4 Services for people with long-term and complex needs

People with long-term and complex needs shall receive good and cohesive help. A great deal of effort has been made to ensure this over a prolonged period of time, but further development is still needed to provide good and proper help. The Government will therefore strengthen the whole treatment chain for people with long-term and complex needs and contribute to increasing the life expectancy of people with mental illness and/or addiction problems. This priority area requires measures for people who need long-term and comprehensive help, including services for those with severe mental illness.

4.1 Basis for the priority area

Many with severe mental illness have a good quality of life and live meaningful lives. At the same time, having a severe mental illness may have personal and social consequences for the individual. Mental illness can lead to exclusion, and many still experience stigmatisation attached to their illness. Severe mental illness might be associated with disability, unemployment, sick leave, physical diseases and reduced life expectancy.1

Mental health, substance use and somatic health must be seen in relation to each other. The number of people with a somatic disease, who also have psychosocial burdens, is increasing.2

Many patients in somatic departments have substance use-related health problems, and some patients referred for cross-disciplinary specialised treatment for substance use disorders (TSB) have levels of co-morbidity3.

As a group, people with severe mental illness and addiction problems live significantly shorter than the general population.4 Inspections have shown that the mapping and follow-up of this group’s somatic discomfort is lacking, and studies show that premature mortality can largely be attributed to somatic diseases. Even though a large percentage of people with mental illness do not have an addiction problem, we know that mental illness and addiction problems or addiction disorders often occur concurrently.5 There are several challenges attached to services for people with severe mental illness and/or addiction problems. Internal collaboration in the health and care services and between different services and sectors is particularly challenging. The Health and Social Services Ombudsman has several cases showing that collaboration and coordination between the specialist health service and municipalities has failed.6

According to the Office of the Auditor General of Norway, some municipalities do not offer outreach services to citizens with addiction and/or mental health problems.7 The municipalities have problems acquiring adapted housing services for the target group, particularly those with a comprehensive need for services and problems with violence.8 The number of people committed to compulsory psychiatric care and committed to compulsory treatment has increased considerably in recent years. Reports and inspections show that both the municipalities and specialist health services have problems ensuring good and coordinated services for people who represent a safety risk and simultaneously safeguarding civil protection.9

Youths with concurrent mental illness and addiction problems do not receive adequate treatment and follow-up. This is demonstrated in the Office of the Auditor General of Norway’s survey on mental health services and the projections of the regional health authorities. Additionally, there are still, despite many years of efforts, major challenges attached to healthcare for children under the care of the child welfare service. Children with comprehensive challenges experience insufficient cross-sectoral cooperation which prevents holistic follow-up. This also applies to children and youth completing sentences.10

Even through many years of commitment to work-orientated measures in combination with medical follow-up and treatment, some municipalities still do not offer evidence-based work-orientated measures, such as individual job support and job-coping follow-up.11 These measures are important because employment and meaningful activities are key factors for improvement, quality of life and a dignified life. Many with mental health issues and addiction problems may have problems completing education and building up work experience. Work and activities as part of treatment are discussed in more detail in Chapter 3.5.

It is essential to ensure good support for next of kin, including children as next of kin. Many next of kin of people with long-term and comprehensive needs, and children who are next of kin, are highly burdened when it comes to their own health and quality of life. The degree to which next of kin are involved in treatment and follow-up, and whether children in the capacity of next of kin are followed up, varies immensely (refer to Chapter 3.8.1 for a more in-depth discussion on user and next of kin involvement).

4.2 Increased life expectancy

People with severe mental illness and/or addiction problems have poorer physical health and, as a group, have a much shorter life expectancy than the population at large. Life expectancy depends on a range of factors, inter alia, living conditions and type of disorder. Mortality is also particularly high among people with severe mental health disorders and concurrent problems with substance use.12 Surveys show that the difference in longevity between people with severe mental illness and/or addiction problems, and the general population is at least 15 years.13 People with mental illness shall have the same possibilities to live a long and good life as the rest of the population. This also applies to children and adolescents with comprehensive needs, including those under the care of the child welfare service. The Government has therefore set a performance measure in the escalation plan stating that people with severe mental illness and/or addiction problems shall have a higher life expectancy, and the difference in life expectancy between this patient group and the rest of the population shall be reduced. In order to contribute to this, a holistic plan to increase the life expectancy of people with mental illness and/or addiction problems will be prepared, and an indicator for premature mortality due to non-communicable diseases among people with severe mental illness and/or addiction problems will be established.

There has been an increase in the prevalence of unnatural deaths among people with mental illness and substance dependence, such as suicides, accidents and overdoses, however, the excess mortality can largely be attributed to somatic disorders for which there is treatment. There can be many explanations for excess mortality, such as genetic vulnerability related to mental illness, lifestyle habits, psychosocial stress and loneliness, cognitive issues, side effects of medicines and poor diagnosis, and delayed or insufficient treatment of somatic disorders. The difference in life expectancy is increasing, and emerges in both national and international studies. The conditions in Norway are equal to those in other Nordic countries.14

Analyses performed by the health atlas service provided by Førde Health Trust in 2017/2019 showed that the use of somatic specialist health services systematically varied in different parts of Norway for all examined illnesses. They did not find the expected increase in the use of the somatic specialist health services for people receiving mental healthcare or cross-disciplinary specialised treatment for substance use disorders (TSB) compared to people without such contact. Increased use was expected due to higher risk of somatic diseases in this group compared to the population in general. The finding indicates underuse of somatic specialist health services for this patient group.

Severe mental illness and addiction problems also often lead to reduced oral health, among other things, due to the use of medications and substances. Poor oral health can also impact mental health. The Government has established a public committee to review the dental health field. The committee will carry out a comprehensive review of public health services, including organisation, funding and legislation, including regulation and rights. The committee will deliver its report at the end of June 2024.

Mental illness, somatic diseases, including dental and mouth cavity diseases, and problematic use of substances may be linked. Treatment in the health and care services should therefore be seen in relation to each other. In national patient pathways for mental health and substance use, a separate product has been prepared with summarised recommendations and measures to ensure better safeguarding of somatic health, including dental health, in people with mental illness and/or addiction problems. The prepared recommendations apply regardless of the level of treatment and describes, among other things, the distribution of responsibilities between municipalities and the specialist health service. The goal of the measures is to contribute to improved health, increased quality of life and increased life expectancy for this patient group. The importance of including somatic diseases is also acknowledged in a new and extended national pathway for child protection, where any somatic health issues, dental health and sexual health problems will be mapped in addition to mental health and substance use.

It is still necessary to strengthen the work on better follow-up of somatic health, dental health and lifestyle habits, particularly for those with severe mental illness and substance use disorders.

Along with other healthcare personnel, GPs are important in the work on taking care of the somatic health of patients with mental illness and/or addiction problems. This requires GPs to have good relationships with patients and good cooperation with other parts of the health and care services. GPs must also have time to prioritise this work. For instance, to stimulate this work a separate rate has been introduced which can be used for full annual checks on vulnerable patient groups. This applies to patients with a comprehensive need for help combined with less ability to ask for help, such as patients with long-term psychotic disorders. At the same time, it is necessary to highlight the groups it concerns, and increase the use of GP check-ups for people with severe mental disorders. The Government wants an effort for the GP service (refer to Chapter 3.2.3).

Co-localisation of services within mental healthcare, substance use and somatics contributes to the facilitation of somatic health services to patients with mental illness and addiction problems. Co-localisation of somatics and mental healthcare departments has been on the agenda for several years, since different forms of localisation create challenges for internal coordination in the specialist health service. This particularly applies to people with conditions within old age psychiatry (dementia disorders), psychosis, severe depression, eating disorders and addiction problems in acute phases. Through co-localisation of mental healthcare, substance use and somatics, it is possible, among other things, to facilitate the treatment of multiple conditions that a patient may have in the same place and at the same time, thereby providing a basis for more holistic and coordinated treatment pathways.

