Diverging realities



    When those on the executive floor have a perception of reality that is at odds with reality as perceived by healthcare professionals in hospitals and GP surgeries, there is a risk of undermining the very trust that keeps the health service working.

    Photo: Einar Nilsen
    Photo: Einar Nilsen

    This year, like most years, the Arendal Week offered a wide range of health-related events and sessions. I was particularly keen to attend the meeting hosted by Central Norway Regional Health Authority to discuss their introduction of the Helseplattformen medical record system (1). General practitioners and hospital staff despair over the many faults and shortcomings of this 'disastrous' project (2). The budget overspend has been enormous. The Norwegian Board of Health Supervision has established that the system represents a risk to patients (3). And the Office of the Auditor General is now set to investigate the entire procurement process (2). Which is why my curiosity had already been piqued as I turned up for this well-attended session.

    It was to be a bizarre experience. While the panel on stage did not include a single representative of the health professionals who use the system, the senior executives had turned out in force. There were as many as five directors present, representing Central Norway Regional Health Authority, Trondheim Local Authority and Helseplattformen, and they were supported by an enthusiastic patient representative from the regional service user committee. They talked at length for well over an hour about the excellent merits of the Helseplattformen system, its superior user friendliness, resource-saving capacity and improved patient safety. Towards the end, they just about managed to squeeze in some vague answers to two critical questions from the audience – about quantifiable evidence of the purported 'excellent merits' and about the need for staff co-determination (4).

    This somewhat surreal happening adds to the sense that there is substantial and increasing divergence between reality as perceived by the governors of Norway's health service and as perceived by those they govern. There are numerous examples, and there is no need to look further back than the last few months. The former CEO of Helseplattformen who put it down to user error, rather than system error, that more than 16 000 letters generated by Helseplattformen were never delivered to the correct addressees, is but one example (5). Another is the statement made by Vestfold Hospital Trust's Chief Executive, who in the wake of the campaign #legermåleve (#doctorsneedtolive) found it necessary to point out that anyone working more than 200 hours of overtime does so voluntarily, and to ask whether the pressure to accept overtime was exerted by colleagues or the employer (6). For rank-and-file hospital doctors, this is a purely theoretical question of no relevance to the realities they encounter. Shifts have to be covered, and it is abundantly clear that several hundred hours of overtime is a responsibility that rests with the employer.

    This slightly surreal happening adds to the sense that there is substantial and increasing divergence between reality as perceived by the governors of Norway's health service and as perceived by those they govern

    If we look a little further back, we can point to the healthcare professionals' virtually unanimous yet futile objections to the closure of Ullevål Hospital and the building of the enormous hospital at Gaustad. The Health Service Campaign can be seen in the same light, in that 'groups of health professionals who traditionally hold conflicting views – doctors, registered nurses, nursing associates – stand united against a growing group of market-led bureaucrats in management roles whose principal priority is the bottom line', to quote Rune Slagstad (7). This is essentially about health professionals having a perception of reality that substantively diverges from that of their senior managers.

    The most important problem is the impact that this has on the mutual trust between the governors and the governed. Trust is the glue that holds Norwegian working life together. In the health service, trust is of critical importance. For the national health service to function, patients need to trust healthcare professionals to have the competence, time and resources to provide good treatment and care. The healthcare professionals, in turn, need to trust their employers to grant them sufficient co-determination and professional autonomy, and to facilitate a safe working environment. This trust is fragile. Research shows that sectors that have robust professional standards and autonomy are particularly vulnerable to having mistrust introduced by governance and control measures (8). This is particularly important in a health service that is hard pressed for resources because trust in working life is positively associated with self-reported productivity (9).

    The problem goes beyond the world of mere theory. The Norwegian 'co-determination barometer 2020' surveyed a range of sectors and found that trust in management professionality and understanding was lowest among those working in the health and social care sector (9). The survey also found that health trusts had the lowest scores in respect of co-determination as an approach to governance and management. Such findings are worrying if we are to preserve a robust and trust-based state-funded national health service.

    The Government has launched a trust reform for the public sector (10). We do not yet know what this will entail for the health service. But the many instances of divergence between reality as perceived by hospital professionals and by hospital executives, suggest that time is running out.

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