5.4 Specialized ambulatory care / inpatient care
Inpatient specialized care is mainly provided by the hospital trusts owned by the RHAs. It is also provided by a few privately owned non-commercial and commercial hospitals under contracts with the RHAs. Hospitals also provide outpatient specialist care in their outpatient departments (called polyclinics). There are outpatient departments for somatic care, mental health care, and alcohol and substance abuse treatment. These departments also provide laboratory and radiology services. Outpatient specialist care is also provided by self-employed privately practising specialists (e.g. obstetricians, specialists in internal medicine, etc.), mostly working in their own practices under a contractual agreement with one of the RHAs.
Medical services of the highest complexity are provided in university hospitals. In addition, there are about 30 different highly specialized services defined as “national services”, such as heart transplantation and care for patients with haemophilia, each of these being normally provided in only one university hospital. Each region has at least one university hospital located in a large city with a university. There are also 45 national highly specialized competence centres, mostly located in university hospitals, which mainly conduct activities related to professional development, competence evaluation and counselling, but sometimes also manage the process of patient treatment in the area of their competence.
The specialist care sector also has a guiding role towards municipal health services (at no cost to the municipalities). For example, GPs may elicit advice from the specialists regarding patients’ health and follow-up. In some areas, especially geriatric care and cancer treatment, specialist mobile teams, comprising various specialists, have been established by the hospitals. They provide guidance and care to patients at home or in other settings within the community.
Specialist care is concentrated in urban, i.e. more densely populated areas, and people living in rural areas have to travel longer distances to access specialists or hospitals (Ringard, 2010; Mundal, 2011). The relatively low number of acute hospital beds per 100 000 inhabitants, compared to other countries in Europe, high occupancy rates and long waiting times (see section 4.1.2) all point towards problems with accessibility of elective hospital care in Norway. Payment for hospital care is not linked to the quality of services and there are still relatively few quality indicators measured at national level. For some services, such as secondary prevention of cardiovascular diseases and smoking cessation initiatives, hospitals are paid extra as an incentive to provide such services (Lindahl, 2012).
5.4.1 Day care
A deliberate substitution policy has been pursued since the late 1980s with the aim of replacing relatively expensive inpatient care with less costly outpatient and day care, and bringing care closer to patients’ homes. Different treatments are now provided as day care, including somatic care (e.g. surgery), psychiatric care (e.g. treatment of eating disorders) and treatment of drug and alcohol addiction (Directorate of Health, 2012d), and the shift towards substitution is reflected in shorter hospital stays and a decline in the number of acute hospital beds (see section 4.1.2). The ratio of outpatient (i.e. day-care and outpatient contacts) to inpatient contacts has also increased, from 4:1 in 1990 to 6:1 in 2011 (Directorate of Health, 2012d).
A recent example of the substitution policy can be found in the area of dialysis treatment. In some municipalities the provision of dialysis treatment is now being carried out on an outpatient basis, although this is done in close cooperation with the local hospital (for instance in nursing homes).
The new Health and Hospital Plan was passed in Parliament in March 2016. The Plan emphasises decentralization of hospital care. The exception will be acute care services which are to be centralized.
Hospitals will be organised in networks, with regional hospitals, acute care hospitals (providing specialised emergency care for 60000-80000 or more inhabitants) and elective care hospitals. A model where smaller hospitals would offer acute services for internal medicine, but not for acute surgery, was proposed. However, decision on whether to develop and adopt it was left with the individual Regional Health Authorities (RHAs). The RHAs can consider distance between hospitals and availability of effective ambulance services when they take their decisions.
The plan calls for strengthening of quality through guidelines and quality requirements for the hospitals and national and regional services, led by the Directorate for Health. A national system of accreditation for hospitals and services was proposed, as well as a network for clinical audits.
The 2012 co-ordination reform made municipalities responsible for co-financing of somatic non-surgical specialist health care services provided in hospitals and for patients ready for discharge. However, the government elected in 2013 abandoned this scheme in January 2015 (see reform log titled ‘End of municipal co-financing of hospital care’ from 6 June 2014). A few months later, in November 2015, the same government decided to make municipalities responsible for providing local (i.e. in the municipalities and not in the hospitals) emergency care beds (ECBs) for patients with a need for pre- or post- hospital services. This was included in the Municipal Health and Care Act from 2011 (§ 3-5), which is one of the key components of the co-ordination reform, but was not sanctioned until November 2015. From 1 January 2016, the municipalities have been obligated to provide ECBs on a 24/7 basis for up to 72 hours per patient within a single episode of care. This limit was included in separate guidelines and was meant to ensure that ECBs are not used for patient with needs for long term care.