Death from overdose is one of the major causes of death among young people worldwide. For the last few years, Norway has had one of the highest registered prevalence of drug-induced deaths per inhabitant in Europe. The National Overdose Strategy 2019-2022 gave directions for the overdose-prevention effort and illuminated measures to face the challenges. In 2023, the Norwegian Directorate of Health has been commissioned to continue the National Overdose Strategy, which will be strengthen the effort against overdose deaths.

Norway has committed to the global targets set by the World Health Organization (WHO) for the period 2010-2025 for reducing premature mortality caused by non-communicable diseases (NCD) by 25 per cent. The goal of reducing premature mortality is continued in the global sustainable development goals with the target of reducing premature mortality by one third by 2030 compared to 2010. Mental illness is included in the disease categories.

In connection with the work on a new national NCD strategy and integration of mental illness in the NCD work, the Norwegian Institute of Public Health prepared a proposal with indicators for morbidity and mortality related to mental illness. The morbidity indicators included a prevalence of 30 days with anxiety and depression, and 30 days of alcohol use disorder. The indicators for mortality included suicide, drug-induced deaths and excess deaths caused by non-communicable diseases among people with severe mental illness. A new comprehensive NCD strategy will be presented.

In January 2023, the Norwegian Medical Association published its report Bedre helse og lengre liv (Better health and longer life) with recommended measures for increasing life expectancy among people with mental illness and/or addiction problems. The report points out that patients with severe mental illness or substance use disorders and dependence need special measures and extra effort in getting health services that are equal to those offered to the general population. In order to actually improve the mental health of these people, it is necessary to implement a range of measures at several levels simultaneously. The Norwegian Medical Association recommends a national effort for improved somatic health and life expectancy with severe mental illness/substance use disorders.15

The Government will contribute to increasing the life expectancy of people with mental illness and/or addiction problems by preparing a comprehensive plan with measures. The key measures will be the prevention of somatic health problems, improved investigation and diagnosis of somatic diseases, and better routines for cooperation between the municipal health and care services and the specialist health service. Measures for increased physical activity, improved living conditions and quality of life shall also be included in the plan. The plan must also be viewed in relation to efforts for preventing unnatural deaths in this group. As part of this work, the Norwegian Directorate of Health has been commissioned to draft proposals for measures and instruments for better access to diagnosing, investigation, treatment and follow-up of somatic health problems and disorders for people with concurrent addiction problems and mental illness focusing on the municipalities’ responsibility for the group.

Measures in a holistic plan that aims to improve living conditions and quality of life will also include measures for children and young people with complex needs such as children in care. It will be necessary to prepare several indicators to observe the performance measures of increased life expectancy for people with mental illness and/or addiction problems. An important part of this will be making sure that children under the care of the child welfare service who need treatment for mental health issues or disorders receive mental healthcare (refer to the discussion on children and adolescents, and services for the child welfare service in Chapter 4.4.2).

4.3 Cohesive services and pathways

The Government wants patients to experience holistic patient pathways where the different parts of the services cooperate effectively. This is particularly important for people with long-term and complex needs. Through the escalation plan, it will also be arranged for the services to reach more people who need integrated and outreach services. Among other things, the Government will continue and further develop outreach services, such as ACT/FACT and Youth FACT.

4.3.1 Good patient pathways

Many patients, users and next of kin experience fragmented health and care services. The goal is for patients to experience holistic patient pathways where the different parts of the services cooperate effectively. The Government’s primary measures for collaboration and patient pathways will be discussed in the National Health and Collaboration Plan.

Many municipalities and health trusts already cooperate effectively. Notwithstanding additional efforts and measures are still needed to support collaboration. Collaboration problems exist internally in the municipalities and in the specialist health service, and between municipal services and the specialist health service, and within each single service and across the sectors. Well-coordinated services are important for everyone with mental health challenges, but extra important for people with long-term and complex needs.

Patient groups with complex needs who need both municipal and hospital services are not adequately taken care of. Transitions between the service levels are failing, and municipalities and health trusts do not have enough joint planning. Several attempts have been made to standardise and formalise coordination and collaboration, yet it is still the case that few of these patients are appointed a coordinator or individual plan.16 The coordination schemes and measures to improve this will be addressed in the National Health and Collaboration Plan.

In order to give the best possible healthcare, it is a prerequisite that relevant and necessary health information follows the patient throughout the patient pathway. This is not always the case today. Health professionals spend valuable time on searching for correct information about medicines or medical histories, and they must often make decisions based on incomplete information.

The State has established within selected areas national e-health solutions (Norsk Helsenett SF (The Norwegian Health Network), Summary Care Record, E-prescription and helsenorge.no). Today, these contribute to collaboration in the services. Experience shows that the solutions provide huge benefits, and contribute to cohesion and unity in that health professionals have easier access to necessary information, and the public has access to easy and secure digital services.

The Government wants to further build on these solutions to reach the goals of holistic and effective collaboration, and development of new functionality that can handle reciprocal needs. In order to cover the need for holistic services moving forward, it is necessary to start using solutions and functionality for collaboration within several fields. Digitalisation in the health and care services will be a central theme in the National Health and Collaboration Plan where the Government will, among other things, present a comprehensive presentation of the e-health policy for the next four years.

The way in which the funding systems for health and care services are set up is important for service development and collaboration between the service levels. Funding schemes that support better cohesion between and efficient use of all resources are needed. Work on the National Health and Collaboration Plan assesses how funding as an instrument can support good patient pathways and collaboration between municipalities and hospitals. In connection with this work, the Norwegian Directorate of Health has been commissioned to investigate how the funding schemes can better support collaboration, cooperation and decentralised services. In the Official Norwegian Report of the Government appointed committee for hospitals NOU 2023: 8 Felleskapets sykehus – Styring, finansiering, samhandling og ledelse (Community hospitals – governance, funding, collaboration and management),17 a proposal was made to amend the funding schemes for the specialist health service, and the introduction of a collaboration budget for municipalities and health trusts that would only be triggered by the result of plans and processes in the medical communities. The Committee’s report is undergoing public consultation up until 30 June 2023, and it will be considered whether to incorporate the proposals in the National Health and Collaboration Plan.

4.3.2 Integrated services and outreach and outward-looking services

It has long been a goal to change the mental health service’s activities from inpatient treatment into outpatient and ambulatory treatment. Outreach treatment is recommended for patients who the health trusts cannot otherwise reach. At the same time, there has been a significant commitment to expanding municipal services within mental health and substance use. Nonetheless, almost 30 per cent of the municipalities do not offer outreach services for adults with mental health issues and disorders nor with concurrent mental health issues and addiction problems.18

The group of patients with concurrent mental health issues and addiction problems often need integrated services. Compared to other patients with no known addiction problem, they are more prone to emergency admissions and re-admissions, and their inpatient stays are shorter. They also tend to need comprehensive and long-term help from multiple actors.19 The mental health and substance abuse fields were early in offering integrated treatment and there are good examples of models for integrated services.

A primary measure in the National Health and Hospital Plan 2020-2023 was the establishment of 19 medical communities. These consist of health trusts and the municipalities in the catchment area. Representatives from health trusts, adjacent municipalities, local GPs and users will meet to plan and develop the services together. This is an important arena for ensuring more integrated services. People with severe mental illness and/or addiction problems are one of four groups that will be prioritised in the medical communities.

