Sweden is one of the countries of the OECD with the highest number of doctors per thousand inhabitants. At the same time that Sweden is well supplied with doctors, the number of appointments with a doctor per inhabitant and year is significantly lower than the average within the OECD. Despite this, Sweden stands out in international comparative studies as one of the countries with the worst results in terms of the perception of how much time patients and doctors spend together. For example, over half of the patients in Sweden maintain that the doctor did not spend enough time with them when they sought medical care or treatment, and just over half of the general practitioners in Sweden express dissatisfaction with the amount of time they spend on each patient. The results indicate that there is potential for improvement in terms of how doctors’ time is spent in the healthcare and medical care services.
Given that demand for healthcare and medical care efforts will increase in the coming years, due in part to the increasing life expectancy of the population and improved methods for the diagnosis and treatment of illnesses, the effective use of doctors’ resources is central if we are to offer citizens a high standard of medical care.
The debate about how to use doctors’ time and expertise correctly has been going on for a long time. The Swedish Agency for Health and Care Services Analysis (Vårdanalys) considers that there is a lack of any coherent analysis of the issue from a citizen’s perspective. Against this background, we have chosen to conduct a study with the aim of identifying the main areas for development for a more effective use of doctors’ time and expertise.
The study answers one overall question:
• What are the main challenges to bringing about a more effective use of doctors’ resources?
We will seek to answer the question through a national analysis based on extensive documentation. The study is unique in the sense that it is the first cohesive analysis conducted at national level by an independent player. The aim is for the results to form the basis for continued work, both regionally and nationally. The next stage is to identify and establish, on the basis of the results of the study, specific challenges within the county councils and then, at both regional and national level, to identify and prioritise among the different improvement measures.
METHOD AND IMPLEMENTATION
The study is based on a large amount of data, and we have used several different methods and data sources in order to illustrate the issue from various perspectives. We have used the following methods:
• Literature and document studies
• Interviews with twelve interested parties
• Interviews with eleven experts
• Interviews with 49 county council representatives
• Questionnaires involving various professional groups
In the study, we define an aspect of the efficiency concept in healthcare and medical care that is termed “clinical effectiveness”. Clinical effectiveness involves an assessment of the base units of healthcare, such as work at clinic and surgery level.
Assesses the healthcare effort itself. Are the results of treatment, medication, operations, etc., on the patient’s health in proportion to the cost? How many patients are affected by complications that it should be possible to avoid?
Assesses the base units of healthcare – the clinic or medical centre – as a production unit. Is the division of responsibility correct between the various professional categories? Is there suitable administrative support in place to ensure that the staff’s time is used in a rational way?
Assesses the coordination between the various parts of the healthcare chain – for example, between hospital care and primary care. Are patients being treated at the wrong healthcare level? Are the primary care services prepared for when patients leave the care of the hospital?
Assesses the organisational structure, geographical distribution, etc., of healthcare. Are there too many emergency hospitals? Is the balance correct between primary care, local healthcare and specialised hospital care? Are the county councils cooperating to optimum effect?
Assesses healthcare as a general system. Does the healthcare system have enough capacity to acquire new knowledge or renew and adapt its operations? Are the healthcare services fair? Does everyone have access to healthcare on equal conditions?
The definition means that the study does not include analyses, for example, of the collaboration among various parts of the healthcare chain (process effectiveness), the balance between primary care, local healthcare and specialised hospital care (structural effectiveness) or the capacity of the healthcare system in acquiring and transforming new knowledge and offering equality of healthcare (system effectiveness). However, effective use of doctors’ resources requires a high level of effectiveness in all three effectiveness dimensions.
The study was carried out during the period January–November 2013.
FOUR AREAS FOR DEVELOPMENT FOR A MORE EFFECTIVE USE OF DOCTORS’ RESOURCES
Vårdanalys considers that there is significant potential in using doctors’ time and expertise in a more effective manner than at present. We have identified four areas for development for a more effective use of doctors’ resources. A brief introduction to each area is given below.
Area for development 1, Prioritise among administrative requirements, describes the scope of the administrative work for doctors. This relates to requirements for measurement, reporting and monitoring as well as patient-related information.
Area for development 2, Improve IT support, describes how IT systems act as tools to help doctors with their work. Area for development 1 addresses the requirements for the administrative work, while area for development 2 illustrates the tools used for the work.
Area for development 3, Develop the division of work between the various professional groups, describes the distribution of work tasks between doctors and other staff.
