The Government decided on 2 March 2017 to appoint an Inquiry Chair with a remit to use the proposals in the report Effective health care (SOU 2016:2) as the starting point to support the county councils, relevant government agencies and organisations in the coordinated development of a modern, equitable, accessible and efficient health care service, focusing on primary care. The Inquiry chose the name Coordinated development for good quality, local health care (S 2017:01).
Historically, the Swedish health care system has been dominated by investments in emergency care hospitals and specialist care other than primary care. In international comparisons, Swedish health care is of a high standard in terms of medical outcomes, but performs less well in terms of continuity, patient participation and access. Today there is an awareness that resources are limited and that it is important to make health care activities as efficient as possible. If we are to maintain or increase the quality of health care, address demographic developments and at the same time control the costs, health and social care cannot be organised as it is at present. Changes to the structure and organisation are required to increase quality, improve access and ensure more efficient use of resources.
Primary care plays a central role in the health care system. Research shows that stronger primary care can contribute to equitable health throughout the population. The primary care sector is also best placed to address individuals’ overall health care needs. This is why patients are expected to contact primary care in the first instance for an assessment. However, a large proportion of patients currently contact other levels of care, e.g. emergency clinics, in part because of lack of access to primary care. The result is avoidable hospital care, as well as non-optimal care for the patient, high costs and a risk of care-related injuries. The Swedish health care system therefore needs to be reformed so that more resources are directed to the parts of the system with the best prospects of offering proximity to patients and handling complex states of health. Primary care needs to be reinforced. It is particularly important to improve care for those with the greatest needs.
Under its terms of reference, the Inquiry is to take the proposals in the report Effective health care as its starting point to support the county councils, relevant government agencies and organisations in the coordinated development of a modern, equitable, accessible and efficient health care service. The proposals in the report address a number of different aspects and target a range of different actors and levels in the health care system. The proposals in Effective health care are by their very nature disparate. Some envisage amendments to legislation and other regulatory frameworks, others encourage increased collaboration (with varying degrees of regulation), while others still are intended to send a signal by clarifying key principles that various actors should take as their starting point and incorporate into their activities. The proposals concern everything from specific problems to overarching governing principles for Swedish health care. This Inquiry is to take particular account of the following proposals:
– amendments to fundamental governing principles for the organisation of care;
– the possibility for inpatient care to be provided outside of care institutions;
– a nationally formulated mission for primary care;
– a clearer emergency care directive for primary care;
– a profession-neutral health care guarantee and amended time limits for medical assessments; and
– the transfer of resources from hospital care to primary care.
Since Effective health care was submitted to the Government in January 2016, various administrative levels, organisations and entities throughout the country have continued their work in line with the analysis and proposals contained in the report. This interim report therefore begins with an overview of ongoing work that is directly or indirectly linked to the proposals in Effective health care and the Inquiry’s remit.
The focus of the upcoming work is outlined. It is based on the idea that the current principles governing the organisation of health care should be replaced with new principles stipulating proximity to the patient, and that are established through changes to the Health and Medical Services Act (2017:30). The new principles specify that health care should be easily accessible in terms of contact, assessments and appointments. A provision is proposed under which health care should be organised in proximity to the people, unless geographical concentration is warranted for reasons of quality or efficiency. Moreover, a legislative amendment is proposed clarifying that outpatient treatment is to be the first choice.
These amended principles for the organisation of care are, in turn, the basis for the joint vision for the restructuring of health care envisioned in the report; a system with primary care as the foundation, in tin combination with hospital and municipal interventions, and clearly based on patients’ needs. A vision based on good quality, local health care.
To achieve the vision, a roadmap is proposed for the coordinated transition to a modern, equitable, accessible and efficient health care service, focusing on primary care. The roadmap starts out from the history of Swedish health care and aims towards the vision. It encompasses the period up to the submission of the Inquiry’s final report in March 2019, and also the subsequent periods 2019–2022 and 2022–2027, since changes will need to be implemented in both the short and longer terms. The formulation of a National Mission for Primary Care should be a priority in the transition. In line with the Inquiry’s terms of reference, this will be addressed in the second interim report in June 2018.
The Inquiry’s remit includes providing an analysis in the first interim report, including an impact assessment, of the proposals in Effective health care concerning the national care guarantee. Two out of four points in the current care guarantee concern primary care: the county councils must guarantee contact with primary care on the same day as a patient seeks help, and the county councils must guarantee an appointment with a doctor in primary care within seven days. There are challenges associated with the current care guarantee in terms of follow-up, and also with its design. There are question marks over the extent to which it supports better access and good care on equal terms and encourages resource-efficient activities by care organisers and providers.
Effective health care proposes changes to the care guarantee whereby an individual must receive a medical assessment within a certain time, and the assessment is profession-neutral, i.e. the guarantee also encompasses professions other than doctors. A time limit of three days was proposed for cases where an assessment cannot be made when the individual first seeks primary care.
Following in-depth analysis of these proposals, the Inquiry proposes that the county councils’ obligation to offer the guarantee in primary care be changed so that an individual receives a medical assessment within a certain time. The medical assessment will replace the current guarantee of an appointment with a doctor. This is intended to clarify the possibility of forms of contact other than meetings in person, and to emphasise the qualitative content of contact. Furthermore, it is proposed that the care guarantee be needs-based, i.e. it should also cover groups of registered professionals other than doctors. A time limit of three days is proposed, in cases where the care provider considers that the individual needs a medical assessment and that assessment cannot be made when the individual first seeks primary care. Overall, these changes aim at a design based more on patients’ needs than at present, and with better access to primary care.
One of the strengths of the health care system – but also one of its challenges – is the engagement generated by its organisational design. All of us are, or will at some time be, patients. We are all employees, relatives, colleagues or neighbours in relation to health care, which makes us deeply engaged in issues concerning the design of the health care system. This means that a large number of people must be involved in the future design of health care and feel that the proposed changes are important. This in turn requires a transparent and iterative process when the proposals that will form the basis of future decisions are produced. This approach affects both the work of the Inquiry and the entire implementation of the transition from hospital-centric care to a new, local care designed according to the population’s current health care needs and expectations. To fulfil the aim of an inclusive process, it is necessary to generate understanding of the fact that the transition from the current hospital-centric health care system to modern, local health care has to take place in many small steps over a long period of time.
In these early stages of the Inquiry, it is already clear that achieving positive results is dependent on confidence in the process and in the changes that we aim to bring about. Confidence in the health care system is, of course, also crucial from a citizen and patient perspective. To bring about the desired change, confidence – not least in primary care – is crucial, and the Inquiry’s proposals must always take this into account.
One particular challenge is the large number of proposals in Effective health care concerning collaboration between the responsible authorities, that is, county councils and municipalities. In some cases there is no structure for collaboration on these issues at different decision-making levels, and it will be a challenge for the Inquiry to contribute to establishing such collaboration where it is lacking. Several areas affecting the design of the new, local health care, based on people’s current health issues, will necessarily involve responsible authorities at both county council and municipal level.