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Between budget and quality of mental health services


In September 2022, I entered the position as Head of Division of Mental Health and Addiction (MHA) at Oslo University Hospital. The MHA division is the Hospitals’ largest, with 3500 employees and a 2.5 billion NOK. budget. MHA gives local and regional services to the population of Oslo and the South-Eastern region of Norway. When I started, the hospital was in an economic crisis, and in need of substantial financial cuts, 10% was indicated, within a short time frame. In the Norwegian public mental health care financial system, the potential for an increase in income is negligible, meaning personnel activity must be reduced to meet the requirements for cost reduction. At the same time, we must meet society’s unchanged need for high quality services. This process of cutting costs is as such extremely demanding for services, patients, and employees.

How would a leader overcome such a challenge?

Firstly, we needed to establish some basic principles for prioritizing. This included analysis of demands and limits imposed by our superiors as well as existing strategies and plans. Our highest priority became the patients’ treatment pathways through our services.

Second, we examined if the current organization allows for efficient and predictable pathways for patients. The way services are delivered and organized in large hospital clinics have historical reasons. Subdivisional development in units and sections often happen without appropriate understanding of the whole picture and without coordination with other parts of the Division. Reviewing the organization might reveal opportunities, giving impetus to make changes perhaps already overdue.

After preliminary considerations, we facilitated the organization to engage in a dialogue process, with both leaders at different levels as well as employees, often experts in their fields, along with union representatives. There was also a need for communication with service users and the public. A dialogue with the municipality and other hospitals affected by potential changes was also necessary.

Existing hospital routines for organizational changes provided a helpful protocol for our work, securing a sufficient process of investigation, risk analysis and involvement at different steps.

Due to the size of the hospital, potential downsizing will be accomplished within ordinary turn-over rate and no employees will have to be terminated.

Main building of Oslo University Hospital, currently used by the director's office. Image by Wikimedia Commons.
Main building of Oslo University Hospital, currently used by the director's office. Image by Wikimedia Commons.

We created work groups meant to identify possibilities of major changes, and we soon had our core concepts laid out. The next step was to dig into the identified concepts of change; defining, risk assessing and refining our suggestions into something we could implement. It was highly important to get sufficient evaluations of the end results if the suggested changes were to be implemented. These suggested changes stirred the engagement of professionals within clinical communities who openly protested.

The early concepts were picked up by the media, causing public interest and political debate at an early stage of our work. Despite our efforts to correct the picture in the media, this caused unfortunate public distress regarding losing important services, whilst also raising political interest. The media and subsequent political attention affected the process at higher levels and probably played a significant part in reducing the Divisions’ financial challenge by half.

Currently we are in a process where we consider the suggestions for organizational change holistically. We weigh the possibilities: cost reduction and the opportunity to achieve our medical priorities against the risks: lower quality, loss of services, splitting of professional teams, loss of personnel. We strive to do this in a comprehensive manner, sticking to the protocol process. Before any final decisions are made, we will have to do renewed risk-assessments and have formal discussions with the employees.

The media and subsequent political attention affected the process at higher levels and probably played a significant part in reducing the Divisions’ financial challenge by half.

My challenge also has a personal aspect. As a psychiatrist and a researcher, the improvement of mental health care is my main motivation as a leader. In my position the need to prioritize often poses a challenge. Employees in highly specialized treatment services are worried that proposed changes may lead to the loss of their unique contributions in the treatment of vulnerable patients.

I sincerely acknowledge the aspirations and sense of ownership felt and communicated by representatives of these services. I cannot guarantee that all these services will remain unchanged. If such changes are to be made, it will be due to my belief that in the greater picture, they are made for the better or to reduce harm of cuts. Some services may be drastically downsized, and some might need to cooperate in new ways. Even after these changes, the services will still do their best to accommodate the needs of the patients.

My hopes is that the ongoing process will provide a broad insight both professionally and economically, that can be communicated and be the basis for discussions and common understanding in making necessary decisions. In the longer term my goal is to find more efficient solutions without compromising quality and scientific development.

Managing financial cuts at a grand scale in the mental health services is both complicated and time consuming. In the midst of this, I must keep my integrity as a helper and scientist. My success will be measured after my ability to do this. □


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