3 Access to good quality care close to where people live

People with mental health challenges need good and easily accessible help. At the same time, a number of surveys show great variation in the services across Norway. Through the escalation plan, the Government wants to contribute to strengthening the quality and improving the accessibility of services for people with mental health issues and disorders. This entails the facilitation of more low-threshold services in the municipalities, strengthening the services in the mental health service, reducing waiting times, and offering children and adolescents clinical interviews within the mental health service for children and adolescents to clarify the need for further treatment. It also entails working systematically on quality improvement. Good cooperation with users and next of kin is an important prerequisite for developing good services. Further, the facilitation of new ways of working, more effective organisation, correct task distribution and good use of available resources (refer to Chapter 1.6 for a detailed discussion on personnel).

3.1 Basis for the priority area

The public shall have equal access to health and care services. In Norway, the services for people with mental health issues and disorders are well-developed. Nonetheless, many people do not receive the help they need.

Several reports show that access to services in municipalities for people with mental health issues and disorders vary, and that the public receives more treatment in some health regions for such conditions than in others. The Office of the Auditor General of Norway also points out that patients who live in areas with a high number of rejections and long waiting times or in municipalities that have not established, for instance, outreach and emergency services, do not have the same access to health services as others.1 The Health and Social Services Ombudsman reports on a shortage of inpatient beds and insufficient capacity at outpatient clinics, long waiting times and the perception that one has to be more seriously ill to get help from the specialist health service than before.2

There is a need to strengthen services for children and adolescents with mental health challenges both in municipalities and the specialist health service. Many found it difficult during the COVID-19 pandemic3, and more than 20 per cent more children and adolescents received healthcare from the mental health service in 2021 than in 2020. Increased waiting times and projections show that the demand is higher than the capacity. Those who are referred also have more severe conditions than before. There has been an increase in the number of young people being admitted to hospital for eating disorders4, and many are not detected and do not receive help early enough. There has also been an increase in consultations in primary health care related to mental health issues in children and adolescents. The number of beds in the mental health service has been reduced the last 20-30 years at the same time as ambulatory and decentralised services have expanded.

Projections show that continued strengthening of municipal health and care services is an important prerequisite for improving capacity in all the services. Many with mental health issues and disorders are in contact with a GP, which is an important low-threshold service in municipalities. The health centre and school health service takes on this role for children and adolescents, pregnant women and families in the postnatal phase. In addition, there are separate low-threshold mental health services. According to the Office of the Auditor General of Norway, 75 per cent of the municipalities have a separate low-threshold mental health service for treating children and adolescents, whilst other municipalities state that other municipal services such as health centres and the school health service, the Educational Psychological Counselling Service (PPT) and/or the child welfare service treat children and adolescents. Approximately one of ten municipalities do not offer low-threshold services or other services for children and adolescents with mental health issues and disorders other than the GP service. During the COVID-19 pandemic, several municipalities established various low-threshold services and group services to deal with the increased demand.5 Geographic variation in municipal services and lack of services in municipalities for those who do not receive help from the specialist health service is confirmed in the Health and Social Services Ombudsman’s Annual Report for 2022. The annual report also points out that patients report insufficient follow-up from GPs combined with poorly developed services in municipalities.

Mental illness is one of the diagnoses that most often leads to sick leave and people receiving disability benefit.6 People with these types of ailments are therefore an important target group for the Norwegian Labour and Welfare Administration. Measures to promote participation in employment along with concurrent medical follow-up are important to prevent permanent disability and reduce the need for health-related benefits. Further, the facilitation of activities and meeting places for people with mental illness and addiction problems is needed.

There is a need for more extensive use of knowledge about the treatment of mental health issues and disorders, and systematic work on quality improvement and patient and user safety. User involvement and next of kin involvement in the services both in municipalities and the specialist health service must be ensured. According to the Health and Social Services Ombudsman, the rights of next of kin are not adequately safeguarded.7 Next of kin, who frequently perform demanding care tasks over time, must receive better support.

3.2 Good accessibility and capacity

Many who struggle with mental health problems or problems with substance use will experience improvement if they use their own resources or receive help from people in their own network. At the same time, everyone must be confident that help is available when the need arises. Several of the ordinary services such as health centres, the school health service and GPs take care of people with mental health challenges. Concurrently, many municipalities report an increased demand for more services within the mental health and substance use fields. These are services that can function parallel to, as part of, or in cooperation with other ordinary services. The Government will work to improve the accessibility and capacity of the offered services for people with mental health challenges, and to ensure that the threshold for receiving help is low. One goal is for the citizens of all municipalities to have access to evidence-based, low-threshold mental health and substance use services. At the same time, the Government will contribute to providing enough capacity and adequate help to those who need more comprehensive treatment both in the municipal health and care services and the specialist health service. One goal is to reduce the average waiting time in the mental health service both for children and adolescents, adults and specialised cross-disciplinary substance use treatment. An important part of building up capacity must, inter alia, be done through changed prioritisation, more effective organisation, improved task distribution and the use of available personnel. Fewer reports and the further development of digital services and new solutions that will increase accessibility will also be important.

3.2.1 Mental healthcare provided at the municipal level

The Health Care Act orders municipalities to provide necessary health and care services for everyone staying in the municipality. The responsibility of the municipalities covers all patient and user groups, including people with mental health challenges and addiction problems. In order to fulfil this responsibility, the municipality must, among other things, offer health-promotion and preventive services, investigations, diagnostics and treatment, and social, psychosocial and medical habilitation and rehabilitation. An assessment of each single patient or user’s needs is the deciding factor in terms of which services the municipalities have a duty to offer the individual. It is important that the municipalities organise their services in a manner so they reach everyone who needs them and safeguards each person’s rights. In the municipalities, health and care services are given to people with mental illness and addiction problems from general health and care services as well as more targeted services in the form of various services attached to mental health and addiction

The Government will contribute to supporting the municipalities to enable them to provide good services for people with mental health challenges in line with local needs and the problems their citizens have.

Some municipalities co-localise services, for instance, in ‘Familiens hus’ (Family House), where various services aimed at children and families are gathered together. Some services are given in cooperation with the specialist health service. In recent years, more people have received better help through new services in across municipalities. The services cover a wide spectrum from low-threshold services, which anyone can contact, to services for people with more complex and long-term needs. Some services, such as health services at home and practical assistance, are allocated through administrative decisions pursuant to the Health Care Act.

Reported figures from the municipalities indicate that the number of people working in municipal services for mental health and substance use has increased in recent years.8 At the same time, the Healthcare Personnel Commission’s report shows that the same increase cannot be used as a basis moving forward. The Government therefore wants to see how the resources within the mental health and substance use fields can be used more efficiently, for instance, in the form of new working methods, correct task distribution, appropriate use of technology and other ways to organise the services. The Government will commit to wide-reaching low-threshold services and methods of helping. Reference is made to Chapter 1.6 for a discussion on personnel and competence.

3.2.2 Evidence-based low-threshold programs within mental health and substance use

The threshold for seeking help when suffering from mental health problems should be low. Many, particularly children and adolescents, seek easily accessible help that does not require a referral without a long waiting time. Low-threshold services may contribute to preventing various problems attached to coping with life, life crises, and mild and moderate issues and disorders developing into more severe conditions. Such services may, for instance, include support conversations, help in finding one’s way around the support services, stress-coping courses, work on sleep problems or short-term treatment of mild forms of anxiety and depression. One of the Government’s goals is that the citizens of all municipalities have access to evidence-based low-threshold mental health and substance use services

‘Low-threshold services’ are not defined in health legislation, but is one way to set up services and it expresses the characteristics of the service’s availability. This often means that it is not necessary to have a referral to contact the services or participate in the activities that are offered. In general, help is promptly available. Low-threshold services may include prevention, early intervention, treatment and harm reduction. They can be set up for different user groups and include a wide range of support services such as advice, conversations and counselling, employment and activity services, investigation and treatment or be a meeting place for social community. For substance use, there are also various low-threshold services offering other types of health services, for instance, cleaning and dressing wounds, infection monitoring, issuance of user equipment, etc. The services can be both stationary and ambulatory.

Through different types of low-threshold services, more people can get help early. Prompt access to help and treatment could be of great importance to some people’s quality of life and coping skills. It might also contribute to reducing the influx of people wanting to access the services in the specialist health service.

By using coping skills courses, psychoeducation interventions and group therapy, it will be possible to help more people without increasing employee workloads. This better exploits the shortage of personnel resources. Digital services and services have the potential to reach an extensive number of people. The development and increased use of these will improve the capacity of the services (refer to Chapter 3.2.4.). Such services may include self-help and coping tools, and digital treatment such as guided online treatment and digital consultations.

Many municipalities have established good low-threshold services for their citizens based on local resources and needs. Prompt Mental Health Care (refer to the discussion below) and Ung Arena (refer to Box 3.2) are examples of services that have been established in several places.

The municipality’s self-reporting and diverse input for the escalation plan shows, however, that access to the low-threshold services varies across Norway, and that there is a high demand for easily accessible support services for people with mental health challenges. It has also been pointed out that it is necessary to clarify what a low-threshold mental health service is and to highlight what municipalities are responsible for in relation to follow-up and the treatment of mental health issues.9 During the plan period, the Government will therefore investigate the advantages and disadvantages of various alternatives in order to contribute to equal municipal low-threshold services within mental health and substance use for all age groups. evidence-based means that the service is based on knowledge from research, the experiences of professionals and the users themselves. Knowledge-based also means that municipal autonomy is taken into consideration in that the municipalities can have more flexibility and take into account their experiences and local frameworks and prerequisites.

Good and accessible low-threshold services in municipalities provide many benefits. They can detect and help people with mental health issues, mental health disorders and addiction problems at an early stage, and prevent worsening of mental health and addiction problems and admissions to the special health service. In addition, the help will be moved nearer to where people live their lives. Low-threshold services will be able to use a wider range of professions in municipalities. Health and social care personnel, people with experiential competence and employees of other sectors, for instance, the child welfare service, the Norwegian Labour and Welfare Administration (NAV), and culture and recreation may be relevant to or in connection with such programmes. It is also important to facilitate formalised cross-sectoral cooperation. The Healthcare Commission points out that in the face of a shortage of some occupational groups, particularly the more specialised groups, it will be important to set up services so that more occupational groups can contribute. For instance, by offering group and online-based services, where there is a knowledge base for such services, it will also be possible to exploit available personnel resources more efficiently.

During the investigation, the advantages and disadvantages of various alternatives that may contribute to equal services across the whole of Norway must be addressed. Many with addiction problems have mental health issues, for instance, in the form of anxiety and depression, and it will not be sustainable or professionally moral to establish separate low-threshold services in the municipalities for this group. Any other problems that can be included in the services must be part of the investigation. The investigation shall also in line with the recommendations of the Healthcare Commission assess the consequences of using personnel in health and care services overall. In addition, the consequences for the entire personnel situation in municipalities should be assessed. Low-threshold services should, where possible, build on existing services and structures, and should not lead to further fragmentation for personnel or users. Tight cooperation between users and professionals is also significant, so that the needs of users are included in defining the content of the help.

Enactment is one of the alternatives that will be investigated. Elucidation in health legislation may clarify the frameworks for the service for both the municipalities and citizens. It will also improve cooperation between the mental health service in that it will be clearer for the specialist health service with regard to what they can expect from the municipalities. At the same time, section 2-2 of the Local Government Act states that self-government should not be limited more than what is necessary. Many municipalities have difficulty getting enough personnel to solve the tasks that they have and a new obligation could exacerbate the problem. A potential obligation to provide low-threshold services may tie up resources that could alternatively be used for other measures to increase the quality in the same field. The advantages and disadvantages of enactment must be weighed up against each other during the investigation. The Government wants to investigate enactment of low-threshold services in municipalities early in the plan period.

The Government will ensure that the municipalities have financial autonomy to prioritise low-threshold services, and give them good and adapted professional support and guidance. The Government will assess how evidence-based practices can be spread and adopted by municipal low-threshold services, for instance, through service support, guidance, etc. For a more detailed discussion on research and evidence-based services refer to Chapters 3.8.4 and 3.8.5, and to Chapter 3.8.5 for development of the resource centres.

Prompt Mental Health Care

Prompt Mental Health Care (PMHC) is a municipal service offering short-term treatment without a referral for people over the age of 16 with mild to moderate anxiety, depression, emerging addiction problems and/or sleep problems. Follow-up is given by a cross-disciplinary team. The service is based on cognitive therapy and is given in the form of guided self-help, courses, individual conversations and group therapy. PMHC is an evidence-based method organised according to a mixed care model where the person seeking help, along with a therapist, agree on which service they will start with based on the principle of right treatment at the right level at both the beginning and during the course of treatment.

Prompt Mental Health Care was established in Norway as a pilot experiment in 2012 following inspiration from England where a national commitment was made to make evidence-based treatment of anxiety and depression better available. The Norwegian Institute of Public Health evaluated the pilot experiment, which showed that PMHC works in accordance with the goal of being a low-threshold service that increases access to evidence-based treatment. The evaluation, and a later randomised control study, showed a strong reduction in symptoms of anxiety and depression after treatment.10

Today, there are more than 70 PMHC teams spread across the whole of Norway.

The benefits and effects of PMHC are linked to more people gaining access to effective treatment with reduced symptoms of anxiety and depression, and the socioeconomic benefit of more people getting help at the lowest effective level of care. During the plan period, the Government will investigate the possibility of extending the target group who receives help from PMHC.

The Norwegian Labour and Welfare Administration and the Norwegian Directorate of Health are working on developing models for coordinated services aimed at people with mild to moderate mental illness and/or addiction problems with emphasis on cooperation with municipal health and care services. Among other things, this involves cooperation between the Norwegian Labour and Welfare Administration and Prompt Mental Health Care. For a more detailed discussion, refer to Chapter 3.5 on work and activities as part of treatment.

