Jorid Kalseth

POLITICAL CONTROL OF ADMINISTRATIVE SPENDING: THE CASE OF LOCAL GOVERNMENTS IN NORWAY*

Excessive administrative spending in local governments has been a concern in the public debate in Norway. Administration takes resources away from welfare services such as primary education and care for the elderly. Since administrative spending varies considerably between local governments, a study of the political and economic factors involved is warranted. The central hypothesis is that the administrators will have more power relative to the politicians when political control is divided between parties. Estimation of a demand model of administration added political structure shows strong empirical correlations between types of coalition governments and socialist controlled governments and the level of administrative spending. Divided political control strengthens the hands of the agenda setting bureaucrats. Copyright Blackwell Publishers Ltd 1998.

Spending and overspending in local government administration: A minimum requirement approach applied to Norway

Abstract A demand function for administration is estimated for Norwegian local authorities, emphasizing the per capita total budget, the population size and sociodemographic variables affecting the composition of local services. The demand function forms the basis of an analysis of the variation in the administrative resource use among the authorities. The methodological approach is inspired by productivity studies of manufacturing industries defining a ‘best practice’ frontier determined by the authorities with the lowest administrative spending per capita given the local characteristics. The minimum required administration serves as a benchmark for the estimation of administrative overspending of approximately 20%.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature

BackgroundPsychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.MethodsComprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.ResultsOf the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.ConclusionThis review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

Cross-country comparisons of health-care costs: The case of cancer treatment in the Nordic countries

The objective of this study is to perform a cross-country comparison of cancer treatment costs in the Nordic countries, and to demonstrate the added value of decomposing documented costs in interpreting national differences. The study is based on individual-level data from national patient and prescription drug registers, and data on cancer prevalence from the NORDCAN database. Hospital costs were estimated on the basis of information on diagnosis-related groups (DRG) cost weights and national unit costs. Differences in per capita costs were decomposed into two stages: stage one separated the price and volume components, and stage two decomposed the volume component, relating the level of activity to service needs and availability. Differences in the per capita costs of cancer treatment between the Nordic countries may be as much as 30 per cent. National differences in the costs of treatment mirror observed differences in total health care costs. Differences in health care costs between countries may relate to different sources of variation with different policy implications. Comparisons of per capita spending alone can be misleading if the purpose is to evaluate, for example, differences in service provision and utilisation. The decomposition analysis helps to identify the relative influence of differences in the prevalence of cancer, service utilisation and productivity.

Trends in place of death: The role of demographic and epidemiological shifts in end-of-life care policy:

Background: Surveys suggest that most people prefer to die at home. Trends in causes of mortality and age composition could limit the feasibility of home deaths. Aim: To examine the effect of changes in decedents’ age, gender and cause of death on the pattern of place of death using data on all deaths in Norway for the period 1987–2011. Design: Population-based observation study comparing raw, predicted, as well as standardised shares of place of death isolating the effect of demographic and epidemiological changes. The analysis was bolstered with joinpoint regression to detect shifts in trends in standardised shares. Setting/participants: All deaths (1,091,303) in Norway 1987–2011 by age, gender and cause of death. Place of death at home, hospital, nursing home and other. Results: Fewer people died in hospitals (34.1% vs 46.2%) or at home (14.2% vs 18.3%), and more in nursing homes (45.5% vs 29.5%) in 2011 than in 1987. Much of the trend can be explained by demographic and epidemiological changes. Ageing of the population and the epidemiological shift represented by the declining share of deaths from circulatory diseases (31.4% vs 48.4%) compared to the increase in deaths from neoplasms (26.9% vs 21.8%) and mental/behavioural diseases (4.4% vs 1.2%) are the strongest drivers in the shift in place of death. Joinpoint regression shows important differences between categories. Conclusion: Demographic and epidemiological changes go a long way in explaining shifts in place of death. The analyses reveal substantial differences in trends between different decedent groups.

Standard comparison of local mental health care systems in eight European countries

Aims. There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems’ Effect on the Quality of Mental Health Care in Europe) project. Methods. A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (≥18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS. Results. The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona – Italy and Girona – Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sør-Trøndelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care. Conclusions. There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.

