The Swedish Agency for Public Management

Coordinated health and social care for the most severely ill elderly people Follow-up of the agreement between the Swedish Government and Swedish Association of Local Authorities and Regions. Interim Report 4 (2013:16)

The Swedish Agency for Public Management (Statskontoret) has been commissioned by the Swedish Government to, over several years, follow up on the agreement between the government and the Swedish Association of Local Authorities and Regions (SALAR) on the coordinated health and social care of the most severely ill elderly people. The aim of this agreement is to reinforce a systematic working practice in the health and social care of the most seriously ill elderly people. The government has allocated about SEK 1 billion for this intervention in 2013.

This report constitutes Statskontoret's fourth interim report. Statskontoret will submit a final report in 2015.

The agreement has become clearer

Statskontoret makes the assessment that the indicators used to measure the development towards a better and more coordinated health and social care for the most seriously ill elderly people have become more clearly defined in this year's agreement than it was previously. The models used to calculate certain indicators have also been developed. Payments for results that have been achieved will only be made once the improvements have become persistent.

The initiatives could be more accurately targeted

In order for the agreement to be targeted accurately, the chosen initiatives need to cover the targets that have been set as part of the agreement. Statskontoret's analysis shows that the initiatives do in fact cover many of the targets. However, just under one third of the targets lack initiatives. For example, there are no initiatives that take aim at the development of staff expertise, despite several of the targets in the agreement involving this aspect. It is also uncertain to what extent this intervention has reached the entire target group of the most seriously ill elderly people.

Furthermore, funds have been allocated within certain areas without there being any specific requirements placed on the organisations that will be in charge of these funds. This carries a risk that these organisations will not actively work with these aspects of the change process. This involves the investment in elderly mental health, where there is a lack of requirements stating how SALAR's initiatives will be put into practice.

Longevity is not assured

So far there has been no sign that the longevity of the organisation's work is assured, despite the agreement aiming to develop just such a long-term improvement process. According to Statskontoret, the set-up of the plan to phase out central government support and the requirements placed on the organisations regarding evidence-based practice in social services within the agreement also serve as an inspiration to promote the longevity of the work involving the most seriously ill elderly people.

Private providers are not covered to the same extent

In the previous progress report, Statskontoret established that there was a risk of the private providers not receiving the same support for systematic improvement work. This could involve, for example, help to interpret and use the results from quality registers. This year's monitoring indicates that this risk remains. It is uncommon for the county plans to include activities that deal with how the private providers will be included.

The avoidable in-patient care indicator does not work as a control measure

In the previous progress report, Statskontoret established that it was unclear to the organisations which initiatives were required in order to achieve the results for the avoidable in-patient care indicator. This year's monitoring indicates that this problem remains. According to Statskontoret, the parties should instead devote themselves to finding a structure or process indicator that highlights the improvements in the work towards coordinated health and social care. Results indicators only become once there is knowledge of cause and effect.

Statskontoret also makes the assessment that the local analysis work conducted to avoid in-patient care has not provided the organisations with sufficient guidance. It is our opinion that it is questionable whether necessary knowledge is best acquired through each county analysing the connection between the initiatives and the results. Statskontoret's assessment is that there is a need for academically-based work at the national level, to identify existing connections factors that impact on the indicator, before it can be used in the performance-based payment model.

Payment based on results works well for the quality registries

Statskontoret has ascertained that payment based on results works well for the quality registries. According to Statskontoret's assessment, additional emphasis should be placed on the achievement of results for the two quality registries, Swedish Palliative Care Registry and Senior Alert. In the case of the two dementia registers, where payment has previously only been connected to registration, the government should also test out payments for use of the registers or for the achievement of results. However, there must be an awareness of risks with regard to various types of slip-ups or errors in the reporting.

In line with the increasing number of primary care centres that have joined the Swedish Dementia Registry, there is also cause to consider rewarding registration in municipal organisations.

Data quality assurance needs to be enhanced

In previous progress reports, Statskontoret has highlighted deficiencies in the quality assurance of the data reported to the quality registries. The quality assurance has improved this year, but the procedures are still relatively poor. The selection of the data that is reviewed is seldom conducted systematically and is not based on a risk analysis.

Statskontoret is also of the opinion that there needs to be a higher level of quality assurance for the data in the output data portal created to monitor the indicator outcomes. There are various interpretations and definitions of key terms in the portal, which reduces the level of comparability. In the long-term, there is a risk of these deficiencies undermining the legitimacy of the intervention. Furthermore, the database is vulnerable as certain sections are looked after by one person.


In preparation of the next agreement, Statskontoret proposes that the government:

  • introduces a plan to phase out the support from central government and place requirements on the organisations to draw up action plans that ensure the retention of existing structures for improvement work,
  • ensure that the circle of people who have experience of administrating the output database is expanded, and that a function is established to assure the quality of data at a regular basis,
  • remove the avoidable in-patient care indicator from the payment system and instead aim to find structure or set of process indicators that highlight improvements in the work towards a more coordinated health and social care system,
  • phase out the funds provided for local analysis and instead provide funds for analyses that are conducted at the national level,
  • make payments to the quality registries conditional, in that the registry administrators must submit a plan indicating how they will be conducting risk-based quality assurance of the reported data over the course of the year,
  • in addition, link payments for Senior Alert and the Swedish Palliative Care Registry to the achievement of results,
  • link payments for both of the dementia registers more clearly to the use of the registers or, if possible, to the achievement of results, and
  • introduce payments in the Swedish Dementia Registry in those parts which concern municipal organisations.