Health centres and the school health service

Health centres and the school health service are the most important preventive and health-promoting services aimed at children, adolescents and their families, in addition to pregnant women and families in the postnatal phase. These services carry out planned health checks on children and pregnant women, and are low-threshold services in municipalities. The services are extremely popular with the public and reach almost everyone in their target group.

Health centres and the school health service are important for the municipalities’ work on giving everyone a good start in life. The services shall contribute to disease prevention and promotion of good physical and mental health in children, adolescents and their parents, the levelling up of health inequalities, and prevent, detect and avert violence, abuse and neglect. Good follow-up after childbirth can help prevent postnatal depression and contribute to uncovering the need for help at an early stage. The services shall also promote health literacy in children, adolescents and parents to enable them to make good choices later in life, and also promote self-coping skills when faced with life’s challenges.

The main challenges for health centres and the school health service are primarily accessibility and capacity. For children and adolescents, this means that the services should be accessible through adapted opening hours and digital platforms, and the capacity should be good enough to enable them to get an appointment at short notice or with no waiting time. Among other things, this requires health nurses to be more present at schools. Through the digital health centre ‘DigiHelsestasjon’ (refer to Box 3.5), which is part of DigiUng, solutions are being developed for digital accessibility at health centres and in the school health service. Digihelsestasjon enables digital dialogue with a health nurse.

The earmarked grant for health centres and the school health service was expanded in 2023. From 2024, the grant will no longer be limited to specific professions, but municipalities will be able to apply for support to cover the cost of full-time posts in the professions the municipalities consider they need.

Additional competence, professional development and research is needed on the work of health centres and the school health service. The Government has therefore allocated funds for the establishment of a national cross-disciplinary advisory unit for health centres and the school health services. The advisory unit is rooted in the Norwegian Institute of Public Health and is located in Levanger.

Health nurse and midwifery education programmes are included in the National Curriculum Regulations for Norwegian Health and Welfare Education (RETHOS). This ensures that the education programmes are up to date and in line with the needs of patients, users and the services.

There are some challenges in relation to recruitment, particularly health nurses. This impacts the capacity of the services. Innovative thinking is therefore necessary when it comes to problem solving, and efficient and appropriate work methods. An additional challenge in public health nursing in that there is a shortage of men. This may prevent boys from approaching health centres and 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.

Good and accessible health centres and school health service can promote health literacy and level up social inequalities. Furthermore, they will uncover and follow-up mental health issues and disorders, and prevent the development of mental ill-health. The health centre and school health service are vital low-threshold services for children and adolescents with mental health challenges. In some cases, children and adolescents who contact the services need to be referred to, for instance, a Child and Adolescent Psychiatric Outpatient Clinic (BUP). The Government will therefore consider piloting referral rights for health nurses to make referrals to BUP. The purpose is improve routines for early clarification of what help children and adolescents need to ensure that those with mental health issues/disorders receive the correct and prompt healthcare at the right level. Health centres and the school health service are in contact with many children and adolescents before and after they have been referred to BUP. Such referral rights will be considered in relation to further development of models for cooperation between municipalities and the specialist health service around children and adolescents including the introduction of clinical interviews. Cooperation with health centres and the school health service will also be considered in more detail when piloting integrated services at one level (refer to 3.4.1).

In order to help children and adolescents to get necessary help and cope with their own lives, health centres and the school health service should cooperate with other relevant actors in the health sector, and across the sectors and services, for instance, coordinating units for habilitation and rehabilitation, the child welfare service, GPs, district medical officer, psychologists and other healthcare services offered by the municipality, the Norwegian Labour and Welfare Administration, the public dental service and educational psychological counselling service.

Educational Psychological Counselling Service

Every municipality and county council should have an Educational Psychological Counselling Service (PPT). This could be organised as a municipal service or cooperation with other municipalities and/or county council.

The Educational Psychological Counselling Service shall help kindergartens and schools to develop competence and their organisations, so the education for pupils who need special adaptation is the best as possible. In addition, the service shall ensure that expert assessments are carried out on the special needs of children and pupils.

The Educational Psychological Counselling Service shall work in a cross-disciplinary fashion when necessary at the local level, for instance, with healthcare services or child welfare service, and at the state level with, for instance, Statped or the specialist health service.

The Storting adopted a new Education Act in spring 2023, which clearly states that the Educational Psychological Counselling Service shall help schools with the work on prevention and early intervention. The new Education Act will come into force in autumn 2024.

Healthy life/teaching and coping services

Health life/teaching and coping services are offered in different ways in the municipalities. Healthy Life Centres are health promotion and preventive municipal health services. The target group is people who have an illness or higher risk of illness, and need support to change lifestyle habits and to cope with health problems. A referral or administrative decision is not required to use their services. In addition to having lifestyle counselling, many Healthy Life Centres have services for people with mild mental health issues, sleep problems and/or risky alcohol consumption. According to the guide for establishing Healthy Life Centres, the services must be adapted, so that everyone in the target group can participate.11 In many municipalities, there is tight cooperation between the Healthy Life Centre and Prompt Mental Health Care (PMHC). Health Life Centres offer services arranged by themselves and/or in cooperation with other actors. Emphasis is placed on a holistic approach and strengthening the users’ physical, mental and social resources for health, change and coping skills. The healthy life services are fundamentally general and diagnosis independent. Mapping carried out by Statistics Norway (SSB) shows that around 20 per cent of the municipalities had courses for coping with depression (KID) and courses for coping with stress (KIB).12 More and more municipalities are offering courses in everyday wellbeing. Around 66 per cent of municipalities have a Healthy Life Centre under their own auspices or through intermunicipal cooperation. Accordingly, the Healthy Life Centres reach approx. 85 per cent of the population.

Helplines and online services

There are numerous helplines, online services and support groups providing good help and contributing with information, counselling and support services for people in difficult life situations and their next of kin. These services are primarily offered by non-profit and voluntary organisations, and they are an important supplement to public authority services. Helplines and online services receive a high number of enquiries, and the services report an increase in the number of people contacting them, and there are more serious enquiries now than before the COVID-19 pandemic.

It is important to have quality assured training for those who work in the support services. Work has therefore started on preparing a common training module for mental health helplines. The initiative follows up both the Quality of Life, Mental Health and Substance Use during the COVID-19 Pandemic Report from the expert group, which has assessed the implications of the pandemic on the population’s mental health and substance use, and the Action Plan for Suicide Prevention 2020-2025 – No one to lose. The coordination of relevant helplines within the field of mental health and other relevant helplines via a joint national number and the possibility of establishing an emergency button will also be considered.

In the National Budget for 2023, the Government has facilitated the strengthening of a fairer grant scheme for guidance, support and counselling services within mental health, substance use and violence. The goal is that good and effective services shall encounter predictable frameworks, at the same time as grant administration is transparent and fair. The Government will consider additional strengthening of guidance, support and counselling services within mental health, substance use and violence during the plan period.

3.2.3 Access to general practitioners

Patients with mental health challenges represent a large portion of the work at GP surgeries. Out of more than 16 million GP consultations, every fourth consultation concerns mental health symptoms, and mental illness is the main diagnosis in more than every tenth.13 For many, a long relationship with their GP makes them a natural first point of contact, which also applies to patients with mental health issues. The majority of those who contact their GP are treated and followed up without a referral to the specialist health service. GPs are an important low-threshold service for citizens and are available in all municipalities in Norway. At the same time, GPs are important contributors in guiding patients to other municipal services for mental health and coping. For patients with severe mental illness, GPs are often coordinators in following up municipal healthcare services and specialist health services.

Somatic disease may be an underlying cause of mental health issues. Investigation of somatic causes is therefore an important part of a GP’s follow-up of mental health issues. People with anxiety, depression and stress-related diagnoses contact their GP more often and have more somatic ailments than others.14 GPs have the competence to look at mental health and somatic ailments in relation to each other and make good diagnostic and treatment-related assessments.

Capacity problems in the GP service reduces availability and continuity in the therapeutic relationship for patients with mental health challenges as well. In addition, there are challenges attached to coordination between the GP service, other municipal mental health services and the specialist health service. A lack of insight into municipal services among GPs may lead to unnecessary referrals to the specialist health service and subsequently healthcare not being as good or as resource-efficient as possible. Challenges with coordination between the GP service and other municipal services may lead to somatic causes of mental health challenges, or somatic diseases resulting from mental illness, not being detected.

The Government is carrying out ongoing work on increasing the capacity and recruitment to the GP service. Such strengthening is essential to ensure equal and accessible services for patients with mental health challenges, and to improve the internal coordination in the municipal health and care services and with the specialist health service. Trials with several occupational groups at GP surgeries have shown that the patients and healthcare personnel perceive the services as better coordinated with better collaboration. During the trial, one of the GP surgery’s employees was a psychiatric nurse and another had a psychologist in its team. The findings correspond with findings of other work studying experiences with psychologists at GP surgeries.15 In the work on strengthening the GP service, the Government wishes to facilitate multidisciplinary GP surgeries.

In 2023, the Government proposed a historical commitment to the GP service. The funding is used to strengthen and make the basic grant patient-adapted to specialty training in general practice agreements (ALIS agreements) to increase recruitment and for research. An ALIS agreement is an agreement between a municipality and doctor undergoing speciality training in general practice. Changes to the basic grant will give GPs more support for patients who it is assumed will have more need for services. It shall enable GPs to spend more of their time on follow-up and coordination in respect of patients with serious complex needs, which applies to many patients with mental health challenges. Patient-adapted basic grants are based on selected indicators that shall predict the estimated need for GP services for citizens on GP lists. The indicators are sex, age, use of GP services, education level in the municipality or borough and centrality. The model was introduced in May 2023. The Government has an ambition to further develop the model to better establish the health condition of patients, inter alia, for patients with mental health challenges and addiction problems.

24-hour out-of-hours medical service and immediate assistance

Much of the work that is carried out by the out-of-hours medical service is related to acute mental health challenges, particularly late in the evening and during the night. A large portion of the consultations carried by the out-of-hours medical service are for severe mental illness and surpass those at GP surgeries. One major challenge is that the out-of-hours medical centres are less integrated with other municipal health and care services, and information flow between the centres and other services in municipalities is severely lacking.

The obligation of the municipalities to provide 24-hour immediate assistance was extended to apply to patients with mental illness and/or addiction problems from 2017. The introduction of immediate assistance for mental health and substance use shall contribute to strengthening the general services in the municipalities. Patients relevant for inclusion in this service are those with mild or moderate mental health problems and/or addiction problems, often in combination with somatic diseases/ailments. This may be patients with a clarified condition or known diagnosis who relapse or whose mental health disorder and/or addiction problem becomes worse. In such cases, hospitalisation may remedy or relieve a difficult life situation.

The Government has announced that there will be a separate white paper on emergency medical services to review the chain of assistance that is given from the point in time that a patient needs emergency healthcare up to and including admission to the emergency department at a hospital.

3.2.4 Mental health care provided by specialist health services

Since the last escalation plan, treatment services in the mental health service have undergone a major overhaul with more emphasis on outpatient and ambulatory care than inpatient care. This development has contributed to more patients receiving help and help being given closer to where people live. At the same time, the need for inpatient care has increased, including those committed to compulsory psychiatric care. There has also been a significant increase in the number of referrals, particularly during and after the COVID-19 pandemic, and waiting times have increased. Regional health authorities observe that there is a need to increase the capacity of the mental health service in terms of both outpatient and inpatient services, and have consequently revised the national projection model. Application of the new model will contribute to reducing undesired geographic variation and strengthen treatment services for patient groups with a greater need for treatment from the specialist health service moving forward, particularly those with severe mental illness and children and adolescents. The Government wants the average waiting times to be reduced and will proceed with the goal of the average waiting time in the longer term being less than 40 days for mental healthcare for adults, 35 days for mental healthcare for children and adolescents and 30 days for cross-disciplinary specialised treatment for substance use disorders.

The Government will enable the regional health authorities to increase the capacity for treatment and follow-up in the mental health service. based on projections and what is feasible and realistic to accomplish within the framework of hospital finances. An investigation will also be conducted on how a joint referral unit can include cooperation with the municipalities to ensure better prioritisation and task distribution so patients receive essential healthcare at the right treatment level. The Government will assess recommendations from the Expert Committee on Thematic Organisation of Mental Health Care, proposals for reorganisation measures from the regional health authorities and review of reporting requirements in the mental health service. Further, the Government will assess recommendations in a report on forensic psychiatry and other measures for those committed to treatment. The Government will also assess recommendations from the Committee, which will investigate how inmates with mental health disorders can be taken care of and evaluate the special penal sanctions referred to in Chapter 4: services for people with long-term and complex needs.

Trends in the use of mental health services

After several years with a stable patients rate in the mental health service, there was an increase in the number of patients from 2020 to 2021. The increase was particularly large in the services for children and adolescents. In the same period, there was an increase in both the activity and capacity of outpatient clinics (including ambulatory) measured in the number of consultations and man-years. This applied to services for children, adolescents and adults alike. For adult inpatient services, there was a reduction in the number of beds and inpatient stays from 2012 to 2021 (refer to Figures 3.2 and 3.3). There was only a minor change in the inpatient services for children and adolescents during the period.

Source: The figure is based on the statistics from SAMDATA Specialist Health Service, Department of Comparative Statistics and administration information at the Norwegian Directorate of Health. Data are collected by the Department of Health Registries and the Norwegian Directorate of Health.

In the child and adolescent mental health service, the contact/consultation rate was relatively stable from 2012 to 2017 (refer to Figure 3.2). From 2017-2018, the consultation rate dropped due to, inter alia, the introduction of a new patient data system in Central Norway Regional Health Authority (RHA). The drop must also be seen in connection with the introduction of activity-based funding (ABF) in 2017, which may have resulted in changes to reporting practices.16

From 2019 to 2020, there was a clear increase in the number of contacts with patients in the child and adolescent mental health service linked to telephone and video consultations in connection with the COVID-19 pandemic. There was a slight decline in these types of contacts from 2020 to 2021, but institutional outpatient clinic contacts increased. Overall, the rate for inpatient care in the child and adolescent mental health service increased slightly.

