Väntetider på sjukhus i Östergötland Waiting time policies in Swedish health care from single step to process thinking Marianne Hanning, Senior Researcher and PhD, Department of Public Health and Caring Sciences, Uppsala University and National Board of Health and Welfare, Sweden.
Contents 1. Swedish health care system 2. Waiting times in health care some basic thoughts 3. Maximum Waiting time Policies and the Que-billion 4. Measuring waiting lists and waiting times 5. Waiting times in cancer-care
Sweden Population, 9 million Health care services: - 100% Health insurance coverage, tax-based - Health expenditure per capita, 2010 = 3 800 USD - 9.6 % of GDP
Swedish health care in numbers Life expectancy years, women men Sweden - 2010 83.5 79.4 Infant mortality/1 000 births 2.5 % public exp 81.7 Physicians /1000 3.8 Doctors consultations per capita and year Acute beds/1000 2.7 Hosp. discharge rate/100 000 163 Average length of stay in days 5.7 Share (%)of cataract surgeries carried out as day cases 2.9 97,4 Hip replacement/100 000 210 Source: OECD
Unions and profressional organisations Who decides? EU WHO Parliament and Government 16 County councils, 4 regions, 1 municipality Social Committee Social Ministry Committiees and Boards Public authorities (i.e. NBHW), State Institutes, County administrative boards, Research and Education Swedish Assosiation for Local Authorities 290 Municipalities Committiees and Boards Social insurance
Who does what? Parliament and Government; Legislation and regulation Authorities; Guide Lines, control, revision and evaluation County councils; Finance (taxation), plan and provide their population with health care services. Municipalities; Finance (taxation), plan and provide their population with social services, health care in socialservicehomes and in homes.
Health care service organisation Primary care Medical servicecenters (n=1024) Mother and child care Somatic: - Medicine - Surgical - Diagnostics Specialised care Out-patient In-patient Psychiatry: -General psychiatry - Child and youth psychiatry - Forensic medicine University/regional hospitals n=7 County hospitals n= 28 Other services -Rehabilitation/ habilitation -Dental care Local hospitals n=40
Waiting times in health care the Achilles heel of Health Services in Sweden. DEMAND SUPPLY
Swedish Waiting Times for Health Care in an International Perspective (SALAR, 2011) Waiting times in days for all elective surgery Countries that perform temporary measurements are also included as long as they claim to be nationwide. Sweden: The point in the interval at which the median (45) lies has been estimated on the assumption that waiting times are normally distributed within the interval (waiting times due to the patient's own choice have been excluded).
Swedish Waiting Times for Health Care in an International Perspective hip replacement (SALAR, 2011) Waiting times in days for total hip replacement surgery Countries that perform temporary measurements are also included as long as they claim to be nationwide. Sweden: The point in the interval at which the median (45) lies has been estimated on the assumption that waiting times are normally distributed within the interval (waiting times due to the patient's choice have been excluded). Canada: The median waiting time varies from 42 to 178 days depending on the province.
Waiting times in health care some basic thoughts
Waiting time A Key issue of quality with multiple dimensions and many interested parties - Political - Medical - Economic - Managerial
Reasons for imbalance between demand and supply: - Lack of resources - Inefficiency and low productivity - Variations over time - Changes in indications
Widening indications cataract surgery The golden triangle of ophtalmology : the relation between different thresholds of visual acuity and the cataract surgery rate. Data recorded from the Visual Impairment Project. Visual acuity Surgery rate per million Ratio Sweden,1980 (964) 6/60 1 300 1 6/36 2 300 2 Sweden,1992 (4 528) 6/18 3 200 2,5 6/12 6 000 5 Sweden,2006 (8 333) 6/9 11 500 10 6/6 25 300 20 Source: Br J of Ophtalmology,2000;84:1-2
The Patient s Roadmap Follow-up Therapy Prognosis First contact Diagnosis Waiting time depends on: Need and priority Treatment Care giver Patients wishes
Demand side policies Priority setting and Scoring systems Patients rights Free choice of provider Maximum Waiting time Guarantee Supply side policies More resources Increase productivity Use of private capacity Incentives Financial Regulation Education/information/ persuasion
National indications for cataract extraction Priquest questionnaire to patients NIKE-instrument - medical examination
National indications for cataract extraction 4 Indication groups based on: Visual acuity in both eyes (NIKE-tool) Difficulties in day-to-day activities as a consequence of the cataract (Priquest) Cataract symptoms (glare, difference between the eyes) (Priquest) Ability to live independently (work, homecare, car driving, etc.) (Priquest) Medical/opthalmic reasons for urgent surgery
Cataract Surgery - waiting time (mean) in months per priority group 2006-2007. NIKE 1 NIKE 2 NIKE 3 4 3,5 3 2,5 2 1,5 1 0,5 0 Kv.1 2006 Kv.2 2006 Kv.3 2006 Kv.4 2006 Kv.1 2007 Kv.2 2007 Kv.3 2007 Kv.4 2007
Priority setting and long waiting times % 55-year old man, no healthproblems before. Pain since 2 years in the left groin after walking 5-10 km. No pain at night. No medication. Minor restrain in the hip. No limp. X-ray shows incipient artrosis 50 40 <25 percentile >75 percentile 37 45,7 30 26,8 29,3 20 10 22 4,3 13 17,1 4,9 0 < 3 months <6 months > 6 months Return More information Priority
Maximum Waiting time policies and the Quebillion
Waiting time Guarantee in Swedish health care the first policy initiative 1992-1997 Maximum waiting time guarantee for selected procedures. A patient covered by the guarantee shall be offered treatment within 3 months from the decision to treat. Patients who can not be treated within 3 months shall be offered care at another hospital in the health services district, in another county council or through private providers. - Angiography - Benign prostate hyperplasia - CABG - Urine incontinence in women - PTCA - Prolapse of the uterus - Hip and knee replacement - Hearing aid fitting - Gallstone - Inguinal hernia
Conclusions in the evaluation of the first Guarantee: Waiting lists are a complicated interplay between demand and supply. More resources are not the only answer to a more efficient way of managing waiting lists. Too much attention is given to the supply side when there is a need for better knowledge and discussion about the indications and priorities at the clinical level. Concentration on one step in the care process can create longer waits between other steps in the process, i.e. imposing limits on the waiting-time for treatment can give longer waits for outpatient visits. Patients influence and freedom of choice have increased, but few patients use the opportunity to change provider. There is a lack of common terms and rules for the management of waiting lists and waiting times in Swedish health care.
