NHS Kernow study trip to Sweden
October 2014
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As part of the Leading for Population Health programme run by NHS Kernow, I
joined a party that visited Jönköping, a county in Southern Sweden of 337,000
residents. The purpose of the visit was to learn from alternative health and social
care systems, in particular with a view to seeing how the integration agenda can
be better served locally.
Key Points
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Focus on designing a microsystem rather than on commissioning separate
organisations to perform individual roles
Embedded culture of learning focusing on positive outcomes rather than
on negative episodes.
Integrated approach to learning between primary and secondary care.
Everyone is encouraged to help with system design from carers to
consultants – a genuine bottom up approach rather than top down
reorganisation
Patient centred approach to systems, with patients involved in designing
pathways
Patients encouraged to manage their own risk
Introduction
The Swedish Health and Social care systems have many similarities with
England, but also some fairly significant differences. Their funding comes from
ring-fenced fixed taxation and has a higher proportion of spend on social care
than on health. England spends approximately 9% of its GDP on health care and
a further 9% on social care. In Sweden however the annual spend on social care
is significantly higher (approximately 18% of GDP) with a similar cost to England
on healthcare (9%). It is worth noting however that there is virtually no
voluntary sector in Sweden, whereas the relatively robust third sector in
England makes up for some (although not all) of the differences in spend on
social care. Health care is not free however there is a cap, meaning that patients
will pay for the first £120 per year, after which the cost is born by the state.
In the early 1990’s Jönköping went through a period of financial crisis, which led
to a breakdown in some services. This kick-started a period of considerable
service improvement, and ultimately cost cutting (although this was a secondary
aim at the time), which has taken over 20 years to develop. The politicians at the
time took a brave decision to enshrine the core values of the health and social
care services, which has led to a relative lack of political involvement since – all
service improvements are driven by clinicians and social care professionals
which has led to significant stability in the service.
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At the time that the integration projects were started, Sweden had
approximately 90 hospitals. There are now 60, and the genuinely held belief by
the clinicians that we met was that 45 is probably the number that is required.
Focusing on social rather than health care, which in turn has led to an increased
sense of wellbeing amongst patients, has led to this huge reduction in the
number of hospital beds and subsequent pressure on health services. Most
standard residential homes in Jönköping have now closed in favour of increased
home care, and specialist nursing homes for the occasions when this is not
feasible. This has led to a significant decrease in costs but has also led to a
decrease in admissions to the acute sector.
Integration is taken for granted amongst all professionals in Sweden, and
everyone is encouraged to think about service improvement from a very patient
centered approach. This patient driven agenda has led to a very different
approach to risk management – rather than clinicians or social care
professionals carrying risk, patients are encouraged to manage their own risk.
The often seen result of this shift in risk management is that patients are much
more empowered and make more appropriate decisions about the level of
intervention that is required to maintain their own health and wellbeing. A very
good example of this is in the self-dialysis unit, which will be covered later in the
report. This increase in patient led risk management has led to a reduction in
costs and an improvement in the quality of services.
The Culture of Learning
The main focus of the visit was Qulturum – A Jönköping County Council run
centre for learning and service improvement, which sits within the grounds of
the main hospital in Jönköping. It is staffed by clinicians and academics and aims
to improve services through a patient centred approach. In developing a system
improvement centre, which is allied to both the hospital and primary care,
Jönköping County Council has managed to ensure that a very positive culture of
learning has emerged where all employees are encouraged to take part in system
improvement.
A good example of one of the ideas that has come from Qulturum is the way in
which clinical audit is used. All clinicians are encouraged to undertake a number
of audits on an annual basis (as they are in the UK), but more importantly the
results are then shared across all departments. Four times per year there is a
large educational meeting in Jönköping, where clinicians from both primary and
secondary will share the results of their audits. Commissioners, who can take the
ideas forward to ensure that there are contractual service improvements as a
result, also attend these meetings. This feels very different to the UK model
where individual departments in a hospital or health centre will undertake audit
with a view to service improvement, but not necessarily share the learning
across the whole health spectrum.
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The meetings have a theme and tend to ask a big question that comes from a
specific pathway that needs developing – for example the theme may be “How do
we deal with the frail elderly who fall?” This integrated learning has led to a
much better understanding between primary and secondary care, and given that
there is a very patient centred approach to the meetings has led to some big
advances for patients. One example that was given is that of hip fractures. At one
of the quarterly educational meetings the pathway for treatment of fractured
neck of femur was discussed, and the message that came out was that the elderly,
particularly if they suffer with dementia, find it very distressing to spend time in
A+E. The subsequent pathway that has developed is that the patient spends as
long at home as possible before going into hospital, and returns home as quickly
as possible afterwards. In practice this means that the attending paramedic will
prep the patient for theatre by getting them dressed appropriately, taking
bloods, putting in a cannula and even starting the consent process before taking
them straight to the x-ray department (rather than A+E) and if possible onto
theatre afterwards. As soon as possible after surgery the patient is then
transferred back home to have as much of their rehab and reablement in the
environment they know best. Given that all departments involved the pathway,
are also involved in its design, and that the focus is on what is best for the
patient, clinicians are encouraged to think “how can I make it easier for the next
person in the pathway to do their job?” All too often in the UK, where systems
are not necessarily as integrated, the focus is “how can I achieve my target of
getting the patient out of my department as quickly as possible?”