When looking at the period from 2012-2021 as a whole, the rate for outpatient contacts/consultations in the adult mental health service also increased (refer to Figure 3.2). There was also a decline in the consultation rate in this sector from 2017 to 2018 followed by an increase in the last three years.

In the adult mental health service, the inpatient rate decreased in the whole period from 2012 to 2021. There was a higher decrease in the volume of inpatient stays from 2019 to 2020 compared to previous years. This is connected to the fact that emergency preparedness represented a large portion of the treatment offered during the pandemic. On the whole, the duration of immediate help/admissions is shorter than other admissions and leads to a reduction in the volume of inpatient stays.

In the services for adults, the inpatient rate decreased for the whole period up to 2021, whilst the inpatient rate for services for children and adolescents was relatively stable (refer to Figure 3.3).

Source: The figure is based on the statistics from SAMDATA Specialist Health Service, Department of Comparative Statistics and administration information at the Norwegian Directorate of Health. Statistics Norway (SSB) collects data on inpatient beds in the mental health service.

Projection of the need for services

Mental health service be of high quality and correctly dimensioned in line with the population’s needs. The regional health authorities are responsible for dimensioning the services, and the work on projections is strategically important to enable the regional health authorities to plan for enough capacity in the longer and shorter term.

The regional health authorities have recently assessed what the demand will be for mental health services and cross-disciplinary specialised treatment for substance use disorders (TSB) in the years to come. This applies to the demand for inpatient beds, outpatient clinic services and ambulatory treatment, and whether there are any groups that will need more health services in the future. Based on the analyses, they have revised the national projection model for the need for services, personnel and competence in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB).

A new projection model will facilitate good professional solutions and sustainable development of health services up until 2040, contribute to reducing undesired variation and strengthen the services for groups who will have a greater need for health services in the future, improve quality and increase the use of technology. The model shall form the basis for planning education and recruitment of personnel, planning of new buildings, procurement of health services, establishment of technological infrastructure, and the organisation and setting up of health services.

The analyses on which the projections are founded show that there was a significant increase in the number of referrals and activity within child and adolescent health care from 2019 to 2021. Scoring of the patients’ level of functioning shows a slightly lower level compared to earlier. This indicates that these patients are considered to need healthcare from the specialist health service and do not have mild disorders that could be taken care of by municipal health and care services. Eating disorders are one of the most severe mental health disorders suffered by children and adolescents. and a higher increase than the previous year has been observed. In 2021, the number of patients with eating disorders amounted to 30 per cent of the total national consumption of inpatient admission days.

There was also an increase in referrals to the adult mental health service from 2019 to 2021, particularly in the 18-25-year age group, but the increase in the total volume was lower. This shows that the highest increase in the special health service from 2018/2019 to 2021 were those between the ages of 12 and 25. The waiting time in the adult mental health service increased from 46 days in 2021 to 50 days in 2022. In the child and adolescent mental health service, the waiting time increased from 50 days in 2021 to 53 days in 2022.

There is currently little indication that the burden on the child and adolescent mental health service will be reduced, and facilitation of a general increase in the capacity of the child and adolescent health service is needed, particularly a strengthening of outpatient services in general and more specifically services for patients with eating disorders. It is also necessary to strengthen the service for children and adolescents under the care of the child welfare service with mental health problems and disorders.

Both inpatient care and outpatient clinic services for patients with severe disorders need strengthening. The analyses also show that there has been a significant increase in the number of people committed to treatment in recent years. At the same time, there has been a general increase in the number of inpatient days for patients referred for some form of compulsory treatment. There are also indications of comorbidity changes in some patient groups. In this case, patients with concurrent addiction disorders and mental health disorders (COD patients) particularly stand out. The projections show there are problems with capacity throughout the treatment pathway for people with severe mental health problems. A well-developed day and outpatient service may reduce the need for inpatient admissions provided there are time-intensive treatment programmes and strengthened outreach efforts at outpatient clinics. services for patients with severe mental illness are discussed in more detail in Chapter 4.

In 2023, the Government has increased the National Budget with earmarked funding for mental health. MNOK 150 of the increased basic hospital funding in 2023 will go towards strengthening inpatient child, adolescent and adult mental health care. In the revised National Budget for 2023, the Government has proposed that the framework for hospitals will be permanently increased by BNOK 2.5 above the adjustment for prices and wage growth. Mental health has been singled out as an important prioritisation for the funding.

A projection shows that a key prerequisite for improving capacity in all the services is continued strengthening of municipal health and care services with services for patients with mild and moderate conditions. The projection has not investigated how a measure for building up municipal health and care services with services for patients with mild and moderate conditions will impact the municipalities or whether the municipalities will have the capacity or competence to do this. New tasks for municipalities must be authorised by law and investigated in line with the principles and guidelines for state management of municipalities (refer to Chapter 3.2.2 for a discussion on developing low-threshold services in municipalities). The Government will facilitate the strengthening of low-threshold services in the municipalities early in the plan period.

Health and care services are continuously changing. This is necessary in order to improve investigation and treatment, safeguard sustainability and to exploit joint resources as best as possible. For improved sustainability, the use of effective treatment, increased use of technology and better coordination across the service levels is paramount. It is expected that new treatment methods, building designs and better use of technology will impact several aspects of the health services offered. They can increase the accessibility of health and care services, shorten the duration of treatment, reduce the need for inpatient admissions and contribute to reducing the implications of geographic distances.

The regional health authorities have been commissioned to work further on measures to increase the capacity of priority areas within mental health care and cross-disciplinary treatment for substance use disorders where necessary in the longer and shorter term, and measures to retain and recruit personnel within mental health care and cross-disciplinary treatment for substance use disorders to cover the need for staffing and competence. The regional health authorities will submit their recommendations and reorganisation measures in early autumn 2023.

Demand projections are first and foremost a tool that enables the health regions to plan and dimension the services, and the regional health authorities recommend that the projections for what is needed are revised every four years. The updated projections form the foundation for the regional development plans up until 2040.

On the basis of the analyses from the projection, the Government will within the frameworks of hospital finances enable the regional health authorities to strengthen the general capacity to treat and follow-up children and adolescents with mental health disorders in the specialist health to reduce the waiting time, and to have special focus on treatment pathways for patients with severe mental illness. One of the Government’s defined performance measures is to prevent the reduction of today’s total number 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 goal will be evaluated every four years in line with the projection revision. The Government will further assess how inpatient care can be arranged in the best possible way based on the projection and recommendation of the Expert Committee on Thematic Organisation of Mental Health Care.

Moreover, additional measures to strengthen the cooperation and to assess the distribution of responsibility between the child welfare service and health services for children with mental health challenges and addiction problems will be considered following submission of the Expert Commission on Child Welfare’s report in autumn 2023. It is important that these two sectors are viewed in relation to each other and that the treatment needs of children under the care of the child welfare service are covered by the right sector.

The new and more detailed projection model for the mental health service forms a good foundation for the regional health authorities to strengthen the service for those who will have more need for health services moving forward. In addition, this model will contribute to reducing undesired variation in the services offered. The regional health authorities will be asked to provide information about how they are doing compared to their own projections annually.

Joint referral unit

Today, patients who are referred to a contracting specialist, specialist doctor or specialist in psychology, who have an operating agreement with regional health authorities, do not have the same rights as patients who are referred to a District Psychiatric Centre (DPS). Their rights are not assessed in accordance with the Patient and User Rights Act This means that the patients do not have the right to have their referrals assessed within ten days. Additionally, the patients do not have a legally binding deadline for when healthcare must start at the latest.

The regional health authorities have been commissioned to establish a joint referral unit where GPs/referring parties can refer all patients who need investigating and treatment within the mental health service to one place. This is where referrals will be assessed, and those who have the right to healthcare will receive it from a contracting specialist or District Psychiatric Centre (DPS).

The establishment of a joint referral unit will in all likelihood lead to a change in referral practices and prioritisation in the mental health service. The change will lead to more equal and appropriate prioritisation of referrals to the specialist health service, whilst at the same time provide a better overview and better exploitation of the total capacity. By establishing a one-way-in referral system, patient rights will be maintained at the same time as it will be easier for GPs to refer patients to the specialist health service.

A joint referral unit will also provide the opportunity for further developing the cooperation between the specialist health service and municipal health and care services in connection with the assessment of referrals. During the plan period, the Government will investigate how a joint referral unit can include cooperation with the municipalities to ensure better prioritisation and task distribution so patients receive essential healthcare at the right treatment level.

3.3 Further development of digital programmes and services

Correct use of technology and digital solutions are fundamental to the development of services, and are important for ensuring sustainable health and care services. The introduction of technology and digitalisation may contribute to correct disposal of available resources in new and better ways. Digital programmes and services can make health and care services more accessible, improve capacity and enable flexible pathways and early assistance. In turn, this can reduce inequalities in the services offered and good digital tools may make it more attractive to work in the services. At the same time, the use of digital solutions requires awareness of the fact that such measures are not necessarily suitable for all recipients of services or in all phases of a treatment pathway. By encouraging more people with mild mental health issues to use self-help tools and digital programmes, it allows those with specials needs to have more time with healthcare personnel.

More use of digital services and programmes requires citizens and patients to have good digital literacy skills. Digital health and care services is a priority area in the municipalities’ joint e-health plan. A national introduction strategy for Helsenorge is being prepared.

Conversion to extended use of digital solutions can be resource-demanding during a transition period, as it sets new requirements in relation to employee skills in using, understanding and interacting on new platforms.17 Additionally, it is necessary to build up a culture for changing and adapting to new digital tools in the health and care sector. At the same time, future healthcare personnel will have knowledge of digital services as part of their education, which may contribute to increased digital awareness of the work tasks that healthcare personnel will meet in their working lives.

The use of digital consultations within mental health care increased massively in Europe due to the COVID-19 pandemic.18 The Health Policy Barometer 2021 showed that 29 per cent of the population believes it would have been easier to seek help for mental illness if it had been available digitally.19 At the same time, municipalities report that digital contact during the pandemic functioned poorly for some of those with the most severe disorders. This was due to a lack of equipment, expertise, personal preferences or the illness was not suitable for digital follow-up.20

Increased digitalisation of services and programmes provide more opportunities but also lead to a higher risk of digital exclusion. As planned, the Ministry of Local Government and Rural Development will present an action plan in June 2023 for increased inclusion in a digital society. The action plan is primarily aimed at groups who experience digital barriers and digital exclusion. It highlights the fact that one’s health and life situation can stand in the way of digital participation. This must be taken into consideration when designing digital services by taking care of the principles of universal design and assisting with good training and guidance for users with limited or deficient digital skills.

Children and young people have excellent digital skills and many spend a lot of time in digital arenas. Digital arenas give children and young people the possibility to become familiar with support services on their own terms and when it suits them. DigiUng shall offer both self-help tools and individual follow-up at ung.no This is an important effort to give adolescents accessible help. See below for a more detailed discussion on DigiUng.

The Government will continue to build on the national e-health solutions such as Norsk Helsenett SF (The Norwegian Health Network), Summary Care Record, E-prescription and helsenorge.no. This enables the municipalities and hospitals to work better together and put into place technology and new functionality that all the health and care services need. The solutions will contribute to relevant personnel having access to the right information at the right time and place. These digitalisation measures will largely have a positive effect on the services and therefore the services aimed at mental health. The benefits of digital solutions are immense in that they improve availability and give better access to the services. Furthermore, there are socioeconomic benefits in the form of giving help at a lower effective care level. In the National Health and Coordination Plan, the Government will give an overall presentation of digitalisation in health and care services. Additionally, see Chapter 4.3.1 regarding good patient pathways.

From calendar-based to needs-based follow-up

Patients have traditionally experienced a hospital-based and calendar-based specialist health service where patients are called in for outpatient follow-up according to a defined time interval. Digital health services allow patients to alternate between physical and digital meetings as needed, and different types of digital treatments facilitate more expedient dialogue between patient and practitioner.

Remote follow-up and user-controlled outpatient clinics will to a greater extent contribute to patients with long-term conditions and disorders being followed up over time, but the follow-up will be adapted to the patient’s need for help during different illness phases.

The Government wants to test user-controlled outpatient clinics at District Psychiatric Centres with digital monitoring. User-controlled outpatients clinics have barely been used in the Norwegian Health Service, but are discussed in a new model for projections in the mental health service and the effect of digital health services have been added to the model. The regional health authorities have been commissioned to continue working on conversion measures and will submit recommendations in autumn 2023. The need for national measures will be discussed in the National Health and Collaboration Plan.

Guided online treatment

A considerable amount has already happened with digital mental health services. Online treatment allows more people, who need it, to seek help. In 2019, the Beslutningsforum for nye metoder (New Methods Decision Forum) approved the use of therapist-guided online treatment for mental health disorders when it is considered appropriate. Online guided treatment with the eMestring program has been taken into use for treating patients with depression, social anxiety and panic disorder. It is based on a treatment programme developed by Haukeland University Hospital Trust. It will now be used in all regions, and the Government will facilitate further development and implementation of guided online treatment.

Digital self-help tools

More recent evidence syntheses indicate that apps and other digital self-help tools can prevent and contribute to coping with mild to moderate mental health issues and disorders.21 Apps and other digital self-help tools may give people better support in preventing and coping with various issues and problems, or support self-monitoring during various illness pathways.22 Many can benefit from learning, training and practising some steps that can help to improve coping with stress, anxiety and apprehension.

The advantage of apps is that they are accessible whenever and wherever a person is, and can be used by the patient/user themselves or via a digital referral. Some people may also find it easier to use an app than to seek physical support services. A variety of good tools developed by Norwegian expert environments already exist. Apps can be good educational tools based on recognised principles in a new and engaging wrapping. Such tools can be used with or without the support of healthcare personnel.

The public can find digital tools and courses for mental health issues at helsenorge.no that may substantially help and benefit them. It is important to make these tools more accessible. The tools may contribute to preventing exacerbation and postponement of more expense and resource-intensive treatment measures, particularly if they are used for early intervention in collaboration with the health service.23 Infrastructure is in place to enable GPs to send digital referrals to a digital tool to their patient via the ‘Verktøyformidleren’ app. The patient finds a prescribed tool via a text message with a link to the tool catalogue at helsenorge.no.

