Specialization and Professionalization

From 1893 to World War II the central health administration (led by a Medical Director) was divided into a department located in a Ministry (from 1913 the Ministry of Social Affairs), led by a jurist, and a Directorate of Medicine, led by a medical director. In 1940 the two units were (again) merged, under the leadership of the medical director, appointed by the Nazi government. The Norwegian health administration organized by the free Norwegian government in London (Stockholm and Washington) was also organized as an integrated unit, led by a medical director (Karl Evang). Dr. Evang wanted to keep this Nazi-introduced system, though under national leadership. He had his way, but gradually the systm came under attack. It was visibly weakened when Evang resigned in 1972. His successor, Torbjørn Mork, also turned out to be a defender of the medically led health administration. In 1983 he suffered a major defeat when his directorate of health was reduced in size and moved out of the Ministry. He and his directorate thus lost much of its old authority. This led to a protracted tug-of-war between the Ministry and the Directorate. The Ministry wanted to “dissolve” the Directorate, but parliament decided that it could continue to exist, though as a supervisory agency.

In this study we show how the old directorate gradually lost its most typical directorate functions, like the policy development and policy implementation functions. Instead, it became a more and more supervisory, or controlling, agency. It was from 1994 called a Board of Health Supervision. The transitional period lasted until 2002, when the agency became an almost purely supervisory agency. Briefly put, a once primarily offensive directorate became a mostly defensive inspectorate. But as this happened, the need for what the old directorate had been, an offensive agency, became pronounced. Thus, in 2002 (2008) an offensive directorate was again formed or resurrected. That was in a way the final humiliation of Torbjørn Mork, and indirectly Karl Evang. The new directorate did indeed become an offensive agency, but also a politically obedient agency.

But what happened around the turn of the century is indicative of a more pronounced change of the governance structure of the Norwegian political system. In general governance assumed a more goal-oriented nature in Norway, like in many other Western countries, from the 1980s. Norwegian governance became more New Public Management-oriented. Structurally this meant that governance functions assumed a broader basis. The policy-oriented functions were gathered in a small ministry and a large directorate (the major instrument of the Ministry), the “diagnostic,” knowledge promoting functions were placed in a renewed public health institute, and health practice surveillance in a shrunk supervisory agency. “On the sidelines” a new, enlarged medicines agency was created – more or less as a response to the “privatization” and commercialization of much of the medicines sector, later medical products agency.

But more began to happen now: It was not only in the health sector that supervision became more important, and more professionalized. Many sectors came under the form of control exemplified by the supervisory agencies. Thus, after the great reorganization the health supervision agency also gradually became a supervisory agency for social services, child protection, military health care and health research. The health supervision agency now also gradually expanded its cooperation with other supervisory agencies.

Karl Evang had been an ”institutional” director of health. He was appointed for “life” (retirement age). He personalized the Directorate: In health legislation it was referred to the Director, not the Directorate. This situation continued in most respects when Torbjørn Mork became Director General of Health in 1972. But under his reign the legislation became “secularized.” This trend was strengthened under his successors, Anne Alvik (1992/93-2000), Petter Øgar (2000) and Lars E. Hanssen (20002012). Under Dr. Hanssen the institutional title was removed. Dr. Hanssen was appointed as Director General of Health, but from 2004 his title was changed to Director of the Norwegian Board of Health Supervision. The director the new Directorate of (social and) Health Affairs (2002) became Director, not Director General of Health. However, the Ministry of Health (and Care Services) after 2004 did accept that he used the old title, though not as an institutional title.

When Anne Alvik succeeded Dr. Mork as Director General of Health she also actively sought to “secularize” the role. She became less distanced and authoritarian than he had been. She justified her decisions more professionally and less with reference to her title and position. She socialized with her staff, including the Chief County Medical Officers, much more than Dr. Mork had done. She was also less active externally than he had been. She had been the “minister of the interior” under Mork. She continued to some extent to play that role when she became director. Her successor, Lars Hanssen – we disregard here the provisional director, Petter Øgar (2000) – resembled her in important respects, though he became more active externally. He was a clever PR person, but also socialized actively with other administrative directors, especially directors of supervisory agencies. After the reorganization of the health administration system in 2002 Hanssen became an increasingly influential central administration person. He also became influential through his membership of the overarching leader group of the central health administration. The permanent secretary, Anne Kari Lande Hasle, organized this group, consisting of her and the other institutional leaders, Bjørn-Inge Larsen (The Directorate og Health), Geir Stene-Larsen (The Public Health Institute) and Lars E. Hanssen (The Board of Health Supervision) every Friday.

