Policies and Service System in Norway
The development of psychiatric and mental health services in Norway follows the general pattern of welfare state dynamics, but with some peculiarities. Modernisation of national welfare policies has up until recently, in general terms, primarily been the result of broad alliances between political and professional actors. The health sector – by some authors labelled “the Queen of the Welfare State” - incarnated the integration of political ambitions and professional management. From its beginning, psychiatric services have, for their part, been dominated by the medical profession and political bodies were reluctant to challenge suggestions put forward by psychiatrists. Thus, psychiatrists attained monopoly over what was regarded as relevant knowledge, simultaneously administrating the mental health central administration and dominating the local implementation of mental health policies in the capacity of combined professional and administrative leaders in the mental health hospitals.
Since the beginning of 1990’s several reforms have changed policies regarding target groups, the formal structure of service organisations, scientific approaches to mental health work, and the relations between professional actors and governmental bodies at different levels. These changes are reflections of the general trends towards new governance systems in the European welfare states, but also some distinctive developments within the mental health field in the country. Three developments have particular implications for the structuring of general (municipal) and specialised (hospital) services. These developments are embedded in reforms at the municipal level (the new Municipal Act of 1992) and in specialised services (the hospital reform of 2002), and the Mental Health Action Plan of 1998 – 2009. These reforms have had a great impact upon the way structure, actors and knowledge intertwine in present mental health field developments.
Norwegian mental health service provision has, in accordance with European trends, changed through three major developments: from an “era of the asylum”, via the rise of mental health hospital systems to present-day vertical and horizontal extension of mental health care. The Mental Health Action Plan 1998 – 2008 has played a major role in developments in the last phase. Mental health service provision now see a substantial extension in policy ambitions and services, which makes new (evidence- and practice-based) knowledge and issues related to collaboration and coordination of services focal points in the implementation of the Action Plan.
The mental health reforms (The Action Plan) and the administrative reforms (municipal and hospital) were initiated in the 1990’s, and have changed the design of service provision substantially. Three major developments can be identified:
Firstly, the mental health field has seen a growth in economic resources, number of patients, mental health professionals, and service agencies. The evaluations of the Action plan conclude that the quantitative targets of the reform have been fulfilled.
Secondly, there is agreement that the qualitative aspects of the reforms have not been reached. This relates partly to the problems of coordination of service provision. Here, the lack of coordination at the state level in the design of the reform initiatives would be one important explanation: For specialised services, the hospital reform did not refer to the Action plan, and vice versa. While the Action Plan was designed according to “traditional” welfare reform implementation tools, the hospital reform was a comprehensive New Public Management reform. For general – municipal – services - the idea of the “new municipality”, and the “governance” - partnership model of state – local relations led to a complex web of semi-autonomous municipal decisions about the organisation of municipal mental health services on the one side, and state audit systems on the other. State governance about how to organise specialised and general services, increasingly has been performed by state guidelines, but in close collaboration with local actors.
Thirdly, there is agreement in the evaluations and among national political decision makers that the users’ perspective has not been sufficiently elaborated in service provision. This arguments should, however, be modified: while empowering users through legal rights of individual patients are strengthened by a new Law on Patients’ Rights, there still is a problem to make patients having influence upon their treatment therapies and social roles in everyday life. As we see it, two developments are particularly interesting for the understanding of the relationship between knowledge and politics in the Norwegian mental health field. First is the formal restructuring of services. The policy of formal restructuring/decentralization of service provision includes two interconnected issues: an emphasis upon organizing general/municipal services and a regionalization (i.e. decentralization) of specialized/hospital services (District Psychiatric Centers - DPS).
While the implementation of the restructuring has been subject to substantial evaluation research, the genealogy of the knowledge processes - particularly about the relationship between bio-medical/psychiatric knowledge and sociopsychological/ sociological scientific knowledge, and learning from international developments - has not been subject to analysis yet. The restructuring / decentralization seems to be informed mainly by two kinds of knowledge: scientific approaches, in which the way bio-medical, sociological and psychological understanding of mental health are represented and balanced, and administrative approaches, in which cost-efficiency in service provision both in hospital reforms and in municipal service provision are represented. Likewise, the interplay between (different) scientific knowledge(s) about mental health problems and treatment strategies on the one side and administrative approaches on the other, in processes of restructuring services should be scrutinized.
We argue that within the KnowandPol project research questions should concentrate on 1) where and by whom knowledge production takes place, how knowledge producers advocating decentralization where given priority in the formulation of mental health reform policies, and how “decentralization” was operationalised. Different types of knowledge are mobilised in the restructuring process, both regarding the extent of decentralization, and the design of service provision organizations (tasks, size, management, recruitment/competencies). Knowledge and actors should be seen to interplay in complex ways that need to be analysed through case studies. We suggest some tentative hypotheses about the relationship between knowledge and actors: The distribution of knowledge / actors follow a pattern in which bio-medical knowledge is represented in psychiatric hospitals, and tend to defend existing structures by the mobilization of evidence-based medicine, while the actors advocating a restructuring / decentralization are represented in DPSs and municipalities, on the basis of sociological approaches to mental health problems.
2) The emphasis on user/citizen involvement, and the policies of empowerment should be further analysed. The policy of user/citizen involvement represents as we see it a “paradigm shift” – as the Action Plan has formulated the need for increased influence of users/citizen perspectives on service provision. One important aspect of this policy is the separation of professional/specialized knowledge and the user/citizen perspectives or knowledge. This contrasts the historical development of welfare state policies, in which professional knowledge was said to include “user/citizen perspectives” as well. Here, one should ask where and by whom the knowledge production takes place, what is meant by “user/citizen involvement” in policy formulations, how this policy influence the relations of power between professionals and users, and how this policy has been included as a specific, central goal of the reforms.
RAMSDAL Helge, VOLD HANSEN Gunnar, HELGESEN Marit & FEIRING Marte (2008), Mental Health in Norway: Actors, Organization and Knowledge, KNOWandPOL Report.