1 Introduction

Mental health is one of the Government’s most important priority areas. The overarching goal of the escalation plan is for more people to enjoy good mental health and quality of life, and for those who need mental health services to receive good and easily accessible help.

In this plan, the Government identifies a pathway for developing our mental health policy. A stronger effort is needed to prevent mental health issues and disorders. The threshold for receiving help must be lower. At the same time, those with severe mental illness must receive more holistic treatment and follow-up, and we must pay greater attention to personnel resources moving forward. The distribution of tasks and organisation of services impacts the use of personnel. Services for the mentally ill should be good workplaces with opportunities for professional development, and patient and user involvement in the services must also be strengthened.

The escalation plan is a complete plan to improve mental health in Norway and develop the general services in the years ahead. The Government proposes to increase funding for mental health by MNOK 3 from 2023-2033. As part of its effort, the Government has for the 2023 budget year proposed MNOK 150 for measures linked to the mental health escalation plan, and the substance use prevention and treatment reform. MNOK 150 of the increased basic hospital funding was also earmarked for strengthening inpatient child, adolescent and adult mental health services.

The escalation plan means that the Government prioritises mental health and that its commitment to mental health will be increased through a ten-year plan. In the early stages of the plan period, the Government will prioritise cross-sectoral preventive efforts and accessible low-threshold municipal services in order to further prevent mental health issues developing into mental health disorders. The services offered by the specialist health service must be strengthened to give better help to those in greater need. The Government will return to the Storting in the annual budgets with updated assessments, priorities and proposals for concrete measures. This means that the Government’s escalation plan is a dynamic document steered by the overarching goals of the plan built on the most updated and available knowledge at any time.

The Government has chosen three priority areas for the escalation plan.

• Health promotion and preventive mental health work

• Good and accessible services where people live

• Services for people with long-term and complex needs

Under each priority area there are selected thematic areas with associated measures The three priority areas must be seen in context. For instance, improved and more accessible municipal services will in the longer term contribute to reducing the need for permanent help from the specialist health service. Some of the patients, who currently receive healthcare from the mental health services, would instead receive adapted, accessible, good and effective municipal healthcare.

1.1 Performance measures

The measures in the escalation plan aims to contribute to better mental health and quality of life in the population, and the existence of good and easily accessible help for people with mental health challenges. In order to follow the development and achievement of goals during the plan period, the Government has formulated eight performance measures. The performance measures cover the three priority areas in the plan.

• There has been a 25 per cent reduction in the number of self-reported mental health issues from children and adolescents.

• There has been a reduction in the percentage of young people who become disabled due to mental health issues and disorders.

• Citizens of all municipalities have access to evidence-based low-threshold mental health and substance use services.

• Children and adolescents who are referred to the child and adolescent mental health service

(PHBU) are offered a clinical interview to clarify further follow-up from the specialist health service or municipal health and care services.

• In the longer term, the average waiting time for mental health care will be reduced to less than 40 days for adult mental health service (PHV), 35 days for child and adolescent mental health service (PHBU) and 30 days for cross-disciplinary specialised treatment for substance use disorders (TSB).

• Prevent the reduction of beds and ensure that the inpatient capacity of the mental health service is at a level that satisfies the demand for taking care of children, adolescents and adults with severe mental health disorders who need inpatient treatment.

• The life expectancy of people with severe mental illness and/or addiction problems is higher, and the difference in life expectancy between this patient group and the rest of the population has been reduced.

• Healthcare personnel have more time for patients, users and professional development.

Existing data sources for observing developments shall primarily be used. Nonetheless, new indicators must be developed for some of the goals. Refer to Chapter 5 for a detailed description of how the goals will be followed up.

1.2 Prioritisation and execution

At the beginning of the plan period, cross-sectoral health promotion and preventive efforts will be central. The foundation for good mental health and quality of life is formed throughout life and in many arenas. The measures must therefore be developed and implemented in multiple sectors. The Government will further prioritise increased access to low-threshold services in the municipalities that do not require a referral or diagnosis. The performance measure of providing access to evidence-based low-threshold services will be operationalised through further investigative work. The Government will follow the development and implementation of such services, inter alia, to ensure that the development of low-threshold services does not accidently have a distorted effect on access to personnel, existing services or the flexibility of the municipalities for local adaptation of their services and what they offer.

