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Previous studies of health system legitimacy have almost exclusively paid attention to patterns of service satisfaction and preference for state involvement. These two dimensions are related to substantial and procedural justice; i.e. the value of a certain policy and the way it is implemented. This study contributes to the research field by focusing on a third dimension that have been little studied so far: the willingness of citizens to contribute on a solidaristic basis. This dimension was captured through three health policy preferences: public healthcare spending willingness, opposition to co-payments and opposition to private health insurance. Building on the literature on welfare state legitimacy, the empirical model distinguished between two sets of predictors to explain individual differences: self-interest and ideological belief. Old age, poor health and poor economy is positively associated with opposition to co-payments for "self-inflicted" diseases, while low education and poor health is positively related to support for more public spending. Increasing age is furthermore positively associated with opposing co-payments and easier uptake of insurance. Liberal-conservative voters are less willing to spend more on healthcare but more willing to increase the use of co-payments and insurance.

Background Health systems across the world have implemented reforms that call for a reconsideration of the role of management in hospitals, which is increasingly seen as important for performance. These reorganisation efforts of the hospitals have challenged and supplemented traditional profession-based management with more complex systems of management inspired by the business sector. Whereas there is emerging evidence on how medical professionals in their role as leaders and managers adapt to the new institutional logics of the health care sector with increasing demands for efficiency and budgetary discipline, no previous studies have investigated whether leaders’ emphasis on clinical or financial priorities is related to how hospital physicians’ view their working situation. The purpose of this study was therefore to examine the relationship between leadership style and hospital physicians’ organisational climate. Methods We utilised data from a survey among 3000 Norwegian hospital physicians from 2016. The analysis used three additive indexes as dependent variables to reflect various aspects of the organisational climate: social climate, innovation climate and engagement at the workplace. The variables reflecting leadership style were based on an item in the survey asking the respondents to rate the leadership qualities of their proximate leaders (department chair) on 11 specific dimensions. We used factor analysis to identify two types of leadership styles: a traditional profession-based leadership style that emphasises the promotion of professional standards and quality in patient treatment, and a leadership style that reflects the emerging management philosophy with focus on economic administration and budgetary control. Controlling for demographic background, leader role, foreign medical exam and specialty, the empirical model was estimated via multivariate regression. Results The results documented a clear relationship between leadership style and organisational climate: a ‘professional-supportive’ leadership style is associated with better social climate, innovation climate and engagement at the workplace, while an ‘economic-operational’ leadership style is associated with a poorer social climate. Conclusions The cross-sectional study design makes it impossible to draw inferences about direction of causality and causal pathways. However, the positive relationship between professional-supportive leadership and organisational climate is a matter, which should be seriously considered regardless of direction of causality.

Background: Integrated care is seen as integral in combating the current and projected resource scarcity in the healthcare systems of developed economies. Previous research finds positive effects from implementing intermediate care but there is a lack of research on how this shift towards care integration has affected traditional quality indicators within healthcare, indicators such as mortality rates and hospital readmissions. We seek to contribute to the discourse by studying how the introduction of intermediate care in the form of municipal acute units (MAUs) in Norway has affected age adjusted mortality rates and hospital readmissions. Data and methods: In this retrospective cohort study we utilize yearly population-based registry data from 2010 to 2016, analysed with fixed-effects regressions. Data on the implementation, characteristics and localization of the MAUs were gathered by telephone during the implementation period. Data on mortality rates and hospital readmissions were collected from Statistics Norway and the Norwegian patient registry. Results: Our analyses finds that the introduction of MAU was associated with a statistically significant reduction in both aggregated mortality rates and hospital readmission rates. In depth analyses finds that our results are contingent upon the age of the patients treated at the MAUs and the clinical characteristics of the medical units themselves. Conclusion: Our findings indicate that the shift towards intermediate care through the introduction of MAUs has increased performance within the public healthcare sector in Norway. Our findings indicate that the introduction of MAU have had a positive public health impact by lowering the mortality and readmission rates for the oldest population cohort in Norway. Our findings suggests that countries with comparatively similar healthcare systems as Norway could achieve similar benefits from implementing intermediate care in the form of somatic medical institutions in the local communities.

