State Secretary Steinulf Tungesvik

Opening speech at an international seminar on rehabilitation and service delivery

Vettre, 25 November 1999

Ladies and Gentlemen,

It is a great pleasure for me to wish you all welcome to this international conference on rehabilitation and outcome assessment in assistive technology. The conference has been organised by Rehab-Nor and the Norwegian Ministry of Health and Social Affairs.

Due to increasing longevity and the high birth rate over recent years, Norway and other European countries will have to face the fact that the elderly will make up an ever increasing proportion of the population. There have been many advances in medical technology too, and this will mean that people suffering from chronic illnesses or disabilities will also enjoy a longer lifetime.

These factors constitute several challenges – not only in terms of the socio-economic burden on the welfare state. We must find the solutions that can provide those in need of help with the kind of individual assistance which is needed to lead an independent life as possible.

One method of meeting these challenges is to pursue a holistic rehabilitation policy. This would offset any excessive focus on illness and passive patient roles, and would stimulate personal responsibility and the learning of how to live with a disability.

Norway is one of only a few countries in Europe to have drawn up an overall rehabilitation policy. The Norwegian parliament has, in fact, just recently debated a white paper on the issue and has determined a policy based on the following definition:

Rehabilitation is a process or a set of processes which:

• is planned
• has well-defined goals and means,
• is limited in time,

and where several professions or services co-operate in assisting the individual in his or her own effort to:

• achieve the capability to function and cope with problems due to the disability,
• promote independence, social participation and integration.

The goals of independence, social involvement and integration, with help of the individuals own effort, will thus form the guiding principle of the new Norwegian policy. It means that rehabilitation will require more than stimulating greater functional abilities in respect of the day-to-day activities of users at home.

This philosophy isn’t unique to Norway, of course. We’re no “world champions” – even if we like to think so from time to time! In the next contribution, we’ll be hearing from the World Health Organisation how the new ICIDH-2 system is coming along. As you may know, this system places greater emphasis on activity, social involvement and physical and social environments and.

Real rehabilitation must involve user participation in determining how the rehabilitation process is to function. Otherwise, we cannot really call it rehabilitation. If we are to reach our new goals – social involvement and integration – the need for genuine user participation is even greater. The rehabilitation process is the individual’s process.

For this reason, we intend to increase user participation here in Norway in a far more systematic way – in part by means of legal instruments. The Norwegian parliament has given those users requiring long-term assistance and co-ordinated services the right to their own individual plans. Users must play a key role in determining their respective plan – to the extent their medical conditions allow. These plans must identify the process of change required, by focusing on the users’ aims, relevant measures, responsibility, support and assessment. This right will cover many people requiring rehabilitation, but it will not cover all the users of assistive devices, I suppose. However, if the need for services extends over a long period of time, and co-ordination of other services is demanding, users may be entitled to their own plan. The legal right to such plans will be restricted to those plans that cover health services. In purely practical terms, however, the plans are likely to have to cover other measures, such as assistive devices.

In Norway, as in other countries, rehabilitation has never been a high priority. It has often been left to chance who is offered assistance, what kind of assistance is offered, the parties involved, and how and why the offer of assistance is made. Individual action plans with clear targets and measures will now go a long way to making the rehabilitation process more systematic and predictable.

The National Insurance Administration is the uppermost authority for assistive services in Norway. These services are organised in a separate directorate under the auspices of the Ministry. Administration of applications is too slow and the waiting time for service delivery is too long. The National Insurance Administration wishes to simplify the application process. The National Insurance Administration is thus currently starting a project called “Individual habilitation and rehabilitation plans as the guiding principle in the process of service delivery”. The aim of this project is to establish ways to facilitate users’ access to assistive devices. The project will see the development of individual habilitation and rehabilitation plans and their use in simplifying the administration of applications. An effect of this effort could be reduced waiting times. Particular attention will be lent to children during the transfer stage, those with visual or hearing disabilities and those with progressive illnesses.

It is of vital importance that the rehabilitation services can be provided as local as possible and outside the institutions. It is in the users own environment that we can find the best conditions for participation of the users, their quality of life, and the confidence necessary to overcome the challenges in their lives. If the local health and social services do not involve and step in to help when hospitals and more specialised institutions relinquish their responsibilities, the effect of more advanced services can disappear. Norway suffers from disparities in the rehabilitation services offered by the various local administrative units. We aim to do something about this.

The country has a highly decentralised welfare state – and this gives plenty of room for local autonomy with regard to the services offered. The government I represent is, in general, cautious about standing up for detailed, new requirements concerning the provision of local services. Nevertheless, from the national level there have been long expected that the municipalities in our country honour the commitments in the health legislation concerning rehabilitation. The government is therefore going to draw up more precise regulations and instructions to encourage local administration to understand and accept its responsibilities. These regulations will also specify the responsibilities the local authorities have for providing and trying out assistive devices.

