Justice in modern health care conference:

Experiences with the Swedish health system Johan Calltorp, MD, PhD Professor of Health Policy and Management The Nordic School of Public Health, Gothenburg Former Director of Health Services, Western Health Services Region, Sweden [email protected] +46 8 708327490 Justice in modern health care Bochum Calltorp

Dimensions for comparisons (The ”iron triangle”) • Financing – who pays? • Structure and organization – who delivers and how ? • Quality – who get´s what, when and with what results ? • ”Health Care - can there be equity ?” Landmark US-UK-Sweden study by Odin Anderson, 1972. Justice in modern health care Bochum Calltorp

• • • • • • • •

The Swedish health system – the historical “imprint” Dominantly public regarding financing, ownership and delivery of services Minor “private” elements integrated in the public financing – mostly working on contracts from the county councils Local strong base for the delivery of services with 21 county councils responsible for financing planning and delivery of services Ca. 75 % of total financing based on local county council tax, government “block allocations” ca 15%, patient fees ca 5 % A regional planning regarding highly specialized care since the 1960´ s Traditionally hospital orientation, weak primary care Salaried physicians since 1970, fixed working time The “welfare society”, intersectorial health actions Justice in modern health care Bochum Calltorp

The evolvement of a strongly integrated health system • Coordinated ”health insurance” tax financed (1950´s) • Integration of hospital care, primary care psychiatry and government run hospitals) into the county councils (1960 – 1970) • Resource expansion through raised local taxes (1960 – 1980) • Well developed public health measures in the health system and intersectorial • Power balance government – county councils Justice in modern health care Bochum Calltorp

Justice in modern health care Bochum Calltorp

Decentralization, but still national coordination and steering through many formal and informal mechanisms

• Legislative and economic control by gvnmt. • Supervision and control by authorities (medical, pharmaceutical, disciplinary) • Well developed patient data bases ( based on “personal numbers”) • Technology Assessment (SBU), QA focus in several national bodies Justice in modern health care Bochum Calltorp

Prioritisation • National prioritisation committee worked 1992 – 1995 • ”Ethical platform” + a list of 5 priority groups (similar as Norwegian proposals 1987, 1997) • For discussion and guidance • Parliamentary decision to recommend this model 1995 • National Center for priority setting at Linköping University • ”Uneven adoption” within county councils – but some very concrete examples of implementation • Partly embeddied in the national model for pharmaceutical reimbursement Justice in modern health care Bochum Calltorp

Share of GDP to health 12

10

8

6

4

2

0 Danmark

Finland

Norge

Sverige

Justice in modern health care 1995 2000 2005 Bochum Calltorp

1990

UK

SHI-land

Distribution of resources over population groups in Sweden Age 0-15 16-64 65-

Population 18,1 64,5 17,4 100 Over 75 40% Final year of life 25%

Resources 6 36 58 100 Of total resources

Justice in modern health care Bochum Calltorp

Public resource control overall ”policy” through both economic turmoil and growth

• GDP-spending to health care an almost constant fraction of GDP 1987 – 2010 • Government (both social democratic and liberal coalitions) interacting with and controlling county councils • Budget control and ”lack of resources” has been a strong driver for change in delivery of health care– sometimes ”healthy”, sometimes areas become neglected Justice in modern health care Bochum Calltorp

Local/regional/national dynamics • National resource constraints during 1990 ´s “triggered” structural reforms of hospital mergers, closures and integration of services (“seamless care”) • A pattern of local initiatives and experiments and key national coordination • The process that county councils merge to regions has a resource and quality drive Justice in modern health care Bochum Calltorp

System changes judged so far • A rapid pace of reorganising of hospitals debate over lack of ”bed capacity”, confrontations between staff, polticians and management. From 90 to 60 acute hospitals in 10 years • Seldom whole system reconfiguration – the links between primary and secondary care – and especially chronic patient patways • Municipalities responsible for ”non-medical” and longterm/eldery care. Much needs to be done in integration • Intersectorial health cooperation works • Somewhat growing disparities in health outcome, growing differences in use Justice in modern health care Bochum Calltorp

The policy agenda in Sweden since 2006 • Political shift in October 2006 to a liberal coalition government. New election September 19, 2010. The liberal coalition will continue, but not in majority • A focus on diversity, innovation, ”renewal”, access • The law is changed to allow for-profit companies to own and to operate health facilities – if county councils want • Allowed to mix public and private financing – some county councils do • A gradual diversity regarding delivery of services is evolving – especially primary care and within Stockholm • For profit ? Not for profit ? Long term role of the County Councils ? Justice in modern health care Bochum Calltorp

Policy steps • Implementation of a GP-system (UK, Danish – style) with patient choice among providers and freedom to establish for care givers given certain certification requirements. Capitation system. Changes linked to ”companies” not to individual doctors • Pressure on county councils to increase contracting with private providers • Pharmaceutical monopoly abolished recently. Publicly owned pharmacies soled – mainly big Swedish and international financial actors as owners • Public-private partnerships in financing – the new Karolinska Hospital as a ”model project” Justice in modern health care Bochum Calltorp