Area for development 4, Optimise staffing on the basis of patients’ needs, describes how the planning of the staffing by doctors at clinical/medical centre level works in relation to the patients’ needs.
Vårdanalys would like to emphasise that the four areas for development are closely linked. This means that a change affecting one area for development also has the potential to affect one or more others.
AREA FOR DEVELOPMENT 1. Prioritise among administrative requirements
The development has been towards more stringent requirements on documentation and reporting, both at regional and national level. This has led to doctors spending a significant part of their working hours on administrative work. Previous studies show that, in many cases, administration accounts for around a third of working hours. However, there is great variation depending on the speciality and clinic/surgery. Doctors devoting more time to administrative work is often described as something negative and something that “steals time” from the patients. There is also no uniform definition of the term “administration”. A large portion of what is referred to in daily parlance as “administration” is work on patients that can neither be removed nor transferred to someone else. The fact that we now place more stringent requirements on documentation, metrics, reporting and monitoring has also led to greater knowledge of healthcare and medical care in terms of results, quality, equality, patient safety, etc. This is valuable information when working on the development of healthcare and medical care services. At the same time, there are aspects of administrative work than may be questionable. Vårdanalys takes the view that there is a need for prioritisation, where the value of certain administrative requirements is investigated and clarified.
Vårdanalys has identified two challenges:
- The value of a certain amount of the metrics, reporting and monitoring in relation to the work effort has been questioned
There has been an increase in the requirements for metrics, reporting and monitoring at both national and regional level. Many people question the extent of this work. On the other hand, there are few specific requirements for metrics, reporting and monitoring that are considered entirely unnecessary. Instead, it appears to be the sum of a large number of administrative requirements as a whole that causes people to question whether the value of the metrics, reporting and monitoring is in proportion to the work effort required. County council representatives also feel that some of the requirements are an expression of a mistrust of the medical profession rather than a means for learning and development.
- The value of a certain amount of the patient-related administration in relation to the work effort has been questioned
It is perceived that the requirements for patient-related documentation have increased, particularly as far as the contents of the patient’s medical records are concerned. The increasing requirement for information in the medical record is attributed to an increase in the work being done on quality, more stringent requirements on patient safety and traceability in the medical records, and more extensive requirements for information to the patients. Many people question the need for medical record notes to be signed and certificates retrieved, particularly medical certificates for the Swedish Social Insurance Agency. As well as doctors finding the requirements for patient-related administration to be extensive, it is also said that anxiety about being reported and about complaints are leading to excessive documentation in the notes. It is also the case that doctors and other healthcare staff, particularly nurses, document the same information in the patient records.
AREA FOR DEVELOPMENT 2: Improve IT support
The introduction of IT has had a major effect on the administrative work in the healthcare service, but it has not led to the streamlining of the work that many within the operation had hoped for. The IT environment in which doctors work does not provide full support to the work, and there is a general agreement that the IT support used is not tailored to the needs of users.
Vårdanalys has identified two challenges:
- Doctors are working using IT systems that are not felt to be user-friendly
It is felt that there is a lack of user-friendliness about the IT systems. The lack of user-friendliness of the patient note systems is criticised in particular. Specific failings include: a poor level of clarity, poor readability, difficulties finding a way through the various menus and tabs, the absence of search functions, uncertainty about the meaning of concepts and terms, and a poor level of intuitiveness. The information in the systems is not structured and presented in a manner that facilitates the work. Many describe the absence of a uniform use of terms and concepts, which makes it more difficult to search for information in the patient records.
- Doctors are working with many incompatible IT systems
Doctors use a number of different kinds of IT support, but there is felt to be a lack of compatibility among the systems. Having a number of parallel systems entails continually logging in and out. The fact that information is not always automatically transferred between the various systems has consequences in terms of efficiency, the working environment and patient safety.
AREA FOR DEVELOPMENT 3: Develop the division of work between the various professional groups
There is much evidence that the skills of doctors are not being used to the full extent. It also appears that many doctors carry out tasks at work that could be done by other professional groups without any loss of quality. The proportion of doctors using their highest level of expertise for the majority of their working hours fell between 1992 and 2010, and 36 per cent of doctors feel that they frequently, or very frequently, perform tasks at work that it should be possible for someone else, or another professional group, to do (8). In addition to this, nurses, auxiliary nurses, physiotherapists and medical secretaries also indicate that they should be able to take over some work tasks from doctors. Overall, there is the potential to review the division of work among the various professional groups in order to use the expertise of doctors and other staff in a more effective way
Vårdanalys has identified two challenges:
- Doctors carry out administrative tasks that other staff could take over
Doctors are nowadays performing administrative tasks that were previously taken care of by other professional groups. According to the county council representatives, many of the administrative tasks being carried out by doctors could be left to other staff while maintaining or even improving the quality. Other professional groups – primarily medical secretaries – consider that they can and should take over certain administrative tasks from doctors.
