as documentation centres for innovation with follow-up research and dissemination.
Promote the development of good models for the implementation and use of welfare technology
The development of good models for the implementation and application of welfare technology will ensure that the technology becomes an integral part of the services and is not applied only as individual solutions. Therefore, the Government wishes to extend the InnoMed network beyond the specialist health care services to encompass the municipal health and care services as well, and to conduct innovation activities across administrative levels in the health care services. The scheme for public sector R&D contracts in Innovation Norway must be made more easily accessible and be adapted to the innovation needs within the health and care services sector, especially with an eye to welfare technology. In order to encourage a greater degree of municipal innovation, a separate knowledge centre will be established as part of the Government’s municipal innovation strategy.
Training and competence-building for employees, users and family members must take place in advance of and alongside the implementation of welfare technology. Training must be carried out primarily in the form of internal training programmes in the municipalities, preferably in cooperation with and with the assistance of educational institutions, technical aid centres and other professional circles. Some of the practical training must be tied specifically to the implementation of welfare technology. Therefore, the Norwegian Directorate of Health, in cooperation with relevant professional circles, will develop a training package that provides basic expertise in welfare technology. Health and care services personnel must also be given knowledge about welfare technology through educational programmes, and changes in health and social care education should be assessed in light of the needs created by the implementation of welfare technology.
The programme will also help to ensure that the municipalities are supplied with the necessary expertise within innovation and innovation management, as well as with practical tools for mapping out needs. Knowledge about change processes, mapping of needs and implementation are critical for ensuring that the technology covers the intended needs and is in keeping with what is practically and organisationally possible in the municipalities. An educational programme on municipal innovation efforts for municipal managers and professionals in the sector will be developed as part of the Government’s municipal innovation strategy. This programme will enable employees, managers and publicly elected official to learn about innovation processes and how to plan and implement an innovation project.
In order to ensure legal clarity and to lay a better foundation for new technology that will give the individual greater capacity for independence, safety and physical activity, the Government has presented Prop. 90 L (2012–2013), a bill on amendments to the Patients’ Rights Act related to the use of notification and locating technology.