Embarking on transparent priority setting – different strategies in Sweden Peter GarpenbyPer Carlsson Mari Broqvist National Centre for Priority Setting in Health Care Sweden

The Swedish health care system Universal system National framework legislation (HSL 1982) 21 local government bodies (county councils) - Directly elected political bodies - Right to impose taxes - Right to decide on the appropriate health care package to the population A majority of public service providers

National initiatives in Sweden 1995 Report by the Priority Commission 1997 Principles established by the Parliament (human dignity, need, cost-effectiveness) 2001 The National Centre for Priority Setting in Health Care established as clearing-house 2004 The first National Guideline to include explicit priority setting issued by the NBHW

The first wave

County Council of Östergötland 2003 Clinical departments responsible for ranking of services Scrutiny by medical advisors Final political decision on service release Dialogue

The features of the first wave Negative framing – focus on rationing Communication strategy in place but undeveloped Confusion of objectives (e.g. between the process of priority setting and the process of hospital restructuring) Undeveloped interaction & dialogue Politicians in the driving seat Politicians left alone to defend content Transparency on the result (output)

Explicit priority setting

The second wave 2008-

The second wave of explicit priority setting in Sweden County Council of Västerbotten (AC) County Council of Jämtland (Z) County Council of Kronoberg (G) County Council of Västmanland (U) More local authorities in progress

The stages of the priority setting process All clinical departments separately identify options for resource release corresponding to 10 % of the net budget (the vertical prioritization) A critical review and comparison of proposals followed by group decisions on resource release corresponding to 4 – 6 % of the net budget (the horizontal prioritization) A second review of data applying political criteria, and a final decision scaling down to 2 – 3 % of the net budget (final decision)

Ranking of services by clinical departments Clinical directors and managers work together to compile horizontal priorities Final decision by politicians Scrutiny by politicians and managers in general forum Peer review and test round Västmanland County Council 2009

Priority setting process in the County Council of Västmanland October 2009

The common features of the second wave Learning from past experiences Intention to speed up the process Positive framing (priority setting as reallocation with the aim to modernize health care) Proactive communication strategy Use of formal model (the vertical prioritization) Priority setting as a collaborative process

The common features of the second wave Shared responsibility for the result between politicians and clinical directors Identification of a list for investments Transparency on the process and the result

Divergences in the second wave The handling of options for disinvestment and options for enhancing organizational efficiency (separated or in parallel) The use of micro and macro strategies in developing the process for priority setting Level of involvement for politicians in the rating of options for reductions

Results from the second wave (so far) Experiences are encouraging Minimal opposition (staff and public) County councils will repeat the process

Challenges The involvement of stakeholders (health care staff and citizens) The appropriate role in the process for key actors like clinicians, managers and politicians The identification of proposals for investments The legitimacy of the process when “hard” evidence is mixed with “soft” evidence To find the optimal level of transparency in the different stages of the process

What long-term effects will explicit priority setting have on the trust for universal health care? What long-term effect will explicit priority setting have on the trust for universal health care ?