1. Ian Forde Health Policy Analyst OECD Health Division May 2014
OECD REVIEWS OF QUALITY OF HEALTH CARE RAISING STANDARDS: THE NORDIC COUNTRIES
Fourth in a series of country reviews of Quality of Health Care
Structure of the Report:
Assessment and Recommendations
Chapter 1: Quality of Care in the Swedish Health System
Chapter 2: Primary care in Sweden
Chapter 3: Long term care for the elderly in Sweden
Chapter 4: Care after stroke and hip fracture in Sweden
Ian Forde
Health Policy Analyst
OECD Health Division
May 2014

2. Where are the Nordic countries today?
Very good health and LTC systems
Excellent performance on most quality indicators
A strategic vision of how health services should develop over time
Preparing the health system to face new challenges
Commitment to health coverage for the whole population
Health and long-term care systems regarded as models to be emulated across the OECD
Impressive quality monitoring and improvement initiatives, for example the most extensive sets of quality registers seen in the OECD
High degree of local and professional autonomy
Rich use of data and feedback, through open comparison of indicators and quality registers
Judicious use of financial incentives
Extensive patient involvement, in policy planning and through satisfaction surveys
Investment of 140 million Euro in 2010 to improve co-ordination of care for elderly people and strengthen quality registries, to extend their use beyond the health sector to other welfare services such as LTC.
And innovation - increased use of market incentives and provision by private and social enterprises in an effort to drive up quality and efficiency through competition

3. Good outcomes, especially for hospital care
The survival rate for heart attacks is one of the single most important measures of health care quality. Given that cardiovascular disease is the single largest cause of death, this makes heart attacks an excellent sentinel condition to use for measuring quality. As it also one of the most common causes of admission and death, it is also a fairly stable measure that can be used to look at hospital performance.

4. Health systems are generously funded
Health expenditure per capita, 2011 (or nearest year)

5. High levels of public expenditure on LTC
Long-term care (LTC) expenditure has risen over the past few decades in most OECD countries and is expected to rise further in the coming years.
The highest spenders are the Netherlands and Sweden, where public expenditure on long-term care was two-times greater than the OECD average (at 3.7% and 3.6% of GDP).
Regarding the social part of public LTC expenditure, Sweden has the highest share, reaching 3% of GDP, much higher than the OECD average of 0.7%. But te boundaries between health and social LTC spending are not fully consistent across countries, with some reporting particular components of LTC as health care, while others view it as social spending.

6. EMERGING CHALLENGES

7. Primary care is strong
Primary care is often arranged as multiple partner establishments staffed by a group of GPs and a wider multidisciplinary team including nurses, physiotherapists, occupational therapists, midwives and psychologists, providing a broad range of clinical care.
Many GPs and nurses have special interests in areas such as diabetes or child health.
Since the 1970s, Sweden has also encouraged “one-stop shop” clinics where patients can access GPs, specialists and some radiography or laboratory services, thereby extending the range of services available to patients outside hospital
90% users report being treated with respect, 80% report being involved in treatment decisions.
Admission rates for asthma, COPD, diabetes are all below OECD average.
OECD’s new indicators on the quality of prescribing in primary care show Sweden as one of the best performers

8. … but often ‘flying blind’
Primary and community care is being asked to do more and demonstrate better value for money…
… but often ‘flying blind’

9. Increasing pressure on community services
In line with other OECD countries, the average length of stay in hospital is falling – from over seven days around a decade ago to 5.5 days today – meaning that community health systems are being asked to further increase the amount of preventive and curative care they provide.

10. Co-ordinated and integrated care is much discussed …
… but yet to deliver much benefit for patients and their families
current data infrastructure is unable to give a sufficiently detailed picture of the quality of primary care or long-term care for the elderly.
lack of inter-operability between systems, information standards and classifications, hampering the sharing of information and patient records across providers.
quality registers tend to exist in isolation, with little cross-talk between them.

11. A distinctive policy choice to take LTC outside of institutions
The number of beds in long-term care (LTC) institutions and in LTC departments in hospitals provides a measure of the resources available for delivering LTC services to individuals outside of their home.
In Sweden, the reduction in both hospital and institutional beds reflects the implementation of policies designed to promote home-based care
Comprehensive coverage
Skilled multiprofessional input
Few out-of-pocket expenses
Wide use of assistive technologies
Strong emphasis on supporting people to remain at home for as long as possible

12. Private providers are increasingly important players in the market place of care…
… but getting the right balance between freedom and regulation remains unclear
There is a risk that a market place of providers offering disparate individual services may threaten geographic equity of care or could discourage the co-ordination and integration of care for those with complex care needs
The quality-argument underpinning choice and competition reforms is weakened by the fact that service-users do not have sufficient quality-based information upon which to base their choice of provider.

