Centralising Care with the Patient in the Centre
This report aims to evaluate and analyse how level structuring in national specialised medical care has taken into account the patient’s perspective in inquiries, decisions, processes and organisation. It also aims to identify how the patient’s perspective may gain greater impact in the future.
BACKGROUND AND PURPOSE OF THE ASSESSMENT
Since 1 January 2010, all county councils have had a statutory duty to allow their residents to choose their primary care provider. According to the preparatory work done, the purpose of healthcare choice is to increase patients’ freedom of choice and to facilitate the establishment of more providers. In Swedish government bill 2008/09:74, it is also stated that an increase in freedom of choice can help to stimulate quality development. The logic behind this is that patients are expected to seek the medical centre that offers the highest quality, which is expected to create competitiveness that in turn will spur the healthcare players into improving with regard to quality and accessibility.
A prerequisite for the public being able to choose their medical centre is that they need to know that there is an option to choose, how to choose, what providers are available, and what the differences are between them. A shortage of information can have an adverse effect on the opportunities to choose a provider. One consequence of this can be that the possible effects of freedom of choice and competition are lost.
According to Chapter 9 Section 1 of the Swedish Act on Systems of Choice in the Public Sector (2008:962), the county councils must provide information on all contracted providers. By law, the information must be objective, relevant, comparable, easy to understand and easily accessible. In Section 2(b) of the Swedish Health and Medical Services Act (1982:763), it is stated that patients must be given individually tailored information on the options for choosing a provider.
This study illustrates whether or not the information on healthcare choice currently provided is fit for purpose from a patient and citizen’s point of view. It does this by examining what information the public considers it needs in order to make choices, and whether or not people are finding that the information currently provided is meeting these needs. The purpose of the assessment is to help improve the information that is under development in order to support individuals’ choice of primary care provider. The assessment illustrates the following three issues:
1. To what extent does the public consider the lack of information to be an overall barrier to choosing a medical centre?
2. What information does the public consider it needs in order to choose a medical centre, and is the public finding the information it is seeking?
3. To what extent does the public feel that healthcare choice information is being presented in a user-friendly and confidence-inspiring way?
IMPLEMENTATION OF THE ASSESSMENT
The assessment of healthcare choice information has been carried out in three stages. In the first stage, a literature study was carried out into the public’s use of healthcare choice information, as well as into the public’s wishes with regard to the content, design and provider of the information. Based on the literature, an initial framework was designed for the evaluation of the information’s fitness for purpose. In the second stage, the framework – which was largely based on international studies – was broadened and tailored to a Swedish context. This tailoring of the framework was carried out on the basis of interviews and a workshop of people with experience of healthcare choice, as well as using interviews with experts in healthcare choice information, decision-making and information technology. In the third and final stage, a questionnaire was designed on the basis of the framework aimed at a representative sample of people aged 18 years and over. The questionnaire aimed to illustrate the public’s need for, and perception of, the information on healthcare choice currently provided. A total of 3,354 respondents were included in the questionnaire study.
In the analysis, the respondents have been divided into three groups: those who have changed medical centre (the “changers”), those who have considered changing (the “undecided”) and those who have neither changed nor considered changing (the “non-changers”). Previous research has shown that people often have difficulty describing their need for information when they have never had occasion to search for it, let alone make use of it. A fundamental methodological assumption in the study is therefore that the changers and the undecided are the most interesting groups for study.
The assessment framework includes five dimensions for the demonstration of the fitness for purpose of information on healthcare choice.
1. Definition of well-informed and good choices
This describes the purpose of the information on healthcare choice from a patient and citizen perspective.
2. Reasons not to choose or change medical centre
This describes to what extent a lack of information constitutes an overall barrier to choosing a medical centre or changing medical centre.
3. Content of the information on healthcare choice
This describes the various aspects of information that may be important in choosing a medical centre.
4. Provider, accessibility and up-to-date status of information on healthcare choice
This describes examples of various players that may be responsible for sending the information, and how the information on healthcare choice can be presented so that it is accessible and confidence-inspiring.
5. The individual’s background factors
This describes the background factors that may affect various individuals’ need for information on healthcare choice.
RESULTS AND CONCLUSIONS
- A large majority would like to choose and know that they can choose
The results show that an overwhelming majority of the public – 76 per cent – regard being able to choose their medical centre as important. A total of 95 per cent also know that they are able to choose, while 24 per cent have changed medical centre in the past three years. Eleven per cent have considered changing medical centre during the past year. At the same time, 64 per cent have neither changed nor considered changing. This group is also largely satisfied with their medical centre. Of the 24 per cent who have changed medical centre, barely half state that they did so as a result of moving house. Of the 24 per cent who changed medical centre, 19 per cent indicate that they did so because they were unhappy with their previous medical centre and 12 per cent because another medical centre appeared to be better.
