Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless the nature and intensity of the reforms required are largely determined by each country's basic social security model. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of health care system which underlie these differences? Have recent reforms been effective? Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms.Health system, Beveridge, Bismarck, reforms, performance

Introduction

BACKGROUND: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. METHODS: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. RESULTS: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. CONCLUSION: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 – 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention

'Nurses are seen as general cargo, not the smart TVs you ship carefully': the politics of nurse staffing in England, Spain, Sweden, and the Netherlands

Nurse workforce shortages put healthcare systems under pressure, moving the nursing profession into the core of healthcare policymaking. In this paper, we shift the focus from workforce policy to workforce politics and highlight the political role of nurses in healthcare systems in England, Spain, Sweden, and the Netherlands. Using a comparative discursive institutionalist approach, we study how nurses are organised and represented in these four countries. We show how nurse politics plays out at the levels of representation, working conditions, career building, and by breaking with the public healthcare system. Although there are differences between the countries - with nurses in England and Spain under more pressure than in the Netherlands and Sweden - nurses are often not represented in policy discourses; not just because of institutional ignorance but also because of fragmentation of the profession itself. This institutional ignorance and lack of collective representation, we argue, requires attention to foster the role and position of nurses in contemporary healthcare systems

Comparing estimated cost per patient for dementia care: Two municipalities and Swedish national population data

Abstract Aim: To evaluate a collaborative dementia program for its influence on cost and in which dementia care specialists and primary care centres collaborate with the municipality and, thereby, effect direct cost of dementia care. Methods: The cost of illness (COI) study investigated the cost of dementia care to the municipality, specifically on the Municipality of Kalmar. Municipal costs in the Municipality of Älvsjö and national cost figures for Sweden were used as comparisons. The major costs related to dementia care, such as the cost of home care, day-care centers, and nursing home placement were extracted from municipality records. Results: The yearly municipal cost per person with dementia in Kalmar ranged from 14,206 C to 26,334 C (17,684 USD to 32,780 USD) as compared to Älvsjö 10,610 C to 30,464 C (13,207 USD to 37,921 USD), and Swedish national figures showing costs from 23,600 C to 36,459 C (29,378 USD to 45,384 USD), per patient, annual cost. In Kalmar, 60% of the patients with dementia received help from the municipality as compared to 69% in Älvsjö. Conclusions: Implementation of such a dementia program is a recommendation that would not increase the cost for dementia care in the Municipality of Kalmar

After decades of decentralisation, the state now has a growing role in Nordic health systems

The onset of the financial crisis has forced many European governments into reforming public services, including healthcare. Despite this economic turmoil, the Nordic states have so far been insulated from some of the pressures faced in other European countries. Richard Saltman, Karsten Vrangbaek, Juhani Lehto and Ulrika Winblad look at how the Nordic countries have moved to decentralise the control of healthcare provision over the last fifteen years. They suggest that despite their insulation from the crisis, Nordic governments may be moving towards more centralised models of healthcare provision

Temaledare - Till minne av Björn Smedby

Det finns flera goda skäl att ge ut ett temanummer till Björn Smedbys minne. Det första handlar om att visa på vilket sätt Björn har varit en föregångare när det gäller att introducera ämnet hälso- och sjukvårdsforskning i en svensk kontext och vilken betydelse hans arbete fortfarande har för sjukvården och hälso- och sjukvårdsforskningen 40 år senare. Även om ämnet Health Services Research är väl etablerat på de flesta stora universitet i västvärlden har det hittills saknats en historieskrivning kring ämnets framväxt i Sverige. Ytterligare ett skäl till detta temanummer är att uppmärksamma den stora betydelse Björn haft för vissa specifika frågor, så som utarbetandet av ett klassifikationssystem för olika sjukdomar och utvecklingen av den medicinska fackterminologin