The goal of directing the effort at health promotion and preventive measures, and local accessible services in the municipalities and specialist health service, is to help reduce the prevalence of mental health issues and disorders in the population. This will also contribute to resources not being used to treat issues and disorders that could have been prevented or remedied earlier. The Government will particularly pay attention to the health, education and labour sectors—and cooperation between them—with the aim of reducing the percentage of young people who become disabled due to mental health issues and disorders.

At the same time, the Government will work to ensure that those who need help from the specialist health service receive it and that the waiting time for mental healthcare is reduced. In addition, children and adolescents, who are referred to the mental health service, are offered a clinical interview. During the plan period, the Government also wants to follow up the findings of the regional health authorities’ (RHAs) prognoses regarding the need to strengthen the capacity for people with severe mental health disorders, and children and adolescents. In the early stages of the plan period, the Government wants to strengthen the effort for improved quality of life and life expectancy for those with severe mental illness and/or addiction problems. Another main priority of the Government is that the health and care services are attractive workplaces, and that patients and next of kin are involved in both the help that is given and development of the services, and that they receive good support and follow-up.

This plan identifies a pathway for creating more sustainable and future-orientated services for people with mental health challenges. Several of the proposed measures in the plan require further investigation and will take time to implement. The Government will return to these later in the plan period. Examples are measures for more thematic organisation within the mental health service and forensic psychiatry. Measures in the health and care services cannot exclusively be based on increased access to personnel, but also involve new work methods and changes in organisation. All measures shall be assessed according to the current personnel situation.

1.3 Background

The majority of people in Norway consider themselves to be in good health1 and the mean quality of life in Norway is high. Nonetheless, the quality of life is disproportionate and some groups have severe mental health challenges. A person’s perceived quality of life largely follows the traditional socioeconomic dividing lines. People with a stable job, secure income, good health and rewarding social relationships score higher on indicators for subjective quality of life.2 A society with minor inequalities, security and equal opportunities is an investment in good mental health for everyone.

At the same time, anyone can develop a mental issue and disorder for a shorter or longer period of their life. It is well documented that mental issues and disorders can lead to exclusion, which is an important risk factor for somatic symptom disorder. No illness group leads to more loss of health or increased disability benefit costs than mental disorders.3 Therefore, we must make a greater effort to enable more people to enjoy good mental health and quality of life, and those who need mental health services to receive good and easily accessible help.

To promote good health and quality of life in the population, systematic cooperation between the public authorities, civil society and the private sector is necessary. Sustainable structures and services that contribute to the prevention of mental issues, disorders and problems with substance use that ensure good services moving forward, must be established. The solutions must be evidence-based and adapted to the needs of users. Moreover, they must be sustainable. We cannot plan unrealistic exploitation of healthcare personnel. The Healthcare Personnel Commission believes there is great potential in intensifying the structured work with correct task distribution and good organisation of the work. This will contribute to maintaining the quality of the services, reduction of the use of resources, increased efficiency, attention to the core tasks, and increased motivation and wellbeing among employees. (refer also to Figure 1.2). Greater effort must be targeted towards prevention and health promotion across more sectors, as we simultaneously improve and strengthen the services in municipalities and the specialist health service.

Source: Official Norwegian Report NOU 2023: 4 Time to Act. The Personnel in a Sustainable Health and Care Service.

A health promotion effort is greatly needed to strengthen mental health and prevent mental issues and disorders in the population, particularly among children and adolescents, where there has been a substantial increase in the number of self-reported mental issues. Approximately half of all mental health issues make their debut during childhood and adolescence.4 It is therefore crucial to address these early and target the effort at arenas where one meets children and adolescents. Health promotion and preventive measures often assume long-term cross-sectoral efforts. It is essential to increase each person’s knowledge of how to best safeguard and strengthen one’s own mental health in order to strengthen public mental health.

