The Chronicle: Stig SlørdahlManaging Director of Helse Midt-Norge RHF

IT IS It’s hard to disagree with the president of the Norwegian Medical Association, Marit Hermansen, who recently wrote that we have one of the best health services in the world. Certainly, she was concerned about “dark clouds on the horizon” linked to growing social inequality in health and the emergence of a bifurcation of health services.

In July, a report from the American foundation The Commonwealth Fund compared the health services of 11 rich countries – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States -United. Unsurprisingly, the United States scored the worst, even though no other country spends as much money on health care. Norway shares fourth place with New Zealand, beaten by Great Britain, Australia and the Netherlands.

DIFFERENT SYSTEMS. For many, it may come as a surprise that Britain, with its National Health Service (NHS), comes out on top in comparisons. They achieve the highest scores in all areas except for the results obtained by the health service. Here, Norway is in third place. Nine areas were assessed so that something could be said about the quality of health services in outcome areas such as infant mortality, life expectancy for those reaching age 60, 30-day mortality for those who were hospitalized for heart attacks and strokes, and five-year relative survival for breast cancer and colon cancer.

Interestingly, the top three countries have completely different health systems. Certainly, they benefit from universal health coverage, which means that the entire population has access to health services. In Britain, health services are funded by tax revenue and central authorities play an important role in how health services are organized and managed. Most hospitals are public and employ public employees, while primary care practices are mostly privately owned.

INSURANCE. In Australia, everyone is covered by insurance and financed like the NHS by tax revenues, but the public sector plays a lesser role in managing health services. Most hospitals are private, and about half the population has private insurance to access health services outside the public system.

In the Netherlands, citizens are required to take out private health insurance. Insurance companies are obliged to provide health insurance to everyone who requests it and this must contain a mandatory part similar to the services we offer in our system. The financing consists of two parts, an income-dependent part which is paid into a common fund and a part which is paid directly to the insurance company. A transfer is then made between the joint fund and the individual insurer according to the risk profile of the insurance applicants.

THE ORGANIZATION. Norway comes in second to last place in the area of ​​“process of care”, which must be relevant to the health service as a whole – prevention, patient safety, coordination, patient involvement and patient preferences. These findings perhaps reflect some of the challenges we face with the division of health services between specialist health services, municipal health services and general practitioners.

I wrote in a previous article that Norway would never have organized its health service the way we did if we had to start again today. We would then start from what would have been appropriate for patients and the population as a whole.

Patients think they are dealing with one health service – and we must organize ourselves so that they experience it as one health service. A good start could be to compensate for fragmentation with new funding arrangements and common casework solutions such as the planned health platform in central Norway. In a single health service we must, in the right way, look after the competence, perspective and authority of the primary health care service – including GPs.

ELEVATOR FOR THE WHOLE. We have had the incredible privilege in Norway to have professionally competent and committed general practitioners. In this sense, the signals currently arriving regarding lower recruitment for general practitioner positions are worrying. There are probably several different reasons for this. In Denmark, it is also difficult to encourage young doctors to invest and establish themselves in municipalities, while various private companies set up medical practices following municipal tenders and reportedly have fewer problems recruiting young people. doctors with a fixed salary. Perhaps now is the time to consider more public services and fixed wages.

Going forward, it will be important to prioritize those parts of the health service that need strengthening to keep the whole safe. In recent years we have experienced significant and necessary growth in the specialist health service without, for example, a corresponding strengthening of the working years of doctors in the municipalities. Furthermore, specialist health services should probably support even more strongly what is happening in primary health care services.

TAKE A LESSON! We agree that we have – and will continue to have – a strong and high-quality public health service in Norway. However, we should be able to learn from what is happening in other countries in order to continue to improve. We must of course fight against social inequalities and against the double division of the health service, but we must also place health in a broader perspective.

We will not succeed if social inequalities increase across the board and if policies work against the promotion of good public health. Good public health is much more than a good health service.

Chronicle and debate, Dagens Medisin 14/2017