Decentralisation and public health: inspiration from Sweden

By Rose Taylor and Peter Hawkings

Last autumn, Västerås Hospital and Västmanland County Council, from Sweden, visited PwC and a UK teaching hospital on an international study tour. This was an opportunity to compare the two healthcare systems.

Sweden has impressive health outcomes - the eighth highest life expectancy and fourth lowest infant mortality rate out of the 35 countries in the 2016 OECD  rankings. Sweden also performs well in all the OECD behavioural risk factor rankings associated with poor health, with the second lowest prevalence of smoking, sixth lowest alcohol consumption and the eighth lowest prevalence of obesity. Having compared notes with our Swedish colleagues on the day and followed-up via telephone interview, we have identified two key areas where the NHS could draw inspiration from the Swedish healthcare system.

1. Decentralisation can give local leaders more control and accountability to improve health outcomes

There are three levels of healthcare organisation in Sweden: national, regional and local. In the 1980s, Sweden decentralised their healthcare system and gave the 21 regional county councils considerable autonomy. Sweden’s decentralised model is widely admired, and has two key benefits.

First, regional (and local) leaders have greater accountability and control over their population’s health outcomes and the system’s financial performance. This is because the primary responsibility for providing healthcare services and making decisions about the level of taxation for their population are aligned at a regional level. In addition, there are elections at a regional and local level every four years. This means regional and local leaders have a strong mandate to drive change because they are democratically accountable.

Second, greater autonomy at regional level enables more innovation and quicker replication than a centralised system does. For example, in the last 15 years, Jönköping County Council developed a more patient-centred approach and, in 2009, Stockholm County Council introduced the first bundled payment contracts (OrthoChoice). Both pilots improved health and financial outcomes at a regional level, and were widely replicated across Sweden as a result.

Experimentation and innovation at a regional and local level continues. On the study tour, we were very interested to hear about a new model of care being trialled at Västerås Hospital for Medically Fit for Discharge patients. Watch this space for further details!

2. Investing in primary and preventative care provides long-term economic benefits

Sweden grasped the potential long-term benefits of investing in primary and preventative care about 25 years ago. Two of the most effective public health policies introduced in recent years have been around healthy ageing and occupational health.

The healthy ageing programme focuses on helping people remain in employment for longer, maintain their independence for longer, and participate in voluntary activities that keep them engaged in the community. At the same time, Sweden also introduced a programme where medical professionals could prescribe physical activity, both for preventative purposes and as a form of treatment. These programmes have supported people to live healthier and more fulfilling lives in old age. As a result, Sweden finished top of the Active Ageing Index for European Countries in 2012 and 2014.

Occupational health has also contributed to Sweden’s excellent health outcomes. One example adopted in many workplaces is Friskvård (‘health and wellness training’). Friskvård can be an annual wellness grant that employees receive from their employers to spend on activities ranging from gymnastics to office massage. Alternatively, Friskvård can be physical exercise or other activities that promote well-being provided by the employer during the working day. The government encourages employers to adopt Friskvård by making the grants and expenses tax deductible. As a further benefit, employers have seen the cost of employee absence decrease every year since 2004.

Sweden’s challenges

Of course, Sweden faces its own challenges, many of which are familiar to the UK. These include long patient waiting times, a shortage of nurses and lack of continuity of care, particularly between primary and specialised care. In addition, whilst decentralisation gives the regional counties considerable autonomy to improve services, it also accentuates geographical variations in the quality of care. For example, in Sweden there is a significant variation in the proportion of type I diabetes patients in different counties who have their blood pressure under control (from 26% at worst to 68% at best).

Implications for the NHS

What can the NHS draw from Sweden's healthcare system? First, despite the geographical variations in care, Sweden’s success may be the most compelling case for decentralisation and investing in prevention anywhere in the world. The development of Sustainability and Transformation Plans (STPs) and wider devolution of health and social care demonstrate that the NHS already appreciates the potential benefits of decentralisation. However, comparing the two healthcare systems highlights that there is significant scope to go further by creating Regional Care Groups (RCGs). Learning from the success of the Swedish model, two components of RCGs should be that they are democratically accountable and able to directly raise taxes to fund local healthcare services.

Alongside this, although healthy ageing and employer engagement are both policies identified in the Five Year Forward View, it feels like investing in well thought out prevention campaigns can take a backseat because of the immediate financial challenges facing the NHS. Therefore, we believe the NHS should draw inspiration from Sweden’s long-term approach to public health and not let today devour tomorrow.

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