The study revealed that the municipalities had cooperated on the establishment of emergency hospitalisation services. They reported to perceive the new service as patient-centred and flexible, and as providing room for greater patient co-determination. In their opinion, the service would also lead to competence enhancement in the municipalities. Bed utilisation has increased from provision of the service started until 31 August 2014 in all six municipalities.
The municipalities included in the study have established a formal collaboration, in relation to which it was made clear that they did not wish for any inter-municipal collaboration on operation of emergency hospitalisation services. They had a shared value base and shared ideological views on the service before development started. This emerged clearly from a number of the interviews.
The main objective of the organisation was to achieve patient-centred and flexible services in the home municipality, where all resources were used to produce seamless service provision. This starting point clearly contrasts with findings from a mapping study conducted in 2013
(5, 6). At that time, more than half of all Norwegian municipalities were in the process of establishing emergency hospitalisation services. Three of four had entered into inter-municipal collaboration, most of which were small municipalities. Most of those that had not entered into inter-municipal collaboration had established such services in association with a nursing home, whereas those who engaged in inter-municipal collaboration had established service provision in association with a casualty clinic. The majority of the small municipalities had no service established in their own local community. This means that for most of them, the service is provided in a neighbouring municipality. The municipalities have chosen to organise and operate the service in varying ways.
Our results are more in line with those of Grimsmo and Løhre
(7). They describe a split between the centre and periphery with regard to views on organisation. Inter-municipal service provision in proximity to a hospital appeared meaningless to doctors in peripheral municipalities, because of the excessive travel distances involved. It was also pointed out that many doctors perceived few differences between inter-municipal and local service provision. The difference pointed out by these authors in terms of how central and peripheral municipalities regard the organisation of this service is a key discussion that will have professional as well as organisational implications.
In these municipalities, emergency hospitalisation is mainly a nursing service that requires a clear diagnosis before admission. This is a clear premise for the organisation, which will differ from other types of organisation where diagnostic services are also provided and where there is better access to medical services. Patient selection and the scope of bed utilisation may differ considerably between such services. They may also have varying potential for a reduction in the number of admissions in the specialist health services based on the design of the admission criteria and the diagnostic services provided. Our study cannot draw any conclusions in this respect.
Access to nursing competence in the municipalities was deemed especially important for the establishment and operation of the service. The flexible organisation of the emergency hospitalisation in nursing homes enabled this competence to be used flexibly for several groups of patients and thus help strengthen the overall competence in the municipalities. The extent to which the university colleges will be able to provide relevant competence to the municipalities by way of their training programmes may prove important for the establishment and development of this service.
In all of the municipalities we can observe increasing bed utilisation over time. However, the rate of utilisation was nevertheless relatively low in relation to capacity even in the second year of operation, varying between 10 % and 36 %. Vanylven municipality, which has the longest experience of operating the service, also has the highest rate of utilisation of bed capacity. This may indicate that the doctors need some time to gain confidence in the service and in how they can make use of it. Bed utilisation in these six municipalities is not significantly different from what emerged in the mapping study in 2013
(5, 6). Our study has no data that can show whether the extent of utilisation of emergency hospitalisation services has reduced the use of inpatient beds in the specialist health services.
The study revealed that the informants wished to establish more patient-centred treatment sequences than are seen in the specialist health services, where these are linked to diagnoses. This corresponds with findings made by Røsstad and collaborators
(17) which indicate that a disease-oriented perspective on patient pathways is unsuitable in the municipal health services. A key finding in our study is that the municipalities envisage a need for establishing holistic treatment sequences that capture wider patient groups. Rehabilitation and palliation were examples of areas where such solutions had been established.
One interesting finding is that the informants deemed it easier to achieve co-determination when patients are treated in their local environment. Dialogue on values in the choice of end-of-life treatment was another key finding in our study. Our findings largely correspond to those made by Lappegard and Hjortdahl in Ål municipality, although that service programme is somewhat more comprehensive than the one provided by our municipalities
(18). Lappegard and Hjortdahl found that in the patients’ opinion, the local provision of treatment gave a feeling of overview and continuity of care on home ground. It may appear as though emergency hospitalisation is able to respond appropriately to key intentions of the Interaction Reform regarding reinforcement of the right to co-determination for patients and their next of kin.
The generally positive attitude to emergency hospitalisation came as something of a surprise to us. It is conceivable that if more of the nurses who are involved in daily operations had been included, more of the problems associated with operating the service would have come to light.
The study is unable to reveal the number of patients that otherwise would have been admitted to hospital, and we have no data regarding the distribution by type of service provided to the patients after discharge from emergency hospitalisation.