Waiting time Guarantee in Swedish health care the second policy initiative 1996 Maximum waiting time guarantee for primary care and outpatient visits to hospital specialists. Patients shall get in contact with primary care (either by telephone or by a visit) the same day. If the patient wants to see a GP this should be arranged within 7 days. If the doctor refers the patient to a specialist, the waiting time shall not be more than 3 months for an outpatient visit (1 month if the diagnosis is unclear).
Waiting time Guarantee in Swedish health care - the third policy initiative 2005 Maximum waiting time guarantee for treatment. The waiting time to treatment shall not be longer than 3 months, unless the doctor and the patient have made another agreement. If the patient wants to go to another provider the home county shall also pay for the transport.
> The Swedish Maximum Waiting time Guarantee 2005- Same day Visit to a GP within 7 days > > Investigation, tests, x-rays, etc. < Control/reviews for chronic disease < Decision to refer Primary care > 90 days Treatment starts 90 days Secondary care < Decision to treat Investigation, internal referral, tests > First visit Control/reviews < for chronic disease >
Care Guarantee 2005 - a national co-operation for timeliness in health care Implementation of Process -techniques Medical indications and EBM Measuring waiting times Activities and Metods Efficient referrals Implementation of The Flow-model Administration of waiting lists
What causes waiting lists? Decision Action Copy. 28 BB/Bangalore
Focus on the core question: Delivery after decision to treat! ka calls for a continuent improvement work : processmapping Planning of production- and kapacity Copy. 29 BB/Bangalore
Strengthened health care guarantee new law and the Que-billion initiative Since 2010 the right to receive timely health care has been laid out in law. To ensure that local authorities keep waiting times short, the Government has earmarked SEK 1 billion (140 million USD) per year 2009 -,to be distributed among local authorities that shorten their health care waiting times.
Que billion County councils are paid for performance, i.e if they manage to reach different waiting time goals. In 2012 the model for distributing the money is; - 400 million SEK to county councils where more than 70 % of patients on waiting lists to specialist care (visits) waited less than 60 days. - 100 million SEK to county councils where more than 80 % of patients on waiting lists to specialist care (visits) waited less than 60 days. - 400 million SEK to county councils where more than 70 % of patients on waiting lists to specialist care (treatment) waited less than 60 says. - 100 million SEK to county councils where more than 80 % of patients on waiting lists to specialist care (treatment) waited less than 60 days.
Measuring waiting lists and waiting times
At what point in the patient journey do countries begin measuring waiting times? Primary care Specialist care Contact Appointment Decision to refer Referral written Referral received Appointment Referral evaluated Examinations, Lab measurements Decision to treat Referral received Patient listed Treatment starts Sweden The Netherlands Finland Sweden England (RTT) Scotland Denmark Norway Wales Northern Ireland Denmark Sweden Finland England (HES) Northern Ireland Canada The Netherlands Portugal Australia Ireland
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Access to primary health care (autumn 2012) Phonecall with nurse same day 89 % (max 100 % min 76%) Visit to GP % within 7 days 93% (max 98% - 81%) Waiting for specialist care (autumn 2012) From referral to first visit 86 % waited 90 days or less From decision to treat 82 % on waiting list waited 90 days or less.
Waiting times in cancercare
The cancerpatient s journey five measuring points Patientperspektive 1:st symptom 1:st contact 3.Information on diagnosis to patient 4. With patient agreed care plan 5. Treatment starts Time Producerperspektive 1.Remissbeslut 2. 1:st visit to specialist Decision to treat
Waiting time from decision to refer to start of treatment in different cancerdiagnosis (2011) 100 90 80 70 60 % 50 40 30 20 10 0 % within > 3 months % within 3 months % within 2 months % within 1 month