This volume examines three interconnected themes in political science: the nuts and bolts of government, the complex and evolving relationship between politics and administration, and continuity and change in government. Government ministries and agencies are vital components of the executive branch of government that play fundamental roles in the democratic governing of modern societies. Contemporary public administration is conventionally portrayed as being based on a series of dichotomies: politics versus administration, coordination versus fragmentation, integration versus disintegration, trust versus distrust, etc. As an alternative, this volume, which is composed of a series of case studies from the Nordics and beyond, conceptualises and empirically demonstrates how government bodies at different levels of governance are driven by pragmatism characterised by the co-existence of multiple decision-making premises. To account for the composite aspect of government, this volume illustrates how institutional and organisational factors can structure elements in the policymaking process and how these elements are powerful tools available to purposeful design.

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)’s 2015 Health Survey (N = 2689), this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. © The Author(s) 2019. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com.

Background Physician turnover is a concern in many health care systems globally. A better understanding of physicians’ reasons for leaving their job may inform organisational policies to retain key personnel. The aim of this study was to investigate hospital physicians’ intention to leave their current job, and to investigate if such intentions are associated with how physicians assess their leaders and the organisational context. Methods Data was derived from a survey of 971 physicians working in public hospitals in Norway in 2016. The data was analysed using descriptive statistics and multivariate analysis. Results We found that 21.0% of all hospital physicians expressed an intention to leave their current job for another job. An additional 20.3% of physicians had not made up their mind whether to stay or leave. Physicians’ perceptions of their leaders and the organisational context influence their intention to leave their hospital. Respondents who perceived their leaders as professional-supportive had a significantly lower probability of reporting an intention to leave their job. The analysis suggests that organisational context, such as department mergers, weigh in on physicians’ considerations about leaving their current job. Social climate and commitment are important reasons why physician stay. Conclusions A professional-supportive leadership style may have a positive influence on retention of physicians in public hospitals. Further research should investigate how retention of physicians is associated with performance related to organisational and leadership style.

The growing literature on individual determinants of subjective well-being has given little attention to political factors. This paper considers the welfare state, and how social expenditure affects individuals’ self-reported life satisfaction. The statistical analysis uses indicators of subjective well-being, reflecting individuals from OECD-countries between 1980 and 2012, with data gathered from the Eurobarometer and the World Values Survey - which are analysed in comparison. The results suggest that social spending should be studied in terms of underlying branches when addressing its implications. The results find social spending to be uncorrelated with levels of subjective well-being when considered in terms of total levels. When considered as types of spending however, a majority of the elements are found to have significant impacts. The findings show mixed results among the two data sets; however, important similarities are found in the way social spending related to health care and poverty are having positive impacts, and spending associated with unemployment and labour market programmes have negative impacts. As the correlations of the underlying elements affect life satisfaction in different directions, total social spending appears to be uncorrelated with subjective well-being, although the true impact depends on which socialpolicies are being promoted through such spending.

This paper uses survey data to analyse physician views on the risk of cream skimming under a system with activity based financing (ABF) for hospital services. We used data from two nation-wide physician surveys. A survey undertaken in 2006 captures views following a large NPM-inspired structural reform in 2002. In contrast, a survey undertaken in 2016 captures views after a period of a higher degree of institutional and financial stability. We find that the majority of physicians believed that the 2002 reform both provided incentives for and led to more cream skimming. In 2016, however there is less consensus among physicians about the extent of cream skimming. Looking at different types of physicians we find some indications that physicians in leading positions are less likely to view cream skimming as a problem. However, there is concern that hospital management in general puts too much emphasis on economic issues.

Aims: This work examined the role of cultural values in understanding people’s satisfaction with health services across Europe. Methods: We used multilevel linear regression analysis on the seventh round of the European Social Survey from 2014, including c. 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses led us to believe that some explanations of variance in the dependent variable were to be found at the country level. In search of country level explanations, we attempted to account for the role of national culture in influencing citizens’ attitudes towards health systems. This was done by using Hofstede’s dimensions of power distance, individualism, masculinity and uncertainty avoidance, giving each country in the survey a mean aggregated score. Results: In our first model with individual level variables, being female, having low or medium education, experiencing financial strain, and reporting poor health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems, with the latter variable showing the strongest effect. After including Hofstede’s cultural dimensions in our multilevel model, we found that the power distance index variable had a negative effect on the dependent variable, significant at the 0.1 level. Conclusions: Citizens are likely to evaluate their national health system more negatively in national cultures associated with autocracy and hierarchy.

