Fragmented health and social care in Sweden - a theoretical framework that describes the disparate needs for coordination for different patient and user groups

摘要

Background : Fragmented health and social care for patients and users because of a lack of coordination between different providers is a well-known problem in Sweden. A variety of sources indicate collectively that coordination is one of the main challenges for health and social care in Sweden, especially for patients with chronic diseases. For example the OECD's assessment of the quality of health care in Sweden points to coordination between hospitals, primary care units and social services as being the main challenge to Sweden's otherwise high quality of provided care . Sweden is characterized by a decentralized health and social care system. It is firstly divided between three different political actors: government, municipality and county, all of which have their own taxing rights. Secondly counties and municipalities have significant freedom to organize themselves after their own prerequisites. The decentralization is assumed to generate greater flexibility and adaptation to local conditions. Yet the system also creates multiple, geographically dispersed actors in need to coordinate with each other. Method : The aim with this paper is to develop a theoretical framework that describes the disparate needs for coordination for different patient and user groups. The framework is used to a)identify and b)explore new coordination approaches that have so far been missing in Sweden. Last we propose a refined definition of what coordinated health and social and care means from the perspective of patients, users and citizens in a Swedish context. Starting from an integrated analysis of coordination of health and social care from the patient or client, we made a systematic literature review to develop our theoretical framework. The framework was then tested and developed empirically through qualitative and quantitative analysis. The empirical data came from interviews with local representatives and national experts from both healthcare and social services as well as a quantitative analysis of each group in the theoretical framework and an estimation of their size and cost of health and social care. Together with our patient and user councils, we have drawn up a proposal on how coordinated health care can be defined in a Swedish context. Results/Discussion : Our report presents a framework for how differing needs for coordination – and thus challenges to achieving a better coordination – between different patient and user groups can be described and analyzed. The framework stipulates that population groups in need of similar coordination efforts are closely aligned along a scale consisting of two dimensions. The first dimension describes the degree of complexity of the coordination of that group’s health and care services. Complexity is defined as the number of care providers who need to be coordinated in relation to the organizational characteristics of the providers that facilitate or hinder coordination. The second dimension describes individual care users’ ability to participate in the coordination and coordination of their own care, for example by contacting care providers, relaying information and driving the care process forward. Our analysis shows that about ten percent of Sweden’s population belongs to an especially vulnerable group, with several intertwined conditions requiring multiple specialties and coordination of care. As a result, this group often needs care interventions from a variety of organizations and principals. The group also has a reduced capacity to contribute to the coordination of their health and social care, which means that need of health and social care often can only be met if different actors coordinate their efforts.