4. Physical and human resources
everal trends can be discerned in both the infrastructure and organization of the hospital sector. The number of hospital beds has been declining since the late 1980s within both acute and psychiatric care. The average length of hospital stay has also declined, often thanks to the introduction of new treatment options and modalities. There has also been a deliberate shift towards more outpatient and day-care treatment. However, at the same time, bed occupancy rates are high and this is reflected in long waiting times for elective care. The number of long-term beds has remained stable despite the current government’s ambition to increase this. At the same time, municipalities have managed to increase the provision of home-based services.
Municipalities are responsible for investment in infrastructure such as primary care and LTC facilities, while the RHAs (since 2002) are responsible for investment in the hospital infrastructure within their geographies. Large infrastructure projects, such as the Norwegian Health Network, are the responsibility of the central government.
The availability and use of IT continue to increase within the health care system as well as in other parts of society. Several national strategies for a more digitalized health care system have been launched and implementation of these strategies is now starting to gain momentum. All primary care physicians are now using electronic patient records (EPRs) and the use of other IT tools in primary care is very high. All RHAs use EPRs. Introduction of some types of e-solutions, such as e-referrals from GPs and electronic hospital discharges, has been more difficult due to the lack of coordination between the two levels responsible for provision of care. Electronic booking of doctor consultations is not yet in general use. Ongoing e-health projects include the introduction of electronic medical records on the national scale.
The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. A significant proportion of medical personnel come from abroad and Norway has long pursued an active policy of recruiting foreign health care personnel. In 2011, the government adopted WHO’s ethical code of practice for the recruitment of international health care personnel, which discourages active recruitment from poor countries with shortages of health care personnel.
4.1 Physical resources
4.1.1 Capital stock and investments
Current capital stock
In 2012, there were 21 public hospital trusts in Norway, with over 100 hospital facilities. One hospital trust can cover a vast geographical area (e.g. in Nordland county, the distance between hospitals is more than 500 kilometres). Hospitals are mainly situated in urban areas but some smaller local hospitals are located in remote areas. The number of hospitals is positively correlated with the population density, with the greatest number of hospitals in the South-Eastern RHA. However, the average number of beds per 100 000 inhabitants, at 347, is lower in the most populous South-Eastern RHA than in the other RHAs (Table4.1). The size of the hospital trusts varies, the smallest being Sunnaas trust with 159 beds and the largest Oslo University Hospital with almost 2000 beds (both in the South-Eastern RHA). Six trusts have more than 1000 hospital beds, 8 have between 500 and 1000 beds, and 8 have fewer than 500 beds.
The age and condition of hospitals vary across the country (Auditor General, 2011b). Hospital trusts report to the RHAs on the condition of their facilities on an annual basis and reporting on capital stock and investments is also part of the RHAs’ annual reporting to the Ministry of Health. According to a survey conducted in 2009, the average age of the hospital buildings was approximately 40 years and 21% of hospital buildings were built after 2000 (Fig4.1). The same survey revealed that there were large variations in the condition of the facilities. On a scale from 0 to 3, where 0 means “no symptoms of poor condition” and 3 means “drastic symptoms of poor condition”, 10% of the building stock scored 3, and 40% scored 2. Only 20% of the building stock had no symptoms of poor condition. There were also clear regional differences, for example, the Northern and Western RHA trusts had 60% of the building stock in the lower part of the scale (i.e. scoring 2 and 3) (Auditor General, 2011b).
The report from the Auditor General, which was delivered to the parliament, also includes a response from the Minister of Health. Thus, it feeds straight back to the decision-making and planning processes and to future investment strategies.
Overall responsibility for the planning of infrastructure and capital investments in public health care providers lies with their respective owners: central government in the case of hospitals; and municipalities in the case of primary care providers.
Each of the four RHAs has a wide authority to plan and manage its own infrastructure according to its needs. Health trusts follow accrual accounting principles and are expected to cover the annual depreciation costs within their annual budgets. If they enter into contracts with private service providers, the contracts must take into account the contractee’s needs for capital investment. Decisions over capital investments in hospitals are taken by their boards (Solumsmoen & Aslaksen, 2009). Health trusts finance investments from their general incomes. In the case of large capital investment projects, they may apply to the Ministry of Health for special investment grants. The RHAs may finance investments in the health trusts by borrowing (debt financing). RHAs are not allowed to borrow money in the private market but can borrow money from the Norwegian Central Bank. As the owner of the hospitals, the ministry shares responsibility for the control and monitoring of investments in health enterprises. In addition, the ministry has the authority to approve larger building projects in accordance with special regulations (for such projects 30% of the funding has to come from the RHA).
