1. Future Acute Care in Rural General Hospitals in Norway Professor Tor Ingebrigtsen CEO University Hospital of North Norway

2. April 30, 2008: Therefore managers intend to base the long-awaited service in a "modular" structure fitted out for its needs, and can be transported to another part of the Highlands once it has been replaced by a new hospital in the town.

3. Hospitals in Norway 1998 –56 acute care hospitals 2006 –45 (surgery and medicine) –5 (medicine only)

4. No rural general hospital to be closed Hospital are important for confidence and feeling of safety in local communities But: –Reconsideration of work share between hospitals

5. The chain of acute care Clarification

7. Main conclusions Rural general hospitals provide important health services and have specific strengths and advantages –Access and availability –Broad, general competence –Local knowledge Quality of care must be as good as in larger volume institutions The chain of acute care must be strengthened, and the work share changed Redesigning processes must follow specific procedures involving all parties of interest

8. A change in workload… More –Diagnostic work –Chronic obstructive lung disease –Kidney failure – dialyses –Diabetes –Stroke and rehabilitation after stroke –Palliative cancer treatment – chemotherapy Less –Trauma –Cancer surgery

9. Pyramid of Health University Hospitals Rural general hospitals Primary Care: >90% av the health services needed Nursing homes General practitioners Community based services

10. Main strategies Early diagnosis to lead the patient to the into right clinical pathway Clinical pathways need to be developed across levels of care and geography Implementation of clinical practice guidelines 50 – 70 % of acute care patients can have definitive treatment at rural general hospitals

11. Bridging the gap goes two ways…

12. Acute Coronary Disease Rural general hospital

13. Stroke CT availability 24/7 <10 % thrombolysis Few transfers to larger hospitals

14. Recommendations High quality diagnostic equipment –CT and ultrasound 24/7 (teleradiology network) –MRI at daytime ER organised in collaboration with local council health services Ambulance station and staff organised and localised close to the ER Specialists in internal medicine and anaesthesiology on call at all hospitals

15. Quality of care Equal to that achieved at larger hospitals –Availability and access are central aspects of quality –Outcome is, too... Service at the lowest effective care level –The volume of elective services must be high enough to allow comparison with larger volume institutions –Pragmatic balance between the volume/quality aspect and availability for acute care

16. Two hospital classes Acute care hospitals –Admit and treat all acute care and trauma patients –Physicians on call in general surgery, anaesthesiology and internal medicine –Sub specialised orthopaedic surgeon not necessary –Radiology, laboratory services –Gynaecology and obstetrics?? Acute care hospitals with adjusted functions –Admit and treat most cases except surgical emergencies – Physicians on call in internal medicine and anaesthesiology –Elective surgery, surgeon not necessarily on call

17. Staff recruitment and competence Main problem: Invasive emergency procedures National and regional training courses Formal documentation of competence New specialty in emergency medicine? –Work group appointed, work in progress –National college of surgeons reconsidering ”common trunk” strategy for general surgery

18. 50 mill NOK (£ 5 mill) to redesign projects in district general hospitals National committee on hospital economy –Redistribution of 780 mill NOK (£ 78 mill) from the capital region to the rest of the country –Main reason: Cost of acute services

19. Regional strategy in development Centralisation of acute surgical care to 7 hospitals?