Factors associated with the amount of public home care received by elderly and intellectually disabled individuals in a large Norwegian municipality

This study reports an analysis of factors associated with home care use in a setting in which long-term care services are provided within a publicly financed welfare system. We considered two groups of home care recipients: elderly individuals and intellectually disabled individuals. Routinely collected data on users of public home care in the municipality of Trondheim in October 2012, including 2493 people aged 67 years or older and 270 intellectually disabled people, were used. Multivariate regression analysis was used to analyse the relationship between the time spent in direct contact with recipients by public healthcare personnel and perceived individual determinants of home care use (i.e. physical disability, cognitive impairment, diagnoses, age and gender, as well as socioeconomic characteristics). Physical disability and cognitive impairment are routinely registered for long-term care users through a standardised instrument that is used in all Norwegian municipalities. Factor analysis was used to aggregate the individual items into composite variables that were included as need variables. Both physical disability and cognitive impairment were strong predictors of the amount of received care for both elderly and intellectually disabled individuals. Furthermore, we found a negative interaction effect between physical disability and cognitive impairment for elderly home care users. For elderly individuals, we also found significant positive associations between weekly hours of home care and having comorbidity, living alone, living in a service flat and having a safety alarm. The reduction in the amount of care for elderly individuals living with a cohabitant was substantially greater for males than for females. For intellectually disabled individuals, receiving services involuntarily due to severe behavioural problems was a strong predictor of the amount of care received. Our analysis showed that routinely collected data capture important predictors of home care use and thus facilitate both short-term budgeting and long-term planning of home care services.

The REFINEMENT Glossary of Terms: An International Terminology for Mental Health Systems Assessment

Comparing mental health systems across countries is difficult because of the lack of an agreed upon terminology covering services and related financing issues. Within the European Union project REFINEMENT, international mental health care experts applied an innovative mixed “top-down” and “bottom-up” approach following a multistep design thinking strategy to compile a glossary on mental health systems, using local services as pilots. The final REFINEMENT glossary consisted of 432 terms related to service provision, service utilisation, quality of care and financing. The aim of this study was to describe the iterative process and methodology of developing this glossary.

How to Improve Integrated Care for People with Chronic Conditions: Key Findings from EU FP-7 Project INTEGRATE and Beyond

Background: Political and public health leaders increasingly recognize the need to take urgent action to address the problem of chronic diseases and multi-morbidity. European countries are facing unprecedented demand to find new ways to deliver care to improve patient-centredness and personalization, and to avoid unnecessary time in hospitals. People-centred and integrated care has become a central part of policy initiatives to improve the access, quality, continuity, effectiveness and sustainability of healthcare systems and are thus preconditions for the economic sustainability of the EU health and social care systems. Purpose: This study presents an overview of lessons learned and critical success factors to policy making on integrated care based on findings from the EU FP-7 Project Integrate, a literature review, other EU projects with relevance to this study, a number of best practices on integrated care and our own experiences with research and policy making in integrated care at the national and international level. Results: Seven lessons learned and critical success factors to policy making on integrated care were identified. Conclusion: The lessons learned and critical success factors to policy making on integrated care show that a comprehensive systems perspective should guide the development of integrated care towards better health practices, education, research and policy.

Unplanned Admissions to Inpatient Psychiatric Treatment and Services Received Prior to Admission

BACKGROUND Inpatient bed numbers are continually being reduced but are not being replaced with adequate alternatives in primary health care. There is a considerable risk that eventually all inpatient treatment will be unplanned, because planned or elective treatments are superseded by urgent needs when capacity is reduced. AIMS OF THE STUDY To estimate the rate of unplanned admissions to inpatient psychiatric treatment facilities in Norway and analyse the difference between patients with unplanned and planned admissions regarding services received during the three months prior to admission as well as clinical, demographical and socioeconomic characteristics of patients. METHOD Unplanned admissions were defined as all urgent and involuntary admissions including unplanned readmissions. National mapping of inpatients was conducted in all inpatient treatment psychiatric wards in Norway on a specific date in 2012. Binary logit regressions were performed to compare patients who had unplanned admissions with patients who had planned admissions (i.e., the analyses were conditioned on admission to inpatient psychiatric treatment). RESULTS Patients with high risk of unplanned admission are suffering from severe mental illness, have low functional level indicated by the need for housing services, high risk for suicide attempt and of being violent, low education and born outside Norway. CONCLUSION Specialist mental health services should support the local services in their efforts to prevent unplanned admissions by providing counselling, short inpatient stays, outpatient treatment and ambulatory outpatient psychiatry services. IMPLICATIONS FOR HEALTH POLICIES This paper suggests the rate of unplanned admissions as a quality indicator and considers the introduction of economic incentives in the income models at both service levels.