The state’s block grant transfers are the principal source of financing for the municipalities, including the funding of capital investment. The municipalities are free to distribute this funding according to their priorities. Unlike the RHAs, the municipalities may borrow money in the private sector to finance capital investments (and money from the block transfers can be used to cover the interests and repayments). Investment decisions are taken by the Local Municipalities Councils.
A system of investment grants to municipalities’ assisted living and nursing homes was created in 2008. Subsidy from the government covers 20% (assisted living home) or 30% (nursing home) of the construction costs and is seen as an essential tool for achieving the government’s goal, expressed in the Care Plan 2015, of establishing 12 000 new care places between 2006 and 2015 (see section 5.8) (Ministry of Health, 2006).
In 2011, there was a total of 20 778 beds in the specialist health care sector (Directorate of Health, 2012c). Beds in public health care institutions accounted for 78% of all beds (16 282 beds). During the last 20 years there has been a steady decline in the total number of hospital beds. The number of acute hospital beds declined by 37% between 1990 and 2010, the number of general hospital beds by 29% and the number of psychiatric hospital beds by 7% (Table4.2).
The decline in the number of acute care hospital beds reflects the government’s efforts to improve resource allocation, for example, by shifting inpatients to outpatient settings and to day-care surgery (see section 5.4.1). While this downward trend in the number of beds has also been observed in other countries (Fig4.2), Norway started from a relatively low level and, in 2010, the number of acute hospital beds in Norway, at 2.4 per 1000 population, was well below the EU27 average of 3.9.
Trends in operating indicators in acute hospitals, such as average length of stay (ALOS) and occupancy rate, may reflect the decline in the number of acute beds. ALOS declined by over 40% between 1990 and 2010, and at 4.5 (2010) is much lower than the EU27 average of 6.6 (2009) (Fig4.3). The bed occupancy rate increased by over 20% and, at over 93% (2010), is significantly higher than the EU27 average of 76% (2009) (Fig4.4).
The long waiting times for hospital treatment in Norway compared to other countries may be a symptom of the high bed occupancy rates. According to a 2010 OECD survey, 50% of respondents in Norway had to wait more than four weeks for a specialist consultation (third highest score after Canada (59%) and Sweden (55%)) and 21% of respondents had to wait four months or more for elective surgery (third highest score after Canada (25%) and Sweden (22%)) (OECD, 2012b).
Partly in response to this problem, the coordination reform (see section 6.1.5) includes several measures aimed at further reducing the ALOS (Ministry of Health, 2009b). These measures include: shifting elderly patients from hospitals to nursing homes or to home-based care services; lowering the rates of unnecessary admissions (reducing the number of referrals by primary care doctors); increasing the share of outpatient care provided by hospitals (Rønningsen, Myrbostad & Bergsland, 2012); and improving hospital planning, for example, by reducing the time patients spend in hospital before an operation. It also gives municipalities clearer responsibility for the provision of follow-up care for patients ready to be discharged from hospitals by making them responsible for co-financing of the specialist health care services and for the financing of care for patients ready for discharge.
The reduction in the number of beds in psychiatric hospitals was relatively small between 1990 and 2010 (Fig4.5), compared to reductions that occurred for other types of beds, as substantial reductions had already taken place in the 1970s and 1980s (reflecting the shift towards deinstitutionalization of mental care).
In 2011, there were almost 1000 nursing homes in Norway (Statistics Norway, 2012e). The number of single-occupancy rooms increased from 82% in 1996 to 97% in 2011 and as a result of converting rooms from double to single occupancy there has been a slight decrease in the number of beds (Fig4.6). At the same time, the number of recipients of nursing care has increased and this has been accommodated by the increase in the provision of non-institutionalized care (at home and day-care facilities) (this increase is not reflected in Fig4.6). In the future, the number of beds in assisted living and nursing homes is likely to increase, as the government has allocated a special subsidy to significantly increase the number of care beds by 2015 (see sections 4.1.1 and 5.8).
4.1.3 Medical equipment
Medical equipment is financed in the same way as capital investments (see section 4.1.1). Following the 2002 health care reform, one central purchasing unit, Helseforetakenes Innkjøpsservice (HINAS), was established by the RHAs in 2003 to coordinate procurement on behalf of public health trusts (its services are not available to privately owned hospitals and health care units operated by local municipalities). It was expected that a single entity would be in a better position to negotiate more economically advantageous contracts than each enterprise could achieve on its own (Auditor General, 2012). A common procurement policy is not applied to all purchases but only to those that are large enough, in both sum and volume, to represent a possible gain if conducted on a national scale. A recent report (Bjørnstad, 2011) from the South-Eastern RHA, the largest RHA, concluded that HINAS had been of considerable importance in the procurement of technical aids for patients (HINAS accounted for 70% of purchases) but had not been sufficiently involved in purchasing medical technical equipment for the hospitals. Although HINAS is usually in charge of larger orders, decisions on “big-ticket” purchases may still be taken by the national authorities. For example, the procurement, location and funding of the first positron emission tomography (PET) machine in 2004 was decided by the parliament. To improve coordination of major investments in medical equipment and inpatient drugs, the Ministry of Health has recently established a national system for the introduction of new medical technologies in hospitals (see section 6.1.6).
