Knowledge and Mental Health Policy: Reforming the Structure of Mental Health Services in Norway

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The report analyses “Restructuring of mental health service provision” with a main focus on the formation and implementation of the Mental Health Action Plan 1998 - 2008. “Restructuring of mental health services” in our context relates to the formal organization designs that are set up (evolved/decided) at three levels of government: the national, specialist services and municipal services. Formal restructuring involves processes that intend to reorganize existing service units and design new ones at specialist and municipal levels. These processes are taking place by the combined efforts of state authorities - through a system of regulation tools directed towards influencing local decisions and processes in hospital trusts and municipalities – resting upon the relative autonomy in organizing services in accordance with local preferences. Thus, “restructuring services” is strongly related to “decentralization”. Accordingly, “restructuring” and “decentralization” should be analyzed as processes strongly interconnected, as two sides of the same coin.

Empirical findings

The analyses we have performed in regard to the “public action 1” of “Restructuring mental health services” can be summarized in four points:

1. Contrary to developments in mental health services in many other Western countries at the period of time there was, due to a favorable economic situation for the Norwegian state, a substantial expansion of mental health services. Consequently mental health policies did not implicate a zero-sumgame concerning resource allocations between hospitals and community services after the de-institutionalization phase. There was restructuring of specialist services at the hospital trust level, but also a modest expansion as new funding for specialist services were included in the reform strategy. This eased the tensions between actors at the two levels of service provision.

2. The expansion of services, represented by the increase of District Psychiatric Centers (DPSs) and municipal services also included increasing the number of actors within the services. When municipal services were organized psychiatrists – being a scarce resource nationwide – played virtually no role at all neither as consultants nor as service providers. Here, new professional groups (nurses, other health professions and social workers) planned and manned the services. The “multi-professional” aspect of the service developments could potentially cause disagreements and tensions between professions. Most of the time, this did not happen. Due to the division of attention between specialist and municipal services and the non-zero game described above, developments in municipalities and hospital trusts continued separately. However, this also created an uncoordinated service structure as the aggregated result of hundreds of “micro-decisions” on organization designs by municipalities and hospital trusts.

3. During the expansion of services, new actors and types of knowledge - largely unknown to mental health care before – became increasingly important in the restructuring of services. While the expansion led to the introduction of new actors “from within” the ranks of mental health - the professional groups representing sociological, psychological and caring approaches to mental health problems – some of the new actors came from “outside”. These “outside” actors influenced the organization and steering systems based on global, instrumentalist theories about organizing and evaluating (public) services. The new actors – management consultants, accountants, auditors – mostly had never worked with these services, and often greatly underestimated the peculiarities of mental health service provision. This new knowledge had profound impacts on organizational designs and steering systems. Notwithstanding its vagueness as a theoretical concept NPM approaches pointed to ideas of organizing that primarily related to advanced systems of cost-containment and measurements of service quality.

4. The conclusion on this vital point in our analyses is that bio-medical approaches to mental health – defined as a medical specialty based upon diagnoses, evidence-based medicine and cost-efficient therapeutic methods – through its compatibility with NPM approaches have retained its predominant role in specialist services. This has also led to a revitalization of the psychiatric profession in these services. However, new professional groups, mainly at the municipal level, struggle to settle on a specific “mental health work approach” based on principles of normalization, integration and mastering as the knowledge they represent.

5. Added to the existing multiplicity of health and social professions, political actors at all levels of government and management and administrative professionals, users increasingly played a role in mental health policies. The users’ organizations became increasingly professionalized, and their contributions at the national level included several reports produced in collaboration with social scientists.

Coupling of different types of knowledge play an independent role and does not necessarily turn specific actors into observable “allies”. For instance, in the developments of organization designs, and in the performance of service organizations, some organization designs and steering principles seem to support specific approaches to mental health care. We have been particularly interested in the way NPM approaches to organizing public service provision - as uniform, global knowledge on instrumental organization theories - supported the development of bio-medical approaches to therapeutic methods, thus forming a tight coupling. However, we saw that the NPM-inspired organization designs contradicted the organization principles derived from the “normalization” and “integration” approaches. Also, in the de-institutionalization phase, political concerns on economic matters at the county level were compatible with some therapeutic approaches represented by actors advocating for a reduction of hospital beds. The outcome of the process was a radical shift in mental health policies in the 20 years of the second phase being not the outcome of a linear, hierarchical decision process.

RAMSDAL Helge (2009), Knowledge and Mental Health Policy: Reforming the Structure of Mental Healt Services in Norway, KNOWandPOL Report.

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