Norway has well-developed health and care services. For many years the development of outpatient and ambulatory services within the mental health service and treatment for substance use has been high-priority, whilst at the same time a great effort has been made to expand municipal mental health and substance use services. Following the last Escalation Plan for Mental Health (1998–2008), the conversion to more open and outward-looking services has been continued in the form of strengthened ambulatory and outpatient services in District Psychiatric Centres (DPS) and Child and Adolescent Psychiatric Outpatient Clinics (BUP). There are now more man-years in municipal mental health and substance use work5, and the cooperation between municipalities and the specialist health service has been strengthened through new cooperation solutions.

In both Norway and other countries, it has become more common to organise programmes for people with mental illness and substance use problems in cross-disciplinary teams. Examples of this are ACT (Assertive Community Treatment) and FACT (Flexible Assertive Community Treatment) teams, rehabilitation teams, early intervention teams, substance use teams and habilitation teams. In order to act early in crises, ambulatory emergency teams (crisis teams) have been established at the District Psychiatric Centres (DPS) and user-controlled bed places have been introduced. The purpose is to contribute to early intervention and prevent unnecessary hospital admissions.

The Coordination Reform and Follow-up Plan for Work and Mental Health (2013–2016) set out key guidelines for the desired development and prioritisation in the services aimed at users with mental health problems. One objective of the Coordination Reform, beyond improved coordination and continuity in and between the services, was that the municipalities would provide more healthcare and treatment instead of the specialist health service. The reform also emphasised the need for increased commitment to prevention and early intervention.

The protection of human rights has been a fundamental driving force in the development of legislation and services for people with mental health issues and disorders. Most countries have endorsed binding supranational strategies under the auspices of the WHO and EU, which set out clear guidelines for the development of the countries within this field. This shall contribute to better rights, more resources for prevention, treatment and rehabilitation, and more transparency and knowledge.

More accessible treatment has contributed to many people receiving effective help when they need it. At the same time, surveys show that access to the services still varies, and that in some health regions the public receives more treatment for mental health issues and disorders than in others.

In recent years, there has also been an increase in the number of people requesting both mental healthcare from municipalities and the mental health services, particularly among children and adolescents. With corrections for the growth in population, there was a significant increase (around 15 per cent from 2019 to 2021) in the number of children and adolescents accepted by the specialist health service. The growth for adults was three per cent, but in the oldest age group (65 and older), there was a six-per-cent drop. More people are now referred with more severe conditions than earlier.6 In 2022, 38 per cent of the municipalities reported a large increase in the number of enquiries from children and adolescents, whilst 37 per cent reported a large increase in enquiries for adults with mental health problems.7 Figure 1.3 shows the trend in relation to the number of referrals to Children and Adolescent Psychiatric Outpatient Clinics from 2011 to 2022. The number of referrals has significantly increased since 2019.

Source: South-Eastern Norway Regional Health Authority, 2022.

services offered by the specialist health service must be strengthened in order to give better help to those who need it the most. It must also be a priority to develop accessible services in municipalities where there is a low threshold for seeking help, so that more people can receive help early at the lowest possible level of effective care. Further, the distribution of work must be clearer, and better coordination is needed between the municipalities and the specialist health service. Better coordination is also necessary between the healthcare sector and other sectors to ensure good holistic patient pathways, and to develop good and adapted housing services. Further development of cooperation with the municipalities and specialist health service is needed in connection with clinical interviews upon referral to a Child and Adolescent Psychiatric Clinic (BUP), and future integrated services at one level needs to be considered.

Significant recruitment problems and turnover of personnel have been reported, particularly specialists in the mental health service. Personnel problems will increase moving forward. The problems must be met with a holistic and structured approach to competence and human resources with the goal of offering good treatment, and contribute to obtaining a sufficient number of professionals with the correct competence. This type of structured approach involves, inter alia, proper and correct task distribution and efficient organisation, correct use of personnel-saving technology and treatment methods, a good working environment and better use of research-based knowledge.

The challenges faced by the services create the need for innovative thinking in relation to how we can develop the services and work together. Each municipality and hospital trust, and every health and social care employee must have sufficient freedom and trust to develop and adapt assistance and services in encounters with each single user and patient. Patients shall own their own treatment. Patients, users and next of kin shall have the opportunity to participate in research, innovation and development work to ensure that the solutions correspond to the needs of the population. Professional environments within mental health shall facilitate user involvement in the development of the services, however, there is still a continuing need for more systematic involvement of users and next of kin in both developing and executing the services. Furthermore, it must be ensured that next of kin are better cared for and supported.