The other big cultural difference between the learning styles of the NHS and that
of Sweden is that in the NHS the focus of learning often comes around significant
events (i.e. learning from when things go wrong). In Sweden, significant events
are still used as a learning tool but the bigger focus is on learning from when
things go well. The educational meetings will often focus on the last twenty times
that things went well, and the learning points that can come from that, rather
than looking at the one time it didn’t go so well.
The Esther Project
Another element of the learning process that has developed through Qulturum is
the Esther project. The idea is again to look at specific pathways or questions
that need answering or improving, but rather than just clinicians, everyone from
cleaners through to health care assistants, nurses, doctors, social workers and
carers are engaged in the process. The most important person however is
“Esther”. Esther can be elderly, can have mental health problems, can be a child
or can attend the hospital as an emergency – in short Esther is a patient. When
an Esther meeting is being held to look at a specific question, everyone involved
in the care pathway will get together, along with Esther. The first question will
always be directed to Esther and will be “what do you think should happen?”
This patient involvement in service redesign or improvement means that the
focus is always very patient centred and often leads to surprising results.
Wellbeing measures have increased as a result of this radical patient
involvement and this has led to a reduction in reliance on health services. To
some extent this project matches the Living Well projects that are being rolled
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out across Cornwall and the Isles of Scilly, and it was certainly interesting to see
that the results of a fully developed wellbeing project seem to bear fruit.
Microsystems
As mentioned at the beginning of this report, the purpose of the visit to Sweden
was to see how we could better integrate services. The way that services are
commissioned or designed is at the heart of how this can be achieved. The NHS
has developed into a very complex system over more than 65 years. Services are
currently commissioned at an organisation level, meaning that primary care is
distinct and separate from secondary care, which again is different to social care.
Jönköping has a very different approach to system design in that they will look at
a microsystem rather than an organisation. This approach of looking at the
whole system, rather than individual parts, ensures that everyone is working
towards the same goal and that some of the organisational barriers that we see
in the NHS are minimized. This approach leads to very distinct advantages in
terms of the way that teams work together - the concept that as a clinician you
are not only there to help the patient, but also to help the next professional in the
chain to do their job has come from this approach, and has led to significant
efficiencies. Often in the NHS, assessments will be repeated when a patient
enters a different sector. It is not unusual for example for a physiotherapist to
reassess a patient as soon as they are admitted to a community hospital despite
the patient having been assessed on discharge from the acute sector. This is
wasteful and inefficient, and if the pathway were designed as a whole
microsystem would not happen.
Social Care
Social care is organised very differently in Sweden. As mentioned earlier there is
a larger proportion of GDP spent on social care than in the UK, but there is no
voluntary sector involvement. There is a focus on improving wellbeing and on
looking after people in their own home. This also occurs in the UK, although what
happens in England is that there is a cap on the level of care that can be offered.
This is often set at 4 visits per day with nothing at night. In Sweden there is no
cap on the level of care that is offered, which means that people are able to stay
in their own homes. At the highest level of care, three personal assistants are
employed to work 8-hour shifts with an individual. This has led to a dramatic
reduction in the level of admissions in the frail elderly, and subsequently has led
to the closure of many residential homes, as they are simply not required
anymore. When this system was designed, the focus was on what was best for
the patient, but the interesting side effect is that it is cheaper in the long run as
residential institutions are considerably fewer and hospital admissions are
greatly reduced. This can only be achieved as budgets are big enough to cope – in
the UK budgets are smaller, but more importantly are separate. This means that
increasing the social care spend is difficult to achieve, as it is not the social care
budget that then sees the benefits.
If a patient is admitted to hospital, the discharge process is also different in
Sweden. Vulnerable patients will be met at home by a carer or health
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professional, rather than being discharged to an empty house. They will also
have daily contact from the discharge team, irrespective of whether there is to be
an ongoing package of care, until they are settled and the risks have been fully
determined. In the UK every effort is made to determine what the risks will be
for a patient at home, but this is done from within the hospital, perhaps aided by
a home visit. Once the patient has gone home, the discharge team then passes
onto another team (such as the community rehab team), meaning continuity is
lost. By assessing patients in their own environment, the risks are generally
better understood – an approach which has led to a significant reduction in the
re-admission rate, which in itself is not only better for patients but has led to
considerable cost reduction.