The purpose of this study was to investigate whether increased uptake of private health insurance (PHI) in a traditionally NHS type system is likely to affect support for the public healthcare system. Using the Norwegian healthcare system as our case, and building on a survey among 7500 citizens, with 2688 respondents, we employed multivariate analysis to uncover whether the preferences for public health services are associated with having PHI, controlling for key predictors such as socio-economic background, self-rated health and perceived health service quality, as well as age and gender. The basis for our analysis was the following two propositions related to the role of public healthcare, which the respondents were asked to score on a 5-point Likert scale (1 = "totally disagree", 5 = "totally agree"): 1) "the responsibility of providing health services should mainly be public", and 2) "the activity of private commercial actors should be limited". The regression analyses showed that the willingness to increase the role of commercial private actors is positively associated with having a PHI. However, we found no relationship between holding a PHI and support for public provision of health services when other factors were controlled for.

Research on chronic obstructive pulmonary disease (COPD) that includes geographic information is important in order to improve care and appropriate allocation of resources to patients suffering from COPD. The purpose of this study is to investigate the geography of COPD and factors associated with the spatial patterns of COPD prevalence. Particular emphasis is put on the role of the local socioeconomic environment. Utilising information from the Norwegian Prescription Database on all lung medication prescribed in 2009 we identified 62,882 persons with COPD in the Norwegian population. Patterns of spatial clustering in the prevalence of COPD are clearly evident, even when age and gender are controlled for. Gender and age are strongly related to COPD risk. Socio-economic characteristics of the community such as education and unemployment are also significantly correlated with COPD risk. People living in rural parts of the country are generally associated with less risk than people in urban settings, and in particular people living in communities with high levels of farm and fisheries employment.

Objectives: Prescribed medication consumption for chronic, non-malignant pain may not be beneficial. This study investigated how self-reported treatment outcomes among individuals in a musculoskeletal pain rehabilitation program are related to the prevalence and trends in the dispensing of prescribed medications.Methods: Patients with musculoskeletal pain were recruited as they began a rehabilitation program. Each participant completed a self-administrated questionnaire on pain, health status and socioeconomic factors in the beginning and at the end of the rehabilitation period. Each individual’s baseline data from the rehabilitation sample was linked to the national Norwegian Prescription Database [2004–2010]. Dispensing prescribed medications in the groups of centrally acting analgesics [opioids], anxiolytics and hypnotics were studied.Results: A total of 1562 individuals participated, and there was no loss to follow-up. Controlled medications [Schedule 2] were prescribed in 36.4% [n = 569] of t...

Aims: It has been shown that referral letters from GPs often are of poor quality, but research in this field is scarce, and few efforts have been made to investigate the factors that may help explain the variation in referral quality. Methods: Combining a survey among 1298 Norwegian hospital physicians (response rate: 52%) with information on the hospitals and the communities they are serving, this study investigates how they view the general quality of patient referrals received from GPs, and the extent to which insufficient information in referrals and inappropriate referrals is considered a problem for cooperation with GPs. Results: Only 15.6% of the hospital physicians perceived the quality of the referrals to be “usually good”, and both lack of information in referrals and inappropriate referrals are seen as important barriers to cooperation with GPs. Of the individual factors, former GP practice is associated with a positive view on referral quality, while regular meetings between hospital physicians and GPs seem to reduce the problems of inappropriate and incomplete referrals. Furthermore, both average number of patients on GPs’ lists and lack of free capacity in nursing and care institutions in the hospital catchment area was found to be negatively associated with perceived referral quality. Conclusions: There is a need to increase the knowledge on how contextual, institutional and professional factors affect coordination of care. The main contribution of this study lies in the attempt to address the macro and micro barriers of obtaining good referral care.