It is important that health and social care personnel, users and next of kin exploit the possibilities the technology provides. Digital assistance and services that are easy to use, accessible and adapted to the digital competency in the population may lead to both better quality and accessibility.

The Government will create a strong public health service that is accessible to everyone. It is important that the public health service takes care of a population with varying degrees of healthcare expertise, language proficiency and digital skills to provide a well-adapted health service for everyone. Equitable health and care services shall be offered to the whole population and the services shall be adapted to the individual, so that access to and the quality of the services are equally as good, regardless of the user’s Norwegian language skills, functional ability, cultural affiliation, healthcare expertise and socioeconomic background. All social groups shall be taken care of in the ordinary services. This requires healthcare personnel to have the necessary competence in order to deal with the diverse population.

The plan is aimed at the population as a whole and people who are at risk of developing or have developed mental health problems or disorders, and their next of kin. It is considered that assistance and measures will be aimed at all users and patients, regardless of age, background, sex, gender identity, sexual orientation, functional ability and cultural affiliation.

1.4 Input for the plan

In the work on the escalation plan, the Government has facilitated a widespread input process. Several national input meetings have been held with children and youth organisations, professional organisations, user and next of kin organisations, and student organisations. Regional input meetings have also been held. The option to submit written input for the escalation plan has been possible. Relevant and comprehensive knowledge for work on the escalation plan has been gathered from the Norwegian Directorate of Health, the Norwegian Institute of Public Health, the regional health trusts and resource centres for mental health, substance use and violence.

Adapted options for children and adolescents to participate have been facilitated. A selected number of children and adolescents have been involved through a national input meeting between the Minister of Health and Care Services, the Prime Minister and invited children and youth organisations. In addition, the Ministry of Health and Care Services’ political leadership has held meetings with youth from local youth councils in connection with the regional input meetings. At the input meetings, children and youth were particularly concerned with accessible adults where young people are, for instance, at school, in terms of both milieu workers/therapists accessible in the environment, and an increased number of more accessible health nurses or other healthcare personnel. They describe a need for more knowledge about mental health. Children and youth are also concerned with accessible and safe and sound help when they need it, continuity in the help, sufficient information and the services having the competence to communicate with children. Many are concerned with the fact that mental and somatic health must be seen to a greater extent in relationship to each other. The need for good leisure activities, low-threshold meeting places, particularly youth clubs, were also highlighted by several of the contributors.

Input that is frequently echoed by other groups is accessible municipal low-threshold services and more options to get help without a referral. Several have pointed out the lack of coordination in the healthcare sector and transversely with other sectors. Many would like inpatient beds in the specialist health service to be prioritised. In addition, several highlight recruitment problems attached to the services, and the need to strengthen the GP service for more holistic and well-functioning health and care services.

1.5 Ongoing and future work

The Government has implemented various efforts that will impact the field of mental health during the plan period.

The most central work for this escalation plan is:

The Government’s Trust Reform aims to increase the autonomy of the State and local government’s first line to give them more professional freedom, so the public sector can provide more welfare and improved services to citizens at the right time.

Meld. St. 15 (2022–2023) Public Health Report (white paper) – National Strategy to Reduce Social Inequalities in Health, which was presented to the Storting in spring 2023. The white paper is structured on the premises that health promotion work and prevention must take place in all areas of society.

The National Health and Coordination Plan will as intended be presented to the Storting in autumn 2023. The white paper will cover both municipal health and care services, and the specialist health service. Coordination to create good patient pathways and equal services, digitalisation and healthcare personnel will be some key themes that are particularly relevant to the field of mental health.

The substance use prevention and treatment reform will be presented as a white paper in 2024 as intended. The purpose of the reform is to prevent and reduce negative consequences of substance use, addictive medicines and doping substances for individual people and society. Through the reform, the Government will better prevent substance use and addiction problems, and intervene earlier with adequate help and follow-up.

The white paper for the Storting on the ‘Safe at Home Reform’ will be presented to the Storting in 2023, and shall help the elderly to live longer in their own homes if they can and wish to do so. Solutions that enable as many people as possible to experience that they can cope, and allow them to live good and independent lives, will be critical to the mental health of the elderly.