13. Strong local governance is characteristic
The number of beds in long-term care (LTC) institutions and in LTC departments in hospitals provides a measure of the resources available for delivering LTC services to individuals outside of their home.
In Sweden, the reduction in both hospital and institutional beds reflects the implementation of policies designed to promote home-based care
Comprehensive coverage
Skilled multiprofessional input
Few out-of-pocket expenses
Wide use of assistive technologies
Strong emphasis on supporting people to remain at home for as long as possible

14. Central authorities playing an increasingly prominent role in quality monitoring and improvement…
… but this can create tensions and inefficiencies

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16. WHAT THE NORDIC COUNTRIES COULD DO…

17. Improving the quality of primary care
Nordic countries need to ensure that
there is a clear strategic vision for primary care shared by national government, county councils, municipalities and leaders in primary care
the reforms on choice and competition promote co-ordinated care and avoid fragmentation
payment and incentive systems foster co- operation, co-ordination and joint working.

18. Encourage GPs to adopt a leading role in assuring quality and outcomes
Better co-ordination between primary and secondary care
Developing/ better use of information infrastructure
A clearer role for central government
Coordination
Governance
Information
COORDINATION_Support better joint working within and across local governments by:
encouraging shared patient registers or documentation, jointly developed guidelines or joint purchasing and planning arrangements to integrate local health and long-term care services
ensuring that innovations are evaluated and the learning effectively shared across county councils and municipalities on a county-by-county basis or nationally
INFORMATION_ Develop richer and more effective information systems, for example by:
improving the information infrastructure underpinning primary and long-term care services, by aligning IT inter-compatibility, classification systems and establishing minimum quality standards for IT platforms
validating new quality indicators in the primary care and long-term care services, such as rates of falls, pressure ulcers or polypharmacy in the elderly
extending the systematic measurement of patient experiences to include long-term services, with a particular focus on integration and continuity.
GOVERNANCE_Define a clearer role for central government whilst still allowing freedom to tailor services and improvement activities to the local context, for example by:
providing county councils and municipalities with evaluation frameworks, overviews of evidence, current practice or performance
publishing minimum quality standards around inputs (such as health care professionals and technologies), processes and outcomes

19. Some examples…
define a set of core quality standards for primary care that can be used to consistently and transparently monitor, assure and improve the quality of care
study the effects of recent choice and competition reforms to ensure that they do not fragment services for patients with complex needs
equip the primary care workforce to play a more proactive role in primary and secondary prevention of chronic disease
standardise the information infrastructure in primary care to support improvements in the measurability of quality in primary care on a consistent basis.
Other examples:
define the role that primary care is expected to play in caring for an ageing and increasingly multi-morbid population and in co-ordinating their care across multiple providers
adequately invest in primary care staff numbers and training to ensure that they have the capacity and skills to fulfil this role
encourage and incentivise county councils and municipalities to work in partnership to foster integrated models of care, embedding a central oversight role for primary care within each arrangement

20. Continuous quality improvement in long-term care
e.g. develop quality indicators for the sector and encourage comparison across providers
Strengthen measurement
e.g. make wider use of standards, protocols and guidelines
Balance tailored care against standards
e.g. joint care-coordinators or health and social care planning and purchasing
Encourage co-ordination

21. TO CONCLUDE…

22. Key policy recommendations
Develop richer information systems,
Clarify the role of central government,
Strengthen co-ordination and integration across services
Evaluate closely the effects of recent reforms
Sweden needs to develop richer information systems, particularly by establishing a broader range of quality indicators in the primary and community care sectors, and explore ways of linking data from different sources to capture a more comprehensive picture of the patterns of care for individuals.
A clearer role for central government is also needed, focusing on developing standards, building the evidence base and sharing knowledge.
Local governments are the main providers of publically funded care: strengthening co-ordination and integration across services, encouraging continued innovation in how county councils and municipalities design and deliver services, and sharing learning effectively will all be vital in securing high quality and continuously improving care.
Evaluate effects of choice and competition reforms on integrated care, esp. For the most frail and complex patients.

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