For many years, a commitment has been made to ACT (Assertive Community Treatment)- and FACT (Flexible Assertive Community Treatment) teams. These are cross-disciplinary ambulatory teams aimed at people with severe mental illness and/or addiction problems. Evaluations of both the ACT and FACT models in Norway conclude that the teams provide a better service to people in the target group compared to the persons they had earlier.20 Patients and next of kin are more satisfied and there has been a significant reduction in the number of inpatient days in the specialist health service and use of compulsory treatment. The ACT and FACT teams are an important step in the right direction for giving more holistic and cohesive services. The mandatory cooperation between municipalities and the specialist health service is most important for the success of the model in Norway. It is possible to apply for time-limited support to part-finance the establishment and operation of cross-disciplinary active outreach treatment teams in adherence with the ACT and FACT models. The Norwegian Resource Centre for Community Mental Health (NAPHA) and the Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) are closely cooperating with the county governors, KORUS, the Norwegian Centres for Violence and Traumatic Stress and Suicide Prevention (RVTS), and various user organisations regarding implementation of the ACT and FACT models in Norway. Among other things, a network offering implementation support has been established. The Norwegian Resource Centre for Community Mental Health (NAPHA) and the Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) are working together on further developing and revising both the FACT model description and the establishment handbook (practical guide).

There has been a significant growth in the number of teams, and around 86 ACT/FACT teams have now been established in Norway. Even more teams can be established.

Despite the experiences with ACT and FACT teams being good, there are several challenges related to cooperation barriers, access to experts, long distances and financing of the teams and so forth.

Improvements have been made, but tasks on further development remain to be done.

It is important that children and adolescents with long-term and complex challenges receive help adapted to their needs, and that the services can be in the child and adolescent’s arenas. The Officer of the Auditor General of Norway’s survey on mental health services showed that half of the municipalities do not offer outreach services for children and adolescents with mental health issues and disorders.21

In connection with the National Health and Hospital Plan 2020-2023, three pilot teams where established to test Youth FACT in a Norwegian context. The Youth FACT team has a cross-disciplinary composition that provides integrated and long-term treatment to youth aged 12-25 with a functional disability within the areas of mental health, education, network, work, family, substance use, crime, sexuality and dependency, and where it is assumed that long-term and comprehensive efforts from multiple services and levels is needed.

The Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (NKROP) has evaluated the pilot studies and published the evaluation report in autumn 2022.22 It shows that in the opinion of the team employees, cooperation partners, next of kin and the youths themselves, Youth FACT should continue and be further developed, and that more youths should be offered Youth FACT (refer to Box 4-5 for an overview of the youths experiences). At the same time, the report showed areas of improvement in conjunction with implementation of the model. In the evaluation report, specific recommendations were given for the further roll-out of Youth FACT. The work on further developing Youth FACT has started. The Norwegian Resource Centre for Community Mental Health (NAPHA) is responsible for the coordination and execution of training, and for giving implementation support to the Youth FACT team. During the course of this work, the centre cooperates with other resource centres and a national implementation team has been created.

It is possible to apply for time-limited support for part-financing of the establishment and operation of a Youth FACT team. There are now around 20 teams, including preliminary projects.

The Government will enable the services to better reach people who need integrated outreach services. Among other things, this involves investigating various collaboration models and assessing how the medical communities can be better equipped to support the desired developments within mental health services. Solutions for local adaptations will be looked at in line with the Trust Reform The overall direction for further development of collaboration is put forward in the National Health and Collaboration Plan, and further measures will therefore be concretised over the course of the plan period (refer to Chapter 3.4.1 for a discussion on integrated services for children and adolescents in general).

The Government will continue and further develop outreach and outward-looking services, such as ACT and FACT teams, and Youth FACT teams. In line with this, instruments for supporting integrated treatment will need to be adjusted and assessed on a larger scale, we will facilitate the breakdown of barriers, and look at how the Government can facilitate continuity and predictability in the services.

4.4 Improved care for children and adolescents with long-term and complex needs

Children, adolescents and their families need holistic services adapted to individual needs. Some face complex problems that require coordinated, complex and adapted solutions. As part of the escalation plan, the Government wants to improve services for children and adolescents with complex needs through, among other things, strengthening the work on better coordination of the services offered, continuing and refreshing the health effort for children under the care of the child welfare service, and increasing competence related to recognising/detecting early signs of neurodevelopment disorders and following them up. Children and adolescents completing sentences, and children and adolescents with concurrent mental health issues and addiction problems, must also receive adequate follow-up and help. Services for children and adolescents with concurrent mental health issues and addiction problems will also be followed up in the prevention and treatment reform for the substance abuse field.

Children and adolescents have the right to participate and adapted information. Children’s rights will be maintained in decision-making processes. (refer to Chapter 3.4.1 for a discussion on children’s rights and consequences for children).

4.4.1 Children’s coordinator

The Government is concerned with children and their families experiencing good and holistic help. The Office of the Auditor General of Norway has pinpointed that families of disabled children and adolescents must take a lot of personal responsibility for getting help and coordinating services.23 Families who have or are expecting a child with a serious disease, injury or disability, and will need long-term and comprehensive or coordinated health and care services, in addition to other welfare services, are entitled to a children’s coordinator. This right was introduced on1 August 2022. From the same date, harmonised and stronger rules on coordination and cooperation between the welfare services were always introduced. Joint regulations on individual plans also entered into force on 1 August 2022. The Norwegian Labour and Welfare Administration, the Norwegian Directorate for Education and Training, the Norwegian Directorate for Children, Youth and Family Affairs and the Norwegian Directorate of Health have prepared a joint guide for the regulation amendments. The children’s coordinator shall make it easier for families who have or are expecting a child with a serious disease, injury or disability. The coordinator shall ensure that the family and child receive coordinated and holistic welfare services and necessary information and guidance.

4.4.2 Children and adolescents under the care of the child welfare service

If a child is ill for a prolonged period of time, it can harm the child’s health and development. In particular, prolonged stress is harmful for children. It may lead to the child being more vulnerable to diseases, both physical and mental. A key goal of the child welfare reform, which entered into force in 2022, is that municipalities shall intervene early to help children and families at risk. The reform underlines the importance of a cross-sectoral approach for both early detection and measures. Early intervention can prevent cases from developing into serious child welfare cases, which in turn will reduce the risk of developing mental illness.

Children with measures, who are under the care of the child welfare service, have a higher number of health problems than other children, and there is a significant overlap between the target groups for the child welfare service and the Child and Adolescent Psychiatric Outpatient Clinics (BUP). National and international studies show that both children who receive assistance measures at home, and children who live in a foster home or institution, have a higher risk of developing mental health problems.24 As the Norwegian Board of Health Supervision and others have pointed out in the 2019 Care and Frameworks Report, we see some of the most unwell children in child welfare institutions often with problems linked to self-harm, eating disorders or substance use, and more courses of unsuccessful treatment behind them within the healthcare sector.

The child welfare service find that many have problems linked to self-harm, eating disorders or substance use. These children have the same right to essential healthcare as other children, yet for many years problems have been pinpointed at the cross-over point between mental health services and the child welfare service with the consequent risk that children in care do not receive essential mental health services. The ordinary health and care services and goals and measures for strengthening them are fundamental for ensuring that children in care receive access to essential mental health services based on their support and treatment needs, including inpatient child and adolescent mental health services when considered necessary for health reasons. The priority setting guide for child and adolescent mental health services highlights that the specialist health service along with the first line should pay particular attention to vulnerable groups, such as children under the care of the child welfare service. An unclarified care situation or substance use problem should not be reasons for refusing a person mental health services.

Collaboration and competence need to be strengthened to ensure that children with such complex problems receive adequate help. In addition, it has been necessary to implement special measures to detect and take care of the needs of these children on a larger scale. Cooperation between the health and care sector is particularly important, especially for children in child welfare institutions who often need services from both sectors at the same time. Consistent feedback from the child is important, and the child’s wishes and needs for flexible adapted help must be accommodated. Among other things, this requires the services to work together and in parallel to each other, so children do not feel they are being flung around the sectors.