As part of the escalation plan, the Government will facilitate further development and implementation of digital self-help tools, and increased the grant for this in 2023. The main goal is to ensure effective and accessible digital treatment of mild to moderate mental health disorders for the citizens of Norwegian municipalities.

DigiUng and ung.no

Children and young people need and request quality assured information, advice, guidance and help via digital platforms. They want services that are accessible instantaneously on their own terms. Digital accessibility for both information and services—across the sectors—is necessary in order to reach and help children and young people. The goal is for children and young people to find easily accessible and quality assured information, guidance and services. Digital services are an important part of low-threshold services for children and young people. The Government has concluded that ung.no shall be the state’s primary cross-sectoral channel for digital information, dialogue and digital services for children and young people across the service levels through the realisation of DigiUng. Grants for this will therefore be increased in 2023. Seven ministries and underlying agencies are collaborating on DigiUng. In addition, refer to the discussion on the digital health centre ‘DigiHelsestasjon’ in Chapter 3.2.2. The target group for ung.no is currently young people aged 13-20.

Today, most ten-year-olds in Norway have a smartphone and 56 per cent of them use social media.24 Most children under the age of 13 are online as much as 15 and 16-year-olds despite the fact that they cannot be expected to have the same ability to exercise digital judgement or source criticism. Nonetheless, very few websites and apps are intended for children. Even though many websites and apps have age limits, they are used by children younger than the specified age limit. The content of the majority of websites and apps is not quality assured and many are operated due to commercial interests. Users are largely exposed to advertisements and, in some case, inappropriate/harmful content and unpleasant interactions (refer to Chapter 2.3.5 for a discussion on social media and mental health).

By offering quality-assured and preventive information and guidance to children under the age of 13 online will fill in a gap in public services for children and young people. This will be an important supplement to information and education given in other arenas. It is estimated that ung.no received more than 5,000 questions from around 100,000 users from children under the age of 13 in 2021 despite the lower age limit of the service being 13 years old. This clearly indicates that ung.no and DigiUng may be services that meet the needs of this age group. User insight, however, shows that different age groups have different needs, expectations and user patterns, and that digital services must be age appropriate. The Ministry of Health and Care Services and the Ministry of Children and Families will therefore give the Norwegian Directorate of Health and the Norwegian Directorate for Children, Youth and Family Affairs the task (in cooperation with other relevant agencies) of further investigating the needs of the under 13s as a basis for further work on developing the service for this group.

Single gateway to information

It is important for both those who need help and those who give help that the information on the services offered is transparent and readily accessible. A digital gateway is needed to all information about relevant services in the municipalities for people with mental health issues and disorders, and addiction problems. The measures that are developed to provide an overview of the services must take care of the need to reach out with information to non-digital citizens. Further, they should include information about services linked to psychosocial follow-up after disasters and crises.

The municipalities benefit from giving their citizens good and adapted information about programmes and services, and should have good websites with easily accessible information. This is also important for the specialist health service. When introducing clinical interviews (refer to Chapter 3.4.1), it is particularly important that the specialist health service has good dialogue with the municipality and an overview of its services.

The Ministry of Health and Care Services has commissioned the Norwegian Directorate of Health to investigate whether and how the overall services from the municipalities can be communicated to the citizens through a single gateway at the municipal level. The commissioned assignment may also be relevant to how one can ensure a single gateway for information for citizens with problems related to mental health and addiction.

3.4 Improve services for children and adolescents

Many children and adolescents with mental health challenges receive good help and support from parents, friends, teachers or others in the local community. Conversations with the health centre and school health service, a GP or own low-threshold service can be useful for children and adolescents in recognising what difficult feelings are and what might be symptoms of a mental health disorder. Some have problems that may be long-term and complex, and need more help from support services. The Government wants children and adolescents, who need them, to receive good treatment services.

The Government will therefore strengthen both accessibility to the health centre and school health service, ensure accessible evidence-based low-threshold services in municipalities, further develop child and adolescent specialist health services and models for cooperation between municipalities and the specialist health service, and ensure better cross-sectoral cooperation through continuing to fund programmes for children and adolescents (refer to Chapter 3.4.2 for a discussion on funding programmes). The Government wants children and adolescents, who are referred to the child and adolescent mental health service, to be offered a clinical interview to clarify further follow-up from the specialist health service or municipal health and care services if needed. This means that a rejection exclusively based on a written referral should not normally occur, and assumes good and systematic cooperation between the mental health service and the municipalities (refer to Chapter 3.2.2 for a discussion on the health centre and school health service and evidence-based low-threshold services in the municipalities).

3.4.1 Cooperation between the child and adolescent mental healthcare services and the municipalities

Several reports indicate problems attached to coordination between municipalities and the child and adolescent mental health service. The report of the Ombudsperson for Children Jeg skulle hatt BUP i en koffert (I should have had the Child and Adolescent Psychiatric Clinic in my Suitcase) points out, among other things, problems with various practices when assessing referrals, that children and adolescents who need prompt help are not taken care of, and that they do not always have access to the right healthcare. The Ombudsperson for Children points out that the services in municipalities and the child and adolescent mental health service must be seen in relation to each other and that mandatory measures are necessary. In the report of the Ombudsperson for Children Hvem skal jeg snakke med nå? (Who should I talk to now? from 2022 on healthcare for children and adolescents in the municipalities recommends a flexible and adapted service with the necessary frameworks for cooperation with Child and Adolescent Psychiatric Clinics (BUP).25

The Office of the Auditor General of Norway’s report on mental health services from 2021 shows that youth with concurrent mental health disorders and addiction problems do not receive adequate treatment. Mapping conducted by the Norwegian Healthcare Investigation Board (UKOM) in 2021 on services for children and adolescents in the mental health service shows a gap between health services in the municipalities and those in the specialist health service.26

During the plan period, the Government will further develop models for cooperation between municipalities and the special health service around children and adolescents including the introduction of clinical interviews. This should be entrenched in the medical communities. and will be seen in connection with measures in the National Health and Collaboration Plan. Further, integrated youth services at one level will be investigated and piloted (preferably in all regions) for young people with mental illness and/or addiction problems, and will also include cross-sectoral cooperation. The setting up of cross-sectoral cooperation must be assessed in more detail. For instance, it may be relevant to assess stronger cooperation with the child welfare service and Norwegian Labour and Welfare Administration (NAV).

The problems attached to organisation and coordination can also be addressed in other ways. Among other things, the Government has invited municipalities and county municipalities to apply to become pilot municipalities, and thereby have the opportunity to test new ways of solving tasks through exemption from the regulations. For instance, it may be relevant to pilot challenges connected to coordination and transition between sectors and services both within and between the different welfare services, and other measures that promote earlier and more coordinated efforts for children and adolescents.

It is important to reduce the threshold so that adolescents receive mental health assistance, regardless of finances. The Government will consider removing the deductible for young people up to and including the age of 25 for treatment from mental health services as a way to contribute to reducing the threshold for mental health assistance, and to prevent personal finances deciding what kind of help one receives.

Clinical interviews

Many children and adolescents are rejected by the mental health service exclusively based on written referrals. Apart from a rejection being perceived as problematic by the person concerned, experience shows that some of those who are rejected are referred again. In the meantime, the condition may have got worse. Therefore, they do not receive help when they need it.

The Government is working to ensure that more people receive the right mental healthcare more promptly, and one of the goals is for everyone who is referred to the child and adolescent mental health service to be offered a clinical interview where the service meets those who need help. This also applies to children who have an unclarified care situation and need to be followed up by the child welfare service.

Several of the child and adolescent mental health clinics have established cooperation between the specialist health service and municipal health and care services in connection with the assessment of referrals. This type of cooperation contributes to better and more targeted referrals to the specialist health service and better prioritisation and task distribution, so that patients are given essential healthcare at the right treatment level and there are fewer rejections of the right to essential healthcare. An important added value of such cooperation is that patients/next of kin and the referring party find that their need for assistance, investigation and/or treatment are met. In addition, it will be possible to better plan and exploit the resources in the various patient pathways. It is also important that children, who are under the care of the child welfare service and need assessing by the specialist health service, are assessed (refer to the discussion on children and adolescents under the care of the child welfare service in Chapter 4.4.2).

Many hospital trusts have already come a long way in arranging for children and adolescents, who have been referred to the child and adolescent mental health service, to be offered an interview to clarify their further needs. This enables children and young people to receive more prompt help in the right place at the right time, and they can avoid developing even more serious problems. This is done in various ways and different terms are used for the services.

The comprehensiveness of the assessment that is given during the first interview varies. Some health trusts have established half-day investigations and report that the practitioners find it meaningful to be able to offer prompt and thorough assessments. They experience that more children and adolescents are taken care of by the municipal health and care services, and report that they have become better at looking at what they should offer in their services. It has also been observed that the quality of the referrals to the child and adolescent mental health service has improved.

One important prerequisite for offering clinical assessments is that the child’s municipality of domicile can offer services if the specialist health service finds after the assessment that further follow-up from the specialist health service is not needed, but other help is.

An interview for everyone who is referred to the child and adolescent health service can reduce the threshold for making referrals. In order to ensure a sustainable service for children and adolescents, it is essential that the municipalities have good low-threshold services, good coordination and prioritisation of who will be referred to the child and adolescent mental health service, and correct follow-up for those who do not need help from the child and adolescent mental health service.

During the plan period, the Government will assess instruments that can underpin the introduction and implementation of the initiative for everyone who is referred to the child and adolescent mental health service to be offered a clinical interview. For instance, the assessment of how the medical communities and national patient pathways can be used to contribute to more systematic cooperation between municipalities and the specialist health service regarding clinical interviews. The introduction of clinical interviews for everyone means that around 8,500 new patients will be accepted for an interview in the child and adolescent mental health service, but this does not mean that 8,500 more patients will proceed further in the specialist health service patient pathway. Transitory experiences from, for instance, Øvre Romerike Child and Adolescent Psychiatric Centre (BUP) show that some are rejected after the clinical interview, whilst others are considered to need specialist health services, and others are offered further services in the municipality. The introduction of clinical interviews involves increased cooperation with the municipalities to clarify the right support. This is a major change for the services. The introduction will be evaluated afterwards to enable the development of sustainable models that contribute to satisfied patients and next of kin. The Government wants everyone to be offered a clinical interview in the longer term. As part of the evaluation, an analysis will be performed on the financial and administrative consequences of a potential expansion.

Integrated services

In order to prevent, detect and offer early intervention to children and young people who need mental support services, increased cooperation and coordination between the service levels is necessary. It is also necessary to strengthen the services for young people with addiction problems, children and adolescents in the child welfare service, and children and young people completing sentences, and to include schooling/work to a greater extent in the follow-up and treatment of young people. Increases knowledge sharing between levels and sectors is also needed.

Experience and testing have shown better results with concurrent integrated follow-up and treatment. Research shows that integrated health and work-orientated follow-up in workplaces leads to more people with severe mental illness getting jobs.27 There are multiple ways of giving more cohesive and integrated services.

ACT and FACT are models for assertive outreach and concurrent holistic services for people with severe mental illness and/or addiction problems. The Youth FACT team gives integrated and assertive outreach help to youth with serious complex needs. In the evaluation of Youth FACT pilot projects, the youth described Youth FACT as a service that was adapted to their needs, they were better taken care of in the relationship and they found that the team was more flexible and accessible than other services with which they had experience (refer to Chapter 4.3.2 for a more detailed discussion on ACT, FACT and Youth FACT.

In the projection report, the regional health authorities (RHAs) refer to other countries that organise the service in three parts with services for children, youth/young adults and adults. The RHAs make reference to the fact that a separate youth service, for instance, from the age of 15 to 25 will give better transitions and coherence in the treatment services.

Several initiatives have been implemented to improve the services for children and young people. Among other things, the Government will include more young people in education, the labour market and community life through a cross-sectoral and targeted effort (refer to the social mission in the long-term plan for research and higher education). Cross-ministry work is currently being carried out on following up the BarnUnge21 strategy where the goal was to create a targeted, holistic and coordinated national effort for research, development and innovation for vulnerable children and young people.

The Core Group for Vulnerable Children and Young People was established for, among other things, to facilitate cross-ministry cooperation on children and young people (refer to Chapter 2.1.1 for a more detailed discussion on the core group).

Input for the work on the escalation plan from, among others, the regional health authorities and the Norwegian Directorate of Health indicates a need to investigate and test a model that to a greater degree ties the services together as follow-up for children and young people with mental illness and/or addiction problems. The Government will investigate and test an integrated service model at one level. The Healthcare Personnel Commission also recommends investigating more holistic organisation of the health and care services at one level.

A low-threshold service model and a single gateway to services that are more cross-disciplinary may result in prompter clarification of what help children and young people need by those with the right competence. This may contribute to preventing the need for help and young people being tossed around the sectors. It may also reduce the need for more specialised mapping, investigation and help. The setting up of cross-sectoral cooperation on integrated youth services must be assessed in more detail. For instance, it may be relevant to assess stronger cooperation with the child welfare service and Norwegian Labour and Welfare Administration (NAV).

The age group and which services should be included in a model should be entrenched in the medical communities.

The pilot project will be evaluated afterwards to find out how it should be expanded after implementation, including how any undesired skewed effects should be handled.

3.4.2 Programme funding in municipalities

Financial instruments are vital in making it possible for the state to facilitate cooperation and the coordination of services and initiatives for children and young people. The municipalities receive funds over the municipal framework and through grant schemes. Most grant schemes are aimed at specific services, measures and more defined target groups, and are an instrument for reaching special sector-specific goals. Through programme funding, we want to turn this around so the grant funds are aimed at the target group and not the individual service or/measure/sector area.

