Transcript PowerPoint-presentation

On the structure and organisation of
NORDIC HEALTH CARE SYSTEMS
Pia Maria Jonsson, MD PhD
Senior Researcher
Medical Management Centrum, MMC
Karolinska Institutet
[email protected]
+46-70-990 1427, +358-40-527 1640
H EALTH
E QU ITY
Q UALITY
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EQUALITY
C O S T-E F F E C T I V E N E S S
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”THE NORDIC MODEL”
• Public systems, either through
ownership or requiring private actors to
contract with public bodies
• Predominantly tax-based financing
• Decentralized responsibility for the
provision of services
• Equity of access high up on political
agenda
STRENGTHS OF THE NORDIC SYSTEMS
• Good population health
• Access to care on relatively equal
terms (most inhabitants included in
the systems)
• Democratic rules
PROBLEMS
• Demographics – economy – technology –
consumer expectations
• Regional variations in resources,
production volumes, quality, and
accessibility
• Lack of responsiveness - consumer
dissatisfaction – political problems
• On the other hand: Local /regional autonomy
and decision-making close to citizens highly
appreciated!
ECONOMIC DEVELOPMENT
OECD Health Data 2007
Health expenditure per capita, public and private, 2005
Total health expenditure as a share of GDP, 2005
Health expenditure per capita and GDP per capita, 2005
Annual average growth rate in real health expenditure per capita, 1995-2005
HEALTH CARE RESOURCES 2005
Finland
Sweden
Norway
Denmark
Practising physicians
/1000 inhabitants
2.4
3.4
3.7
3.6
Practising nurses
/1000 inhabitants
7.6
10.6
15.4
7.7
Acute hospital beds
/1000 inhabitants
2.9
2.2
3.0
3.1
Source: OECD Health Data 2007
Acute care hospital beds per 1 000 population,1990 and 2005
1.2004.
HEALTH CARE REFORM
Frameworks and models
• Responsibility: Political - Economic Administrative /operative
• The ”iron triangle”: Patients - Producers ”Third party” payers
• Classification of reform strategies
(Saltman et al.):
Demand side - e.g. freedom of choice,
maximum waiting-time guarantees
Supply side – purchaser-provider split, activity
based funding (DRGs) etc.
HEALTH CARE REFORM
in the Nordic countries
• 1990´s ”first wave”
Looking for increased productivity
and efficiency - decentralisation New Public Management – improved
patient rights
• 2000´s
Looking for high and even quality
and accessibility – centralisation –
increased national steering and
regulation?
NORWAY: Hospital Reform 2002
• Objectives: Enhancing state government steering,
equitable service provision, high quality,
responsiveness to consumer demand, efficient use of
resources, respecting patient integrity.
• The state took over the responsibility for both
financing and organising the services
• 5(4) Regional Health Authorities (RHA), 33 Local
Health Enterprise (LHA, public hospitals including
pharmacies)
• RHA:
1) Owner (state) representative
2) Responsible for organising specialist care
according to population needs and in concordance
with legislation (can also purchase services)
Also research, teaching, patient information etc.
Evaluation of the Impact of Hospital
Reform, NRC 2007
• Quicker increase in production -> access improved,
somewhat shorter waiting lists
• Hospital productivity increased somewhat
• Regional variations decreased inside RHAs, but not
between them
• Some centralisation of advanced care, but less
advanced care not decentralised as expected –
private sector
• Priority setting did not improve – waiting times
shortened especially in low-priority patient groups
DENMARK: Structure reform
2005-2007
• Objectives: Higher quality without increased taxation, shorter
waiting-times in specialist care, international top know how.
Strengthening local democracy through stronger municipalities.
Clearer responsibilities. Better co-ordinated services to weak
population groups.
• 14 counties -> 5 regions, locally elected political leadership,
no taxation right. Funding from the state (80%),
municipalities (20%)
• 275 -> 100 municipalities, at least 30.000 pop. (or
collaboration with neighbours). Prevention, health promotion,
rehabilitation.