- The public search for information only to a small extent before choosing a medical centre
Of those who have changed or who are considering changing medical centre, 14 per cent and 6 per cent, respectively, have searched for information to a very large or a large extent. Around one third indicate that they have not searched for information at all. In other words, relatively few people actively search for information. The results show that self-initiated changes appear to be associated with more active searching for information than are changes caused by external circumstances. For example, more of those who have changed medical centre due to dissatisfaction have indicated that they searched for information than is the case with people who changed because of moving home.
- A small proportion express clear dissatisfaction with the information
Around 50 per cent of those who have changed medical centre are satisfied with the information, while only 9 per cent are dissatisfied. Of those considering changing, 24 per cent are satisfied, while 12 per cent are dissatisfied with the information. Half of the changers, and a majority of the undecided, are neither satisfied nor dissatisfied, or have no opinion on the information.
- A lack of information of healthcare choice is one of several barriers to changing medical centre
Although the expressed level of dissatisfaction at the existing information is low, around one third of all respondents indicate that they do not change medical centre because they lack sufficient information about other medical centres. Those considering changing medical centre (the undecided) indicate to the largest extent that the absence of information is one reason why they do not change. This group is also dissatisfied to the greatest extent with their current medical centre.
At the same time, the respondents indicate other important reasons not to change. Among other things, around a third state that they are tired of all the choices that have to be made in society, as well as the fact that it is difficult starting afresh at a new medical centre. Around a fifth indicate that it takes too long to change, or that there is no other medical centre in the area to change to. In overall terms, the results indicate that the accessibility of information should be seen as one of a number of deciding factors that affect people’s opportunities and motivation to choose a medical centre. The results also show that the process of choosing or changing medical centre involves certain significant transaction costs to the individual.
- The barriers to changing medical centre vary among county councils
There are differences from one county council to the next in the reasons why respondents do not change medical centre. For example, in Dalarna and Jämtland one in three people state that they do not change as there is no other medical centre to which they can change. In Kronoberg, Stockholm and Västra Götaland, the number stating this as a reason not to change is less than 20 per cent. In Kronoberg and Gotland, 27 per cent indicate that they lack sufficient information to change medical centre, while in Västmanland and Kalmar this is cited as a reason by around 40 per cent. The reasons for the differences in the latter case are uncertain. One interpretation may be that the county councils have presented different information, and also worked in different ways to communicate the information. Another interpretation may be that the residents in the various county council areas have different expectations as far as the information is concerned.
- The public finds most of the information that it searches for
A relatively large proportion of respondents who have changed or considered changing medical centre have found the information searched for. The results show that 51 per cent have searched for information about the geographical location of the medical centres and that around 40 per cent have searched for what options are available to choose from and what needs to be done in order to change. Opening hours are an item of information that a relatively large number have searched for. The respondents have searched only to a small extent for information on the physical accessibility of the medical centres, whether or not they have special units, and the medical results of the centres. A large proportion of those who have searched for this information have not found it.
The results may be due in part to the fact that the major part of the population has no great need of healthcare at any given time. It is conceivable that those who have no current need for healthcare services set the greatest store by where the medical centre is located and what alternatives are available. It may be expected that the smaller proportion of the population that has a greater and more immediate need of healthcare has a greater interest in receiving more specific information on, for example, medical results and the range of services provided by the medical centre. Another possible interpretation is that the search for information has been governed by whatever information has been available.
- There is a certain demand for information that is not currently available
Although the respondents in the study have largely found the information searched for, the results point to there being information about the medical centres that is missing. This applies, for example, to information describing the hygiene and cleanliness of the medical centre, the opportunities to see the same doctor, and the ability of the medical centre to coordinate the patient’s various healthcare contacts. Waiting times are another aspect of information that the public seems to regard as important. Despite relatively good access to information on accessibility, a relatively large proportion of respondents who have searched for such information indicated that they had not found it.
- The information does not meet the statutory requirements
According to Chapter 9 Section 1 of the Swedish Act on Systems of Choice in the Public Sector (2008:962), the information must be objective, relevant, comparable, easy to understand and easily accessible. The results show that around 60 per cent of those who have changed medical centre consider the information to be easy to take in, relevant and correct. Around 50 per cent of this group also considered the information to be up-to-date. Those considering changing medical centre have less of a view as to the structure and relevance of the information. Neither those who have changed medical centre nor those considering changing agree that the information was comparable. Only 21 per cent indicated that they were able to compare to a large extent the differences and similarities between the medical centres. The results are remarkable in that this is a clearly indicated requirement in the legislation.