Programme funding shall give the municipalities more elbowroom to work holistically and to prioritise measures adapted to local needs that to a greater extent meet each child and youth’s need for help. The ambition is that programme funding—through creating a common understanding between the service areas, changes in the organisation of the cross-disciplinary work and coordination—shall contribute to giving children and young people the best possible lives.

A programme funding pilot study, which ended in summer 2023, has been carried out and reports from the county governors show that most municipalities have made great strides in terms of entrenching, concretising, piloting and implementing a variety of measures and cooperation models. According to the project group, it is reported that services are better coordinated, there is a more common organisation culture and better structures.

The Government will ensure that instruments are used as effectively as possible. Among other things, this involves assessing how state grants can be better used than today to achieve the goal of improved, and more holistic and coordinated services for children and young people. Programme funding is the setting up of state grants that better facilitate cross-sectoral planning and cooperation, and the Government will continue programme funding during the plan period.

3.4.3 Improve care mental health care for children and adolescents

An eating disorder can have a major effect on the life of the person concerned. In the case of children and youth, eating disorders can make it difficult to participate in important arenas, such as school, leisure activities and in social contexts. Family and other next of kin can also be strongly affected at the same time as they are often an important resource and support network for the ill person.

There has been an increase in the number of referrals to the specialist health service and the number of people treated for eating disorders the last few years.28 The increase started before the COVID-19 pandemic, but was high both before and after the pandemic.

An increase was also seen in the number of eating disorder diagnoses among girls in the primary health service during the pandemic.29 Eating disorders in many people are still not detected and treated, and many wait a long time before seeking help. The health trusts report that many are more afflicted than before when they are first referred.

The prognosis for many people with an eating disorder is good, however, there is still a group of people who have a long-term pathway and significant somatic complications.30 International research shows that anorexia is the mental illness with the highest risk of premature mortality.31

The Government will strengthen prevention, early detection, early intervention and treatment of eating disorders by developing programmes for increased knowledge and competence, models for municipal services and coordination measures, and to assess the organisation of care offered in the specialist health service.

National professional guidelines have been prepared for early detection, investigation and treatment of eating disorders32, and national patient pathways for eating disorders in children and young people up to the age of 23.33 These include recommendations for the primary health service and specialist health service regarding risk and vulnerability factors, investigation, follow-up and cooperation. The health centre and school health service can help with the early detection of children and young people struggling with symptoms of eating disorders and ensuring that they receive necessary help and monitoring GPs are often one of the first in the health service to meet people with eating disorders. GPs are important in identifying, investigating and potentially treating and referring people to the specialist health service, and following up completed treatment from the latter.

All child, adolescent and adult mental health clinics offer services to people with eating disorders, and the regional health authorities have established regional units for treating particularly severe eating disorders.

The treatment services, both outpatient and inpatient care, have been strengthened to meet the increased demand. In a representative proposal (Document 8:166 S) from 2022, the Storting requested the Government to ensure that «…all mentally ill children and young people under the age of 13, if they need it, have access to inpatient treatment both on weekdays and at weekends in their region.» Status information was collected from all the regional health authorities and the feedback showed that capacity had increased and they all had accessible inpatient services the whole week, but in some health trusts patients were transferred to other departments at weekends. However, waiting times and services vary in the health trusts. The projection shows a need for increased capacity in eating disorder treatment in the specialist health service.

A quality registry for eating disorders (NorSpis) has been established.34 The registry does not at the present time extensively cover the whole nation. Extensive work is being carried out to improve the degree of coverage in order to contribute to higher quality in the treatment of patients with eating disorders.

The national patient pathway for eating disorders and the national guidelines on eating disorders primarily focus on the specialist health service. More guidance material is needed for the municipal health and care services.

Many prevention methods have been developed for eating disorders, but there is no updated knowledge base indicating the extent to which these methods can be used to reduce the number of people who develop such illnesses.

The Government has in 2023 granted funding to strengthen the work on prevention, early detection, intervention and treatment of eating disorders. This will contribute to insight work that illuminates the challenges, and which form the basis for measures, including an evidence synthesis on preventive measures, the development of a program for improved knowledge and competence, and development of models for municipal services and coordination measures.

3.5 Work and physical activity as part of the treatment

For the majority of people, who are of working age, work and health are important factors in life. Often they are intertwined. In many cases, participation in work promotes health. Norway has a relatively high percentage of recipients of health-related benefits, and many are excluded from the labour market due to health problems. Statistics from the Norwegian Labour and Welfare Administration show that mental illness is one of the most common diagnoses among people who receive health-related benefits.35 In order to help more people get jobs and to reduce the percentage of young people who become disabled due to mental health issues and disorders, the Government will strengthen the effort for work and activity as part of treatment and follow-up.

In the past, it has been thought that people must be well before they can work. This approach is changing. Many with health problems, including people with mental illness, can and want to work. Work participation can give a sense of acknowledgement, community and personal identity. Inclusion at work has only marginally been used as part of the health and care services’ follow-up. It is paramount that basic awareness of how important activity and work participation potentially is for mental health is prevalent in the services more than what it is today.

An important prerequisite for getting more people in work or activities is still tight cooperation between the health sector and employment sector, and work as a sub-goal must to a larger degree be incorporated into ordinary health and care services. Further, it is important that effective cooperation models between the health, labour and welfare sector are developed, spread and taken into use. The goal is to include more people with mental health issues or disorders in work, activities and education, and reduce non-participation in the labour market through simultaneous or coordinated assistance from both the Norwegian Labour and Welfare Administration and health and care services.

Several models exist for cooperation between the Norwegian Labour and Welfare Administration and health services for different types of users and patient groups. For instance:

The Individual Placement and Support (IPS) is an evidence-based cooperation model which is considered to be an innovative work method in the health and care services. It is a voluntary service for people with moderate to severe mental illness and/or addiction problems receiving treatment from the health and care services. The aim of IPS is to help people, who wish to participate in the labour market, to get a job with ordinary wages through individually adapted treatment and job-orientated follow-up from employment specialists. It has been documented that IPS gives good results for the target group.36

IPS assumes mandatory and tight cooperation between the health and care services and the Norwegian Labour and Welfare Administration where IPS employment specialists are an integral part of the permanent treatment team in the health and care services. The prevalence however varies between the different counties, and continuation and expansion of the IPS service is desirable so that more of the target group can benefit from it.

A separate study for individual placement and support for young adults under the age of 30 has been created to help more people get jobs or complete education/apprenticeships. The study is now being evaluated. Further development of individual placement and support for young adults will be considered based on the evaluation.

The section for clinical drug and addiction research ‘RusForsk’ and the C3 – Centre for Connected Care at Oslo University Hospital Trust have cooperated to use the Early HTA simulation method to measure the benefits of IPS for patients undergoing cross-disciplinary specialised treatment for substance use disorders (TSB). This Early HTA shows that IPS for patients with substance and dependence disorders soon gives socioeconomic benefits.37 At the same time, the evidence synthesis published by the Norwegian Institute of Public Health in 2023 shows that they cannot draw any conclusions on the effect of IPS for those with substance dependence because they did not find enough studies.38 More studies that examine the effect of IPS on people with substance dependence are therefore needed, in addition to other studies on IPS.39

HelseIArbeid is a health promotion and prevention initiative linked to muscle, skeletal and mental health issues. The effort is a cooperation between the health services and Norwegian Labour and Welfare Administration. HelseIArbeid has two main components: a corporate initiative involving the conveyance of health-promoting and preventive knowledge in the workplace, and an individual-based initiative offering cross-disciplinary investigation and work-orientated assessments. In line with the Inclusive Workplace (IA ) Agreement 2019-2024, work is aimed at implementing the measure to a greater extent within the framework of today’s rules and prioritisation regulations. An evaluation of the effects of HelseIArbeid is being carried out and the initial results will be available in 2023.

The Norwegian Directorate of Health and Norwegian Labour and Welfare Administration are preparing joint national professional recommendations for service providers within the field of employment and health. Work is currently being carried out on recommendations for IPS and HelseIArbeid, and the aim is to finished and publish them during the course of 2024.

Many people with mild to moderate mental illness and/or addiction problems will also have the need to combine work-orientated services and treatment. The Norwegian Labour and Welfare Administration and the Norwegian Directorate of Health are working on developing models for coordinated services aimed at this group with emphasis on cooperation with municipal health and care services. More specifically, work is being carried out on developing a model that involves more integrated cooperation between the Norwegian Labour and Welfare Administration and Prompt Mental Health Care teams. The work is built on experience with both well-documented and tested models using existing services, such as Prompt Mental Health Care, as a starting point. The intention is that the model will be tested from 2024. Work is also being carried out on a model for more integrated cooperation between the Norwegian Labour and Welfare Administration and GP surgeries.

Meaningful activities, belongingness and capacity to cope

In addition to work-orientated measures, it is important to facilitate activities and meeting places for people with mental illness and addiction problems. Pursuant to the Act relating to municipal health and care services, etc., municipalities shall ensure that each person has the possibility to have an active and meaningful life in community with others,40 and implement welfare and activity measures for children, the elderly, the disabled and others who need them.41 Ensuring good and inclusive activities may contribute to improved quality of life, coping skills, and the possibility for an active and meaningful life.

During the plan period, the Government will work to ensure that people with mental illness and addiction problems have access to meaningful activities, belongingness and capacity to cope. Meeting places and activity measures form part of the low-threshold services of many municipalities. For instance, day centre services, social cafes and drop-in centres, and various group services. These type of services can be an effective and good way of conducting health promotion work. The common denominator for all of them is that they offer activities with meaningful content. Self-chosen activities contribute to making each person stronger by being the most important actor in their own lives. For many people, culture, activities and creativeness are sources of mastery and growth.42

In addition to the municipality’s own services, the services from non-profit and voluntary organisations are a good supplement to municipal services for citizens with mental health issues and disorders and/or addiction problems, and contribute to the community’s collective commitment to the group.

In recent years, many municipalities have established a clubhouse run by non-profit actors in cooperation with municipalities (refer to Box 3.11).

3.6 Prevent violence and abuse, and help and support those exposed to violence and trauma

It is totally naturally to have strong reactions to traumatic incidents, such as violence, abuse, war events, accidents and terror. For many people, the reactions will diminish after a while, but for some the distress will be permanent and lead to mental health issues. The prevention of violence and abuse is an important goal of this Government. The Government will also work on ensuring that those exposed to violence and people who are exposed to other types of traumatic incidents receive adequate help.

3.6.1 Violence and abuse

Violence and abuse is a serious public health and societal problem affecting a significant percentage of the population in Norway. The Government wants more attention to be placed on the prevention of violence and abuse, and following up and helping those exposed to violence. The Government will continue testing and researching trauma treatment in municipalities through the further development of Trinnvis sammen (Stepped Care Together), and present an escalation plan against violence and abuse against children and violence in close relationships.

The definition of violence covers physical, psychological, sexual and financial violence, and neglect. Witnessing domestic violence is considered violence. Actions termed as negative social control, forced marriage and genital mutilation are also included in the definition of violence. It is well-documented that violence, sexual abuse and neglect during childhood are risk factors for developing mental illness and somatic diseases, substance use problems and suicidal behaviour. Exposure to multiple incidents increases the risk of developing health complaints in adulthood.43 People, who are exposed to violence, report several symptoms of anxiety, depression and post-traumatic stress reactions. Notably, the more types of violence a person is exposed to, the more symptoms of mental health complaints are reported. The burden of symptoms is greatest in people who have been exposed to violence during both childhood and adulthood.44

Municipalities, regional health authorities and county municipalities shall facilitate the health and care services and public dental service in preventing, detecting and averting violence and sexual abuse.45 At the same time, the prevention of mental health issues and disorders is a violence prevention measure. The prevention must be part of a cross-sectoral effort. Violence and abuse occur in all social classes. At the same time, both seem to be more common in people with a low level of education and financial hardship, and those who are divorced or separated. Commitment to reducing issues related to living conditions is therefore an important contribution with regard to preventing and reducing violence and abuse.46

In order to prevent violence and abuse, it is important that the perpetrators of violence receive good help. Clinical research shows that up to eight out of ten children and adolescents who display harmful sexual behaviours (HSB) have been exposed to violence, abuse or other form of serious neglect. HSB may be a consequential condition of ongoing or earlier trauma.47 Experiences with children and adolescents completing sentences show that many of them have been exposed to or have witnessed violence and abuse. Violations, such as violence and sexual violence, committed by children and adolescents affect other children and youth. Several measures have been implemented in recent years to improve services for perpetrators and potential perpetrators. Among other things, all the regional health authorities in Norway have established a counselling and treatment service for children and adolescents with problematic or harmful sexual behaviours (HSB), in addition detfinneshjelp.no has been established. The latter is a low-threshold online chat service and treatment service in all health regions for people who are interested in children sexually – aimed at preventing child abuse.

Considerable resources have been invested in strengthening trauma competencies in the health and care services, and other relevant sectors. The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have a special responsibility for the work on competence development in the field of violence and trauma, and offer a variety of trauma-related competence programmes for the services.

The Government want people suffering from trauma to receive adequate help. Over the course of many years, money has been granted and work has been carried out on the implementation of evidence-based treatment methods for trauma in Child and Adolescent Psychiatric Centres (BUP) and District Psychiatric Centres (DPS) across Norway. It is also important to ensure adequate help for trauma in municipalities. The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) has carried out a study on the Trinnvis sammen (Stepped Care Together) treatment model.

The Government wants to continue testing this model and in 2023 money was therefore granted, as part of the work on this escalation plan, for further testing and research on trauma treatment in the municipalities.