The escalation plan against violence and abuse against children and violence in close relationships

will be presented to the Storting in autumn 2023 as intended. The plan will strengthen the commitment to prevent and combat violence and abuse, and to take care of those exposed to violence. Measures for preventing violence and helping those exposed to violence could help prevent mental health issues.

The Action Plan against Problem Gaming (2022–2025) shall ensure that work on the prevention of gaming problems in the Norwegian population is long-term, systematic and targeted. Many with gaming problems have concurrent mental and somatic health issues, in addition to serious financial problems.8 It is therefore necessary to draw attention to the health problems of people addicted to gambling and computer games with regard to prevention, early intervention, treatment and follow-up.

The Government’s Long-Term Plan for Research and Higher Education (2023–2030) was presented by the Ministry of Education and Research, but was jointly drafted by the ministries. Health is now one of the plan’s thematic priorities. The need for more research on prevention and effective treatment within mental health is discussed in the plan. With the long-term plan, the Government launched a targeted social mission to include children and adolescents in education, the labour market and civic life.

The Government’s Action Plan for Gender and Sexual Diversity (2023–2026) aims to contribute to improving queer people’s quality of life, safeguard their rights and contribute to greater acceptance of gender and sexual diversity.

Strengthening the GP service shall contribute to more doctors choosing to become general practitioners and support GPs in spending more time following up patients with serious complex needs. This is important for many patients with mental health challenges and addiction problems.

The National Quality of Life Strategy, anchored by the Government in the white paper on public health, shall contribute to more knowledge about the population’s quality of life, the development of measures that create a more health-promoting and fair society, and equitable social and geographical differences in the quality of life. The strategy will, as intended, be presented in 2024.

1.6 Sufficient access to healthcare professionals and competences

The most important resource for giving good and safe services to people with mental health challenges is the personnel. There is a shortage of personnel and this will continue to be the case moving forward. In order to safeguard personnel and ensure correct use of competence, various measures must be taken simultaneously. An important part of building up capacity must, inter alia, be done through improved task distribution and the use of available personnel. In the services for people with mental illness, there are significant health problems related to recruitment and loss of employees. Recruitment problems in the specialist health service particularly applies to specialists in psychology and psychiatrists. Municipalities report problems with recruiting psychologists, nurses, including health nurses, social educators and social workers.9 Many decide to work for private sector services and some leave altogether. The Government wants healthcare personnel to have enough time for patients, but also time to become engaged and involved in the professional development of the services. The following performance measure has therefore been set for the escalation plan: Healthcare personnel have more time for patients, users and professional development. This is also in line with the goals of the Trust Reform which, inter alia, entails less detail management and increased autonomy for employees. Measures to ensure sufficient personnel and competence will be further developed through the plan period and in the Government’s upcoming National Health and Collaboration Plan.

In order to safeguard the population’s needs, good services for people with mental health challenges throughout Norway are fundamental. The Government will take active steps to commit to a safe and good working life for all employees in the health and care services.

Through the Trust Reform, the Government will contribute to authorised employees being able to arrange services in dialogue with the user and next of kin. The Trust Reform shall form the basis for the development of services for people with mental health challenges to give a top-down approach. It is about supporting municipalities and health trusts with the right instruments and tools, whilst giving employees time and trust to give users and patients improved services.

The Government wants the services to work in a more health-promoting and preventive manner in general, particularly within the fields of mental health and substance use. Innovative thinking is necessary in relation to how we cooperate and solve tasks, so the correct competence is put in place at the right time and contributes to the best possible use of available personnel.

Figures from Statistics Norway’s demand forecast for healthcare personnel (HELSEMOD) indicates there will be a 33 per cent increase in the need for health and care personnel at national level, i.e., approx. 310,000 in 2017 to approx. 411,000 in 2035. The highest increase will be seen in home services and nursing homes.10 However, as the Healthcare Personnel Commission describes, the staffing trend cannot continue in line with demographic growth, since there will be a greater shortage of personnel moving forward. It is necessary to find new ways to solve tasks, including correct task distribution, changed work methods and personnel-saving technologies.

