5 Financial and administrative consequences, and outcome follow-up

The Government proposes to increase funding for mental health by MNOK 3 from 2023-2033. This involves permanent strengthening to a new level. Increased grants for individual measures depend on priority setting in the annual budget processes.

As part of the commitment, MNOK 150 has been awarded in the 2023 budget year for new and stronger measures linked to the mental health escalation plan and substance use prevention and treatment reform. MNOK 150 of the increased basic hospital funding was also earmarked for strengthening inpatient child, adolescent and adult mental health services.

The escalation plan is a dynamic plan based on the overarching performance measures. Several of the proposed measures in the plan require further investigation and it will take time to estimate the costs and implement them. The investigations will, among other things, assess the consequences related to the demand for personnel of which there is a shortage. Therefore, the plan can also be adapted to the trend and build on the most updated knowledge about the need for services and public health measures. Measures in the plan will be concretised and put forward in the ordinary budget processes. The Storting can therefore consider concrete measures and how quickly they will be phased-in during the course of the plan period. The status and progression of the plan will be presented annually in Proposition No. 1 S.

The cost of following up the performance measures related to access to evidence-based low-threshold services is estimated to be between MNOK 900-1,100. The calculations are based on experiences with the quotes from Prompt Mental Health Care and Ung Arena. According to Sintef’s report IS 24/8 regarding man-years in municipal health work, 11 per cent of the municipalities do not have low-threshold services for children and young people and 20 per cent state they have a partially adapted service for the target group. In terms of Prompt Mental Health Care, 268 municipalities do not currently offer this service. The cost of establishing new Ung Arena services will range between MNOK 2-3 per service, whilst for Prompt Mental Health Care the estimated cost is around MNOK 6 per team. In order to establish such services, many municipalities will have to join forces or use other models, since the models that are used as a basis require a population of 15,000 to 20,000 inhabitants. The cost assessment is based on a need to establish 15 new services for children and young people, and around 140 new services for adults. In addition, it is necessary to further develop the services for children and adolescents equivalent to 20 new services.

The financial consequences of the goal for children and adolescents to be offered a clinical interview when referred to child and adolescent mental health services is estimated to cost around MNOK 30 (2023 NOK) for children and young people up to the age of 18. The estimate is based on calculations from the regional health authorities. It has been taken into account that the introduction of clinical assessments involves taking in around 8,500 new patients for an interview in the child and adolescent mental health services, and that more cooperation with the municipalities must be expected to clarify which support services are the right ones to use. Nonetheless, it 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 Ministry estimates that interviewing everyone will require around 30 extra man-years at a cost of around MNOK 1 per man-year. If the target group for clinical interviews is extended to those aged 25, the financial consequences will increase.

Many of the proposed measures will have positive socioeconomic consequences far beyond the health and care services. However, it is difficult to attach figures to these benefits with the knowledge basis we have today. Mental illness contributes to loss of health from the age of ten. No other disease group causes more loss of health or costs attached to disability benefit than mental illness, and even a small reduction in the percentage of young people, who become permanently disabled, will have a significant effect over the course of some people’s lives as well as for society.

It is also difficult to calculate the benefits of increased life expectancy and quality of life for people with severe mental illness. In 2017, the Norwegian Resource Centre for Community Mental health (NAPHA) estimated that around 26,000 users might be in the target group for follow-up from a FACT team1, and therefore in need of specialised, long-term and complex help for severe mental health and/or addiction problems. The estimate is built on reports from the municipalities in BrukerPlan, and is the number of users that the municipalities have mapped as having severe mental health and/or addiction problems with a very low or serious functioning level score. This means that at 26,000 people have serious complex mental health and/or addiction problems and difficulties in most areas of life. The Holden Group2, in its socioeconomic assessment of the infection control measures during the COVID-19 pandemic, used MNOK 1.4 as an estimate for the value of non-quality adjusted life years. This estimate was based on the Norwegian Directorate of Health’s recommended calculation method. If one takes into consideration a low estimate for lost life years in the group of 26,000 people over the course of ten years, it involves 260,000 expected lost life years. Based on these assumptions, it can be estimated that the value of lost statistical lives and life years for people with severe mental health and/or severe addiction problems will be around BNOK 364.

Experiences from the evaluation of the ACT teams3 show that more adapted follow-up considerably reduces the use of compulsory inpatient stays and increases quality of life. Nonetheless, it is too early to say whether such measures specifically affect life expectancy. Regardless of this, more holistic and comprehensive help will be critical to improving health-related follow-up in connection with mental illness, addiction problems and somatic ill-health.

The benefits of each single measure are illuminated in the respective paragraphs in the plan. In the work on investigating concrete measures within and outside the health and care sector, we will aspire to illuminate the benefits of the measures, and the Storting will receive the presented proposals for concrete measures in the annual budget processes from 2024.

Instruments in the plan

The Government has taken into account that goals and measures aimed at the municipalities are generally funded through the municipalities’ unrestricted income. Today’s municipal expenditure attached to the field of mental health is primarily covered by the municipal sector’s income system, and any further commitment through the municipalities’ unrestricted income will contribute to elucidation and predictability for the municipalities. Unrestricted income also stimulates efficient exploitation of resources in line with local needs, so the municipalities have a cohesive overview of their welfare tasks, including integration of municipal work on mental health in the ordinary services. Similarly, the specialist health service shall be funded through the annual financial budgets for the health trusts. Some priority areas will, however, require special funding, among other things, to give better knowledge support to the services, develop and disseminate new measures and models, and stimulate collaboration.

Following up results

The Ministry of Health and Care Services will, as the coordinating ministry, continuously follow-up the progress and goal achievement in the escalation plan. To ensure a low report burden, existing data sources should be used insofar as possible to keep up with and watch the plan. To map the efforts of the municipalities, the Norwegian Directorate of Health’s IS-24/8 form must be used. In addition, figures from Brukerplan, Ungdata, etc., will give us valuable information about the situation in the municipalities, and the users and their functioning levels. Likewise, the Norwegian Patient Registry and Samdata will give us information about trends in mental health services. Further, the Norwegian State Housing Bank’s reporting routines will be used to follow up the municipalities’ work on contributing to more people with mental health problems having a good place to live. Established indicators for follow-up already exist for most performance measures. New indicators must, however, be developed for three of the performance measures:

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

• 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.

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

During the plan period, it is proposed that the Norwegian Registry for Primary Health Care KPR) is further developed to include municipal services related to mental health and substance use. This will contribute to potential 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.

Completion and evaluation

A ten-year plan period has been set up, and a separate evaluation program will be established. The evaluation should include follow-up of the plan’s goal achievement in the specific performance measures, in addition to the experiences of users and next of kin during the plan period. The Norwegian Directorate of Health will be commissioned to establish an evaluation program from 2024 to follow the effects of the escalation plan as it is gradually completed. The evaluation will be part of the basis for further follow-up and completion of measures during the plan period, including assessment of the need for changes or adjustments to the use of instruments. Status, goal achievement and the progression of measures must be reported annually to the Ministry of Health and Care Services.

It is important to make the plan known and contribute to the development of local plans in the field of mental health. Therefore, the Norwegian Directorate of Health will in cooperation with the county governors be commissioned to oversee that experiences are exchanged and good examples are spread. Entrenchment of the escalation plan in municipal, administrative and political bodies is essential for its execution and goal achievement. The county governors shall support the municipalities in planning and developing community mental health work during the plan period through recommendations and guidance, and their points of contact in the municipalities.