In 2023, the Government will present an escalation plan against violence and abuse against children and violence in close relationships. The Government’s measures for the prevention of violence and abuse, and help for victims and perpetrators, will be included therein. Several investigations and surveys have been carried out in recent years, which point out that the work on violence against and abuse of children and violence in close relationships is challenging, and they also provide recommended measures. This applies to both the Government Committee on Violence against Children’s report from 2017, Svikt og Svik (Failure and Betrayal),48 the Partner Homicide Committee’s report from 2020 Varslede drap? (Forewarned killings?)49 and the Office of the Auditor General of Norway’s survey on the authorities’ efforts against violence in close relationships.50 In addition to these, the GREVIO monitoring committee published its report in autumn 2022 on Norway’s implementation of the Council of Europe Convention on preventing and combating violence against women and domestic violence (Istanbul Convention).51 The escalation plan will, among other things, use these documents as a starting point. In addition, general measures for preventing mental health issues and disorders, and which strengthen the structure around children, such as a strengthened health centre and school health service, parental support, etc., are also measures that may contribute to preventing the occurrence of violence and abuse. General strengthening of treatment services in the form of low-threshold services in municipalities and increased capacity in the specialist health service should also benefit people who need healthcare due to violence and abuse.

The escalation plan against violence and abuse against children and violence in close relationships shall facilitate the development of a holistic and coordinated policy against violence in close relationships, which involves relevant sectors, agencies, institutions and organisations. Online child abuse, negative social control and honour-based violence will be discussed in the plan. People with substantial care needs dependent on other people in daily life are more exposed to violence than other groups, and therefore have a special need for protection against violence and abuse. Several of the measures in the escalation plan will also be relevant for preventing, detecting and following-up violence in these types of relationships. At the same time, more knowledge is needed about this type of violence, so further measures can be developed. Follow-up of the escalation plan for mental health and the escalation plan against violence and abuse against children and violence in close relationships must be seen in relation to each other.

The Criminal Code does not currently have a designated penalty that explicitly prohibits psychological violence. Among others, psychological violence may fall under the section 282 of the Criminal Code relating to violence in close relationships and section 253 of the said Act relating to forced marriages. Due to this, there is reason to investigate whether people who are affected by psychological violence have adequate legal protection, and whether Norway satisfies the obligation of the Istanbul Convention to criminalise the psychological violence. In 2022, a law commission was formed to investigate the general legal problems in cases concerning negative social control, honour-based violence, forced marriage, genital mutilations and psychological violence.

3.6.2 People with war experiences

Refugees

Some asylum seekers and refugees are traumatised after abuse and violence in prison, during war, when fleeing and in refugee camps. Other conditions, including earlier traumatic experiences, can also lead to or exacerbate mental problems. Post-traumatic stress disorder (PTSD), anxiety and depression occur frequently in these groups. The Norwegian Directorate of Health has prepared a guide for psychosocial measures in the event of a crisis, accident or disaster, in which, asylum seekers, refugees and reunited families are discussed.52 A guide has also been prepared on healthcare services for asylum seekers, refugees and reunited families with a chapter designated to psychosocial follow-up.

Many of these and other refugees may have various degrees of war trauma, etc. When meeting patients with an immigrant background, it is important that information is adapted to the recipient’s individual prerequisites, including culture and language background. In some cases, communication through a qualified interpreter may be vital in order to give proper healthcare and to give necessary information to patients and next of kin.

As a result of the Ukraine war, Norway has received many refugees. People who have been displaced from Ukraine, and have temporary protection in Norway, have the same right to health services as the rest of the Norwegian population. The same applies to asylum seekers. The health authorities are observing the situation with the increased arrival of people from Ukraine, among other things, to monitor the capacity of the municipal health and care services.

The Government proposed BNOK 6 extra in the revised National Budget for 2023 for work related to Ukrainian refugees.

Veterans

Personnel deployed to serve in international operations risk exposure to various forms of stress. The physical and mental health of most Norwegian veterans is good, but some have a variety of health problems. Surveys show that veterans who have experienced a great deal of stress or traumatic exposure during service tend to have a higher risk of developing health problems.

In the past few years, competence in veteran health has been built up in the municipal health and care services and specialist health service. The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have in cooperation with the Norwegian Armed Forces developed various training services for healthcare personnel and others who come in contact with this group in their jobs. For instance, a diagnostic and treatment course for doctors and psychologists has been created. All regions have a regional professional network for deployment personnel, which contributes to dialogue and collaboration between key actors, therefore strengthening competence in local and regional veteran work. A national professional network with key actors for veterans has also been established.

In 2023, the Government will present a new cross-sectoral plan of measures for following up and acknowledging veterans and their families before, during and after service in international operations.

Personnel deployed for international service, aid workers involved in international work and deployed personnel in Norway are other groups that may encounter exposure to stress and strain or traumatic incidents through their work and develop health problems. Work has been carried out in recent years on enhancing the general competence in the support services about reactions after exposure to traumatic incidents and trauma treatment. This could also be useful for personnel from international operations and other groups with such experiences.

3.6.3 Psychosocial preparedness and follow-up during a crisis or disaster

Psychosocial work is a key part of the municipalities’ services for preventing and remedying the impact of trauma after a crisis or disaster. Pursuant to the Health and Care Services Act, municipalities have a responsibility to offer help in the event of an accident and other emergency situations, including psychosocial preparedness and follow-up. This is part of the municipalities’ responsibility to provide for their own citizens. Municipalities must ensure that the needs of each person for health and care services are covered both in the short and long-term. The need for help must be individually assessed and cannot be standardised based on what role the person had in connection with a traumatising incident.53 For the affected with severe difficulties, it may be relevant to receive treatment from the specialist health service.

The Norwegian Directorate of Health’s guide on psychosocial measures in the event of a crisis, accident and disaster54 underscores the importance of a proactive approach to psychosocial follow-up. Proactive follow-up entails municipalities actively and directly approaching the affected person(s), and offering them support and assistance at an early stage. Further, proactivity means that after a period of time the affected person(s) is contacted again immediately after the disaster if they do not want/are not capable of accepting help. As part of the follow-up, it is recommended that the affected person(s) receives a permanent named contact person in the municipality, who can contribute with continuity and holistic follow-up. Even though a proactive approach is an important principle in psychosocial follow-up, it is important that the principle does not contribute to people abstaining from seeking help if they need it. It is therefore important that the municipalities give clear information on their websites about available support during a crisis situation (refer to Chapter 3.3 for a discussion on a single gateway to information.

Several support groups have been created after disasters and major accidents. Support groups can also have an important function by supplementing public and professional measures aimed at individual people. Experience shows that network support is crucial and may fill other needs that are not covered by public crisis work.55

The Regional Centres for Violence, Traumatic Stress and Suicide Prevention (RVTS) have cutting-edge competency on psychosocial preparedness and follow-up, and assist municipalities with competence enhancement, guidance and service support on the topic. The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) spreads research-based knowledge and knowledge dissemination regarding psychosocial follow-up in the event of various crises and disasters.

Experiences from, for instance, the quick clay landslide in Gjerdrum, the Ukraine war and other crises show that the ability of the health services to take care of the population’s need for psychosocial support is rapidly overrun in crisis situations. The Government will support the municipalities in the work on psychosocial preparedness and follow-up. In the National Budget for 2023, MNOK 5 was therefore awarded to the creation of a framework agreement regarding psychosocial assistance for municipal health and care services. The purpose is to give individual municipalities assistance in handling the population’s need for help during crises rapidly and efficiently.

The Ministry of Health and Care Services has started work on preparing a white paper on health preparedness. This is the first white paper to the Storting on this topic. The white paper will be overarching and provide guidelines for health preparedness. Psychosocial work will be discussed in the paper.

3.7 Prevention of suicide and self-harm

Suicide is a major public health and societal problem. Many people are affected by suicide and suicide attempts. During the last decades, considerable effort has been made to prevent suicide in Norway and many participate in the work. Despite this, the suicide rate has remained relatively stable the last 25 years. Men are overrepresented in suicide statistics. Approximately two out of three who commit suicide are men.

The Government is focused on suicide prevention and is following up the Action Plan for Suicide Prevention 2020-2025 – No one to lose.56 Eight ministries are working together on the plan.

With the action plan the vision zero for suicide was introduced. It is a moral value that we, as a society, have no to lose to suicide. All measures in the plan contribute to the work on vision zero. An important measure for following up vision zero is the establishment of a systematic work method where every suicide is reviewed. This will provide new knowledge about how suicide can be prevented – both within and outside the health and care services. Based on the findings of this systematic approach, new measures will be assessed. Initially, the method will be tested through a pilot study.

Many authorities, such as ministries, subordinate agencies, resource centres and regional health authorities are working on the measures in the plan. A new national forum has been established for suicide prevention with representatives from knowledge and resource centres, municipalities, the specialist health service and users, next of kin and suicide bereavement organisations. The forum is headed by the Norwegian Directorate of Health. To coordinate the effort across the sectors, an associated directorate cooperation on suicide prevention has been created.

The causes of suicide and suicide attempts are complex and linked to many different life factors. Work on suicide prevention is conducted in several ways in connection with creating an inclusive society, in general with the field of mental health and specifically with suicide prevention. The action plan has both a public health perspective and service perspective. Measures aimed at next of kin and the bereaved are also included in the plan.

A low threshold for seeking help and good accessibility can prevent suicide. It is well-documented that treatment for mental illness, particularly depression, and good treatment pathways in the health service, have a good suicide prevention effect. An important part of providing good help is therefore to ensure that patients receive the right treatment for their underlying mental illness. The prevention of self-harm and suicide is also an important part of work on public health. In addition to continuing the work on measures in the action plan, efforts in this escalation plan will therefore be significant to the suicide prevention work.

Self-harm among young people is widespread. International surveys show that on average 18 per cent of young people between the ages of 12 and 18 state that they have intentionally harmed themselves. The prevalence is highest among teenage girls, but boys also harm themselves. A Norwegian survey found a prevalence of around 16 per cent.57 Self-harm most frequently starts between the ages of 12-15, but can also start earlier or later, and the problem may be transient or longer lasting.58

There may be many complex reasons why someone harms themselves. Often self-harm starts as a coping strategy in a difficult life situation. Self-harm is an expression of something being wrong, but the underlying reason can vary. Research highlights some risk factors associated with why a person harms themself: underlying mental health problems, physical and sexual abuse, neglect, including psychological neglect, loss and separation, and individual risk factors, such as chaotic and overwhelming negative emotions.59 Good communication with those closest to the person and individual resilience may have a protective effect against self-harming behaviour. In order give the necessary help, it is important to carry out a broad assessment. Cooperation between services may be important for following up self-harming children and adolescents well.

There is an overlap between some measures for self-harm and suicide prevention, and self-harm is a risk factor for suicide. Self-harm is therefore addressed multiple places in the action plan for suicide prevention. Self-harm is also a topic in Proposition 121 S (2018–2019) Escalation Plan for Child and Adolescent Mental Health (2019–2024). In line with this escalation plan, the Norwegian Directorate of Health has been commissioned to start development work on self-harm prevention.

The Norwegian Directorate of Health has also prepared guiding material for the municipalities on self-harm and suicide prevention.60 The goal is to contribute to reducing the scope of self-harm and suicide in the population, and improved quality and more unified practices in the services. National guidelines on suicide prevention in the mental health service have been revised and expanded to apply to cross-disciplinary specialised treatment for substance use disorders (TSB) as well. These are undergoing consultation with the time limit being in June 2023.61

3.8 Good quality of care

Good quality health services means that the treatment is effective, and safe and sound. Further, it involves the users, is coordinated, accessible and exploits resources in a good way.

In order to create good services for people with mental health challenges and to ensure more equality in the services offered, it is necessary to have systematic user and next of kin involvement, increased focus on management, change work, quality improvement, and patient and user safety. It involves contributing to user and next of kin involvement at the individual, service and system levels, and giving more support and improved next of kin care. Further, it involves managers having the necessary formal managerial competence, good tools and elbowroom to take care of their tasks and responsibility, and that the services work on change and improvement in a systematic fashion.

The Government will strengthen the foundation for evidence-based health and care services. The Government will also facilitate increased use and better coordination of the assessments in ‘Nye metoder’ (New Methods) and the Norwegian Directorate of Health’s work on standardisation products in the mental health and substance use fields.

3.8.1 User and next of kin involvement

Uses of health and care services shall influence the set-up of the services offered. The goal is to contribute to improved health and care services. User involvement has been adopted as both statutory rights at the individual level, and as organisational guidelines at the service and system levels. Users have the right to participate, whilst service providers are obligated to involve them. Users and patients shall participate as equal parties in decisions concerning their own health and own services. Further, the input and overall experience of users, patients and next of kin should be used as a basis for service development and quality improvement. This is executed in cooperation with users and next of kin organisations, and by using user and next of kin surveys and various feedback tools as a basis for improvement work. Language barriers, etc., can lead to lower participation in next of kin organisations, surveys and feedback. It is therefore important that next of kin with an immigrant background are given access to adapted information and knowledge about who they should contact for help.

User and next of kin involvement at the individual level

User and next of kin involvement can be of major value to the individual. Real participation forms the basis for ownership and participation in one’s own treatment, a better adapted and appropriate service, and improves the relationship between patient/user and practitioner.

User experiences have demonstrated that the possibility for routine feedback through tools can make it easier to interact on goals, treatment planning and strengthen user involvement. Through feedback tools, the recipients of help answer routine questions on their own experience with changes and benefits of the help. In this way, the help can be adapted and make it easier to detect whether the person receiving help actually feels better.

Shared decision-making is a form of user involvement at the individual level which is done with healthcare personnel. Shared decision-making tools can be immensely helpful in this decision process. The tools give relevant and reliable information on different conditions and available treatment options for them. A national shared decision-making tool for psychosis been prepared in the mental health service. The regional health authorities have been commissioned to develop more of this type of tool.

Good user involvement at the individual level is also characterised by the services meeting users, patients and their next of kin from a coping and resource perspective. Further, participation also assumes that the services are organised in a way that safeguards the whole of the user and patient’s existence and life. User and next of kin involvement at the individual level do not play a big enough role in the services, and the right to be informed, participate and be involved is not fulfilled for many users and next of kin.