Textbox 1.4 Healthcare Personnel Commission’s Assessment of Needed Health and Care Services Personnel in the Future

In 2023, the Healthcare Personnel Commission presented its Time to Act Report. The Personnel in a Sustainable Health and Care Service (Official Norwegian Report, NOU 2023: 4).

The growth of the working age population will soon stop and the number of people in the 16-66 year age group will fall in a few years. At the same time, the number of people over the age of 80 will almost double over the next twenty years. This trend also depicts a greater demand for health and care services for the whole population. The Commission states that the need for personnel in the municipalities will increase, particularly in the care services, and that efforts must therefore be steered towards municipal care in the future to handle the increasing number of elderly people. The Commission concludes that there will be fewer employees per patient in the years ahead.

The Healthcare Personnel Commission believes that the main priority of health politicians should be the development of measures and investment in solutions that give the lowest possible personnel growth in the health and care services at the same time as the population across the whole country receives good high-quality health and care services.

In order to develop health and care services that can offer good services in the years ahead, the Healthcare Personnel Commission proposes measures within seven priority areas: task distribution; organisation and coordination; employment conditions and working hours; education and competence development; prioritisation and reduction of overtreatment; and digitalisation and technological development. The Commission considers that the measures may collectively contribute to a reduction in the supply and demand of health and care services. It may also result in better and more efficient use of personnel which at the same time leads to increased individual wellbeing and competence development. Particular emphasis is placed on enhancing the career opportunities for skilled workers in the health and care services that may lead to more applications for vocational education programmes across Norway.

The Healthcare Personnel Commission believes there is more potential in intensifying the structured work on correct task distribution and good organisation of the work. This will contribute to maintaining the quality of the services, reduction of the use of resources, increased efficiency and attention to the core tasks, and increased motivation and wellbeing among employees. With the shortage of healthcare personnel, it is important to be aware of what the personnel shall do and safeguard during the course of the working day. The requirement of responsible conduct shall always form the basis for correct task distribution. This also entails distributing tasks to other personnel when healthcare expertise is not necessary for performing the task.

The Healthcare Personnel Commission’s Report was sent for consultation on 2 May 2023 and will form a knowledge base for, inter alia, the National Health and Coordination Plan, which is planned to be presented at the end of 2023.

Source: Official Norwegian Report, NOU 2023: 4 Time to Act. The Personnel in a Sustainable Health and Care Service; Jia, Z. et al., 2023.

1.6.1 Education of healthcare professionals

The Government is concerned with quality and capacity in the education programmes aimed at health and care services in general and more particularly services for people with mental health challenges.

The programmes of professional study are important for ensuring that the services of the welfare state have adequate access to competent workers. The education programmes must have the right content so that students receive up-to-date and relevant knowledge. It is also important that the education programmes are inclusive, as this contributes to increased representation in the labour market. Competence that can deal with a diverse population is also important for reaching the goal of equitable services for people with mental health challenges. In spring 2024, the Government will present a report to the Storting regarding the programmes of professional study. The report will primarily focus on health and social care programmes, teacher education and engineering programmes.

The authorities and higher education institutions have a collective responsibility for dimensioning the education offered. Central authorities are responsible for the overall education capacity, inter alia, by awarding new places on study programmes. Universities and university colleges are responsible for dimensioning their study programme portfolios consistent with the number of applications for study programmes and needs of the labour market. The education institutions must educate candidates in harmony with the needs of society for competence.

Health and social sciences is highly prioritised when awarding new places on study programmes that have many applicants. Since 2015, the authorities have awarded grants to more than 1,500 new places on health and social care programmes with around half of the places being allocated to bachelor degrees in nursing.

In Meld. St. 14 (2022–2023) Report to the Storting (white paper) Overview of Competency Needs in Norway, the Government looks in more detail at which competency needs will be most important moving forward. In order to handle the demographic trend and increase in the number of elderly people, and to have good nationwide welfare services, more qualified health and care workers will be needed. In the white paper, the Government sets out an expectancy that universities and university colleges shall in their portfolios prioritise resources for the health sciences, IT and areas that are important for the green shift. From this perspective, it will be relevant to prioritise study programmes that may contribute to improving mental health.

