Ulrika Winblad: Health care debate characterised by simplified rhetoric

Ulrika Winblad, professor of health and medical care research

Photograph: Mikael Wallerstedt

Access and diversity or playground for private providers? Opinions about the Swedish welfare model divide along political lines. But what are the facts? Ulrika Winblad, professor of health and medical care research, has studied the reforms and their consequences for 20 years. Personally, she is more uncertain than ever about what is the right path to take.

"The goal has to be the best possible care, but both the reforms and the comments surrounding them are often so definitive and politically coloured. As a researcher, I'm becoming increasingly uncertain about what actually works best, and I also feel uncomfortable with the simplified rhetoric that often characterises the national debate," explains Ulrika Winblad, professor of health and medical care research.

Swedish health and social care were long primarily a public sector issue. By the county councils and municipalities providing the care, that was a guarantee for quality and fairness. But in the 1980s, something happened. The waiting times for care increased, resources were cut and the Ministry of Finance demanded increased efficiency. The Social Democratic model was considered outdated and neoliberal influences from Reagan's USA and Thatcher's England screamed The Market as both means and objective to regain stability in the services. Legislation on public procurements and systems of choice were introduced and suddenly the floodgates were open for private providers straight into the Swedish welfare system.

"Studying the results of these reforms leaves me split about how we should address the challenges facing the health care system. The fact is that I do not even write opinion pieces about the subject any more. At the same time, there are several questions we need to raise and discuss in a more nuanced way: How well does private health care insurance adhere to the Health Care Act's goals for health care on equal terms? And how do we create optimal conditions for innovation and new approaches in health care? In spite of all the years that have passed, there remains an inability to analyse and discuss even the most basic aspects of developments."

There are many questions to examine, not least of which is procurements and the system of choice. The Public Procurement Act is problematic in itself since it often eliminates smaller providers who could contribute to the expressed desire for diversity. The requirements on providers are rarely measurable and this limits the ability to terminate contracts that have not adhered to the specifications. Care recipients also do not seem to be able to judge the range of options or take advantage of their ability to change, something that was supposed to serve as a quality assurance mechanism. All in all, these and other challenges contribute to a series of original ambitions not being achieved.

"Health care is a soft service that occurs in meetings between people. This makes it complex to evaluate, and our research team has grown today to over 40 people from 12 different disciplines. This makes us an unusual interdisciplinary environment, which gives the breadth of expertise required by the field. After nearly two decades, we also have well-oiled collaborations and have been very successful in national grant competitions, but sometimes I cannot help wondering about how interested the health care decision-makers actually are in our results."

Ulrika and her colleagues are often invited to hold talks for the country's regional leaders. It is much less often that they are asked for advice before strategies and policies are formulated. This may grow out of the same belief that makes it so hard for patient participation to gain a foothold in Sweden: Listening to these invaluable insights requires time that does not always exist. But research probably should be given greater attention, since even with all the health care initiatives, the queues continue to grow. And in its wake, a new innovation has seen the light of day – online doctors.

"A friend told me how she recently needed a prescription refilled quickly. The long waiting time at primary care led her to call a private online doctor. She got her prescription, but at what cost for taxpayers? A look at the statistics confirm that online care is primarily used by young, relatively healthy people in major metropolitan regions, which means that the high reimbursement levels for this type of consultation probably need to be discussed."

The wrong patient at the wrong doctor's office is not a new phenomenon. In the 1990s, a reduction of the country's available beds was begun as a way to steer the patient flow to primary care. Although well intended, the effect was that increasing numbers of patients turned to emergency rooms – which today are warning of over run facilities, lack of staff and dangerous waiting times. To address this, the Act on Collaboration on Discharge from Inpatient Care was passed in 2018 to reduce the risk of errors and delays in the transition from hospital, municipality and primary care. The next move will be measures that can result in a paradigm shift in Swedish health care.

"We have spent a lot of time reviewing cooperation among regions and municipalities and the results are striking: Insufficient communication, missed responsibilities and other things that are done twice. What should be easy to arrange is instead weighed down by status attitudes, top-down organisations and insufficient technology. The need for better procedures is crucial, and a transition is now being prepared to increase responsibility for municipalities and home care for ensuring fewer readmissions. It will require reallocation of funding from specialist care but, nevertheless, is a very exciting reform that will place the focus on the patient."

Needs include better arenas for discussions between research and health care. Recently, the research team was invited to follow the process when Region Dalarna was forced to implement cost savings totalling SEK 700 million. Ulrika has also served as an expert in a study of the New Karolinska Solna project. She describes both of these experiences as informative and valuable for all the involved parties.

"As researchers, we gained a better insight into operations. The authorities gain a better understanding of scholarly methods and how they can utilise our expertise. My hope is that we can develop this collaboration and together tackle health care's Achilles heals: weak collaboration, long queues, high pace and skewed access to expertise to name a few. The potential is good actually, and we need to remember that Swedish health care ranks very high internationally. That's something worth maintaining!"