The way in which hospital physicians and general practitioners (GPs) interact has important implications for any health care system, particularly in systems relying on gatekeeping through the GPs for moderating access to hospital and specialist services. Several individual, organisational and contextual factors may serve as potential barriers or facilitators of the interaction between specialists and GPs. Using a survey among 1229 Norwegian hospital physicians the paper tests the role of physician and community factors for hospital physicians’ satisfaction with their interaction with GPs, while also controlling for relevant hospital characteristics. The results indicate that the hospital physicians are only moderately satisfied with their interaction with GPs, and that there is certainly room for improvement. The multivariate analysis shows that the more satisfied the GPs are with their interaction with the hospital, the more satisfied are also the hospital physicians with their corresponding interaction with the GPs. Furthermore, a high GP coverage in the municipalities in the hospital catchment area is associated with a higher satisfaction among the hospital physicians. The results also suggest that meeting GPs face-to-face in meetings is associated with a more positive evaluation of the interaction with GPs.

The reorganisation efforts of the hospital sector in many Western countries in recent decades have challenged the role, identity and autonomy of medical professionals. This has led to increased focus on the role and impact of physicians who are also managers and on the unique discourse being formed through the integration of medical and managerial knowledge. Following the line of studies addressing the professional subcultures in medicine, we investigated whether assessments of health reform differ between medical doctors with managerial responsibilities and their colleagues at the clinical level as well as between those involved in direct patient care and those who are not. The analysis was performed within the context of the Norwegian hospital sector, where a major reform was implemented in 2002, and it was based on a survey of a representative sample of hospital physicians in 2006. The analysis focused on how the respondents viewed the overall effect of the reform and on the reform's effect on three central health policy goals: equity, quality and productivity. Combining data from the survey with organisational and financial data from the hospitals, we employed multilevel techniques to control for a number of individual and hospital-specific factors that could explain the physicians' views. As expected, respondents with managerial responsibilities were more positive in their evaluations of the reform, whereas respondents who spent time on direct patient-related work showed the opposite pattern. Of the hospital-specific factors of interest, the share of department managers with medical backgrounds and the economic situation positively affected the evaluations. Our findings support the view that, rather than managerialist values colonising the medical profession through a process of hybridisation, there is heterogeneity within the profession: some physician managers are adopting management values and tools, whereas others remain alienated from them.

Cream skimming can be defined as the selective treatment of patients that demand few resources while providing high economic refunds. We test whether cream skimming occurs after the introduction of DRG-based activity-based financing (ABF) in Norway in 1997 and if the problem further increased after the 2002 organizational reform when hospitals were turned into trusts. The DRG-system offers the same economic reimbursement for patients classified within day-surgical DRGs irrespective of whether the patient receives same-day treatment or in-patient care over several days. This provides potential for cream skimming and allows us to investigate cream skimming within the actual diagnoses. Patient data from the period 1999-2005 is analyzed. Waiting times are used as indicators of patient selection and analyzed as a function of severity within each diagnosis, controlling for age and gender of the patient, as well as institutional and time-dependent variables. The analysis gives some evidence of cream skimming in the first period of ABF, in particular within the lighter orthopaedic diagnoses. However, cream skimming does not increase after the 2002 organizational reform but is stable, and for some DRGs even reduced. The study indicates that cream skimming may occur if reimbursement systems are not particularly sophisticated. Softening of budget constraints after the hospital reform of 2002 may explain why cream skimming does not increase after the reform. However, further investigation into this mechanism is needed.

A striking common characteristic in many Western countries at the turn of the millennium is the debate on the role of private actors in public health care systems. Following the long line of Norwegian political scientists paying attention to attitudes towards privatization, this article uses data from 2005 on medical specialists to investigate their preferences for private welfare services, and to uncover the relative role of political ideology and self-interest in affecting their attitudes. So far, few attempts have been made to test in depth the impact of ideology and self-interest as alternative explanations of the attitudes of a professional group toward a policy issue that is important to its interests. The analysis documents the fact that both public and private specialists display scepticism towards leaving welfare services in the hands of private actors. The empirical model for the multivariate analysis builds on the large body of literature on political attitudes, and incorporates variables that are derived from economic and psychological theories in order to test the impact of ideology and subjective self-interest (emphasis on high salary for job satisfaction) and objective self-interest (private economy). In addition, the model also controls for a vector of individual characteristics and professional background. For the group of full-time public specialists, both subjective and objective self-interest, together with ideology, turns out to be the major determinants of view on private welfare services. The attitudes of the private specialists are, on the other hand, not at all affected by self-interest – only by ideology.