National curriculum regulations for health and welfare education are developed through the National Curriculum Regulations for Norwegian Health and Welfare Education (RETHOS). The objective is that the education programmes are adapted to the needs of patients, users and the services. The aim of RETHOS is that the education programmes are future-orientated and that both the services and users have increased influence over the professional content of the programmes.

The clinical degree in psychology is included in RETHOS. The National Curriculum Regulations for Norwegian Health and Welfare Education were adopted for psychology training in 2020. Two new national curriculum regulations for continuing education within mental health and substance use have also been adopted. These are a master’s degree in nursing mental health nursing, substance use and dependence (2022), and cross-disciplinary continuing education in work on mental health, substance use and dependence (2022). Many vocational colleges offer education programmes within mental health for skilled workers.

Psychiatrists undergo in-service training in separate posts for specialty registrars (ST3) with an education pathway in accordance with a plan for each single doctor. The Norwegian Directorate of Health is responsible for setting learning objectives and recommendations for associated learning activities. The health trusts are responsible for enabling each specialty registrar to reach the learning objectives. Government authorisation as a specialist in psychiatry is awarded once the learning objectives have been satisfied. To improve recruitment to the specialties in psychiatry and child and adolescent psychiatry, 31 ST1 posts in autumn 2023 were linked to further specialisation in these specialties.

Specialist education for psychologists is currently taken care of by the Norwegian Psychological Association, and specialists in psychology are not awarded government authorisation as a specialist since the learning objectives are not set by the authorities. The Government will investigate a public specialist approval scheme for selected groups of clinical psychologists. Improved adapted education for specialists in psychology can lead to better recruitment and career development. The possibility to offer specialisation locally is particularly important for recruitment in the districts. The investigation of a scheme must be conducted in cooperation with relevant actors including the Norwegian Psychological Association and expert psychological environments. The Ministry considers that the investigation should be based on medical specialty training, but in an adapted and simpler form.

1.6.2 Retaining and recruiting healthcare professionals

In order to contribute to the development of more accessible and adapted services for people with mental health challenges, the Government will assist municipalities and health trusts in ensuring that there are enough personnel with the required competence. In addition to concrete recruitment measures, measures related to management, work and expert environments, and competence development may have a positive effect on recruitment and retaining personnel in the services. The regional health trusts have been commissioned to carry out further work on measures for recruiting, retaining and developing personnel in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). The regional health authorities will submit their recommendations for restructuring measures in September 2023, and the need for national measures will be concretised later in the plan period and the National Health and Collaboration Plan.

The all-round needs of users and their next of kin form the basis for the development of the services offered. Their needs will vary. It should therefore be encouraged to recruit beyond the traditional mental health education groups. Increased emphasis on health promotion measures means that greater professional breadth and cross-disciplinary cooperation is required. It may also require competence in mental health in other services, particularly the child welfare service.

Recruitment problems have been reported, particularly specialists in psychology and psychiatrists, in the specialist health service. There is a high turnover of psychologists. They leave public-sector services to work in private-sector services or walk away from the health service. The Office of the Auditor General of Norway found in its survey on mental health services that more than 60 per cent of outpatient mental health clinics had vacant posts due to recruitment problems and many did not have specialists.11 North Norway struggles the most. At the same time, a significant shortage of personnel in municipal health and care services is reported, and many municipalities have problems recruiting and retaining personnel.12 Increased difficulties with recruitment and retaining qualified persons may lead to diminishment of the professional community. When a service facilitates the professional development of each employee and safeguards a professional environment, it is also an attractive workplace.

The Employer Monitor of the Norwegian Association of Local and Regional Authorities for 2021 revealed that almost all municipalities are struggling to recruit nurses and that the majority are also struggling to recruit doctors, psychologists, social educators, skilled health workers and other relevant skilled groups. Approximately half of the municipalities in Norway are struggling to recruit physiotherapists, occupational therapists, social workers and child and youth workers. Many factors impact recruitment and the causes of the recruitment challenges are complex. Some important reasons are a lack of full-time posts and opportunity for professional development due to small expert environments. In terms of doctors, there are additional reasons, inter alia, increased workloads in general. The out-of-hours medical service in small municipalities is highly overworked.13 When it comes to the recruitment of psychologists in the municipalities, good expert environments, guidance and possibility for specialisation within the municipality were highlighted as important in the evaluation of grants to psychologists in municipalities.14