The Ministry of Health and Care Services and the Ministry of Children and Families have cooperated on the health effort in the child welfare service over time to contribute to improved services through the child welfare service, and services for children and adolescents with mental health challenges. One of the implemented measures is a national pathway for the child welfare service, which aims to ensure that children and adolescents in care are mapped and investigated by the health services for any mental health and addiction problems, so they receive the essential healthcare they may need. The pathway has also been extended to include mapping of somatic, sexual and dental health. The national pathway shall form the foundation for the commitment to improved healthcare for children in care, and it describes responsibility, tasks and cooperation between the municipal child welfare service, municipal health and care services and the specialist health service. The pathway also gives recommendations on how the cooperation can be set up, so that the services can jointly ensure early mapping and investigation of children in care.

Children who will be removed from their parental home can be offered cross-disciplinary health mapping through a cross-disciplinary health mapping team, which shall identify the support and health needs of the child. The purpose is to give the child welfare service sufficient knowledge about the strengths and needs of the child, so the child receives adapted care and follow-up in their new home, and essential healthcare.

To strengthen the cooperation, health managers have been introduced in all child welfare institutions, and the regional health trusts have engaged child welfare officers in the child and adolescent mental health service. Two care and treatment institutions have been established in Bodø and Søgne for children between the ages of 13 to 18, who need long-term care outside their parental home and desperately need mental healthcare. The institutions are regulated by the Child Welfare Act and the personnel have both child welfare and healthcare expertise. This institutional service will be evaluated.

In June 2022, the Ministry of Children and Families appointed a committee to investigate child welfare institutions and proposed essential changes to the service. Among other things, the committee shall investigate which frameworks and competencies the institutions must have to give children adequate care and follow-up services. The committee shall also look at what kind of assistance can be demanded from other important services for children and adolescents, such as health services for those with mental illness. The committee will deliver its report at the end of June 2023.

Despite efforts over the course of many years, recent reports and numerous cases in the media, major challenges still exist in this area. The Government will therefore continue, renew and strengthen healthcare efforts in the child welfare service with the following goals and measures, so that children in care receive holistic and cohesive services corresponding to their needs:

• Early intervention to detect the need for medical and healthcare services with special emphasis on cross-disciplinary health mapping, national pathways and healthcare expertise in the child welfare service.

• Tighter follow-up to ensure that the rights of children in care to receive medical and health services with special emphasis on good cooperation between the child welfare service, health services and other relevant services in a manner that contributes to good access to a GP and other municipal services for children in the child welfare service.

• The development of services that are adapted to the needs of children in care for health care services and stability with emphasis on ambulatory services, prevention of relocations, national pathways, digital services, models for better coordination of cooperation and collaboration and increased expertise on children and substance use.

• Better coordination of efforts aimed at children who need help from different agencies with emphasis on warnings and cooperation between the health and child welfare sector, so adapted help can be implemented when there is a possibility that children at high risk will no longer receive proper services.

4.4.3 Children and adolescents completing sentences

Children and adolescents, who commit crimes, have a worse upbringing and have been in contact with the child welfare service more often than others in the same age group.25 The correlation is particularly transparent for those who repeatedly commit crimes. Experiences with those who are completing the special penal sanctions for those aged 15-17—juvenile punishment and juvenile follow-up—is that they have severe and comprehensive challenges, for instance, mental health challenges, addiction problems, violent and aggressive behaviour and harmful sexual behaviour.26 At the same time, the National Mediation Service experiences that it can be difficult to get the right help for the adolescents. Reports from the City of Oslo and Oslo Police District show that youths, who are registered as repeated offenders over the course of several years, have severe challenges, but have not received the help they need.27 On the basis of this, and through the Core Group for Vulnerable Children and Young People, the Secretariat of the Mediation Services, the Norwegian Directorate for Children, Youth and Family Affairs and the Norwegian Directorate of Health have been commissioned to investigate obstacles for the cross-sectoral cooperation and the welfare services’ participation during the completion of juvenile punishment and juvenile follow-up. The report will be available in autumn 2023 and will recommend measures and give advice for the further work of the ministries.

4.4.4 Children and adolescents with developmental disorders and other concurrent disorders

Challenged children often have complex difficulties. The symptoms can therefore satisfy several diagnoses in the diagnosis systems. A holistic perspective is particularly important when it comes to children, and it is important to consider somatic and mental health in relation to each other when giving help.28

Children and adolescents with neurodevelopment disorders are a complex group. Some have mild problems, whilst others have comprehensive problems that require tight follow-up from a lifespan perspective. The common denominator for these children is vulnerability that can lead to severe consequential mental and somatic problems if they do not receive the right adaptation and help. The complex conditions require cross-disciplinary and cross-sectoral cooperation and coordination. These children and adolescents may need services from many agencies in the municipality at the same time. It is important that schools, the Norwegian Labour and Welfare Administration (NAV) and the culture and leisure sector give good and coordinated help to these children and their families to ensure they have a good life and to prevent exclusion and mental health issues and disorders.

In order to give children and youths with neurodevelopment disorders a good service, early, coordinated, cross-disciplinary and evidence-based help must also be implemented to prevent severe problems. Increased inclusion of children with special needs in ordinary education requires knowledge of frequently occurring conditions, such as neurodevelopmental disorders, in schools and kindergartens.29

Mental illness more frequently occurs in people with development disorders than otherwise in the population, particularly the part of the target group who have cognitive impairments.30 These people are entitled to, on par with everyone else, essential mental health services.

There is a great need to develop expertise and the capacity of treatment for primary and additional disorders in this patient group. Variation in the patient group also leads to a need for many different forms of expertise in the specialist health service to meet the needs of individual patients. Good cooperation between all the involved agencies is important. Cooperation between mental health services, the health and care services in the municipality and habilitation services, is often necessary to give proper mental healthcare to the patients. Increased knowledge about the conditions is also important in other sectors, such as the culture and leisure sector. In order to give these children and adolescents adequate help, the Government will during the plan period investigate measures for increasing competence in recognising early signs and following up neurodevelopment disorders in kindergartens, schools and services in the municipalities and specialist health service, and measures for strengthening cooperation on measures and treatment for this group.

The Ministry of Education and Research has initiated a competence boost in special education and inclusive practices, which shall contribute to municipalities and county municipalities gaining sufficient competence to prevent, detect and follow-up all children and pupils, so they receive an inclusive and well-adapted educational service in kindergartens and schools. The Norwegian Directorate for Education and Training is responsible for the structure of competence boost in cooperation with the Norwegian Association of Local and Regional Authorities and Statped.

In the Official Norwegian Report, NOU 2020: 1 Services for people with autism spectrum disorder and for people with Tourette syndrome, the committee were commissioned to describe the needs and main services from a lifespan perspective for these groups. The committee was also commissioned to assess today’s situation and propose how the services could be improved. The goal for the assignment was to strengthen the overall services for the group and their next of kin. To follow-up the investigation, the Government has commissioned the Norwegian Directorate of Health to draft standardisation products related to autism spectrum disorder and Tourette syndrome. The work on this started in spring 2023.

4.4.5 Children and adolescents with concurrent mental illness and addiction problems

The Government wants children and adolescents with mental illness and addiction problems to receive adequate help. The Office of the Auditor General of Norway pointed out in its survey on mental health services that adolescents with concurrent mental illness/disorders and addiction problems do not in many municipalities receive adequate enough treatment or have not been offered a municipal service.31 Almost 20 per cent of the municipalities do not have services for adolescents with addiction problems, and almost 40 per cent of the municipalities state that the treatment services for adolescents with concurrent mental illness/disorders and addiction problems are not good enough.

A report from the Norwegian Directorate of Health shows that it is necessary to clarify who is responsible for offering specialised substance abuse treatment to children and adolescents in the specialist health service.32 According to the report, it is also necessary to investigate the investigation tools and treatment methods adapted to children and adolescents with addiction problems, and any concurrent conditions. The Directorate’s investigation indicates that there are organisational barriers that cause problems for child and adolescent mental health services in working flexibly inside arenas and with the system around these children. Among other things, the Norwegian Directorate of Health points out that it should be assessed whether funding, including activity-based funding, supports the services in working more holistically with this group and their families. The Government will follow-up the report in dialogue with the Norwegian Directorate of Health and regional health authorities. Measures will be discussed in more detail in the prevention and treatment reform for the substance abuse field.