Background: During the last five years the Norwegian hospital sector has experienced massive reorganization efforts. The aim of this study is to establish whether two such initiatives — the introduction of ring fencing of elective surgery and activity-based budgets at department level — have had any effects on one of the most profiled objectives on the health political agenda: reduction in waiting time. Methods: The sample studied includes 41 hospitals observed at two points of time, 1999 and 2001. Waiting time is expected to be a result of imbalance between demand and supply. Measures representing the supply side (ring fencing, activity-based budgets at departmental level, physician rate, share of emergency admissions, technical efficiency, and hospital type) and the demand side (living conditions and share of persons aged 67 or older) are included in the operationalized model. The model is estimated via stepwise OLS regression. Results: The results document a negative relationship between ring fencing and waiting time, with the estimated waiting time reduction amounting to 22 days. Both the demand side variables also exert significant effects on waiting time. Conclusion: Although information on ring fencing, living conditions, and age distribution renders possible some predictions concerning waiting time, the current research topic should be revisited when a longer time period has elapsed. When the organizational changes have become more thoroughly embedded in the hospitals, more refined conclusions regarding hospital organizations' behaviour and effects of reorganization can be drawn.

Under which circumstances do voters turn against governing parties for their performance in office? This question forms the basis of the considerable research field often referred to as the ‘VP-literature’, which seeks to explain support for governments as a function of economic and political outcomes. After thirty years and more than 200 studies the economic part of the VP-function still remains much better explored than the political part. In addition, focus has almost solely been on the national level so far. The present study therefore sets out to bridge the gap between the VP-literature and the field of coalition studies to examine the relevance of the VP-function for local elections. The ambition is to arrive at a more satisfactory understanding of the political part of the model. Results from the two most recent Norwegian local elections, in 1995 and 1999, reveal that the electoral liability associated with office is almost three percentage points. The multivariate analysis then tests systematically under which economic and political conditions local incumbents suffer the most electorally. The rate of unemployment plays an important role in how the voters evaluate the incumbents, since each extra percentage point of unemployment translates into additional loss for the incumbents. The levels of local fees and charges and service coverage are also significant. Political characteristics are furthermore highly relevant, since the numerical status of the government is in fact one of the most important predictors of electoral success, the advantage enjoyed by minority cabinets over majority coalitions amounting to more than three percentage points of the popular vote. Other important political determinants of local electoral performance are one-party status, national support and ideological closeness.

Norwegian local government has traditionally been strongly rooted in the consensus ideal. When the new Local Government Act of 1992 allowed the municipalities to introduce parliamentary models and abolished the statutory requirement of qualified majority decisions in the councils, this therefore implied a significant change in the local government ideal. Even though the municipalities have been reluctant to formally adopt a parliamentary model, this paper argues that in practice a majority system is replacing the traditional consensual model, with functional roles for a governing majority and an opposition. The empirical analysis employs data on local politicians from 1994 and 1998 to test the proposition that representatives of the governing parties exert more influence on local policies than members of the opposition. Two different indicators of political influence are used: (1) the councillors' budgetary influence measured as the distance between the councillors' ideal point and the actual decision out...

Day surgery has gained increasing significance in Norwegian health care during the 1990s, and now constitutes more than 50% of all elective surgery. Although the underlying general assumption is that this mode of delivering surgery will increase the efficiency of hospitals, most former studies have focused only on the cost-efficiency for specific types of surgical operations. The present study therefore uses data from Norwegian hospitals to test whether the proposition that day surgery spells efficiency also holds true at the hospital level. Hospital efficiency is measured as the technical efficiency of hospitals. This indicator captures how efficient hospitals are in utilising their total resources, and builds on a variety of hospital inputs (inpatient care, outpatient care) and hospital outputs (physician full-time equivalents (FTEs), other labour equivalents, medical expenses). Our empirical analysis is based on a simple decision model where the hospitals maximise utility functions of income, patients and effort under the constraint of the budget and various structural characteristics. The empirical model thus controls for several other important determinants of efficiency, such as hospital budget, the outpatient revenue share, irregularly long length of stay, hospital type and the share of emergency admissions. After accounting for these variables, our results document significant effects of day surgery on technical efficiency. The results furthermore show that the positive effect of day surgery is contingent upon hospital budget, as hospitals with large budgets experience stronger efficiency effects of day surgery.

