Integration in healthcare – lessons from Norway

Norway is often used as a comparison country for Scotland. It has a similar sized population, around five million, and both have faced major reforms to the structure of their health and social care systems in recent years.

Scottish reform – health and social care integration

In Scotland, the Public Bodies (Joint Working) (Scotland) Act 2014 brought in the foundations for the integration of health and social care. It aimed to bring health boards and local authorities together to design and deliver services for the people in their area. It also envisaged a situation where more people were cared for in the community and hospital stays could be avoided except for planned surgery.

Although progress is being made, a number of organisations, including Audit Scotland, have stated that the pace of change is not happening fast enough to take account of reducing budgets and increasing demand from an ageing population.

The healthcare system in Norway

The healthcare system in Norway is organised differently from that of Scotland. The responsibility for providing health care is divided between over 400 municipalities and the state, through four regional health authorities.

  • The regional health authorities are responsible for all specialist (acute) health services.
  • The municipalities are responsible for the management of all primary health and care services and provide services such as:
    • health promotion and prevention of illness and injuries
    • diagnostics, treatment and rehabilitation
    • nursing care within and outside of institutions
    • GPs
    • emergency first aid
    • social care.

Norwegian reform – Coordination Reform

Problems with the relationship between the regional health authorities and the municipalities had been evident for a number of years. To address these problems, the Coordination Reform was introduced in 2012. The main motivation was to encourage the municipalities to expand their local, primary health care services. In 2012 the Public Health Act  and the Municipal Health and Care Act  were passed.

One of the key initiatives of the reform was municipal co-payment by which the municipality pays 20% of the cost of emergency hospital stays. This was financed by transferring money from the regional health authorities to the municipalities. It was hoped this would encourage the municipalities to improve their own services and public health approaches. However, in 2015, following an evaluation which showed there hadn’t been any decrease in the use of specialised health care, the co-payment was stopped. Some people believe this was too early to expect results, as they depend on more profound changes that will take time.

From 2012, municipalities were required to pay for delayed discharges, or ‘bed-blocking’. If a person is considered ready for discharge, but is still in hospital, the municipality has to pay around £370 for each extra day to the regional health authority. Although this has resulted in shorter stays for patients, delayed discharges were reduced more than 50% the first year, some believe that people are being discharged before they are ready and that they require high-level care in the community which the municipalities are not always in a position to provide.

Just as in Scotland, community based services are not developing at a fast or consistent enough pace to address prevention adequately to keep people out of hospital.

 From 2016, the municipalities were required to have a number of emergency beds available. These beds are used by people with known conditions, such as chronic obstructive pulmonary disease (COPD) or diabetes. Only people that can be treated safely within primary care are admitted and their stay should not exceed three days. There has not been much use of the emergency beds, but this may be the result of it being a new service or risk aversion on the part of GPs.

 Six years on there appear to be positive moves towards realising the aims of the Coordination Reform but transformation takes time and some believe there is still a long way to go.

As with other countries, including Scotland, there is some uncertainty whether the measures in place will be enough to cope with the future challenges of an ageing population with chronic conditions and multi-morbidities.

In Norway, there are also moves towards municipal reform which is hoped to result in fewer, larger, municipalities capable of handling more health and care services. But attempts to reduce the number of municipalities is proving very difficult politically.

Scotland – looking ahead

In Scotland, the integration of health and social care is still in its infancy and four years on from the legislation (two years since full implementation) there is much discussion on the progress and impact of integration. Later this year Audit Scotland, will be publishing its second audit on integration.

The Scottish Government intends, over the next year, to “accelerate our efforts to ensure that the widely supported aims of integration of health and social care translate into positive changes in every community” and is undertaking a Review of Progress with Integration which will consider progress against outcomes, ensuring best use of resources and effective relationships.

Although Norway is further ahead in its reform journey, when considering the transferability of approaches from one country to another, it is important to bear in mind that successful integration is often dependent on the local context.

Readiness to change and the relationships between leading/key individuals and between the key organisations are often the biggest factor in the success of integration.

Further information on can be found in:

Lizzy Burgess, Senior Researcher, Health and Social Care.

We would like to thank the Norwegian Parliamentary Research Service and the University of Oslo for their assistance.