Dr. Mork had not least based his authority on his personal charisma. Alvik based her influence more on her formal authority. She could be strict, if she thought that that was necessary. She became an ardent, though not uncritical, adherent of the new public management; that is to say, management by objectives (goals). However, that led to tensions with some of the older Chief County Medical Officers who had also based their authority on traditions and personal charisma. When the conflict between Ministry and Directorate was at its most intense (1991-1992), the staff of the Directorate, though not all the Chief County Medical Officers, enthusiastically gathered around their chief, Dr. Mork. When a “complaint case” (about an alleged “euthanasia”) became a sensitive issue (nationally) in 1998–2000 director Alvik did not receive the same active support from her staff as Mork had done. The Ministry also “used” the case to “oust” her (first through a “recommended” leave of absence, then by making it difficult for her to come back after the leave).

Dr. Hanssen was (is), like Dr. Alvik, loyal upward. When he wanted to challenge the Ministry, like in the reorganization process around 2002, he did so more through wit than “moralization.” Dr. Hanssen was, and is, a sharp and witty person. This gave him authority. As head of the Supervisory agency, he was, however, a “mild” leader, preferring affirmative to disaffirmative ways of managing.

The Board of Health Supervision did what it could to follow up the prescriptions for management by objectives. However, like other agencies, and for that matter ministries, it soon learnt that it was very difficult. The ministers, and politicians in general were both unable and unwilling to define precise goals. Thus, it became even more difficult for administrators (at lower levels) to do so. It was obvious that the “final” goals would have to be based on opinions of health, on the distribution of services aimed at realizing the health goals and on views about the desired outcomes of disease prevention and health promotion measures, but politicians balked at being very precise. Then it also became impossible to set priorities in any concrete way. Since any health policy measures involved setting priorities between health goals and other goals, goal preciseness became an utterly illusive “goal.” In practice health values were used as guiding principles and then concrete measures (tasks) as operational “goals”. Hence, typical goals for the Board of supervision became to increase the number of system supervisions the next year by say 3 to 5 percent or reduce the waiting times for the completion of complaint cases by a set amount the year to come.

The Board was keen to “keep within the budget,” but did not have as a goal to increase its cost effectiveness by this or that much in the coming year. Indeed, it kept very clear of all sorts of effectiveness considerations, that is of questions having to do with what one got back from investing money in various supervisory activities. The question was: did health supervision, like any sort of audit, pay off?

The NPM and, in general, the goal-or task-oriented management, was integrated (from 1988) in a special plan, called the Institutional Plan (“Virksomhetsplan”). The plan was followed up by an annual (results) report. The name of the plan was appropriate: It was a an activity (“virksomhets-“), more than a goal-oriented, plan.

The old Directorate was in the main organized based on institutional criteria or task criteria. After the reorganization of 1983, legally trained personnel began to press for the establishment of a department of health law, that is a department based on a functional/managerial criterion. Legally trained administrators disliked being managed by physicians only. They were heard and from 1989 a new, legal department was established. In 1994 a new department of social medicine (public health) was also established. The latter department came as a response to the changing nature of the Board of Health Supervision: The Board was to become an agency for supervision. But since supervision now, increasingly was based on law, it meant that the new Board became more permeated by legal thinking.

The 1990s also saw the growth of a quality development wave. As a goaloriented way of managing, this wave posed a challenge to the law-based Board of Health Supervision, but a challenge that did not lead to the transformation of the Board of Health Supervision. It continued as a Board of Supervision. It handed off the (strategic) quality task to the new Directorate of Health and Social Affairs, or rather, it was deprived of the task.

