The first week in Oslo

Winston Churchill Memorial Trust Project 

Norway's Pioneering Approach to Drug Addictions. Lessons for the UK?

My project studying Norway´s approach to substance misuse in Oslo has finally got underway this month. Norway is one of the most prosperous countries in the world thanks to a strong economy buoyed by its oil industry which began in 1969 following it´s discovery. Norway is fortunate to have the financial ability to invest in new approaches within its healthcare system. However in 2014, Norway had the second highest rate of drug overdose deaths in Europe after Estonia. In the process of tackling its complex drug problem it become the first country to introduce a standalone addiction specialty for doctors: Rusmedisin (Addiction Medicine). It has also pioneered the Akuttpost (Emergency Dextoxification Posts) and extensive psychological services, a common feature of Scandinavian healthcare. Addiction specialist training in the UK currently falls within the spectrum of psychiatry services in the UK and has much less financial investment compared to Norway. What can we learn from the innovative work in this country? I am to answer the following questions during my stay:

1.Would a standalone medical speciality in addictions improve treatment of substance misusers in the United Kingdom?
2.What is the relationship between Kommune (Council) health services and hospital trusts for substance misuse?
3.How does aftercare (post-detox) treatment differ in Norway?
4.Does the use of specialist Akuttpost (Emergency Detoxification Posts) prove more effective than treating via conventional Emergency Medicine departments in the UK?
5.How does a larger provision of psychological services impact on Norwegian addiction services?
6.How does the two-tiered emergency service structure of Legevakt (Cottage Hospital) and separate speciality emergency services at regional hospitals in Norway improve hospital care for addictions.
7.Has the integration of primary and secondary healthcare services through the Legevakt helped in Norway to treat substance misuse
8.How has the drug scene in Oslo evolved over the last few decades, with particular regard to the large levels of immigration?

My first week has been spent orientating myself within Oslo University Hospital services with is the largest hospital trust in Scandinavia and made top of three main sites Aker sykehus, Rikshospital, Radiumhospitalet and Ullevål sykehus. I´m currently based within the klinikk psykisk helse and avhengighet department which is the umbrella organisation for addictions linked with psychiatry from a managerial perspective. I am spending half my time observing the stabilisation service post detox at Ullevål and then the other half of my time within the acute detox service at Aker. Along side this I have arranged interviews and visits within other aspects of the health service such as SERAF (addictions research team in Oslo), Legevakt (community cottage hospital service), Helse Sør-Øst (Strategic Health Authority for Oslo), Helsedirektorat (NHS England equivalent) along with a variety of community services. My first blog will focus on some of the background to the Norwegian Health service. 

Norway is the first country in the world to have created a stand alone medical speciality in drug addictions. There had been a growing desire for this within the last decade within Norways health system in recognition of the fact that drug dependence often requires close medical management. Specialist trainees spend 5 years training which is a common training period for most medical specialities, including GP training in Norway. There are no exams, regular teaching, close supervision but with much earlier emphasis on trainees training full management for patient care with more arms length support from seniors. This is noticeable from when junior doctors start their Turnus (Foundation programme) which is a shorter 18 month period rather than 2 years in the UK. There are roughly 50% more doctors per 1000 people in Norway and this doctor to patient ratio is one of the highest in Europe beaten only by Estonia and Greece based on 2012 Eurostat statistics. Spending per patient is also almost exactly double what the UK spends on patients. The majority of this is likely to be accounted for by significantly higher wages and staffing levels which usually make up the majority of health expenditure. 

Life expectancy in the UK (81.5) and Norway (81.45) is roughly the same, however population density in Norway is (14 people per sq. km) UK (269 people per sq. km). This is interesting given that the population in the UK (63 million) is 12 times greater than than Norway (5 million) however the land area in Norway (385,178 km²) is 50% large than the UK (242,495 km²). Therefore Norway has had to provide high quality healthcare over a huge area   to a smaller population which historically has had population virtually along the entire coastline all the way to the Russian border in the Artic Circle and including the many small islands off the western and Northern coastline. In contrast to other countries in Scandinavia there is much more a spread of population throughout the country although the majority of the population doe still live in the more southern regions.

Some of the obvious differences within the substance misuse patterns in Norway are lower levels of alcohol excess, likely in part due to a stricter approach to pricing and availability. Alcohol is taxed by strength at higher rates than in the UK and only lower strength alcohol can be bought in supermarkets which all wine and spirits only available in the Vinmonopol, which is a state run monopoly that is closed most of the day on Saturday, all day Sunday and not open past early evening during the week. Methamphetamine use is more prevalent here compared to my experiences in North West England however Spice (Synthetic Cannabis) which is becoming an increasing difficult problem to manage in Manchester is currently almost unheard of in Oslo.

The training and work culture is much more relaxed and informal in Norway with no real feeling hierarchy, senior staff all work on first name terms and are always readily available for advice. I attended the weekly teaching with LIS lege (specialist trainees) this week and there is a great emphasis on learning from best practice and actively looking at research from innovators across there world. There is definitely a feeling within the service that due to higher staffing levels, the medical staff have time to spend looking at how to implement changes and improve services rather than just drowning in service provision. 

Culturally there is also a greater emphasis on working together. At the end of my first week the entire department and patients took part in the traditional communal spring cleaning work ´Dugnad´ which is taken very seriously by the entire population. Everyone got together and cleaned the large garden area around the inpatient unit and had a BBQ afterwards. In comparison to work in the UK there is much more opportunity for everyone to sit down together at lunch, team meetings and teaching sessions regularly during the week. The result is a much friendlier work environment. 

http://www.emcdda.europa.eu/publications/edr/trends-developments/2014

http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Healthcare_indicators,_2002_and_2011_12_(per_100_000_inhabitants)_YB15.png

http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Current_healthcare_expenditure,_2014_YB17.png

http://data.worldbank.org/indicator/EN.POP.DNST