The Norwegian Institute of Public Health has a national function for measuring user-experienced quality in health services, and conducts surveys in both the primary health service and specialist health service. In terms of mental health, continual electronic measurements are carried out among adults in inpatient care in the mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). From 2022, the Norwegian Institute of Public Health will also be conducting surveys on patient experiences in the child and adolescent mental health service at every outpatient clinic in Norway. In summer 2023, a new major user and patient survey on how users and patients experience outpatient treatment services in the adult mental health service and cross-disciplinary specialised treatment for substance use disorders (TSB). The survey is a cooperation between the Norwegian Directorate of Health and Sintef and will provide important knowledge for further development of the service. One-hundred and four-thousand people will receive an invitation to participate in the survey. The results will be available at the beginning of 2024.

Children and adolescents have the right to participate and adapted information. The type of participation should be adapted to the child’s ability to give and receive information. It must be arranged for children to receive information about available and suitable types of services and investigation and treatment methods that exist which they can potentially choose between. Emphasis shall be placed on the child’s view according to the child’s age and maturity. The main rule is that children are responsible for decisions about their own health upon turning the age of 16. The legal position of children in health and care services is specially regulated in the Patient and User Rights Act. These provisions are designed, among other things, based on Article 12 of the Convention on the Rights of the Child.

Assessment of the rights of the child and consequences for the child may ensure safeguarding and highlighting the rights of the child in decision-making processes. Most of the measures the authorities propose will either directly or indirectly have consequences for the child. Assessment of the rights of the child ensures that the consequences for the child are mapped and the child’s best interests are assessed. The Ombudsperson for Children has prepared a practical guide on the Convention on the Rights of the Child, and how the authorities when proposing new measures can map the consequences for the child and assess the child’s best interests, etc.62

The Interpreting Act prohibits the use of children as interpreters, Public bodies must not use children for interpreting or other conveyance of information. Exceptions can be made in emergency situations, etc.

The Norwegian Directorate of Health is now developing national professional recommendations for user involvement in the mental health and substance use fields. It is planned that these will be launched in autumn 2023.

User and next of kin involvement at the service and system levels

User involvement at the service level means that user and next of kin representatives are drawn into service development and quality improvement in cooperation with professionals in the health services. The services must ensure that structures for collecting the experiences and views of patients and users are established, and that representatives for users and patients are heard when designing health services.

Further, the services should enable user and next of kin representatives to directly participate with their experiential-based knowledge in processes where service development and quality improvement work is carried out. User and next of kin knowledge should be weighted equally to clinical experience and research in accordance with the principles of practice-based knowledge. It may also be appropriate to employ peer support workers in the services.

Next of kin

Health and care services shall facilitate good cooperation with next of kin and offer necessary support. The services shall have systems and routines facilitating continuous information, and adapted and close dialogue with next of kin.

A lot is known about the importance of involving and supporting next of kin, particularly if children and adolescents are the next of kin of persons with mental health and/or substance abuse problems. Next of kin are often the patient or user’s most important support persons and in most situations they want to be a resource for the patient or user. The tasks attached to caring and being responsible for their close family member are highly demanding. Next of kin are also important to the services, and can contribute with important information to give the best possible treatment.

The services are not adequately adapted for a whole family perspective when one or more family members have mental health challenges. The knowledge base shows that it is important to direct the effort at families where there are mental health problems and/or addiction problems. This applies to preventive municipal work on public health, early intervention and upbringing, in treatment and in research.

Healthcare personnel shall contribute to taking care of the need for adapted information and follow-up that minors may have when a parent or sibling is a patient suffering from mental illness, substance dependence or a severe somatic disease or injury.63 Surveys have shown significant shortcomings in taking care of children and adolescents as next of kin.64

The Norwegian Directorate of Health has recently carried out a national next of kin survey. The purpose of the survey was to contribute to more insight and knowledge about how young next of kin (aged 16-25) live their lives, how they experience their situation and their needs. Among other things, the survey shows the negative impacts on young next of kin, and that they consider their mental health quite a lot worse than youth in general. Those who are next of kin to someone with mental illness state their own health as worst.

The Women’s Health Commission (NOU 2023: 4) recommends a commitment to increasing the competence of personnel about next of kin and next of kin cooperation.

The Government will contribute to improved cooperation between the services and next of kin. The Government has therefore requested the Norwegian Directorate of Health to prepare a tool in the form of a next of kin agreement, which will form the basis for good routines for such cooperation. The agreement contributes to structuring by clarifying roles and expectations, and gives predictability and sufficient adapted information. The agreement will ensure systematic participation, mutual information exchange, and next of kin experiencing that they are noticed.

The next of kin strategy and action plan Vi – de pårørende 2021-2025 (We – the next of kin) shall contribute to improving the situation of next of kin, and take care of and include them. One of the main measures in the strategy is the grant scheme Helhetlig støtte til pårørende med krevende omsorgsoppgaver (Holistic support for next of kin with demanding care tasks). The scheme shall enable municipalities to develop models for improving the situation of next of kin, and shall contribute to highlighting, recognising and supporting next of kin with demanding care tasks. To contribute to adequate help and follow-up of next of kin for persons with mental health and addiction problems, the grant was increased in 2023.

3.8.2 Equity of care and adapted help

Equal health and care services shall be offered to the whole population. Social categories such as disability, sex, gender identity, ethnicity and sexual orientation may coact and affect living conditions and the mental health of some people. Regardless of these factors, everyone shall have access to services when required. It is important that those who work in the services are familiar with diversity, so they can take care of everyone as best as possible.

A person’s language proficiency shall be irrelevant when it comes to receiving the correct and adequate help. The Act relating to public bodies’ responsibility for the use of interpreters, etc. (Interpreting Act) sets the requirement of using qualified interpreters when needed. The Act shall contribute to ensuring legal protection, and proper help and services for people who cannot adequately communicate with public bodies without an interpreter.

Disabled people

Disabled people have the same right to good quality health and care services as anyone else. The right to health also includes the right to the health and care services one particularly needs due to disability.

In Statistics Norway’s survey on living conditions in 2019, almost 30 per cent of people with a disability between the ages of 20-66 said they had severe mental health issues.65 There is a clear difference between the population at large where ten per cent stated the same. Disabled people also state that they are less satisfied with their own mental health, suffer from loneliness more, and are more dissatisfied with life than the population on the whole.66 The Norwegian Federation of Organisations of Disabled People (FFO) point out in the report Koble kropp og sinn – sammenhengen mellom somatisk sykdom og psykisk helse (Somatisation and the Mind-Body Connection) that many people with a disability and chronic disease find that they do not receive the follow-up they are entitled to, that waiting times for talking to someone with psychological expertise are long and that healthcare personnel with psychological expertise lack knowledge on somatic health.67 Among other things, it is pointed out that increased knowledge of mental health in support services that meet disabled people and the chronically ill is needed, in addition to more interdisciplinarity, increased coordination between services and better mapping of the patients’ need for follow-up.

Adequate competence is a prerequisite for good, efficient and safe services. Personnel, who offer services to disabled people, must have sufficient knowledge and competence to offer services in a professionally sound and good manner. By detecting early signs of developing illness, worsening mental health, loss of functional ability or problems, measures for changing, improving or mitigating potential worsening can be initiated early. This requires the services to meet each individual based on earlier needs and prerequisites with a holistic approach above and beyond the disability or illness. A person-centred approach can contribute to safeguarding mental, social and existential needs, and increased trust and confidence.

Services for the Sami population

The Ministry of Health and Care Services has a special responsibility for facilitating essential health and care services for the Sami population. In order for these services to meet the Sami population’s needs, sufficient knowledge is needed on the risk factors for developing illness, and accessibility and quality of the services. This might be language and cultural issues related to communication between Sami patients, and the health and care services. The contributors to the escalation plan also point out a lack of low-threshold services adapted to the Sami population (refer to Chapter 3.2.2 for a more detailed discussion on evidence-based low-threshold services within mental health and substance use).

Some studies indicate that the prevalence of anxiety, depression and dissatisfaction with life may be higher among the Sami people.68 In 2020, the Norwegian Institute of Public Health conducted a population survey in cooperation with the counties. An additional model prepared by the Centre for Sami Health Research was included for the northernmost counties regarding, among other things, the Sami people. The survey included questions on health, lifestyle, living conditions and quality of life. The responses from Nordland County show that the majority of the participants reported good or excellent health, however, for Sami women and men fewer stated that their health was good. Women reported mental health issues more than men. This applies regardless of ethnicity.69 At the same time, young Sami people report high resilience and a relatively strong feeling that life has meaning.70 Surveys conducted by the Centre for Sami Research have also shown that the prevalence of most forms of violence is higher among the Sami people than non-Sami people in the same geographical area. This particularly applies to Sami women.71 Mental health challenges was more widespread among those who had experienced domestic violence and violence in childhood, regardless of sex and ethnicity.72

Sámi Klinihkka was formally opened in January 2020 offering specialist health services within somatics, mental health, substance abuse and dependence, and is adapted to the language and culture of the Sami population. The clinic comprises a specialist doctor centre and Sami national competency service – Mental Healthcare and Substance Use (SANKS). SANKS is organised as six clinical units consisting of a national team that shall help promote equal and culturally adapted treatment for Sami people across the whole of Norway.

To contribute to building up and improving the quality of the health and care services for users who speak Sami and have a Sami background, a separate grant scheme has been established for professional development and competence enhancement. These measures will be aimed at areas that include citizens with a southern, northern and Lule Sami language and culture. The grant will contribute to acquiring, initiating and disseminating knowledge of the needs of Sami citizens receiving municipal health and care services, and to address how these needs can best be met. It will also help to improve competency among health and care professionals who provide services to Sami users. It will also help to improve competency among health and care professionals providing services to Sami service users.

The Centre for Health Research (SSHF), Sámi dearvvašvuodadutkama guovvdáš, is allocated support for basic funding through the Storting’s annual budget resolution. In addition, the Government has set aside funds for completion of SAMINOR 3. The SAMINOR surveys on health and living conditions is the centre’s most important research project. SAMINOR is one of the most important sources of knowledge about the health and living conditions of the Sami people and population of northern Norway. The purpose is to gain knowledge about the prevalence of illness and risk factors related thereto, prevent disorders and improve health services for everyone.

The Government has decided that the theme for the white paper on Sami language, culture and civic life in 2024 will be public health and living conditions in Sami areas.

LGBT+

The LGBT+ community are one of the groups with the lowest subjective quality of life in Norway.73 This group also had the highest decline in satisfaction during the COVID-19 pandemic. Compared to the population at large, sexual and gender minorities are more exposed to bullying and social exclusion, hateful comments and violence in public spaces, violence in close relationship and sexual violence. LGBT+ people also have a higher risk of developing health issues and problems, self-harm, suicidal thoughts and suicide attempts compared to the rest of the population.74 Bisexual women and transgender people report more symptoms of anxiety and depression than other LGBT+ people.75

The LGBT+ community is complex, and the level of vulnerability and experienced discrimination varies immensely. At the same time, the interactions between the various vulnerability factors are complex, and health-promotion and prevention efforts must be implemented across the public sectors to ensure good care. Knowledge of and awareness of this complexity is a prerequisite for designing public services, including health and care services, which effectively are equal.

The Government will improve the living conditions of LGBT+ people and therefore launched an action plan for gender and sexual diversity in spring 2023. The action plan will apply up until 2026 and include a special commitment to improving the quality of life of LGBT+ people, secure their rights, and contribute to greater acceptance for gender and sexual diversity. In addition, the Ministry of Health and Care Services has created a new grant scheme with the goal of good mental health and quality of life, and more equal health and care services for groups in the population who break away from the standard genders and sexuality.

People with an immigrant background

As per 2022, immigrants and Norwegian-born people with immigrant parents account for just over one million citizens in Norway. This is a diverse group with, among other things, many different migration stories. length of residency in Norway, experiences and Norwegian language skills. The migration process involves settling in an unknown country and adapting to a new culture, in addition to experiences in the country of origin prior to leaving. All the phases are associated with situations and experiences that may impact health, particularly mental health. The percentage of immigrants with a high level of mental illness is on average slightly higher than in the population otherwise. In some groups, stigmatisation and taboos are also attached to mental ill-health.76 Further, experienced racism and discrimination can also significantly impact mental health.

The Government has started working on a new action plan against racism and discrimination on the basis of ethnicity and religion, which according to plan will be presented during the course of 2023. The main topics in the plan are climbing the ladder in the labour market, and the experiences of youth related to racism and discrimination in social arenas, such as school, education, the voluntary sector, leisure and social media.

3.8.3 Leadership, quality improvement and patient and user safety

In order to create good and safe services for people with mental health issues and disorders, good management and systematic work on quality improvement and patient and user safety are essential. Quality improvement is a continuous process on improving current practices, testing out innovative ideas and applying research-based knowledge in practice. The regulations on management and quality improvement highlight the responsibility of the enterprises in this work.

The holistic and systematic national work on quality and patient and user safety will be incorporated into the National Health and Collaboration Plan.

Fewer professionals per patient in the future with the attached challenges connected to recruitment and retaining competent personnel indicates an increasing need for the services to work on quality improvement and patient and user safety in an evidence-based and systematic manner. On top of this, there are rapid medical and technological developments that set new competency requirements and create expectations on the part of patients, users and next of kin (refer to Chapter 1.6 for a discussion on personnel and competence).

Management entrenchment is an important prerequisite for systematic work on quality improvement and patient and user safety, a good and safe working environment, and adaptation for professional development and evidence-based practice. The span of control (the number of employees per manager) in the health and care services is extremely high, at the same time as formal managerial competence is low. This has major consequences for the working environment, including sick leave and turnover, staffing and quality of the services. In order to contribute to increased managerial expertise in the health and care services, the Government will continue and strengthen management education for the primary health service and specialist service.

The Ministry of Health and Care Services will also facilitate the development of a short online manager training programme corresponding to the online manager training programme for GPs, and other managers in municipal health and care services. Given the substantial work pressure and numerous managers, a formal manager training programme should be designed to allow as many managers as possible to take the programme and reach a higher level of expertise. In order to enable managers in municipal health and care services to easily gain an overview of various tools and manager competency measures, the Norwegian Directorate of Health has been commissioned, along will relevant actors, to develop the programme. Increased attention on core tasks, innovation, reorganisation and improved work sharing requires good management. The Government will support trust-based governance and management, so the services can to a larger extent develop services and test new work methods.

