When money doesn’t solve it

The Local Government Association (LGA) is the national membership body for local authorities in England and Wales. This article is part of the LGA children and young people's mental health think piece series, and was first published at their website.

For many years, Norway has been in an enviable position when it comes to public finances. Fuelled by an oil-driven economy, expansion of the national public health and welfare services has been the order of the day. Difficult questions and priorities have been put to one side. As an illustration, Norway currently has the highest number of nurses per capita in the European Economic Area (EU27 + Norway, Iceland, and Liechtenstein) and is at least in the top three when it comes to the number of doctors per capita.  

Investments in the national health system have also been seen in mental health, with the last 25 years seeing a significant increase in mental health policies, initiatives, and interventions, not least at the local government level. From 2016 to 2022 alone, there was an increase in full-time equivalents (FTEs) allocated to working in mental health or substance abuse in the municipalities by more than 22 per cent. However, Norway is paying a price for being affluent. With fewer incentives to innovate and make healthcare services efficient than in many other countries, Norway may not be getting good value for money.

An ageing population is changing the dependency ratio. Estimates by Statistics Norway suggest that the need for manpower in health services will increase by 30 per cent before 2031, or the equivalent of 100,000 additional FTEs (Norway has a population of approximately 5.5 million). During the same period, due to the demographic changes, the increase in the available workforce is 10 per cent. For a few years already, there has been a strong increase in the number of municipalities reporting difficulties recruiting all categories of health personnel. Norway, it seems, will run out of people long before it runs out of money.

A leaner, more efficient healthcare system will have to be built. Unfortunately, political and institutional factors make it likely that Norway will struggle to solve this problem in a satisfactory manner. There are at least three reasons for this:

First, although a scarcity of the workforce has been predicted for the last 30 years, if not longer, health governance has been attempting to improve the health service. The Ministry of Health and Care Services and the Directorate of Health develop new policies, produce new guidelines, and propose new measures. They are far less well adapted to the downscaling of health care provisions. As we know from organisational theory, it is very hard for organisations to shift focus and do something different.

Second, the general public has become used to incremental improvements in healthcare provisions and has high expectations that this will continue. For example, recent years have seen a strong increase in self-reported mental health concerns particularly among children and young people. Whether this can be linked to the use of social media, digital stress, social background, or lack of sleep, is unclear and the jury is still out as to whether the increase is real. However, there remains pressure on the political system to respond to this and other problems related to mental health. Particularly following the pandemic, mental health issues have acquired high political salience.

Third, politics must take its fair share of the blame for building expectations with the electorate. Consecutive governments have kept making promises, launching new initiatives, and occasionally ceding to pressure from interest groups. Politically, it seems impossible to adapt the discourse to the realities. This is well illustrated by the government’s recently published plan for mental health. While acknowledging that there will be a critical lack of people, the proposed policy initiatives largely fail to take this into account. Arguably, the mental health plan should have been about how to improve mental health in the population despite the increasing difficulty of finding qualified personnel.

All in all, the Norwegian political system seems ill-equipped to make the tough choices necessary. Most likely, this will lead to a worse situation than had the political and administrative system been better at adapting to changing circumstances.

In Norway, the municipalities are responsible for providing primary care and long-term health care. However, with time, many of them have also taken on more specialised tasks. To the Norwegian Association of Local and Regional Government, some of the answer is that the municipalities must be given more freedom in how they organise their health services, including mental health services. A stronger independence from the national level will open more possibilities for exploring alternative ways of improving health. It is also important that the specialised state-run part of the national health service takes more responsibility for treatment and clinical work. During the last 15 to 20 years, the municipalities in Norway have taken on many tasks that were previously the responsibility of the state level. This development, to some degree at least, needs to be reversed.

The municipalities need the flexibility to concentrate on what should be their primary task, health promotion rather than clinical work. For that reason, the relationship between the state-run specialised health services and the services provided by the municipalities should be recalibrated. Moreover, in the field of mental health, treatment is much more costly than prevention.

One strong lesson learnt from the pandemic is that pressure on mental health services increases when schools, sports clubs, and arenas for social interaction close. Rather than developing new and workforce-consuming policies to meet the perceived increase in mental health problems among children and young people, one should concentrate on creating, or sustaining, inclusive local communities. This means investing in families, kindergartens, schools, libraries, and all sorts of cultural, social and community-based activities. Mental health should not and cannot be the sole responsibility of the health services, and certainly not at a time when there is a limited workforce.