Placing all bets on one winner

Now, we have (yet) another new red-green Minister of Health. Will he cut to the chase and declare that the enterprise reform was a mistake?

Photo: Einar Nilsen

It ended as we expected: We have yet another new Minister of Health, the fourth one in seven years. Bjarne Håkon Hanssen took over from Sylvia Brustad in 2008, but retired from politics the following year. He was not an «implementer» (of the interaction reform). Anne-Grete Strøm-Erichsen was charged with this task: «Effectiveness in implementation was the decisive factor in choosing a minister of health (…) She has a kind of discreet authority that renders her able to implement challenging processes,» a key source in the Labour Party told Aftenposten (1)

Now, the baton is passed to Jonas Gahr Støre, PM Stoltenberg’s strongest runner. The expectations and the pressures on him are high. The public health services cannot bear any more fancy promises, quick fixes, glossy vision documents and PowerPoint presentations. It cannot bear any more nebulous palaver, abrogation of responsibility and mutual accusations. And the necessary mutual trust between patients, next of kin, health personnel, managers and politicians must be restored really quickly. If not, Norwegian health services as we have known them will have a very poor prognosis indeed.

Støre is one of the best-trained men in Norwegian politics. He was educated in Norway, France and the US. He co-authored the book Scenarier 2000 («Scenarios 2000») when he was in his mid-twenties (2). From before the age of thirty and for almost ten years he was a key political eminence grise. As Special Adviser and later Director General at the Prime Minister’s Office, Støre was described as the knowledge bank, the generator of ideas and the strategist who provided analyses, preconditions and assessments to four different prime ministers. Both the Conservatives and the Labour Party wanted to have him on their team, since he had not yet declared any party loyalties. When Gro Harlem Brundtland was appointed to the directorship of the WHO, she brought him with her and made him her key adviser. In other words, he was no political novice when Jens Stoltenberg brought him home to Norway to take up the post of Chief of Staff at the Prime Minister’s Office after establishing his first cabinet in March 2000. It is precisely this experience during Stoltenberg’s first years in office that may prove to be of utmost benefit to the new Minister of Health. Because what happened? The minority government wanted to modernise the public sector on the basis of business models – with the health sector as its highest-profile undertaking. Tore Tønne was recruited directly from Norway Seafoods as an expert on restructuring and as a «strategist who was alien to the field», as described so brilliantly by Rune Slagstad in a recent «Perspectives» article in this journal (3).

The health-sector enterprise reform was implemented in record time by a relatively small number of people, with Tore Tønne assisted by Jonas Gahr Støre, his extremely capable chief of staff, in the driver’s seat. They involved very few others in the processes, and were not particularly open to opposing opinions.

The intentions were praiseworthy. Everybody should be provided with better, more accessible and equitable health services. Public resources should be used more efficiently. However, as I noted in an editorial immediately after the adoption of the hospital reform in 2001 (4): «To the patients, good intentions or the identity of the hospital owners are not the crucial issues. The crucial issue is the identity of those who make the final decisions on to the treatment and care provided to the patients.» On this point, Tore Tønne’s report to the Storting was crystal clear: «(The reform) will have immediate and long-term consequences for responsibilities and the exercise of responsibilities, for the distribution of roles among various actors, and for the opportunities for further development of one of society’s most important sectors» (5). There was also a discussion of how «the professions have been allowed too much latitude» (6, p. 30). The reform shifted power away from the politicians, the patients and the healthcare professions and onto the new enterprise boards. Thus, the priorities that these would choose to establish were the main question.

Now, eleven years later, we can see the results. Some things have improved (many hospitals have sorted out their finances), but many things have taken a turn for the worse. Most worryingly, the vociferous protests from the most engaged, competent and responsible doctors and other health workers have become more muted. A growing number of those who are able, leave for private service providers. It is far too simple to say that they are drawn by the money. Most of them do so because they find it to be more meaningful (7). Those who heard and saw the thoughtful and obviously weary figure of Senior Consultant Christian Grimsgaard in a televised debated on 17 September could well appreciate the crux of the matter: «Many of our colleagues have resigned themselves to the situation, we are losing many good ones, and we may not receive the applicants whom we would want.» Some want to turn this into a problem just for Oslo, but that is too simple. Until now, only the Oslo region has provided real opportunities to escape. Others may follow, though.

Private alternatives are not the main threat to a public healthcare system based on solidarity funding – the main threat is an erosion of the public healthcare system itself. Not through lack of money, but through lack of a sense of the importance of personal engagement, professional self-respect and a willingness to assume independent responsibility. A failure to recognise competence and appreciate individual effort is much more dangerous than a lack of money.

«If we cling to old solutions that fail to work, we will undermine the confidence in public solutions. Then, we will impair our welfare and increase social inequalities. From this, we all stand to lose,» Stoltenberg said in the Government’s inaugural address to the Storting on 22 March 2000. There is every indication that many of the solutions that were chosen to address the very real problems in the specialist health services over the last 15 – 20 years now belong to the category of «old solutions that fail to work»: Performance-based funding quickly led to adjustments and tampering with codes. The interaction reform is so unclear that it is hard to tell how it should be assessed. The enterprise reform has turned into a system for abrogation rather than allocation of responsibility. Stoltenberg and Støre have both observed this from up close.

Cicero and Seneca have both been credited with the statement that to err is human, but to persist in the error is diabolical. The Minister of Health will most likely be familiar with it.