It is no mere coincidence that from 2002 the institutional departments were dissolved, and that also the legal department was made a thing of the past. Out of the radical reorganization process of 2002 two main departments emerged, one for case supervision (treatment of complaints etc.) and one for planned supervision. The administrative department was kept, though. Thus, the Board of Health Supervision became almost a purely supervisory agency. That also meant that the Directorate of Health of Evang and Mork had become a thing of the past, and not least because of the latter. However, later institutionally based departments, e.g. for social services and child welfare services, were introduced. Also, other changes were to take place. Thus, a director of legal affairs was appointed.

In chapter 5 we have given a portrait of Anne Alvik as Director General of Health from 1992/93 to 2000. We have described her as very different from her two dominant predecessors, Karl Evang and Torbjørn Mork. She wanted to manage in a more low-key manner than them and did so. Were they were withdrawn but outspoken, she was more outgoing, but also more “bureaucratic.” She was a rule-follower. This holds both for legal and ethical rules. Her background from the religiously active West coast, played, and continues to play, a role in her life. Though she was in so many respects different from her predecessors, like them she held leftist view on the organization of health care.

As a mother of four she started out as a parttime physician, but then gradually, and almost accidentally, entered administrative medicine. In 1985 she became appointed “medical councellor” (“medisinalråd”) in the Directorate of Health. Thus, she became Dr. Mork’s second in command and later his successor. As such she headed the work to transform the Directorate into a Supervisory Board. When she resigned, she had almost succeeded in doing so.

A complaint case (opened in 1998), mentioned above, became the reason for her resignation. The case started in the summer of 1998 when a physician at a local hospital in Bærum outside Oslo reported his colleague to the director of the hospital for having performed euthanasia on an elderly, severely ill patient. The case was reported to the health supervision board, later also the police. Newspapers, and not least the country’s largest (Aftenposten), followed, and almost controlled the development of the case. The Board of Health Supervision was heavily criticized for its handling of the case. The Ministry also became critical and that led to the director’s downfall.

That a strict rule-follower, like Anne Alvik, should end her career in this way came as more than a surprise for all who knew her, and had observed her work as director. The Justice Ministry’s department of law, and later (fall 2001) the Attorney General, concluded that the Board of Health had treated the case in a satisfactory way. Eventually, then, Anne Alvik got her reparation. However, in many ways it was too late.

The main externally directed task the Board of Health Supervision was faced with after 1994 was of course to find out what it should mean by supervision and how it should develop itself as a supervisory agency. This task was challenging for there were few such agencies in other countries. In most other countries supervision was a side task for a directorate-like agency. However, there were some other supervisory agencies in Norway, like in the area of occupational health, environment and security, and the Board of Health supervision could look to that for inspiration. It did so too. Yet, it had to do much of the work itself. Thus in 1995 it appointed a supervision project, under the direction of a public health physician, Magnar Kleppe. The project was of course based in the public health (social medicine) department.

In the old days supervision was a combination of control and, often relatively informal, collegial advice. After 1983, and still more after 1994, the inspection and control became dominant. In practice this meant that the formal supervisors (or rather, inspectors) checked if health personnel and health institutions behaved as they should. Thus, supervision largely became a legally based activity. Supervisors, like Chief County Medical Officers, could still exercise some, but not much, judgment.

Supervision could either be proactive or reactive. In the old days it was mainly reactive. Supervisors, in the end the supervising institution, the Board of Health Supervision, could punish those they had found had broken the law. It was difficult to punish institutions, often owned, directly og indirectly, by the state or “its” local arm, municipalities or counties. With the enactment of the law on health supervision (1984) the powers of the Board of supervision were (gradually) extended. Now the Board could, in the most serious cases, both close institutions and fine them. Individual care providers had always risked strict punishments. In the final analysis they risked having their license to practice revoked. Individual practitioners could of course also be criminally prosecuted. That individual practitioners could be sued by their patients for damages is not a part of the supervisory system.

Even if a punishment is reactive, it is a reaction to an illegal practice (malpractice), it also has a proactive function. It scares institutions and individual practitioners from transgressing the law and not adhere to what is considered to be good medical practice.