4.5 Improved services for adults with long-term and complex needs

The Government will strengthen services for people with long-term and complex service needs, and facilitate holistic and simultaneous cross-disciplinary services from different levels and sectors. More outreach, cohesive, integrated and flexible services are needed in municipalities and health trusts for people with long-term and complex needs (refer to Chapter 4.3 for a discussion on cohesive services and pathways). As part of the escalation plan, the Government will further develop models for mandatory collaboration and integrated services for people with concurrent substance abuse and mental health disorders (ROP) and support implementation of national professional recommendations on involuntary admissions in adult mental health services. In addition, the Government will aspire to ensure better housing services for people with long-term and complex needs.

4.5.1 Concurrent mental illness and addiction problems

The Government will work towards ensuring that the quality of the services for people with concurrent substance abuse and mental health disorders (ROP) are improved. Patients and users with concurrent substance abuse and mental health disorders (ROP) must receive integrated treatment and follow-up. Those offering the services shall arrange the necessary collaboration. The goal is that the resources of the patients and users are supported and used in such a manner that their health and quality of life improves.

Many patients with severe mental illness receive treatment from the mental health services for their addiction problems. Addiction problems can exacerbate the patient’s challenges and are important in relation to what services and treatment the patients need. It is particularly challenging to get cohesive and integrated services for people who have both severe mental illness and substance use problems. Patients with concurrent mental illness and substance abuse problems are more prone to emergency admissions and re-admissions, and their inpatient stays are shorter compared to patients with known addiction problems.33 They need comprehensive and long-term help from multiple actors. Follow-up and treatment of somatic conditions are lacking. This is reflected in the group’s higher risk of increased morbidity and premature mortality. Life expectancy is discussed in more detail in Chapter 4.2.

People with concurrent substance abuse and mental health disorders (ROP) have a higher risk of being violence.34 Mental illness and addiction problems are also risk factors for exposure to violence.35 KORUS and the regional resource centres for violence, traumatic stress and suicide prevention (RVTS) have been commissioned by the Norwegian Directorate of Health to develop knowledge modules on integrated treatment of substance use and violence. The purpose is to increase competence among employees working in services for people with mental health challenges and addiction problems, so that services of a more holistic nature can be given to people with addiction and violence problems36 (refer to Chapter 3.8 for a more detailed discussion on violence).

In 2017 and 2018, the Norwegian Board of Health Supervision carried out a nationwide inspection of the services offered to people with concurrent substance abuse and mental health disorders (ROP).37 The inspection included specialist health services, municipal health and care services and social services, and revealed that people with concurrent substance abuse and mental health disorders (ROP) did not receive the services they need, which could have serious consequences for their health and life situation.

The Government will further develop concrete models for integrated services for patients with concurrent mental illness and addiction problems, and aspire to better enabling the medical communities to support service development for this group. This must be seen in relation to measures that are put forward in the National Health and Collaboration Plan.

The services for people with concurrent substance abuse and mental health disorders (ROP) will also be a theme in the substance use prevention and treatment reform.

4.5.2 Preventing compulsory treatment in mental health services

The main rule is that all healthcare is voluntary, regardless of whether the help is aimed at somatic, mental or substance use/related health challenges. In the mental health services, most people receive help on their own accord and with their own consent. In some situations it is necessary to give care and treatment even if the person does not want help or is not able to assess what help they need. Compulsory treatment can be given if the conditions of the law are satisfied. For instance, it is required that voluntary solutions have been unsuccessful or it must be evident that it is futile to try such solutions. With an imminent and high risk of endangering one’s own health and life, or that of others, compulsory treatment may be enforced, regardless of whether the person has the capacity to give informed consent or not. The obligation of the State to protect the life and health of individuals and the population shall in such cases take precedence over the main rule that healthcare should be voluntary.

Feedback has been received stating that the condition of incapacity to give informed consent may have negative consequences for the patients concerned, next of kin and society at large. Among other things, the concerns relate to the law amendment potentially having caused an overall increase in the use of compulsory treatment, the actual patients being more ill before they receive treatment, and the police increasingly helping the Norwegian Health Service to deal with severely mentally ill people. The Government has therefore appointed an expert committee to evaluate the condition relating to incapacity to give informed consent for compulsory treatment. The committee’s opinion is expected by 15 June 2023. The expert committee will look more closely at the challenges the rule has generated for the services, users and next of kin.

Psychiatric emergency departments, inpatient wards in District Psychiatric Centres (DPS), and local and regional forensic units treat mentally ill patients with various levels of severity. The scope of aggressive behaviour, risk of suicide, self-harm and risk of violence varies between and within the treatment levels. Similarly, the need for compulsory treatment and security measures varies. At the same time, the available local expertise on managing problems with aggression and other boundary-breaking behaviour impacts the institution’s ability to solve difficult situations without using force and preventing compulsory treatment from becoming the only option. Professionally, it is well-documented that compulsory treatment can be significantly reduced with targeted and systematic prevention work. In order to succeed in limiting the use of compulsory treatment, systematic and consistent work is required at multiple organisational levels and between cooperating actors. This entails active leadership and the development of a culture, organisation and expertise that promotes voluntary solutions.

The Norwegian Directorate of Health has prepared national expert recommendations for the prevention of involuntary treatment in adult mental health services, which became effective on 1 March 2022.38 The expert recommendations are intended to be an instrument for a more uniform understanding of how the use of involuntary treatment can be prevented. A key goal of the recommendations is to reduce undesired variation in the use of involuntary treatment, and to contribute to quality improvement in health and care services.

The Norwegian Directorate of Health cooperates with the regional health authorities regarding use of the new recommendations. It will be necessary in the future to follow-up how the expert recommendations are being used in the health trusts, including whether the health trusts’ own plans for preventing and reducing involuntary treatment have been updated in accordance with the new national guidelines.

4.5.3 Housing services

Good living conditions and the basic needs that housing covers are important for all human beings (ref to Chapter 2.4), including those with long-term and complex needs. During the plan period, the Government will aspire to ensure that this basic need is covered for people with long-term and complex needs. This involves working towards better housing services for people with long-term and complex needs, and assessing which measures should be implemented to achieve this. This work includes solutions for patients who are subject to involuntary treatment pursuant to the Mental Health Care Act and people who are at risk of being violent It should also be seen in relation to measures for people who have been committed to compulsory psychiatric care, and include an investigation on staffed housing services and services that result in improved use of available resources from both levels. The work must be seen in relation to measures under Chapter 4.7 relating to good and coordinated services from the health and justice sector, and it will be carried out in consultation with the Ministry of Local Government and Regional Development, and the Ministry of Justice and Security.

Homelessness

Even though most people live well in Norway, this does not apply to everyone. The homeless are the most vulnerable group in the social housing policy. In Norway, the homeless are defined as people who do not have their own home to live in, and are referred to random and temporary housing services; people who live temporarily with friends, acquaintances or relatives; people who will be discharged from an institution or the Norwegian Correctional Service within two months and do not have a home to go to; and people who sleep on the streets. Temporary accommodation services, for instance, hostels, boarding houses or camping huts. The homeless have been mapped through suitable surveys every four years since 1996.39 Mapping was last performed in 2020. There were around 3,300 homeless people. One in four of the homeless (749 people) had children under the age 18, and 112 of these were homeless with their children – at least 142 children. The mapping showed that twelve per cent of all the homeless were in institutions and six per cent in the Norwegian Correctional Service. In 2020, there were 798 people with concurrent substance abuse and mental health disorders (ROP). This constitutes 24 per cent of all homeless people. Those with concurrent substance abuse and mental health disorders are more frequently evicted from their homes compared to other homeless people, and they receive treatment more often.40 Two of three in this group have repeatedly been homeless over the course of several years or for more than six months. The new Social Housing Act (refer to Chapter 2.4) may contribute to more disadvantaged people receiving essential help and the municipalities having more equal levels of housing for welfare stock.