Violence and threats against employees are a problem in both the municipal health and social care sector15 and the specialist health service. The Norwegian Directorate of Health’s mapping from 2017 shows that there was an increase in the number of reported cases of violence and threats in the health trusts in the period from 2012-2016.16 There is much to indicate that the increase has continued after 2016.17 Threats of violence is a factor that must also be taken into consideration when recruiting to some professional areas such as acute and forensic psychiatry. Another challenge is racism, discrimination and harassment in the workplace. Research has shown that many health and care workers with an immigrant background experience racism, discrimination and harassment when carrying out their work. The Government will present a new action plan against racism and discrimination.

In the Office of the Auditor General of Norway’s survey on mental health services it emerges that 70 per cent of practitioners within mental health do not have enough time for professional development and that every fourth practitioner has difficulty getting updated knowledge on the effect of treatment methods. With a view to implementing effective treatment, and to recruit and retain personnel, it is important to safeguard professional development and competence enhancement as part of day-to-day operations. Systems that guarantee professionals access to research, knowledge and new treatment methods will be important moving forward.

Many professionals report time pressure and little capacity for core tasks. Among other things, it is pointed out that reporting requirements hinder the performing of core tasks. One of the goals is to reduce and streamline reporting in mental health care. This is also in line with the Trust Reform which, inter alia, aims to reduce detail management and give the workers in the services more autonomy.18 In 2023, the regional health authorities have been commissioned to review reporting requirements in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). At the same time, the Norwegian Directorate of Health is working on the further development and simplification of national patient pathways, and will look at the reporting requirements that are not currently used for national quality indicators, which therefore may potentially be removed. The Norwegian Directorate of Health will also observe which changes and measures the regional health authorities will recommend during their assignment, and which time to event data the new national quality registers for both adult mental health, and child and adolescent mental health, plan to use. The revised patient pathways will be sent for consultation in autumn 2023 and will be ready for implementation in the services in 2024.

Most healthcare personnel groups have competence within mental health. For instance, general practitioners, nurses and skilled health workers also take care of this aspect of patients’ health as part of their work in all health and care services. Skilled health workers and assistant occupational therapists with special training within mental health are important to the work on building fundamental services in the municipalities. The professional education programmes are offered nationwide as continuing education, and there is a large and unrealised potential for better usage and development of the competence of skilled workers throughout their working life. In order to ensure better use of available personnel, the Healthcare Personnel Commission proposes to establish a principle where staffing of the services starts from the bottom (see Figure 1.4), so the competence and capacity of the personnel is exploited as best as possible. A concrete example is to expand the use of skilled health workers in both the municipalities and specialist health service.

Nurses represent the largest personnel group in the mental health service. A new master’s degree programme has been created for specialist nurses within mental health and substance use.19 Other large personnel groups working in mental health care are social educators and social workers. It is reported that the highest shortage of personnel and most difficult groups to recruit are doctors/psychiatrists and psychologists/specialists in psychology.

A structured approach to correct task distribution between the personnel groups will be important in order to better use personnel resources and free up time for more patient contact. Task distribution between personnel groups, and in cooperation between teams internally and across specialist and municipal health and care services, may also contribute to a lighter workload and simultaneous building of a professional community. Other professional groups such as social workers play a vital role in taking care of, inter alia, psychosocial problems in the health and social care services and schools.

Gender balance among personnel

From 2016 to 2020, there has been a steady increase in the employment of men in municipal health and care services. At the same time, men still only accounted for 15.2 per cent of all employees in municipal health and care services in 2020.20 Few men in the services is challenging for many reasons. For instance, it is challenging when users and patients want to deal with a male employee. Few men in the services will also have an impact on the employees’ working environment.

The Government wants to increase the percentage of men working in health and care services. For instance, very few men study to be health nurses. This is challenging for those who may want to deal with a male health nurse at health centres or in the school health service. The Government will consider measures for improving gender balance in health nurse education, including the assessment of gender points or quotas. Additionally, refer to Chapter 3.2.2 on the health centre and school health service.