Assistive devices can also be a very useful tool for helping those with disabilities to integrate better, to participate more, and to improve their ability. In the past, the philosophy surrounding rehabilitation, and the society’s efforts aimed at rehabilitating the disabled, were completely dominated by the responsibilities and services of the health service. Measures within other sectors and in other fields were insufficiently covered by the collective services offered. The authorities in the field are therefore particularly anxious to prepare the ground for better integration of the services within the framework of local rehabilitation measures.

I presume you can all see the significance of this and are working towards this – especially in connection with the assessment of the effectiveness of different services. To put it another way, you need to consider how assistive devices benefit quality and effectiveness when they are provided together with other measures, and what effects are produced when the assistive devices are provided alone – without any kind of holistic co-ordination.

When the Norwegian model of organising the service delivery was developed, it was emphasised that the system would have to be designed so that the users should have simple, local and skilled access to assistive devices. The system of service delivery was based on a unique concept of organising public services: it was organised from a “bottom-up” perspective. The philosophy behind this concept was to develop an organisation model suitable for solving tasks that didn’t restrict themselves to one subject, one public authority, or one level. The important ideas of the system were:

• holistic measures provided on the users’ terms
• clearly defined lines of responsibility for each stage of the provision process
• close co-operation / decentralised services

This, then, is the basis of the system in Norway today.

Assistive devices and practical preparations may be of great significance for learning, independence and the quality of life. May the increase of personal coping with the help from assistive devices can relieve some of the burden on the services in the nursing and care sector. Hospital stays could also be put back. The service delivery will for many people be essential for being able to lead a meaningful life.

Furthermore, a better prepared society will also be able to reduce some of the practical difficulties that many people with disabilities currently have. The government I represent has presented an action plan for the disabled in which one of the four central concepts is a more accessible society. Possibly, the requirement for special assistive technology can be reduced as en effect of this plan. Of course, a well-organised and accessible society will never be able, however, to ignore completely the need for different rehabilitation services.

People with disabilities will always be dependent upon assistive devices designed to compensate for a reduction in, or loss of, a function. As mentioned earlier, the service delivery is just one of many important areas of rehabilitation work. It is essential to view these measures as parts of a large whole in order to achieve better quality of life, user satisfaction and effectiveness.

Some of the important aims are to ensure that the resources are allocated efficiently and to achieve the required usefulness for users. Therefore it is important that the assistive devices offered are the correct ones for the respective users, and that these services are used in the right way. Only when these services meet the users’ needs and the training is good enough, can we say that the assistive devices have had the outcome we intended. Assistive devices that remain unused represent very poor administration of public resources and don’t lead to satisfied users. Expenditure on assistive devices in Norway is increasing and we must try to halt this trend. It’s important to consider at all times any measures that can slow the growth in costs. We will need to find out more on the extent to which the assistive devices help the users, and we must continue work on establishing good methods and tools for assessing this. It’s also important to make use of the knowledge we obtain in seeing assistive devices provided in co-ordination with other measures. This could lead to more rational use of various types of services and save money. The usefulness of the services and the satisfaction of users are key concepts and must be focused on. Quality assurance will be an important efficiency goal. We will have to work towards this under the motto: “the right assistive devices for the right user at the right time”. We can also add the expression “the right assistive devices at the right price”. This could further increase effectiveness and good resource utilisation.

The National Insurance Administration is currently working on the development and quality assurance of a nation-wide tool for creating user surveys to find out how assistive devices are perceived. The results will be used to improve the service delivery, and to assure the quality and efficient use of the services. The aim of the work is to obtain well-documented, long-term data showing the effects of various measures including service delivery. This tool is intended to be a template for designing both nation-wide and regional surveys in this field. The weakness of many of the surveys carried out in Norway earlier was that they were not designed to take account of trends and comparisons over the long-term. In these general surveys, service delivery was, furthermore, such a small and specialised area that they didn’t manage to capture sufficiently relevant feedback from the users. The National Insurance Administration reckons on having this survey tool ready for use by summer, 2000.

It is one of the aims of this country to ensure that all public service authorities will soon have to give any users who demand it a so-called service declaration. Such declarations are intended to ensure that the users know what kind of services they can expect. Together with individual plans, these declarations will enable both users and the public service authorities to predict and plan ahead. Individual action plans will make it easier to obtain and try out the most effective assistive devices. We also hope that these plans will maximise user satisfaction, whether with the assistive devices or with other measures.

Users are not categorised into sectors. The end product – the quality of life, which we hope will improve as a result of a comprehensive rehabilitation programme, cannot be split up into parts either. I hope, therefore, that this conference will see how assistive devices can be an integral part of the users’ lives.

Good luck and thank you for your attention!