The Norwegian Directorate of Health points out that continuous work on quality improvement is not given sufficient priority in the services or at the system level. An important reason for this is the lack of time and resources, but also insufficient improvement knowledge and research competence, access to tools, support functions and research infrastructure, and good insight into the effects of such work. Some experience systematic quality improvement as a new area where work methods and processes are unknown. Systematic work on quality improvement, knowledge development and research can with preference be looked upon as an activity that takes place parallel to ordinary operations.

Good data is important for planning, implementation, research, evaluation and, not least, correction of one’s own practices. This means that the whole of the quality improvement cycle, on which regulations on management and quality improvement are built, must be taken into use. The Norwegian Board of Health Supervision has pointed out that the services are quite good at planning and implementing measures, but less so at following up the measures with evaluations and corrections. The Office of the Auditor General of Norway found in its survey on the boards of directors follow-up of quality, that the boards in the specialist health service rarely requested the effect of measures.77

For the municipal mental health and substance abuse services, performance data is still lacking. The Norwegian Directorate of Health points out that neither the municipalities, county governors nor the Norwegian Directorate of Health have sufficient data to observe developments in the services. The municipalities need simple adapted statistics to use in planning, managing and quality improvement.

State and municipal reporting (Kostra) and the Norwegian Registry for Primary Health Care (KPR) are statutory reports which take care of the central authorities’ need for data from the municipalities. IS 24/8 is Sintef’s annual mapping commissioned by the Norwegian Directorate of Health in all the municipalities/boroughs in Norway. The goal of the mapping is to observe the trend in resource use in municipal mental health and substance use work over time.

The purpose of the Norwegian Registry for Primary Health Care (KPR) is provide a basis for planning, managing, funding and evaluating municipal health and care services. The KPR does not at the present time contain data on the mental health and substance use fields. The Government will therefore start work on further developing the registry so it also includes data on mental health and substance use. This will contribute to knowledge development and better municipal service data for observing developments in this field. There is also a need to further develop the Norwegian Patient Registry (NPR) to give better and more all-encompassing event history analyses.

3.8.4 Research, development and innovation

The possibilities for knowledge development and participation in research and innovation activities contribute to improving quality and patient safety in the services, a better basis for setting the right priorities, more effective prevention and helpful treatment, in addition to updated and more motivated professionals. In the long-term, it may lead to better use of society’s resources.

The Government wants health data to be better used in research, more research-based quality improvement projects and for clinical research to be an integral part of patient treatment for mental health. More knowledge about the organisation, control and management of the services, work-saving innovations in the face of a short supply of healthcare personnel and implementation research will be important moving forward. The topic will be followed up in the National Health and Collaboration Plan.

Distribution of research funding from national and European sources shows that mental healthis the therapy area that receives the most funding for research followed by cancer and general relevance to health.78 Mapping carried out in 2019 shows that most research funding was used for research on psychoses and schizophrenia, depression and dependence. In 2021, research on mental healthcare constituted 11.6 per cent of all research efforts.79 In the European Union’s research and innovation framework programme, Horizon Europe, there has been more calls for proposals related to mental health in the programme’s health priorities. This is partly due to the consequences of the COVID-19 pandemic and partly because the area represents a large and growing disease burden in Europe.

Increased knowledge development must be facilitated in municipal health and care services in line with the Government’s Long-term plan for Research and Higher Education. Results from research must be made available, conveyed and used. The Government will facilitate more research relevant to the municipalities’ need for knowledge, and investigate how the municipalities can receive better support and guidance in their knowledge development work on mental health and substance use.

The National Programme for Clinical Research in the Specialist Health Service (KlinBeForsk) shall accommodate the need for more high quality national clinical trials. The purpose is that more patients across the whole of Norway will be invited to participate in clinical trials. The programme will contribute to coordination of competence, resources and infrastructure. In 2022, research on clinical treatment for child and adolescent mental health was particularly prioritised.

Knowledge about the effect of measures is an important prerequisite for setting the right priorities. This means that measures that have a documented effect should be implemented instead of measures where the effect is more uncertain. As a follow-up of Meld. St. 38 (2020–2021) Health benefit, resources and severity, the Ministry of Health and Care Services has commissioned the Norwegian Directorate of Health to prepare a national professional guide on setting priorities in municipal health and care services. The guide will be an important decision-making support tool when the municipalities set their priorities.

Preventive measures generally take place outside the health and care services, which requires a cross-sectoral research effort (refer to Chapter 2 for a discussion on health promotion and prevention measures).

The Office of the Auditor General of Norway’s survey on mental health services concluded that the work on increasing knowledge about mental health issues and disorders is not good enough. Among other things, it was found that they lacked knowledge about which type of treatment was effective for several mental issues and disorders.80 A general problem when researching mental health measures is that causation is complex and unknown, and compared to somatics it is more difficult to identify objective and measurable endpoints. Treatment is also more context-dependent, and there is a wider variety of measures and study designs in research on mental health than what is common within somatics.

Activity in research on personalised medicine in mental healthcare has increased.81

3.8.5 Evidence-based care

Healthcare personnel shall work in an evidence-based manner. Evidence-based practices involves taking professional decisions based on systematic collection of research-based knowledge, experiential knowledge and the patient’s wishes and needs in a given situation.82 At the same time, it is important that evidence-based methods are applied. A distinction must be made between the extent to which sufficient documentation of the effect of different treatment methods actually exists and whether the knowledge has been implemented in the services. An Australian review from 2018 shows that we do have knowledge about treatment for most mental illness.83 At the same time, more research needs to be conducted on patients in Norway and what is needed to increase the use of knowledge in practice. Knowledge is not sufficiently used in the services, and facilitation of local adaptations and the evaluation of effects when implementing and spreading innovations and research results through systematic use of health data, health services and implementation research is required.

In order to offer the best treatment to patients, the services must have access to updated knowledge, and they must have routines for further educating personnel. This applies to the municipal health and care services and specialist health service alike. The national patient pathways provide external frameworks, whilst national professional guidelines provide directions for the organisation and professional content of investigations and treatment of each single condition. To ensure adequate treatment, the professional guides must cover the most common disorders and be updated regularly. The guidelines must also clearly state the distribution of responsibility and tasks between municipalities, the specialist health service and other relevant actors.

The mental health service must have routines for examining the effect of treatment that is given. Good effect goals include both symptoms and level of functioning, and patients must regularly be asked about any experienced benefits from the treatment. New medical quality registries for mental healthcare will provide national infrastructure and data as a basis for systematic work on quality improvement and patient user safety in the services. National guidelines and national patient pathways for mental health and substance use recommend using feedback tools during treatment. With systematic use of feedback tools, continuous feedback is received from the person receiving help about any experienced changes and benefits from the help. The feedback tools can identify and prevent negative outcomes from the treatment and contribute to more adapted help.84 Several services have started using various feedback tools. At the same time, work still has to be done on assuring patients and users access to such tools.

Healthcare personnel, who are up to date on research, have better ability to critically assess established and diagnostic methods, offered treatment and technologies. In its survey on mental health services, the Officer of the Auditor General of Norway found that the possibilities for participating in research on mental healthcare were worse than for somatics in relation to opportunities for sideline jobs and leave of absence for research. In research on schizophrenia, it has been found, among other things, that clinical research has the greatest impact on subsequent changes to clinical practices and that the largest social and health benefits are achieved through interdisciplinary research teams.85

Better knowledge is important for making decisions on the introduction of new methods. It is also important for phasing out methods that are used today, but do not have the desired effect. For instance, the need to strengthen documentation of pharmacological or other treatment methods that the service started using before the establishment of ‘Nye metoder’ (New Methods) (see below for further discussion) and the introduction of guidelines stating that new medicines must be methodologically assessed.

‘Nye metoder’

‘Nye metoder’ (New Methods) is a system in the specialist health service for assessing both the introduction and phasing out of methods based on evidence. ‘Nye metoder’ can basically assess all measures used for prevention, investigation, diagnosing and treating illnesses, including measures for rehabilitating patients and organising health services. ‘Nye metoder’ is not limited to specific professional fields, but an overview of methods that are reported show that methods for treating mental illness are only registered in a very few cases. It relies on the industry, professional environments, service, patient and user organisations, etc., reporting relevant assessment methods and the existence of a documentation basis for assessing the methods either nationally or through mini-method assessments in the health trusts.

If the evidence basis for the measures to be assessed in ‘Nye metoder’ is lacking, it has been arranged for these to be registered in the program for clinical research on treatment in the specialist health service, as a relevant need for evidence. This is part of their adaptation to so-called user-identified research. The user-identified research instrument is characterised by processes where special needs for knowledge are identified and constitute the basis for special calls for proposals for research funding. This instrument can be used within all relevant therapy fields where more certain knowledge is needed.

Several health regions have made adaptations for assessing new methods within mental healthcare and cross-disciplinary specialised treatment for substance use disorders (TSB) through linking professional environments within mental health and substance use to ‘Nye metoder’. ‘Nye metoder’ could be a relevant instrument for building up evidence-based practices in the mental health service in that the basis for knowledge that is presented for the methods is systematically reviewed with a methodological assessment. This knowledge can be disseminated through coordination of the decisions in Nye metoder with normal products, such as treatment guidelines, guides, standardisation products, etc.

Standardisation products

The Office of the Auditor General of Norway demonstrated in its report on mental health services that more than half of the national guidelines and guides on the mental health field had not been updated the past four years.86 The Norwegian Directorate of Health’s work on reviewing standardisation products in the mental and substance use fields is ongoing. In 2022, the recommendations for using mapping tools were updated.

In 2023, an overview will be prepared of the proposed prioritisation of recommendations that need updating and which can be unpublished. Possibilities for improving the work process when developing standardisation products will also be considered.

National medical quality registries

There has been a great commitment to the development of new medical quality registries in mental healthcare since 2019. In 2022, three new quality registries within mental healthcare received national status (refer to Box 3.17 for an overview of which). The Quality Registry for Child and Adolescent Mental Health Care applied for national status in 2022. The Norwegian Quality Registry for Eating Disorders received national status in 2015.

Medical quality registers contain structured information about investigations, treatment and follow-up, which makes it possible to assess the quality of patient treatment. Knowledge from the quality registers shall contribute to improved quality and patient safety. A national registry makes it considerably easier to assess whether one’s own practices comply with national professional guidelines and whether the treatment has the desired effect. Quality registries also uncover whether there is undesired variation in the treatment offered in Norway. The quality registries are an important source for researching the effect of different treatment initiatives.

National services in the specialist health service

National services a joint term for national treatment services, multiregional treatment services and national competency services in the specialist health service. National and multiregional treatment services include highly specialised treatment that should be centralised in one or two places in Norway. Centralisation of the treatment offered shall contribute to health benefits in the form of better prognoses and quality of life for the patient, improved quality and competency in the treatment, and better national cost effectiveness.

A national advisory unit shall within a period of five or ten years secure national competence building and competence dissemination within its specified area of expertise. The establishment of an advisory unit will not lead to centralisation of patient treatment or competence, but to competence enhancement in the field nationally. The goal is that after the function period of the competence service ends, its areas of expertise will be safeguarded by all the health regions that are part of the ordinary services offered albeit with the possibility of continuation under the auspices of the regional health authorities as a national quality and competence network, centre or by other means.

The system for national advisory units shall be dynamic with the possibility to establish services in areas where competence building and dissemination is needed, including mental healthcare and substance use.

The regional health authorities are responsible for applying for approval to establish new national services. Several of today’s mental health advisory units were established approximately ten years ago. This applies to the Sami National Advisory Unit on Mental Healthcare and Substance Use (SANKS), the Norwegian National Advisory Unit on Concurrent Personality Psychiatry (NAPP) and the Norwegian National Advisory Unit for Concurrent Substance Abuse and Mental Health Disorders (ROP). The frameworks for establishing and creating the national advisory units will be discussed in the National Health and Collaboration Plan. During the plan period, it will be relevant for the regional health authorities to assess the need for advisory units in the areas that underpin the goals in the plan.

National and regional resource centres outside the specialist health service

In addition to the national advisory units in the specialist health service there are a range of national and regional resource centres for mental health, substance use and violence outside the specialist health service. These are important for the development of competence in mental health, substance abuse and violence. In addition, they are key suppliers of knowledge for the services, contributors when implementing knowledge in the services, and professional advisers for public authorities and services. The centres should be a service both for the services, and the preventive and health promotion activities in the municipalities.

The centres shall operate or participate in the summary of research in their own field, participate in practice-orientated and practice-relevant research, and participate in relevant research networks. The Healthcare Personnel Commission considers that the potential of the resource centres and advisory units has not been realised. In the Commission’s view, it is necessary to investigate how they can be developed through linking the centres tighter to the health and care services to help improve the quality of the services offered in the municipalities and special health service.

During the plan period, the Government will investigate how the municipalities can receive better support and guidance in their work connected to mental health and substance use In connection with this, it should be assessed whether resource centres are organised in the most appropriate way. The Ministry of Health and Care Services shall in consultation with the affected ministries investigate more unified organisation of the resource centres outside the specialist health service with the aim of establishing a more holistic system for better and more coordinated support to the municipal sector. The basis for the investigation is a decentralised structure with expert environments in proximity to the services. The Government will return to the Storting about this matter in an appropriate manner.

The BarnUnge21 strategy, which was finalised in 2021, also recommended a review of the role of the advisory units and resource centres in the production of knowledge, knowledge dissemination and the application of knowledge with the aim of highlighting their mandate and role in a holistic and evidence-based childhood policy. It was recommended that the review should look more closely at the extent to which all expert areas are covered and the organisation contributes to children and adolescents receiving equal, safe and effective services, regardless of geography. This recommendation with be assessed in the forewarned investigation on more unified competence centres outside the specialist health service. The Ministry of Health and Care Services cooperates with, among others, the Ministry of Children and Families in relation to how the recommendation will be followed up.