However, the ambition of the new health practice supervisors was primarily to prevent malpractice without having to resort to scaring. The “new” supervisors found that that could be done through organizational measures. They were inspired by what had happened in the work life area. Here employers are legally obligated to have a system of so-called “internal control” in place. In other words: Supervisory authorities make the institutions they are to control into their “own” agents. In this way they not only reduce the risk of organizational failure but also individual failure – since most of the practitioners are employees of institutions, not independent practitioners.

Thus, in the course of the period we are now discussing control with the internal control became an important part of what the health supervisors now did. It was often referred to as system audit. To learn as much as possible from the internal control activities carried out, the Board of Health Supervision each year decided that one or two parts of the health care system should be subjected to partly standardized internal control audits.

Magnar Kleppe and some of his colleagues were eager promoters of the IC-based type of audit. However, he and some others began to harbor some doubts about the IC-based supervision system. IC-based control is oriented toward preventing negative events from occurring. It did little to increase the volume of positive results. Elsewhere, also in the public administration, others worked to improve the output, and its quality. Dr. Kleppe, as a physician (and not a lawyer) showed quite a bit of interest in the quality work (movement), but little happened about that in the period we write about here. That is not surprising. The Board of Supervision, dominated by lawyers and IC-oriented physicians, could not change their ways that much, that is, become a directorate again. Responsibility for quality policy was transferred to the new Directorate of Health.

The individual supervision remained a reactive activity, indeed a very reactive activity. The Board of Health Supervision needed too much time, often more than a year, to conclude in the various cases. Starting in 1997, three projects, one after the other, were organized to reduce the backlog of cases. The projects succeeded, at least to some extent. Through two chapters we show how difficult complaint cases can be, and why they can take such a long time. In the first chapter we use a case (two cases) where a girl and a boy died in a hospital after having been sedated with the medicine Diprivan. It took almost the entire decade (1990s) to handle this case. The other case is the so-called Bærum-case (1998-2000), mentioned above. It received much public attention. Indeed, the news media almost orchestrated the handling of the case. As we have said, it led to the resignation of the Director general of Health, Anne Alvik (2000).

The last form of supervision was what we may call the systemic supervision (“overordnet faglig tilsyn”). It has as its object the entire health system. It comprised a diagnostic (evaluative) task: How well does the system function, given its more or less precise objectives? Given the “diagnosis,” the next systemic task was to recommend reforms. Thus, the systemic task was partly political. The Board of Health supervision did not define the policy goals itself, though. It took as its point of departure the goals one might say were explicitly og implicitly defined in the legislation and official policy plans. That means it was equality or quality oriented, especially the former, but more in an indicative than a precise way. It was not particularly cost-effectiveness oriented. In general, then, the systemic supervision was expenditure-driving, as was supervision in general.

As we have seen, from 2001 to 2002 the health governance structure was fundamentally reorganized, mostly based on NPM-ideas. The reorganization was developed and driven by some NPM-inspired chief administrators, like the permanent secretary of the Ministry of Health, Anne Kari Lande Hasle and the head of a division in the Ministry, Vidar Oma Steine. However, they succeeded because they had the enthusiastic support of the incoming minister (of health) (Spring 2020), Tore Tønne. Some important catchwords for characterizing the reorganization is clearer lines of authority, clearer definition of the roles managers at each hierarchic level have and functional specialization and centralization. However, the organization of the medical commodity sector continued to be different.

Anne Kari Lande Hasle and her reform people saw to it that also parts of the clinical sectors were adapted to the reforms at the top. They were made operationally more independent of their owners (and governing agents). This was especially the case for the hospitals, which were taken over by the state and organized as regional health enterprises (2002). To some extent it was also the case for the primary care physicians who now (2001) became partly private practitioners (contractors). In some respects also the municipalities now began to organize their activities based on the principle of distinguishing between owners/managers and providers.

Later changes in the structure of health administration governance and the relationship between this structure and the (pre)clinical structure have mostly been minor. They have not fundamentally challenged the principles of the Hasle reforms of 2001 and 2002.