1. Procurement of Health Care services in Stockholm County Council Part 1 Background Objectives Legal conditions Present state of the process

2. Background I The Swedish system Based on taxation Since 1997: County Councils (regional taxation) responsible for health care (cure) Local authorities (local taxation) responsible for long term care (nursing homes etc.) Purchaser – provider split in more than 50 % of County Councils Public provision very dominant in all County Councils, except Stockholm

3. Background II The role of private provision 1997 Nearly 400 external providers accounted for 17% of the care financed by Stockholm County Council. (High level, to Swedish standards.) Today Nearly 500 external providers, 25% of the care financed by the County Council. Additionally approximately 65 units are waiting for procurement. Mainly primary care and smaller units. But now one private acute care hospital (the company sold by the County Council, not the building)

4. Initial political conditions Continued co-operation between providers Patient’s freedom of choice at least as today Good conditions for keeping and recruiting qualified staff Good conditions for medical development Pluralism Number of emergency-service hospitals unchanged Number of university hospitals unchanged Geographical considerations

5. Objectives Increased diversity, freedom of choice for patients and staff, competition and openings to new initiatives More “power” and “reality” into the purchaser – provider interaction

6. Legal conditions One private and two public “corporatised” hospitals triggers the Swedish Law on Public Procurement Temporary law against for-profit acute-care hospitals

7. The size Hospital services for two million people, a quarter of the Swedish population Approximately 1 billion euros per year A “one time” tender for five-year- contracts, with options for two years of extension

8. Val Original schedule START - Present map - Model Identification + needs SO Decision Needs SO plan Decision Routing questions 2 Work on FF – description of service FF Ready FF Referral SO + committee Decision FF at HSN Tenders in Evaluation + negotiations 1/4 Agreement signed. Decision. 1/1 Start of operations Joint evaluation Decision Routing questions 1 Political decision

9. Present state Many conditions and alternatives have been examined, but the procurement model is still under work and discussion

10. Procurement of Health Care services in Stockholm County Council Part 2 Challenges and Dilemmas – closing and still open questions

11. Heavy risks No interesting tenders; present providers needing more money to do what they already do Dynamics in procurement will “eat” continuous dynamics; long term contracts to defend status quo No continuity at end of contracting period Focus on itemised production rather than on need and result Heavy administration Private oligopolies, taking away all real power from purchasers and patients Parallel private payments erodes solidarity in financing

12. What we have already seen Wider range of providers raises wages – and costs – for demanded staff Widened opportunities for entrepreneurial doctors, nurses and others Competition will sometimes open doors that seemed to be totally blocked Prioritisations are more difficult to hide in budgets Initial distance is maturing to growing interest in cooperation Improved focus on guidelines, production, quality and result are now necessary – but useful even in the traditional structure Many of the “new” risks are already present

13. An evolving picture? Basing process on market scan; only services that someone will provide can be purchased Purchasing responsibilities rather than production Competition focused on quality and inventions; economy rather a framework Large integrated objects, opening for subcontracting Defining present state as starting point, evaluating on capability to develop Making continuous flexibility a part of the agreement Following choices made by patients/in referrals A marginal for single sided purchaser initiated yearly change Openings both for external and in-house tenders Regulation of parallel financing