Johan Calltorp AcademyHealth Pragmatic Health Reform: Second-Order Strategies from Europe Swedish Experiences on chronic care Johan Calltorp, MD, PhD Professor of Health Policy and Management The Vårdal Research Foundation Former Director of Health Services, Western Health Services Region, Sweden Mail:

Johan Calltorp AcademyHealth Basic assumption Health services ”production methods” are increasingly becoming international Health services delivery is still shaped very much by culture, tradition, social and economic context It is increasingly important to develop methods to compare between countries for learning and understanding of the issues

Johan Calltorp AcademyHealth Europe and North America Within Europe more detailed comparisons of health systems begin to develop due to the dynamics of the European Union.The European Observatory on Health Systems and Policies is an important actor Also integration between the European systems will increase – but the pace is slow because of ”cultural” conditions It is of great interest to develop methods to compare health services between Europe and North America

Johan Calltorp AcademyHealth The Swedish health system 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 (80 % of total), planning and delivery of services A regional planning regarding highly specialized care since the 1960´ s

Johan Calltorp AcademyHealth The Swedish health system,cont. Physicians salaried since 1970 – relatively small differentials between specialities and parts of the country The system is mainly budget based and controlled, little “incentive” thinking A public health perspective in planning and well developed intersectorial cooperation has been important for health results and outcome

Johan Calltorp AcademyHealth Distribution of resources over population groups in Sweden AgePopulationResources , , , Over 75 40%Of total resources Final year of life 25%

Johan Calltorp AcademyHealth Indicators of mortality and morbidity Life expectancyPotential years of life lost at birth 1998 per pop Male FemaleMaleFemale Sweden76,981, UK74,679, US73,979, Median74,680, OECD countries Anderson and Hussey, Health Affairs, May/June 2001

Johan Calltorp AcademyHealth

A division of responsibility for care of the elderly and chronic patients County councils are responsible for all needed medical care – inpatient and outpatient specialized care and primary care Municipalities are responsible for “nursing care” in the home and “sheltered living” Advanced home health care is developed rapidly but unevenly over the country

Johan Calltorp AcademyHealth 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

Johan Calltorp AcademyHealth Development of specific “tools” for medical quality “management” Around 60 national medical quality registries based on diseases/diagnoses monitoring major acute and chronic disorders Detailed and structured “medical treatment protocols” (guidelines, pathways) developed nationally for big patient groups (heart disease, stroke, anxiety/depression), cooperation between research/profession

Johan Calltorp AcademyHealth Local/regional/national dynamics National resource constraints during 1990´s “triggered” structural reforms of hospital mergers, closures and integration of services (“seamless care) Spending presently approx 9,8 % of GDP 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

Johan Calltorp AcademyHealth Health reform examples through the described dynamics “The local care” (närsjukvård) Basic care, close to home, mostly for chronic “multidisease” patients To increase continuity, access, quality To enhance “functional” cooperation between specialized hospital care, primary care and the municipality care. Locally tailored. Linked to hospital restructuring. Problems in remote areas with few people.

Johan Calltorp AcademyHealth Western Health ServicesRegion 1,5 million pop. 17 hospitals, 60 health centres, dental care

Johan Calltorp AcademyHealth Examples of innovations Specialist “on site” consultations to primary care and to municipality social services Information network building, IT-support on distance, shared patient charts etc. On-line booking systems to radiology, specialized diagnostics, surgery etc. Pharmaceutical rounds – analyzing and acting towards overuse and underuse

Johan Calltorp AcademyHealth Examples of innovations Advanced home health care is developed through the structured cooperation mechanisms. Teams of doctors, nurses, technicians are organized jointly by county council and municipality For terminal care enhancements in pain treatment and palliation at home Cooperation regarding psychiatric “multidiagnose” patients enhanced as well

Johan Calltorp AcademyHealth Health reform example: Stroke guidelines and quality registry A national treatment protocol developed – medical results, evidence, health economy A detailed “condition – treatment” content Covers all from prevention to rehabilitation Prioritized actions A “not to do” list (methods to stop doing) Monitoring through the national quality registry

Johan Calltorp AcademyHealth Health reform example: Cancer care No specific “cancer hospital” tradition, oncology as a speciality in main hospitals and forming of cancer teams “Regional oncology centers” developed since 20 years – epidemiology, information, feed-back Presently an incremental development of regional cancer treatment programs – medical protocols, quality supervision, organizational cooperation, forming “virtual” cancer clinics in each region.

Johan Calltorp AcademyHealth Chronic care in Sweden means: Functionally integration between actors - specialized care, primary care, municipality services Active use of new “medical management methods” like quality registries, treatment protocols, feed-back of practice variations. Local/regional dynamics for new ideas and organizational development interplay with national coordinating mechanisms