Limited national information is available from hospitals and primary care facilities on existing medical equipment and its use, and it is therefore difficult to assess whether it is available in sufficient quantities. Information on diagnostic imaging technologies is available from the Norwegian Radiation Protection Authority (Table4.3). According to OECD data, Finland had approximately 20 magnetic resonance imaging (MRI) scanners and 21 computer tomography (CT) scanners per 1 million inhabitants, which is similar to the ratios observed in Norway (OECD, 2012a).
4.1.4 Information technology
IT use by households
Computer use is very high in Norway. According to data from a survey conducted in early 2012 (Statistics Norway, 2012c), 95% of the respondents had used a computer in the last three months prior to the survey. Almost everyone under 55 years old and 74% of people aged between 65 and 74 years old had recently used a computer (the 2011 figure in the latter group was 67%). General Internet access is also very high. According to the same survey, all households with children and 90% of households without children had access to the Internet at home. Only 4% of the population between 16 and 74 years of age had no access to the Internet. The Internet is mainly used for reading newspapers, searching for information on goods and services, and for Internet banking.
Internet use for health purposes has, according to surveys studied by Wangberg et al., increased from 19% of respondents in 2000 to 67% in 2007 (Wangberg et al., 2009). The Internet is most commonly used for reading about health or illnesses and its importance as a source of health information is increasing. The Internet is also increasingly used for ordering OTC medicines and other health-related products. Forty-four per cent of those having used the Internet for health purposes reported having searched for lifestyle-related information.
IT use in the health system
The use of IT in the health care sector has been strongly promoted by the Norwegian government. Between 1997 and 2008, four action plans for IT development in the health sector were published. The fourth and current one, “Teamwork 2.0” (2008–2013), highlighted the priority areas and goals for the next five years, including the development of e-health tools, such as e-prescriptions and EPRs. Other documents on e-health include the “Strategy for ICT in the Public Sector 2003–2005” and the 2006 White Paper “An Information Society for All” (Doupi, Renko & Giest, 2012).
The level of IT use in the Norwegian health system varies and is most advanced at the level of primary care. In terms of IT infrastructure, 98% of GP practices use a computer and 87% of practices have an Internet connection (2009 data). The storage of electronic patient data is common practice and almost all GP practices store at least one type of individual patient data. Most GP practices have (98%) and use (93%) a computer in the consultation room for consultation purposes with patients. Decision support systems were also used in the majority (93%) of practices. The use of electronic exchange of patient data is also high. In 2009, 35% of practices exchanged medical data with other care providers or professionals, and 88% of GP practices received laboratory results in a digital form. Electronic exchange of administrative data was also high with, respectively, 25% and 19% of practices exchanging such data with other care providers and reimbursing entities. Since 1 January 2010, all GPs are obliged to file for reimbursements electronically (Doupi, Renko & Giest, 2012). EPRs were introduced in the early 1980s and are now used by all GPs (Ministry of Health, 2012). E-prescriptions were piloted in 2010 and implemented nationally in 2011 with full rollout expected to be achieved by the end of 2013 (Directorate of Health, 2012e). The use of e-referrals to specialist and hospital care is still relatively poor. In 2007, only 8% of referrals were sent electronically. The number had increased to between 40% and 50% in 2011, but there are still substantial differences between RHAs and between hospitals (Directorate of Health, 2012d).
The use of e-tools in hospitals is less common than in general practice but has been improving. Electronic exchange of discharge summaries was used in 50% of cases in 2007. In 2012, one region (Northern RHA) had implemented it for all hospitals (80% in others). EPRs are used in all hospitals. There are no electronic appointment booking systems for elective hospital care and currently no plans to introduce such systems (Directorate of Health, 2012d).
