Organisation of decentralized radiological services
As described in an earlier study by Pavoloni and Vicarelli , one of the benefits of decentralisation is that this brings the health care services closer to where people live and is confirmed in this study. Saltman and Bankauskaite  have identified different models for organising decentralised health care. As previously mentioned the rural radiological service in the studied district is organised in three-fold. However, these three layers of provision of radiological service found in this rural area have different ‘owners’. A consequence of these different health care levels and ownership is that decision-making processes in these organisations are not integrated. The radiological service at the local medical centre is a satellite from the regional hospital, and decisions follow the hospital’s protocols. Whereas decisions for the X-ray service in GPs practices is taken by each GP in collaboration with the health system in each municipality. For the third service, in the acute unit, decisions are taken by the service itself in collaboration with municipality coordination. This is complex and may lead to local systems or “personal decisions” made on a more ad hoc basis, rather than a coherent service. Consequently, there may be a risk that health care services have different service provision and different standards of service in different areas.
With the current organisation, there appears to be an overlap in radiological services in this region, and there is probably potential for improvement in the organisation, which would result in a more cost-effective service, possibly of higher quality. Recommendation for a high quality service is to have radiological service as a satellite from a hospital, were radiologic competence is available. In addition increased use of telemedicine support. As Roberts et al.  states, the technology now exists to maintain technical quality at remote locations.
Quality in decentralised radiological services
Quality can be defined by factors such as efficiency of services, safety, the possibility of user interaction, coordinated services, the efficient use of resources, availability of services and their equal distribution . This is a challenge in rural areas. The quality indicators at stake in this study were mostly related to no radiography staff at the GPs practices as well unsafe use of x-rays. Hana and Rudebeck  states that the professionals working in rural areas play an essential role for quality of health care services when these services are decentralised. Participants in the focus groups confirmed the need for experienced, dedicated high-quality staff, and reported a high level of satisfaction with the radiographer working at the LMC, however they could only provide limited coverage of the area and time. Overall there were limitation in human capital, both in terms of capacity and capability. To address this gap dedicated and competent staff are essential in a decentralised health service, and the competence of administrative staff and those in leadership positions in primary care are also of importance for the quality of health services in rural areas. This is in line with studies from Australia and New Zealand [19, 20].The people working at the GPs practices (physician, nurse and secretaries) as well as at the LMC and the regional hospital were all very committed to deliver high quality services, however that does not mean they have radiographic competence. The recommendation is that non-radiographic staff need competence and training in x-ray imaging.
The issues mentioned above may lead to discussions amongst professionals about skills and responsibility. Different professions may wish to protect their own discipline, without reflecting on possible consequences for patients. This inter-disciplinary rivalry presents a challenge for professional identity, for example image quality, radiation protection and standards are an inextricable part of the radiographer’s professional role, and in addition to the radiologists’ role in diagnosis and treatment. In contrast, the GP’s role is to diagnose and treat, and they perceived image quality and radiation dose as relatively minor concerns .There is therefore an urgent need for continuing professional education and a closer connection with a radiological environment for both radiographers and other staff who perform x-ray imaging in rural areas, a point also highlighted by Smith and Jones .
Smaller operating units will probably offer poorer quality than larger ones, partly because qualified staff in all disciplines is more difficult to recruit and retain. Health care services in rural areas are made up of small organisations, are distributed across extensive areas, lack qualified staff and a large range of tasks have to be performed by a limited number of staff .
Fredriksson and Winblad  found in their study that a decentralised model for health care services results in inconsistency in rules and regulations. In this study it was found that there is a lack of clear and consistent x-ray procedures in GP practices, and decision-making based on x-rays or clinical examinations differed between GPs, depending on their experience, which was also found by another study identifying GP- related factors such as experience, as an important factor for rural practices . Indeed in the region studies there were differences in the working experience amongst GPs which influenced their refferal practice to specialised health care; experienced GPs reffered less than not experienced GPs. Participants in the focus groups confirmed the need for experienced, dedicated high-quality staff, and reported a high level of satisfaction with the sole radiographer working at the LMC.
When discussing quality and staff competence, radiation protection is an additional issue. One of the provisions of the Regulations on Radiation Protection is the presence of a responsible doctor. The regulations state that x-ray and MRI machines have to be operated by radiographers or a doctor with a relevant specialty . Personnel using x-ray equipment should undertake training in radiation protection and use of radiation related to each working tasks every year. Clearly, this is not the case in the GP practices.
According to Saltman and Bankauskaite  decentralisation may lead to lower costs, since lower planning and administration costs are closely related to political decentralisation. Local politicians can have greater influence on how to use money in their own area. There is however a lack of consensus regarding the benefits of economic decentralisation. Dilemmas such as how to use taxes payment  and disagreement about policy for financial grants from the central government to local level governments are some of the issues still to be resolved.
Duplication of services in decentralised health care as is found in this study may make these services more expensive than central government controlled services. Results from this study indicate that the region studied has the potential to achieve a more economically efficient radiological service, due to the current organisation being three-part and, in some areas, overlapping. A key issue is the balance between effectiveness and efficiency. The fact that the Norwegian health system illustrates in Table 1, are organised in different levels, also have impact to the funding.
The way health care services are organised in Norway seems to hinder the efficient organisation of decentralised health care services. To provide high quality health care services to patients in all situations, the cooperation between the health care levels, primary health care and specialised health care, must be raised to a higher standard than is currently the case. The coordination reform  aimed to reduce these problems, and health care managers are working to reorganise the services by improving and increasing cooperation between levels.
Regarding the Cooperation reform  there is a need for cooperation between the levels in health care, with the aim of providing better health care for the patients. Participants in focus group one, felt that the cooperation reform had contributed to improved cooperation between the rural area and the hospital. The reform had also improved the hospital’s understanding of the rural area’s needs. Because of the systematic cooperation, the hospital’s thinking and understanding of needs in the rural area was increased, and has already resulted in an expansion of the radiological services and the opportunity to receive a second opinion about images. This is a positive result of the reform and will be monitored once the new equipment and services are all in place.
Whilst acknowledging that stakeholders participating in the study agree that decentralised radiological services in the region are necessary and indeed are a requirement by politicians, professions and citizens, it is the view of the authors based on this study that services could be delivered more efficiently and effectively. Furthermore, a Swedish study found that decentralising health services can lead to local variation or inequality in services. Moreover there is a potential conflict between central and local decision making . Organisational culture emerges from that which is shared between colleagues in an organisation, including shared beliefs, attitudes, values, and norms of behavior . Results from this study show that managers are taking the cooperation issue seriously, but not all problems have been resolved, there are still certain problems like common IT systems and procedures. Ferlie and Shortell  state that the lack of integrated IT systems can inhibit a high quality health care system. Although Hillestad, et al.  are of the opinion that IT systems have potential for savings in the health care system; however they have to be fit for purpose. Technological development has the potential to be better utilised; digital imaging and tele-radiology have fundamentally changed radiology inasmuch as radiological images can now be sent electronically from a remote location to a radiologist in another location for interpretation or consultation Therefore, common IT platforms have the potential to facilitate knowledge sharing and ultimately improving quality. However, as noted earlier such developments brings with them data protection and security issues.