Evaluation of the agreement between the Swedish Government and the Swedish Association of Local Authorities and Regions.
Between 2010 and 2014, the Swedish Government and the Swedish Association of Local Authorities and Regions (SALAR) were part of an agreement on interventions for the most severely ill elderly people. This agreement covered a total of SEK 3.8 billion. These funds have largely been conditioned upon municipalities and county councils achieving a certain performance or result. The aim was to reinforce a systematic working practice in the health and social care of the most severely ill elderly people. The Swedish Agency for Public Management (Statskontoret) has completed its commission from the Government to evaluate the agreement.
Statskontoret's overall assessment is that the conditions for working with the most severely ill elderly people have improved. Working practices within health and social care have improved in activities where personnel have for a longer period entered data in quality registers. However, the results from these quality registers are not used to a sufficient extent. In addition, health and social care services have not become more coordinated. The evaluation also shows that the permanence of the improvements has not been secured.
Working practices have changed, but are insufficiently systematised
The agreement has led to a more systematic working practice in activities where personnel have entered data in quality registers over a longer period of time. For example, individual evaluations of elderly people with dementia have led to better care, which has made them calmer. However, the transition to a changed working practice has not been completed since the results from the quality registers are not used to a sufficient extent.
Statskontoret also notes that the knowledge bases for achieving a coordinated health and social care are not fully systematised. The local analysis work that has been conducted has not provided the responsible authorities with sufficient guidance on how they should proceed.
Structures have been built up for working with the most severely ill elderly people
Statskontoret notes that all counties have built up structures for collaboration between municipalities and county councils. The agreement has also helped to disseminate methods for following up activities. Funds have been used to spread selected quality registers. The two quality registers originally included in the agreement have also been widely disseminated in health and social care. Personnel perceive the quality registers to be relevant and feel that they cover important areas.
If the quality registers are to visualise the results of health and social care, the reported information needs to be accurate. However, Statskontoret's assessment shows deficiencies in the quality assurance of this information.
Health and social care services have not become more coordinated
Statskontoret's assessment is that health and social care services have not become more coordinated to any greater extent, i.e. that health and social care services are individualised and coordinated across specialties and organisational boundaries. This is an important prerequisite for being able to achieve the final goal of good health and social care. In addition, several of the agreement's sub-goals have not been directly aimed at ill elderly people and at developing collaboration.
The permanence of the improvement work has not been secured
County councils and municipalities have the responsibility of ensuring that the improvement work for the most severely ill elderly people continues now that the agreement has ended. Statskontoret's assessment is that continued efforts are required on the part of the responsible authorities if this work is to become permanent, since the structures for improvement work in the counties have not yet been secured. SALAR has an important task to support municipalities and county councils in this work.
The quality registers have conditions for continued existence
Statskontoret's assessment is that there are conditions for municipalities and county councils to be able to continue using quality registers. However, there is a risk that data entry will reduce or cease at units where motivation to enter data is low. How the use of quality registers will develop largely depends on how senior and line managers direct and organise the work. One success factor is responsible committees requesting results from the registers. Furthermore, managers need to make clear the benefits of quality registers and allocate time for their personnel to work with them.
Performance-based payment has been effective to varying degrees
Statskontoret's assessment is that properly designed performance requirements can enhance the control effect of an initiative. Performance-based payment can, for example, be appropriate for stimulating improvement work within health and social care. Among other things, Statskontoret's evaluation shows that the quality registers have led to some improvements in health and social care for the elderly. Performance-based payment has also had a positive influence on pharmaceutical treatment for the elderly. It has contributed to more accurate pharmaceutical treatment.
However, performance-based payment is not appropriate when the knowledge of cause and effect is low. This applies to the performance indicators for coordinated health and social care. Performance-based payment has not led to any development, and it has been unclear to the responsible authorities which interventions have been required to achieve the goals.
Statskontoret's proposals and experiences from the evaluation
Statskontoret proposes that the Government in its continued work:
- commissions the agencies involved in the Council for knowledge-based governance (Rådet för styrning med kunskap) to produce a national strategy for knowledge support concerning health and social care for the elderly,
- commissions the National Board of Health and Welfare, in consultation with SALAR, to design an explicit support for register administrators to assure the quality of information reported.
In this report, Statskontoret accounts for experiences that might be worth highlighting in preparation of similar initiatives within health and social care. Among other things, this concerns how to reach private providers of this type of initiative. Private providers did not gain access to the funds and the improvement work concerning health and social care for the most severely ill elderly people to the same extent as public actors. Statskontoret also submits recommendations in regard to when it is appropriate to use performance-based payment, how the requirements on the responsible authorities should be designed and how knowledge should be obtained and disseminated.