Norway, like other Nordic countries, has traditionally promoted telemedicine applications as a tool to improve equality of access to health care, especially in remote areas with dispersed populations, such as the northern region of Norway. Although it is not widespread, the use of telemedicine is increasing. The Norwegian Centre for Integrated Care and Telemedicine at the University Hospital of North Norway in Tromsø is the academic research centre for telemedicine in Norway. Norway was also an early promoter of telemedicine applications. For example, a fee schedule for telemedicine that made all telemedicine services reimbursable by the NIS was implemented in mid-1996 (Castro, 2009). Newer applications include teleradiology (for use in consultations between hospital and the primary care sectors and to obtain second opinions, including in emergencies) and videoconferencing in the area of psychiatry and cancer care. In some areas, telemedicine is also used in the area of radiology and dialysis, enabling patients to avoid long journeys for consultation and assessment.
The Norwegian Health Network (Norsk Helsenett, www.nhn.no) was founded in 2009 in order to provide an efficient and secure electronic exchange of patient information via a health communication network between all relevant parties within the health and social services sectors and to enable establishment of cooperation between administrative levels and across regional borders. Currently, all public hospitals and pharmacies, and 365 municipalities (covering over 90% of the population) are connected to this network (www.nhn.no).
The aims of the 2017–2022 e-health strategy are to ensure easy and safe access to patient information by both healthcare professionals and patients and availability of data for healthcare management and quality improvement, health monitoring, and research. However, the use of personal e-health services by the population appears to be low. For example, the Core Medical Record (kjernejournal) (see policy update published on 21 May 2015) was accessible to nearly all citizens by December 2016, but only 10% of the population had actually accessed it.
In order to avoid a digital divide in the area of e-health, the Government has called for all municipalities to provide a guidance service to their inhabitants needing help in navigating e-health tools. Financial support will be provided to 35 municipalities and/or public libraries to pilot guidance services to their citizens in 2018. The Government and the Norwegian Association of Local and Regional Authorities are cooperating on developing a toolbox for the municipalities to be published at the end of March 2018. Meanwhile, online tools and courses teaching basic digital skills are available at kompetansenorge.no.
Two ministries are responsible for e-Health policies in Norway: the Ministry of Health and Care Services, which defines the strategies and provides funding for their implementation and the Ministry of Local Government and Modernisation, which is in charge of setting ICT strategy for to the whole public sector. The first action plan for e-Health, titled “More health for each bIT”, was published in 1997 and was followed by "Say @h!” action plan in 2001. In 2006 a white paper outlining ICT strategy for the public sector was released.
In 2014 the National ICT Health Trust was established as a state enterprise governed by the four Regional Health Authorities (RHAs) in order to ensure coordination of IT systems of suppliers and various user groups throughout the country. The Trust is now implementing the Core Medical Records (“kjernejournal”), developed by the Norwegian Directorate of Health, for all patients in Norway. The kjernejournal is a new tool to be used in addition to the medical records kept by primary and secondary health care providers. The purpose of the kjernejournal is to improve patient safety and quality of care by providing easy access to up-to-date core patient information for health care providers at different levels of care (primary and secondary). It will contain information from the national registries, information on serious medical conditions or allergies registered by the physician, and any information entered by the patients themselves and the patients’ physicians in consultation with the patients. Patients can access and alter these core records through the public health portal helsenorge.no.
The Health Registry Act from 2001 regulated the handling of patient information and health related information in the registries. The increasing amount of available data and the increasing complexity of patient journeys in the health care system led to a revision of the existing Act. In 2014 two new Acts, the Patient Records Act and the Health Registry Act replaced the 2001 Act. The Patient Records Act regulates information related to the treatment of patients (Patient Records) and the Health Registry Act regulates the secondary use of health information for statistical purposes, analysis, research, quality improvement, governance and emergency preparedness. It will enable an easier access to information by regulating the access to information for different purposes.
The Patient Records Act enables access to patient information regardless of where the patient receives treatment, but at the same time it ensures the protection of privacy of patient information. For example, access to the Core Medical Records is only granted to providers authorized by the Health Directorate. It will only be available to health care professionals providing medical care to patients, including out-of-hours services, medical centres, emergency departments and hospitals. In order to gain access to Core Medical Records health care professionals must identify themselves and their activity is logged. Patients can monitor who has accessed their Core Medical Records, and can also limit the access to information. Core Medical Records will be created automatically for all inhabitants of Norway but patients will be free to opt out of the system at any time. The Western RHA has already established Core Medical Records for all patients in the region.
Two new Acts related to patient health information, the Patient Records Act and the Health Registry Act came into force on January 1, 2015. The purpose of the Patient Records Act is to ensure that health personnel have rapid access to all patient information. The Health Registry Act ensures an easier use of information for statistical purposes, analysis, research, quality improvement, governance and emergency preparedness (before, accessing such information used to be very bureaucratic). However, patients’ privacy will be protected: access will be tightly regulated and it will be possible to see who accessed the records and when.