Issues
• The financing model – lack of congruence
• State governance – centralisation and
decentralisation
• Primary health care /public health
interventions, primary care physicians
private practitioners
SWEDEN: Committee on Public Responsibility
2003-2007
1. Better national (state) coordination – divided into six
to nine counties /regions in all national functions,
improved steering, coordinated supervision
2. Six to nine regions (regionkommuner) instead of
counties – the same division as for national
administration, new responsibilites in regional
planning
3. Regional responsibility for health services, uniform
state governance and stewardship, legislation on
patient rights
4. Responsibilities of the municipalities clarified, no
structural changes
SWEDEN: Committee on Public Responsibility
2003-2007
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No changes in the distribution of responsibilities for
financing and organisation of services
• ”Self-organisation” starting 2007 in dialogue with the
national government, to be finished by the
elections 2010
• Accomplished by 2014
-----------------------------------• Political consensus in the Committee, but not in the
parties
• Local and regional representatives mainly supportive
• Report from discussions with local and regional
representatives, May 2008:
• Seven regions, political support in six of them, but not in
Stockholm
FINLAND
• Structural reform PARAS:
Legislative basis for ”spontaneous”
merging of municipalities
• New Health Care Act
Maximum waiting-time guarantee
Sweden
Finland
• November 1, 2005
• Agreement bw. National
government and SALAR
• PHC, hospital care incl.
mental health services
• Extra funds annually
according to county
/region population base
• No economic incentives
built in the guarantee
• March 1, 2005
• Legislation
• PHC, hospital care,
mental health, dentistry
• 50M EUR to reduce
accumulated waiting lists
2003-04, additional 380M
EUR allocated by the
municipalities 2002-07
• Supervision by TEO:
fines?
Maximum waiting-time guarantee
Sweden
Finland
• 0 – 7 – 90 – 90 rule
• Specialist treatment
at hospital in 3
months from verified
need of care
• Monitored by NBHW,
SALAR
• Assessment in PHC in
3 days, by hospital
specialist in 3 weeks
• Specialist treatment
at hospital in 6
months from verified
need of care
• Monitored by Stakes,
MoH, Local
Authorities
Maximum waiting-time guarantee
Sweden
Finland
• National medical
indications for
planned care
supported by SALAR
and the NBHW
• WG:s in 15 clinical
areas drafting
documents
• First qualitative study
of attitudes and
experiences in fall
2007
• National criteria for
non-emergency care
published and
distributed by the
MoH in 2005
• Implementation at
healthcare units and
compliance to
guidelines studied in
sample surveys
Finland
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EFFECTS
Shorter waiting lists, fewer waited longer than 6
mo. 2006, effect flattening 2007
Regional variations somewhat decreasing
Redistribution effects between specialties,
orthopaedics expanded, gynaecology and
psychiatry down - reflected in physician staffing.
No verified changes in the distribution between
specialist care /primary care - 60/40
No initial trend changes in the frequency or costs
of sick leaves in selected diagnoses
Finland
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REPORTED CHANGES IN LOCAL ORGANISATION
AND WORKING PROCESSES
Better process descriptions /models
Queue administration
Private producers
Day surgery
More effective use of operation theaters
Leadership
Flexible working hours
Economic incentives
Shared responsibility with other personnel
categories
Issues
• Better, register-based monitoring of
waiting times and the medical quality of
care
• Quick and smooth updating of national
medical indications /criteria
• Supervision, sanctions, fines?
COMMON TRENDS
• Centralization, monitoring, regulation,
legislation
– State ownership (NO)
– State (part)funding (DK, FIN)
– Legislation (waiting list guarantee FIN)
– Stronger national monitoring, regulation,
supervision (DK, NO)
• NPM still going strong
- DRG
- activity based funding
- purchaser-provider split
- increased diversity of provision
- political and EU pressures
COMMON TRENDS
• Patient /consumer empowerment
- freedom of choice
- ”patient-centered” care
- transparent comparisons
----------------------------------• How to guarantee patient safety?
• Staffing?
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