According to the mapping performed by Sintef of municipal work on mental health and substance abuse, 16 per cent of municipalities experience that the housing situation for this mental health group is poor or extremely poor. The most common challenges are stated to be housing for people with concurrent substance abuse and mental health disorders (ROP disorders), insufficient differentiated housing services and lack of housing/shared housing where users have essential access to personnel.41. People with substance abuse and mental health disorders may need help to cope with living in their own home, for instance, advice, guidance, practical assistance or training. For people with concurrent substance abuse and mental health disorders (ROP),42 coordinated services are particularly important (refer to Chapter 4.5.1 for a more detailed discussion on services for these people).

Adapted housing for people who need care

People with long-term and complex needs should have access to housing adapted to their needs. The work on improved access to adapted housing for people who require care is also addressed in the report to the Storting (white paper) about the ‘Safe at Home Reform’. The reform is limited to the elderly, but several of the measures in the reform will apply to the whole population and be relevant to people with mental health and addiction problems. For some people with long-term and complex problems, the need for housing with 2.hour health and care services might be a solution (refer to the Health and Care Services Act, Section 3-2). The investment grant for 24-hour care places, which is managed by the Norwegian State Housing Bank, aims to stimulate the municipalities to renew and increase offers of nursing home places and residential care homes for people who need 24-hour health and care services, regardless of the resident’s age, diagnosis or disability. The investment grant is arranged so the municipalities, in addition to increasing the number of 24-hours care places, can also replace, renovate and upgrade all existing buildings. The Government will contribute to making the investment grant for 24-hour care places known to Norwegian municipalities to stimulate the provision of more dwellings to people with addiction problems and/or mental health problems.

In connection with work on the substance use prevention and treatment reform , the Norwegian Directorate of Health has been commissioned to map the scope and type of inpatient care that the municipalities offer to people with addiction problems and mental illness, and to assess if it takes care of this group’s needs. The assignment will also be relevant to the work on following up the escalation plan.

Housing services for people with higher violence and safety risk

When giving input for the escalation plan, many municipalities reported challenges linked to obtaining adapted housing particularly for those who need comprehensive services and have a problem with violence, This includes those who have been committed to compulsory psychiatric care. Users and patients with problems related to violence and aggression represent a smaller group that needs specially adapted and simultaneous health and care services. They are often the worst off in the housing market in terms of finding suitable housing and keeping a tenancy over time.43 Challenges linked to discharge processes for patients with severe mental illness and concurrent serious violence problems have been described in multiple reports in recent years.44 This patient population has comprehensive challenges and complex needs, and it is increasingly stated that both the specialist health service and the municipalities struggle with providing adequate safety, treatment and care services.

In 2020, mapping was performed of patients and discharge processes from forensic units.45 The mapping shows that many municipalities receive patients with complex challenges from forensic psychiatry units and that there is an increase in the number of discharges. The findings indicate that these patients have comprehensive and complex needs, and there are challenges in the municipalities that receive them. This concerns legislation, finances, expertise, collaboration culture and the formation of a common understanding of the challenges between everyone involved.

The report highlights which measures are potentially significant to improving the legal protection and quality of life of this patient group. The measures are linked to housing types that take care of this patient group’s treatment and care needs, and legal protection in terms of restricted freedoms and use of force, whilst at the same time ensuring that the community is protected.

In February 2023, Fafo published the report In no man’s land. Social protection and forensic psychiatry from a municipal perspective.46 The report discusses the challenges of the municipalities to provide proper services to people discharged from mental health services/forensic psychiatry to complete compulsory psychiatric treatment outside inpatient institutions (TUD), and where regard to the protection of society is central.

The report shows that municipalities provide services to a complex group of users with severe mental illness, often with concurrent addiction problems, where it is considered there is a higher risk of violence or safety risk. A range of services in the municipalities are involved in following up this target group. The people in this group often find themselves in no man’s land between the responsibility of the municipal services and the specialist health service. They often have co-occurring needs for the different instruments that the specialist health service and the municipality can offer. Municipalities are responsible for housing services, however, municipal services are based on the citizens wanting to receive them voluntarily. The report shows that municipalities and the specialist health service often understand and assess patients’ needs differently, and have limited knowledge of each other’s context and frameworks. There may be disagreements about the patient’s situation and their needs, what is a suitable and good service, and who is responsible for giving essential services, treatment and follow-up. Limited inpatient capacity in the mental health services puts pressure on discharging patients and a higher threshold for admissions.

The regional health authorities have been commissioned to create an overarching plan for forensic psychiatry. Among other things, the health trusts shall assess the need for long-term strengthened housing services in cooperation with the municipalities and whether it is purposeful to establish cross-disciplinary ambulatory teams to take care of people who represent a safety risk.

4.6 Using medicines correctly

Medicines can have an important place in the treatment of mental illness, particularly for more severe conditions. When psychopharmacology is needed, it should be part of a holistic treatment pathway. The Government will contribute to promoting correct use of medicines.

The use of medicines to treat mental illness is increasing. Figures from the Norwegian Institute of Public Health show that around 390,000 Norwegians were dispensed at least one antidepressant and antipsychotic drug in 2021.47 Antidepressants are the most used but the use of antipsychotics is also increasing. The number of people taking sleeping pills and sedatives per 1000 inhabitants has on the whole not changed the last few years.

There may be genetic conditions affecting the way the body metabolises the active ingredient in the drugs for several of the most used antidepressants and antipsychotics. Personalised medicines can contribute to optimising the use of pharmaceutical drugs for each patient. The Centre for Psychopharmacology at Diakonhjemmet Hospital has over the last 20 years developed and introduced pharmacogenetic analyses for precision dosing of psychopharmaceuticals. The genetic investigations contribute to increased precision when choosing a drug and dose for individual patients. The vision of the Government’s strategy for personalised medicine (2023–2030) is for personalised medicine to become an integral part of prevention, diagnostics, treatment and follow-up from the healthcare services, where the objective is to improve health and coping skills throughout life. One measure in the strategy is that the Norwegian Directorate of Health will assess the need for recommendations linked to pharmacogenetic analyses. This will particularly contribute to meeting the need for such recommendations in municipal health and care services.

Several studies also indicate an increase in the total use of psychopharmaceuticals in the 0-17 years age group during the last decade in Norway, especially among young girls.48

There is limited knowledge about what type of consequences the use of psychopharmaceuticals in children and adolescents will have in the longer and shorter term. The Medicines for Children Network, Norway, aims to ensure that paediatric medicinal treatment is appropriate and safe. The network has been commissioned to establish and operate a national medicines network within child and adolescent psychiatry. The Nasjonalt kompetansenettverk for psykopharma til barn og unge (the Child and Adolescent Psychopharmacology Network) started up in January 2022 and consists of a cross-disciplinary group with pharmacists and specialists in child and adolescent psychiatry from various health trusts.

National professional recommendations for using psychopharmaceuticals for children and adolescents were published in September 2022. Among other things, the recommendations shall help ensure that only children and adolescents with the required indications receive psychopharmaceuticals and that the treatment is followed up systematically and ended if no effect is received or there are serious side effects.

The national patient pathway contains recommendations on how medicine usage should be followed up and specific recommendations for following up the use of antipsychotics.49 The Norwegian Medical Association has prepared recommendations for tapering and the cessation of antipsychotics.50

Non-pharmaceutical treatment

Non-pharmaceutical treatment in the mental health services was first introduced in all regions in 2017 upon commission of the Ministry of Health and Care Services. The basis for the effort was a clearly communicated need from users to have an alternative to the traditional pharmaceutical-based treatment in mental health services. The service helps people to improve their mental health without side effects from pharmaceuticals or to manage with lower doses. It is therefore an important contributor to better coping skills and the reduction of unnecessary use of psychopharmaceuticals.

