The patient's health service
In Norway, we have numerous examples of local inpatient facilities at the intersection between specialist and municipal health services. These are to some extent part of a long tradition, such as the GPHs in Finnmark county, and partly of a more recent origin, such as the municipal acute bed units. Their designations, forms of organisation and functions all vary, although they all target those parts of the patient pathway where the need for services is in a grey zone between the options provided by hospitals and municipalities respectively. Nevertheless, all these services require highly skilled healthcare personnel.
Our studies have shown that local units may offer safe and high-quality services, and that the patients prefer the local alternative close to home to treatment in a large hospital. This finding is in line with international studies showing that patients prefer treatment in less hectic local units (11).
In 2014, the Knowledge Centre for the Health Services summarised results from Norwegian and international studies that compared the effect of admitting patients to a local, supplemented primary care unit with admitting the same kind of patients to a hospital. Only three studies fulfilled the inclusion criteria. The results showed that compared to hospitalisation, an admission to a supplemented primary care unit may lead to higher patient satisfaction, but it could not be determined whether such admissions had an effect on physical functioning and quality of life or on the number of readmissions (12). It has also been shown that elderly patients in particular are admitted to the municipal acute bed units and that the occupancy rate is lower than expected (13). Broadly formulated statutory provisions have permitted a variety of solutions and adaptations at the municipal level. The major differences between the units nationally and internationally and the resulting difficulty in making comparisons and drawing conclusions have been part of the discussions about the local medical centres, intermediate care units and the municipal acute bed units.
Service provision in smaller units may be an appropriate alternative to hospitalisation. Such units provide relief for the hospitals and may have positive health consequences for the patients at a lower cost. In this way, these options represent a service that provides an alternative to the hospitals, but they also add an independent quality that matches the needs, especially those of patients who are elderly or suffer from chronic diseases. This includes solutions with local service provision (proximity, small, 'homelike' and transparent services without the hospital's stress level), continuity and a holistic approach. However, certain reservations need to be made. Not all local services can be deemed to provide alternatives equal to those of hospitals. The facility needs to have a correctly selected group of patients, medical services with a satisfactory skill level and a systematised observation competence (14).
The Norwegian policy to 'let the thousand flowers bloom' represents a challenge. There is no consistent approach to the provision of intermediate services. These range from half a bed in a nursing home to 116 beds at Øya health centre in Trondheim. They are differently organised with a variety of owners and funding schemes, and they provide a variety of treatment options with the aid of a varied range of medical skills. In the encounter with the increasing number of elderly people and a growing group of patients with chronic ailments, the hospitals as we know them today, with their constantly increasing requirements for efficiency and specialisation, will be unable to provide satisfactory services to these groups of patients. To face the future with sustainable health services we need a national study that investigates existing service provision at the intersection between the specialist and municipal service levels. This study should serve as the basis for a new national health plan. There is a need to clarify responsibilities as well as what these service options should look like. The health plan should be based on 'the patient's health service', in which the requirements for enhanced efficiency should be kept subordinate to the patients' needs.