Back in the day, Norway followed the UK's lead in building a robust public health service. Are we now also about to follow its lead in dismantling the health service?
Photo: Einar Nilsen
In Norway, we are rightfully proud of having one of the world's best public health services. The inspiration and model for such a universal and publicly funded health service came from the UK, where a radical public health reform in 1948 led to the formation of the National Health Service (NHS), giving all citizens the right to free health care at the point of use. Since then, the NHS, known as 'the mother of all publicly financed health services', has been one of the UK's proudest achievements (1) .
However, decades of underfunding, compounded by competitive tendering, bureaucratisation and New Public Management, have plunged the once-flourishing 76-year-old NHS into an escalating series of crises. The situation is now worse than ever. On 3 January 2024, junior doctors in England started the longest strike in NHS history (2) . The industrial action was prompted by years of real wage decline, together with unsustainable working conditions in a run-down and understaffed public health service (2, 3) . The maintenance backlog now amounts to almost £12 billion, of which urgent works alone exceed £2 billion (4) . Thousands of doctor positions in the NHS remain unfilled, and an increasing number of doctors are moving to the private healthcare sector (3, 5) . The doctors that remain in the NHS are characterised by high staff absence levels, burnout and low morale (6) . A recent UK-wide survey shows that two out of three NHS doctors suffer from 'moral distress' because they cannot provide adequate health care (3) .
In addition to the GP crisis, Norway is now among the countries in Europe with the fewest somatic beds per capita and the shortest average length of stay in these beds
Following the development of a robust public health service in the UK, Norway followed suit a few years later. There are now strong indications that the dismantling of the health service seen in the UK is also underway in Norway – again with a few years' delay. In 1991, Margaret Thatcher introduced market principles and competition to the NHS (1) . The year 2002 saw the launch of the health trust reform in Norway, which was largely based on the same market-inspired ideology (7) . Both in the UK and Norway, the various subsequent governments have been responsible for the slow and steady underfunding of their respective health services. In addition to the GP crisis, Norway is now among the countries in Europe with the fewest somatic beds per capita and the shortest average length of stay in these beds (7) . As in NHS England, the extensive maintenance backlog is growing in Norway, and in 2020, only four of Norway's 20 hospital trusts had a building stock that satisfied the goals in the National Health and Hospital Plan (8) . Underfunding, combined with the governance model, has led to regional health authorities in Norway having to devise completely unrealistic long-term financial plans in which an increasingly diminishing number of healthcare workers are expected to treat a growing patient population in fewer and fewer beds (9) . This again echoes the development in the NHS with a delayed timeline (5, 6, 10) . Meanwhile, doctors in Norway, and particularly junior doctors as in England, are reporting increasing dissatisfaction, difficult working conditions and moral distress (3, 11) . Also akin to the situation in England, more and more doctors in Norway are turning to the private healthcare sector, where growth from 2015 to 2021 was more than double that of the public health service (8) .
In the UK, there is dismay over the fact that billions of pounds of NHS spending is lining the pockets of private American companies (5) . In Norway, the US company Epic has raked in a substantial share of public health spending through the scandalous Health Platform IT system, and the health minister has declared that reversing the process is out of the question. In the Dagens Medisin publication, Norway's Minister of Health and Care Services noted that 'this would mean having to take money from the patients' (12) . Austerity measures and cuts in public spending are clear government policy signals (8) .
In a recent article in the BMJ, Kamran Abbasi wrote 'The indicators for the health service are on red alert. Yet the political response is one of denial, disengagement, and delay.' (10) . In Norway, we still have one of the world's best health services, but even here, the indicators are no longer green. The signs of dwindling political will to maintain a geographically and socially equitable public health service are becoming all too evident. The NHS is on the brink of collapse.
This time we should not be inspired by the UK.