The evaluations from the Competence Centre for Lived Experiences and Service Development (KBT) show that the service has anything but met the users expectations in terms of assistance with tapering or ending psychopharmacological treatment. Other forms of therapy (for instance, conversation therapy, group therapy, music and art therapy and animal-assisted therapy) and support measures, can help improve functional ability and contribute to less discomfort from pharmaceutical side effects.

KBT’s last report shows considerable variation in implementation non-pharmaceutical services, and that a lot of work still remains to be done to make the services accessible on par with other mental health services.51 According to the report, the non-pharmaceutical services are considered difficult to access for the users. This is partly due to a lack of information about the availability of the service and what the alternatives to pharmaceuticals involve. Non-pharmaceutical treatment has a natural place in modern, patient-orientated mental health services. Further development of the service should be carried out in dialogue with the expert environments, users and next of kin.

4.7 Good and coordinated services from the health and justice sector

Many inmates or people, who have been committed to treatment or compulsory care, have comprehensive and complex mental illnesses or intellectual disabilities that require adapted conditions for serving the sentence and following up health problems. The Government will facilitate good and coordinated services from the health and justice sector, which will contribute to improving the life situation and health of each single person, whilst at the same time safeguarding society.

4.7.1 Court-ordered committal to compulsory psychiatric care

Court-ordered committal to compulsory psychiatric care and court-ordered committal to compulsory care are special penal sanctions (the Norwegian Criminal Code, Sections 62 to 65). These special penal sanctions replace prison sentences for people who were criminally insane at the time when the offence was committed.

There has been a significant increase in the number of people committed to treatment in recent years, especially from 2020 to date52 (refer to Figures 4.2 and 4.3). The increase coincides with the amendment to the conditions in the Criminal Code for ordering transferral to compulsory psychiatric care, which entered into force in October 2020. There has been a massive increase in some areas causing capacity problems. According to the regional health authorities’ projections, if the trend continues for the next ten years, there will be 500-600 convicted persons in psychiatric care, which is double the number today. A significant increase in capacity will be needed to treat and follow-up patients, who have been committed to compulsory psychiatric care, if the conditions for using special penal sanctions remain unchanged. The Government will soon appoint a committee to, among other things, evaluate the arrangements involving sentences ordering transferral to compulsory psychiatric care and committed care.

Most people complete court-ordered committal to compulsory psychiatric care in inpatient departments. Some are in forensic units (regional or local) and other in ordinary inpatient departments in hospitals or District Psychiatric Centres (DPS). Notwithstanding many also complete the sentence without inpatient stays.

Reports and inspections show that both municipalities and the specialist health service have problems ensuring good and coordinated services for people who represent a safety risk whilst simultaneously safeguarding society.53 Challenges exist in relation to capacity, expertise, housing services and cooperation between the police and healthcare services. If the increase in the number of people committed to treatment continues, the current challenges will be exacerbated, and further impact the general capacity and use of personnel in the services.

Holistic and stable services are necessary prerequisites for safeguarding society during completion of court-ordered committal to compulsory psychiatric care without inpatient stays. Adults without legal residency however are only entitled to immediate help and healthcare services that are completely essential and cannot wait. People sentenced to special penal sanctions, but are staying in Norway illegally, therefore risk remaining in a specialist health service inpatient facility longer that what is justified in relation to the person’s need for treatment.

Based on an enquiry from the Parliamentary Ombud, the Norwegian Directorate of Health along with the Norwegian Directorate of Immigration and Norwegian Labour and Welfare Administration were commissioned to propose practical solutions, within the boundaries of today’s regulations and systems, for situations where the attending practitioner in charge at a psychiatric facility is of the opinion that a foreigner, who does not have a resident permit and has been sentenced to special penal sanctions, should be discharged from a psychiatric inpatient facility. The report was delivered in October 2022.

As of October 2022, five specially punished people without legal residency in Norway were still in a psychiatric inpatient facility even though the professional in charge was of the opinion that they were ready to be discharge from the specialist health service. Notably in respect of the progression of treatment, they should have been transferred to compulsory psychiatric care without inpatient stays. The main conclusion of the Norwegian Directorate of Health is that it is not possible within the boundaries of today’s regulations to ensure that specially punished persons without legal residency in Norway can be discharged from an inpatient facility when the professional in charge is of the opinion that it is correct to do so. Nonetheless, solutions have been proposed—within the boundaries of today’s regulations—that can remedy the situation up until they are returned. The Ministry of Health and Care Services will in cooperation with the Ministry of Justice and Security and Ministry of Labour and Social Inclusion consider how the investigation should be followed up.

Measures are needed both in the specialist health service, the municipalities and in the cooperation between the former and latter to meet the increased number of committed people.

In 2022, the Ministry of Health and Care Services commissioned the regional health authorities to prepare an overarching plan for forensic psychiatry and other measures for people committed to compulsory psychiatric care. According to plan, the report will be completed in summer 2023. Among other things, the plan will explain the need for content, organisation and cohesion in the forensic psychiatry service with the purpose of facilitating better patient pathways in psychiatric care. The report will also address capacity needs and guidelines for cooperation between the specialist health service and the municipalities. The report will be directional for the further path to take in forensic psychiatric services.

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

4.7.2 Court-ordered committal to compulsory care

Committal to compulsory care is a special criminal punishment that was originally established for people with severe intellectual disabilities who had committed serious crimes against other people’s lives, health or freedom (for instance, sex crimes, arson, gross violence, etc.). A national unit has been created with responsibility for completing this special penal sanction. The Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care) is located at St. Olavs Hospital, Central Norway Regional Health Authority. The specialised unit is responsible for ensuring that all convicted persons are investigated in the unit’s inpatient department. When consideration towards the convicted person and safety considerations do not argue against it, the specialised unit can enter into an agreement stating that the care can be completed outside the specialised unit, for instance, in the convicted person’s own municipality of residence. In addition to responsibility for accepting convicted persons for compulsory care pursuant to sections 63 and 64 of the Criminal Code, the specialised unit is obliged to accept people placed surrogate remand in custody pursuant to section 188 of the Criminal Procedure Act and/or forensic psychiatric observation pursuant to section 167 of the Criminal Procedure Act.

From starting up in 2002 up until 2019, relatively few people were ordered by a court to complete compulsory psychiatric care (up to two persons per year). Since 2020, the number of convicted persons has increased considerably. More people have entered the scheme in the last three years than the total number in the period from 2002-2019.54 The is primarily due to amended rules in the Criminal Code regarding culpability and conditions for court-ordered compulsory care. The amendment was effectuated in autumn 2020. Following the law amendments, court-ordered compulsory care is no longer reserved for the intellectually disabled. People with mental illnesses involving a high symptom burden, and equivalent organic and somatic conditions affecting the mind (for instance, dementia, Alzheimer’s disease, brain damage and autism disorders) can be sentenced to the scheme if the prosecuting authority and court consider it fitting for the crime. Compared to earlier, it is at the court’s discretion to order special penal sanctions (court-ordered committal to compulsory psychiatric care or committal to compulsory care) based on what the court considers best in each single case. In addition, the guiding IQ threshold for severe intellectual disability in the sense of the Criminal Act has been increased from 55 to 60.

Further, the trend in court-ordered committal to compulsory care has put the scheme under a lot of pressure. The capacity of the ward at Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care) has been exceeded and the Central Norway Regional Health Authority has had no choice but use beds in regional forensic departments. It may be necessary to extend the already newly built forensic building at St. Olavs Hospital to handle the stream of new convicts. The trend in the number of court orders has also caused a substantial increase in costs with repeated overspending of grants awarded to the scheme in the National Budget. The administrative and financial consequences of reducing the threshold and expanding the scope of application for court-ordered committal to compulsory care were not sufficiently investigated prior to the law amendments.