Self-Dialysis Unit
We also visited a pioneering unit in the hospital, which aims to “give” patients
their own risk to manage. This concept came from an Esther meeting where the
patient said I want to be in control of my own dialysis. Initially this started as a
pilot project but there has now been a whole unit opened up to allow patients to
regain control over there own lives. Patients have a smartcard to let themselves
in, and will then cannulate themselves, take their own bloods (and look them
up), attach themselves to the dialysis machine, determine how much dialysis to
undertake and then dispose of reagents etc after they have finished. This was
initially met with scepticism by clinicians, who are used to managing risk on
behalf of patients, although it was soon discovered that patients are often better
at managing their own risk as they have a vested interest. At the time that we
visited the unit there were 6 people having dialysis, with one staff nurse on duty.
This was actually fairly quiet, with the capacity being up to 12 patients at any
time (again with the same level of staffing).
We met a young man who is awaiting his second transplant, and who has a
young family and job. Prior to his last transplant he had to dialyse 3 times per
week during office hours, which meant that he was unable to work. This had a
profound effect on his self-esteem and therefore his wellbeing. With this new
system he is now able to dialyse in the evening, or even overnight, meaning that
he can hold down a job, see his children after school, then treat himself at a time
that suits him. This has revolutionised his life but has also improved his risk
management as he is back in control. Being able to adjust the timings and
frequency of his own dialysis (within preset limits), but also checking his own
bloods means that he is much more involved in his own care.
Conclusions
Visiting an alternative health and social care system was both fascinating and
enlightening. It is often only when you see how things can be done differently
that you are able to focus on what happens within your own system. There was a
big cultural difference in the way that learning occurs – in the NHS we often
focus on the negatives, whereas in Sweden the focus is more on the positives.
System improvement in Sweden is very patient focused and can be influenced by
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all members of the team rather than just by the managers or leaders. There is a
genuine bottom up approach to service redesign that occurs within
microsystems – this has led to much less political involvement but also to much
greater engagement by members of staff in their organisations. Cost cutting is a
secondary gain to this method rather than a primary concern, but in the long
term this brave approach to look at the bigger picture rather than focusing on
the immediate day-to-day problems has led to greater savings.
The other big difference is in the way that patients are encouraged to age their
own risk. This felt quite alien, as a clinician, but ultimately the clear message is
that people are able to manage their own risk effectively – as one clinician
pointed out, most people do not want to suffer or die and will therefore adopt a
healthy approach to looking after themselves.
The future for Scilly?
I believe there are some lessons that could be brought back to England, and
specifically Scilly. The most important of these are around integration and the
culture of service improvement.
At present we have multiple providers of services ranging from primary care
organisations through to community services including the hospital, social care,
ambulance and mental health providers. There are relatively limited resources,
and providers generally work well alongside each other, however because of the
structure of multiple organisations there is still sometimes a lack of cohesion
between providers. If there was one provider organisation that covered all
aspects of health and social care, the idea that each employee would be working
not only to help the client they are working with, but also to help the next person
in the chain could be brought to life. This would increase efficiency and would
help to make the most of the resources we have.
The other aspect of integration that would work really well for Scilly would be
around social care. At present health and social care budgets are separate,
meaning that systems are inflexible. It is very clear from the Sweden experience
that being more flexible in the delivery of social care could lead to a reduction on
the burden on health care, but more importantly to an increase in patient
wellbeing. This would require a rethink on how care is provided – for example at
present the only option for night care is at Park House or the hospital. There are
many instances of recurrent admissions to St Mary’s hospital that could be
prevented if there was increased domicillary night care available. This may
include hospital staff being more flexible in where they work (for example
leaving the hospital to provide care at home) or could be a stand-alone carers
post for the night-time. Either way if there were a truly integrated service there
would not be a perceived pressure on one or other service to provide the care,
but the benefits would be to the patient who could stay at home. I believe this
would also lead to a reduction in costs.
The patient centred learning and system improvement that occurs in Sweden
could also work very well on Scilly. The idea of Esther meetings could be easily
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reproduced and could really help to improve the systems we have in place.
Allowing everyone to have a say in how systems should be run, and learning
from positive experiences rather than focusing on the negative also seems to
bear fruit, and should be looked at being introduced to Scilly.
All of this would require buy-in from all organisations, but with the right
leadership this could be achieved. We have limited resources on Scilly, so any
new service needs to maximise how we use those resources, and that can most
effectively be achieved if there is true integration between services and more
importantly budgets.
Dr John Garman
November 2014
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