Challenges • How to move towards a ”needed” (unavoidable?) diversity without losing for example cost control ? • How to ”decide” on limits and coverage ? • How to use ”entrepreneurial spirits” among health professionals for innovation ? • How to maintain ”equity in spirit” within services, how to increase equity in outcome and access ? • How to enhance macro and micro management of the system – given the heavy political influence structurally ? Justice in modern health care Bochum Calltorp

Challenges for health management • Works more adaptive and quick • Uses more precise ”tools” designed for health services purposes • Uses new powerful ”tools” that builds on today´s quality methods, medical technology assessment, evidence based knowledge base (Cochrane etc) • To implement and to act on best available knowledge Justice in modern health care Bochum Calltorp

Strategies and steering tools for successful health care – What can Sweden learn – and ”benchmark” with the most advanced models internationally ? Johan Calltorp Göran Maathz Supported by The Vårdal Research Foundation

Justice in modern health care Bochum Calltorp

Some examples • Waiting time management – a multidimensional approach • Prioritization used as a framework and a tool for management • Active use of rich information and quality measures • Other health research as ”tools” ? Justice in modern health care Bochum Calltorp

Maximum waiting times in Swedish health care

0 - 7- 90 – 90 (days)

Justice in modern health care Bochum Calltorp




>

Decision to refer

>

Investigation, tests, x-rays, etc.




Primary care

90 days

Secondary care

90 days

Decision to treat

Investigation, internal referral, tests

First visit

>

Treatment starts




Justice in modern health care Bochum Calltorp

Western Health Services Region Model for Prioritization Developed 2003 and onwards Need and resource allocation Geographical areas Local political boards

Vertical medical prioritisation 22 medical expert groups

Horizontal prioritisation Resource allocation between medical areas Political regional health council Justice in modern health care Bochum Calltorp

Western Health Services Region

Justice in modern health care Bochum Calltorp

Purpose • to implement the national proposals regarding prioritization • to maintain and develop a more equitable health system • to develop better tools for managing the system both at clinical and regional level • to develop a “balanced” contract between clinicians, managers and politicians • to break the traditional habit of “Old Maid” and accept prioritization as a joint task Justice in modern health care Bochum Calltorp

22 regional medical expert groups • • • • •

leading medical experts representing all hospitals and primary care representing all main medical fields medical faculty representative ordinary task to give medical advice to management and politicians • a systematic priority setting exercise did go on for 3 years

Justice in modern health care Bochum Calltorp

Vertical prioritization process Each medical speciality listed it´s activity according to a common framework. Distinct groups of patients categorized according to: Need of care - national 4 level grouping (prio) - a detailed 10 score list (prio) Methods for intervention - preferred method of intervention - medical acceptable waiting time - effectiveness according to common clinical understanding - scientific proof of evidence (if accessible) - cost/effectiveness (if accessible) Justice in modern health care Bochum Calltorp

Example from vertical priority list Indication

Treatment

Gallbladder cancer

Operation

Gallstone with symptoms without symptom

Lap/open operation Expectancy

Obesitas BMI>40 BMI>35 Soft tissues overflow disabling cosmetic

Prio Prio Acceptable Level I - IV 1 - 10 waiting time of Amulatory care Weeks

Acceptable Effectiveness/ Evidence waiting time benefit Operation Weeks

1

2

2 L, R

2

A, B

III IV

5 8

12 L, R 26 L

12

B

Operation

I

5

26 L, R

26

C

Operation Operation

III IV

5 9

26 L,R

52

D D

III III IV

3 6 8

2 6 12 12

Menopausal dysfunction severe Medical treatment medium Medical treatment light Medical treatment Expectancy

P P P P

Justice in modern health care Bochum Calltorp

B B D D

Good Good Good

The quality agenda. Value based health care • More precise measurement of outcome and results – within departments and for individuals (patients and professionals) • Measurement of satisfaction from patients • Combined measures (quality, resources) • Powerful examples among the 60 clinical disease specific quality registries in Sweden – and their potential use Justice in modern health care Bochum Calltorp

Development of protocols and guidelines • This area is under development and will be further more effetive and forceful • Examples within Sweden of guidelines and protocols regarding for example heart diseases, stroke, cancer • Examples from the National Board of Health in Sweden and the Technology Assment Agency (SBU) Justice in modern health care Bochum Calltorp

Evolving evidence based medical practice • Based on the two earlier points there can be a development of much more precise ”tools”, making possible effective ”evidence based” medical practice • The IT systems will be key in developing powerful new tools for this • This development will become a challenge for example within the medical profession and in relation to managers and politicians Justice in modern health care Bochum Calltorp

And an evolving ”knowledge informed” health policy ? • The extremly complex health care system under democratic control and decisions • An increased need for new knowledge through interdisciplinary research – combining disciplines. • A focus on research into action - models from other sectors of society ? • Arenas and mechanisms for bridging research and policy Justice in modern health care Bochum Calltorp

What is it about ? ”Knowing is not enough; we must apply. Willing is not enough; we must do.” - Goethe Cited by Institute of Medicine Justice in modern health care Bochum Calltorp

Thank you!

Justice in modern health care Bochum Calltorp