Source: Sentralfagenhet for tvungen omsorg (central specialised unit for compulsory care), 2022.

4.7.3 Prisoners

The prevalence of mental illness among prisoners in Norwegian prisons is higher than in the population at large and it is not uncommon for prisoners to have several concurrent mental health disorders. Studies show a high prevalence of comorbidity and that 92 per cent of prisoners have some type of personality disorder or other mental health disorder.55

Many prisoners in Norwegian prisons therefore need health care services. Some prisoners already have comprehensive and complex mental illness or intellectual disability prior to imprisonment, which sets higher requirements for prison conditions and adequate follow-up of mental health challenges.

Without good prison conditions and sufficient healthcare, there is a higher risk of prisoners becoming isolated and the possibility for rehabilitation to a life without crime being reduced. This is a joint responsibility of the Norwegian Correctional Service and the health and care services.

Restricting the right of an individual to have social contact with others is a serious invasion of personal integrity and autonomy. Additionally, restrictions on human contact, lack of activities and meaningful community with others—and in many cases total or part isolation—harms both physical and mental health. The extent to which prisons facilitate social contact, community and activities is therefore vital for the physical and mental health of prisoners.

Norwegian authorities have been subjected to special criticism in recent years where it has been pointed out that many prisoners in Norwegian prisons are isolated. In June 2019, the Parliamentary Ombudsman (now Parliamentary Ombud) submitted a special white paper to the Storting on isolation and lack of human contact in Norwegian prisons (Document 4:3 (2018–2019). In its recommendation, Innst. 172 S (2019–2020), the Storting’s Standing Committee on Scrutiny and Constitutional Affairs asked the Government to implement measures and to put forward proposals to the Storting for essential law amendments to follow up the recommendations of the Parliamentary Ombudsman’s special white paper. The Parliamentary Ombudsman recommended improvements, such as enactment of the responsibility of health care services to follow-up isolation and use of solitary confinement or restraint beds, and to ensure that the prison health service is given a joint professional platform. Amendments to the provisions of the Execution of Sentences Act regarding exclusion from community and strengthening of the scrutiny scheme were also among the recommendations. Both the Ministry of Justice and Security and the Ministry of Health and Care Services are working on measures to follow up the Parliamentary Ombudsman’s report.

The use of isolation in the Norwegian Correctional Service has gone down. The Ministry of Justice and Security sent proposed amendments to the Execution of Sentences Act and the Health and Care Services Act (community, exclusion and means of coercion in prisons) for comment in February 2023. The time limit for comments is 1 June 2023. The intention of the proposals was to remedy the problems with isolation in prisons, to take care of consideration for prisoners and employees, and to safeguard society’s need for adequately secure prisons and prisons with a good rehabilitative effect. The Storting has adopted new rules on scrutiny boards for the Norwegian Correctional Service. The amendments concern new rules pertaining to independency, appointment, authority and organisation, in addition to rights and obligations during scrutiny.

The Norwegian Correctional Service’s buildings consist of many relatively small prison units, and several of them are in a poor technical condition minimally fitting for modern prison operations. A major problem is that many prisons and departments do not have suitable space for health and welfare services, and for community and prisoner activities. An overarching goal of the Norwegian Correctional Service is to enable as many prisoners as possible, including the mentally ill, to socialise with others and join activities in adapted common areas (if applicable).

Prisoners have the same right to essential health and care services as the population at large. The municipality in which the prison is located is responsible for providing health and care services and the health trust is responsible for providing specialist health services. The Norwegian Correctional Service is responsible for enabling prisoners to receive essential health care services. National professional guidelines for municipal health and care services for prisoners has been submitted for comments. The time limit for comments is 2 June 2023.

The regional health authorities have been commissioned to establish local specialist services for mental health and cross-disciplinary specialised treatment for substance use disorders (TSB) This shall guarantee regular local services at regular times within both fields in prisons. The regional authorities have also been commissioned to establish strengthened national services for the most debilitated prisoners at Ila Detention and Security Prison for men and at Bredtveit Detention and Security Prison for women. It is important that the local services and strengthened units are allowed to operate over time with the planned and recommended resources.

It is necessary to investigate how prisoners with severe mental illness or intellectual disability can best be taken care of during remand, serving sentences and when returning to society. The Government has decided to create a committee to investigate this matter and evaluate the penal sanctions on remand, court-ordered committal to compulsory psychiatric care and court-ordered committal to compulsory care.

There is a substantial minority of female prisoners and convicts. At the same time, several reports and surveys show that the percentage of women with mental health problems is markedly higher than for men.56 Female prisoners are a particularly vulnerable group when it comes to exposure to suicide and suicide attempts. In 2022, there were 95 suicide attempts in prison and the majority were carried out by women.57 The Parliamentary Ombud also pointed out this situation in the Selvmord i fengsel (Suicide in Prison) report in 2023. The Norwegian Correctional Service pays great attention to preventing suicide in prison, and when suicide is indicated. an action plan is prepared. The health care services must be informed when this type of plan is prepared. It may also be relevant to place vulnerable prisoners in separate high-security units in prisons where available.

Insofar as possible, women, shall carry out their stay in prison in separate prisons or in prison facilities adapted for women. It is necessary to assess what special considerations must be applied for women in connection with remand in custody, serving sentences or completing special penal sanctions, and the need for new measures and solutions that may improve the mental health of these women.

The threshold for imprisoning children and adolescents is high, and a prison sentence is only permitted when specifically required. Children who are imposed an unconditional prison sentence, generally serve the sentence at one of the specially adapted juvenile units established under the auspices of the Norwegian Correctional Service. Young prisoners have the same mental health problems as other prisoners. but are also highly vulnerable due to their age. Basic staffing in the juvenile units must be cross-disciplinary with the addition of an interagency team to ensure participation from a variety of agencies. If a child turns 18 whilst serving their sentence, they will normally be transferred from the juvenile unit to an ordinary prison. This can be experienced as a major transition, and there is a risk that good return and rehabilitation pathways come to a halt. Cross-disciplinary youth teams have been established at several prisons to give those aged 18-24 stronger follow-up. Cross-sectoral cooperation and local services are also needed, but the degree to which this works varies. Through the Core Group for Vulnerable Children and Young People, work is therefore being conducted on a joint assignment for the relevant directorates to investigate obstacles and possibilities for cross-sectoral cooperation and participation of the welfare services prior to, during and after the completion of sentences for those aged 18-24.

4.7.4 Responsibility when transporting the mentally ill

In some cases, health care services need assistance from the police when transporting mentally ill people. Such assistance may, for instance, involve taking people to compulsory medical examinations or transferring them to psychiatric care. The requirement is that police assistance during transportation is essential, however, the health care service assesses and decides to request assistance, and the degree to which it is necessary. Several regional and local measures have been implemented in recent years to increase competence and collaboration between the actors who meet the patients during various parts of the pathway, including the police. The cooperation works extremely well in many places. At the same time, experience shows that the police occasionally feel they are called upon too often, and the health care services sometimes have difficulty getting police assistance.

Along with the Norwegian Police, the Norwegian Directorate of Health has been commissioned to revise the circular regarding the responsibility of the health care services and the police for the mentally ill. One goal of the cooperation is to solve the responsibility tasks in the least possible invasive way and for the best of the individuals. The revised version shall, among other things, particularly specify when police assistance is needed, for instance, in connection with transportation and when the health care services cannot safeguard this themselves. The revised circular is expected to be finished in summer 2023. Broad implementation of the revised circular is planned.

The Government will present a white paper to the Storting regarding emergency medical services where it will also be natural to discuss any problems related to the transportation of mentally ill patients.