- Close friends and relatives and the county councils provide the greatest degree of confidence as providers of information on healthcare choice
Family and friends, the medical centres and the county councils’ websites are important sources of information on healthcare choice. The majority of people have turned to these for information and they enjoy a high degree of confidence among the public. Most respondents state that they would like to obtain information about the medical centres, and how to change medical centre, from the county councils’ websites, even though they have not turned to these to any great extent currently. It is stated in law that the county councils have a duty of responsibility for the information. The great confidence in the information provided by the county councils, as shown in the results, also shows that this is a good arrangement from the public’s point of view. The website 1177.se is owned jointly by the county councils and also acts as the platform on which a large part of the comparative information on the medical centres is currently presented. At the same time, the results show that this source is less well known and engenders a lower level of confidence than do the county councils’ own websites. One interpretation for this is that it is unclear to the public that the county councils are behind 1177.se.
- The public’s choice of medical centre may primarily have an influence on accessibility and how they are dealt with
Few people in the main have searched for information before choosing a medical centre. Insofar as the respondents have searched for information, they have for the most part sought information about the geographical proximity of the medical centres, which centres are available to choose from, and how to change medical centre. The majority have based their choice on the proximity of the medical centre, the way in which they are treated by staff, and the waiting times. To a lesser extent, the respondents have searched for information and based their choice on the medical results and treatment options available at the medical centre. One explanation may be that the public assumes that there are no differences in quality in medical terms, and that this is not a decisive factor, therefore, when choosing a medical centre. Another explanation why medical quality has not generally been a deciding factor for respondents may be that the information is sparse and probably of greatest interest to small target groups with greater healthcare needs. This is one of the reasons behind the need for in-depth analyses of information on healthcare choice based on the requirements of various groups. The results indicate that the public’s choice based on current information can primarily have an influence on factors such as accessibility and how they are dealt with. It is important, therefore, that the county councils – whatever the extent to which public choices drive forward developments in quality – do not surrender their responsibilities for continuously monitoring and securing the overall quality of the operations.
Recommendations to the county councils:
- The county councils should ensure that they meet their obligations to provide the public with information on healthcare choice
The results show that the county councils are not fulfilling their statutory requirements to make the information relevant, comparable, easy to understand and easily accessible. In order to comply with legislation, the county councils must therefore improve the information in each of these respects. There are deficiencies in particular in respect of the requirement for comparability. The assessment shows that only 21 per cent of the respondents who have searched for information considered that they were able to a very large or a large extent to compare the differences and similarities between medical centres. If the choices of medical centre made by the public are to drive forward competitiveness and quality development, one requirement will be for comparable information to be available regarding the various quality dimensions. As already mentioned, the legislation also imposes requirements for the provision of comparable information. If the overall aim of the legislation is to be achieved, it is important to develop and make available information for comparison purposes.
At the same time, developments in information on healthcare based on statutory requirements should be tailored according to the needs of the public. Based on the results, it is difficult to comment on the extent to which improved information will be used in practice. On the one hand, the results show that many people are satisfied with the existing information on healthcare choice and that those who have elected to choose are searching for information to only a small extent. On the other hand, the public is saying that it lacks important information. This applies to continuity and waiting times, among other things. It is also possible that improved information on healthcare may, in the long term, drive a change in user behaviour. For this reason, the county councils should – on the basis of the statutory requirements – generally develop the information on the basis of balancing the cost against the expected benefit in the short and the long terms.
- The county councils should make their role as providers clearer and further develop the information channels
It can be seen from the assessment both that the public has a high level of confidence in the county councils as a source of information and that it wants the county councils to be a player that satisfies the need for information on healthcare choice. 1177.se is one of the county councils’ principal channels for communicating information on healthcare choice. The results show, however, that respondents neither know about this nor have the same high level of confidence in this website as they do in the websites of the county councils. The county councils should therefore make it clear that they are responsible for providing information on healthcare choice and should communicate the information via sources with which the public is familiar and where the public wishes to study it. This can help to further increase the use of, and confidence in, the information.
Recommendations to the Swedish Government:
- The Government should be careful to ensure that developments move towards improved information on healthcare choice
The Swedish Act on Systems of Choice in the Public Sector requires the county councils to take responsibility for providing objective, relevant, comparable, easy to understand and easily accessible information about all contracted providers. From the assessment, it can be seen that the public does not fully consider that the information meets these requirements; nor does the public consider it has enough information to make a choice. There are also differences among county councils in respect of the public’s perceived access to information. The Government has an important role in supporting and monitoring the implementation of the reform in various ways. They should therefore be careful to ensure that developments move towards improved information on healthcare choice.