The politics of European local government is often assumed to take place in a rather depoliticised and non-partisan environment. This feature is especially apparent in Norway, where local government institutions are designed to create a high degree of consensus and accommodation. No local cabinet takes office, and therefore no formal roles of a majority government and an opposition are offered. This paper tells a different story, however. Following the 1999 elections many municipalities are now experiencing partisan cooperation based on binding political agreements. In these cases the common practice of proportional distribution of the important political positions is replaced with a ‘winner takes all’ principle, as only the majority constellation is rewarded with office payoffs. Given that this form of cooperation is the closest analogue to any cabinet formation at the local level, it is clearly of interest to uncover under which conditions it occurs. The empirical analysis therefore uses variation in structural, socioeconomic and political characteristics to predict the local coalition behaviour. The empirical model captures some important determinants in the variation of structural characteristics, and, as expected, explicit and binding coalition agreements are found in the large and central municipalities. Socioeconomic setting is furthermore important, since municipalities with a high degree of financial autonomy and poor policy performance experience this kind of formalised cooperation more frequently. Systematic effects are also found for political characteristics, with electoral volatility, party fragmentation and functional organisation models all increasing the probability of coalition agreements.

The main emphasis in coalition studies has so far been on national coalitions—with the local level being rather overlooked—and in most studies estimating the impact of local politics researchers have used various indicators of the electoral strength of parties as their main political variable. In this analysis we investigate the genuine composition of coalitions in each and every municipality in Norway, describing which parties serve as the majority base for the mayor and the deputy mayor. This approach gives us the opportunity to investigate both the impact of the genuine political office holders, as well as the structural properties of coalitions, on policy output. Using a decomposition of school expenditure suggested by Falch and Ratts0, we are able to ask in what ways money is spent inside the sector, in addition to how much money is spent. The empirical results show that coalitions can be linked to policy output; the preferred spending objects vary both according to the parties forming the coalition and the structural composition of the coalition.

In the Nordic countries, health care is an integral part of what is often termed the Scandinavian (or Nordic) model of the welfare state (Esping-Andersen 1990). Thus, health care is generally seen as a public responsibility, with universal access, negligible user fees, and a strong focus on equity (Martinussen & Magnussen 2009). In this chapter we discuss the Nordic model of health care primarily by focusing on one country, Norway.We also highlight similarities and differences between Norway and the other Nordic countries. While Norway is a small country in terms of population, it covers a large area and thus geographical equity is an important issue. This is reflected throughout the system; in structural issues, in choice of (political and administrative) governance models, and in choice of financing system. Although Norway, as are the other Nordic countries, is characterized by a tradition of locally elected governments (municipalities and counties), health policy and healthcare reforms in the past 15 years serve as illustrations of the potential conflicts between public articipation, local governance, and a stated goal of national equity.

The Norwegian hospital reform of 2002 aimed at improving several aspects of the health-care service, i.e. the definition of responsibility between hospitals and their owners, equality in access to hospital-based health services, the quality of medical work, organisation of hospitals and productivity. This paper describes to what extent hospital-based physicians consider these aims to have been achieved.A postal questionnaire was disseminated to 2 500 hospital-based physicians in January 2006. The questions comprised work conditions and remuneration, organisational matters and the perceived results of the 2002 hospital reform. The respondents were asked to compare the situation in 2006 with the pre-reform situation, and to assess whether the situation was closer or further away from the aims.1,298 of the doctors responded, i.e. a response rate of 53%. The average opinion was that the aims regarding organisation, access to hospital-based health services, and quality of medical work had become more distant. 38% stated that the aim to improve the quality of medical work was more distant than before the reform as opposed to 8% who perceived it as being closer. 58% of the physicians thought productivity had increased after the reform. There were some regional differences; e.g. the physicians in the southern region experienced stronger than those in the other four regions that responsibility between hospitals and hospital owners was less defined and the quality of medical work was worse than before the reform. 49% of the respondents felt that the hospital reform had mainly had a negative impact on hospitals, whereas 18% felt that the impact had been positive.