Although many British observers look to Scandinavia as the paragon of advanced welfare states, we in Norway actually owe a huge debt to the NHS. It was while our government was in exile in Britain during the second world war that it was inspired to create a universal health system free at the point of use, as outlined in the 1942 Beveridge report, which paved the way for the NHS.
Today, most Norwegians are very proud of our health service. We spend roughly 9% of GDP on health, which is about average for OECD countries. But in a country of 5.2m people, this translates to more than $6,000 per capita – almost double the spend-per-person in the UK.
Our system has undergone immense change in recent years. Until the 1970s, Norway operated a highly decentralised health system funded by local authorities. An act of parliament in 1970 made the state the main funder, and since then a growing proportion of the government’s budget, swelled by oil revenues, has gone into health. In 2002, the government took over ownership of all hospitals in the country.
How is this relevant to the NHS? Well, against a backdrop of similar systems in both countries, the past few years have seen a concerted attempt to centralise health services in Norway.
In essence, this has meant concentrating certain types of surgery in fewer, higher-volume hospitals to improve patient outcomes. On the ground, this has meant the downgrading and closure of smaller hospitals and longer journeys for some patients. In a country like ours, with a population density that is 17 times lower than the UK, this is significant; one extreme example saw elderly patients having to make a 260km round trip for orthopaedic treatment.
There have been public protests in many places, not to mention a political storm. The Norwegian minister of health and care services, Bent Høie, was even accused of being “eager with the scalpel” by a national newspaper for his apparent enthusiasm for cutting services from smaller hospitals.
Høie has pointed out, however, that Norway would need an extra 44,000 health professionals over the next 25 years to keep pace with rising demand from an ageing population, without the reconfiguration of services.
As professionals working in the Norwegian health service, we firmly support the rationale for centralisation of more advanced services. Put simply, it’s in the best interests of patients.
It just isn’t possible to provide consistently high-quality procedures in rural centres with low volumes. In part, this is due to the greater specialisation in surgical training – the days of generalist surgeons operating on everything from hernias to knees are gone. We’ve also found that hospital recruitment in very small rural areas can be a major challenge.
The scientific evidence base indicating a correlation between higher volumes and lower mortality is complex and varies across procedures and conditions. However, most medical professionals would accept the principle that the more you do something, the better you get at it.
One study by researchers at Haukeland University hospital in Bergen found that 30-day death rates from kidney cancer were significantly lower in centres that treated more than 40 cases per year.
We work for the South-Eastern Norway regional health authority (Helse Sør-Øst), which serves around half of the population of Norway. In 2008, plans were drawn up for the creation of seven hospital catchment areas, each serving between 300,000-500,000 people. These were to be established through merging smaller local hospitals. The long-term plan for each area is to replace the smaller, older hospitals with one big hospital. So far, three new hospitals have been opened in two catchment areas and two smaller local hospitals have closed.
One service that has been centralised is coronary angioplasty. All ambulances in our region are fitted with ECG equipment, allowing staff to take a scan which is sent to a cardiologist. If the coronary artery is completely blocked by a blood clot, patients are sent – by helicopter if necessary – to a centre that offers the surgery. The system is working well – we’ve been able to concentrate angioplasty in just four centres serving 2.8 million people.
Through our participation in Dr Foster’s Global Comparators international health benchmarking network, we have access to around 40m data records from hospitals around the world. We can see that our outcomes are among the very best globally.
Other international data such as the OECD’s Health at a Glance report also supports this. In 2013, the latest available year, Norway’s mortality rate 30 days after suffering a heart attack was just 7.6 deaths per 100 adults aged 45+, compared to the UK’s figure of 9.1.
The NHS England chief executive, Simon Stevens, has stated his opposition to what has been termed mass centralisation, while “viable smaller hospitals” are named as a new care model in the Five Year Forward View. How do you go about judging whether a small hospital is viable?.
With the enormous changes planned for the NHS over the coming few years, centralisation is a subject that won’t go away. Our experience in Norway shows that if you follow the data and the evidence, you can make decisions that use resources more effectively and deliver excellent outcomes for patients.
Dr Ole Tjomsland is director of quality at the South-Eastern Norway Regional Health Authority (Helse Sør-Øst). Stein Bruland is chief medical officer at Østfold hospital trust. They are participants in Global Comparators, a not-for-profit network established by the healthcare data analysis company Dr Foster. The programme brings together 40 hospitals in 12 countries to benchmark performance and work on shared projects.
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