- Doctors perform medical care and treatment that other staff could take over
Doctors are performing medical care and treatment that the county council representatives consider could be taken over by other staff without any loss of quality. Other professional groups, too, feel that they should be able to take over certain aspects of medical care and treatment from doctors. This would allow doctors and other professional groups alike to use their time more effectively.
AREA FOR DEVELOPMENT 4: Optimise staffing on the basis of patients’ needs
If the medical care services are to meet the patients’ needs then the planning of medical care activities and the staffing by doctors and other personnel must be done on the basis of an analysis of patients’ needs. The majority of county councils carry out the work to plan and manage staff working hours, often under the concept “production and capacity planning”. The trend is a positive one, but in many places the work has been started recently and there is therefore a significant potential for development.
Vårdanalys has identified two challenges:
- The planning of doctors’ working hours is not based on the patients’ needs
The planning of doctors’ working hours is not always based on an analysis of the patients’ needs. In many places, there is a lack of any management of how the activities involved in medical care are planned in relation to how the operation is staffed. It can also be the case that the planning of the working hours of doctors and other professional groups is done separately, which leads to a lack of joint planning between doctors and other staff.
- The opportunities for effective planning are not being utilised under the current regulations and agreements
There is much to suggest that it is not obstacles in legislation or agreements that are inhibiting effective production planning. There are great opportunities to manage staffing within the existing frameworks, but the county councils do not always make use of these opportunities. The effect of the on-call agreement is disputed. Vårdanalys will not analyse the manner in which, and the extent to which, the structure and application of the on-duty agreement affects the opportunities for effective staffing.
RECOMMENDATIONS FOR THE CONTINUED WORK
The study shows that there is great potential for more effective use of doctors’ time and expertise within the four areas identified for development.
There is a strong perception among many doctors that administrative work has displaced the time available for meeting the patients. Previous studies have shown that doctors devote a significant proportion of their working hours to administration, though there are large variations among the different activities and specialities. The term “administration” has also been variously defined in the studies, thus making it difficult to draw any general conclusions about the actual time devoted to administrative tasks. Vårdanalys considers that the discussion about how much time should be devoted to administration must also include what type of administration is being carried out and whether or not it can be warranted in terms of running a good healthcare service. The alternative costs arising from the introduction of requirements that lead to administrative work must be taken into account. For the requirements considered both warranted and necessary, the work should be aimed at facilitating the processes by clarifying the procedures for the administrative work, reviewing the support systems that are in place, and examining the extent to which it is possible to transfer work tasks to other professional groups. Not only must the right work tasks be performed by staff with the correct level of expertise, it is important to ensure that staffing in the healthcare and medical care services is based on the patients’ needs.
The next stage of the work, on the basis of the results of the study, is to carry this knowledge forward by conducting analyses at regional and local level, starting with the areas for development and challenges identified in this study. This will identify the internal requirements within each county council. It will then be possible to identify and prioritise the various measures for improvement. At national level, it is important to identify and prioritise – on the basis of the areas for development and challenges identified – the various improvement measures in order to achieve a more effective use of the staff resources.
Vårdanalys has identified four main areas for development and challenges for a more effective use of doctors’ resources
The county councils should identify specific challenges at regional/local level, starting with the areas for development and challenges identified in the study
The county councils should identify and prioritise among the various improvement measures at regional/local level
The Government should identify and prioritise among the various improvement measures at national level, starting with the areas for development and challenges identified in the study
Vårdanalys would like to underline the importance of taking a holistic view of the continuing work. This holistic view is, on the one hand, about seeing the relationship between the four areas for development and, on the other, not limiting the work to doctors alone, as efficient healthcare and medical care means using all staff resources effectively. We have additionally identified areas for development in the dimension of clinical effectiveness, but we believe that this will also require initiatives from other effectiveness dimensions in order to achieve a more effective use of the time and expertise of doctors and other staff. It is also important to consider the time perspective and to analyse what is possible and what is a priority in the short, medium and long term. Finally, Vårdanalys would like to stress that it is important for doctors and other professional groups to become involved in the continuing work, as staff themselves have vital knowledge of how healthcare and medical care function and how they can be developed.
Vårdanalys recommends that the county councils take the work forward in two stages:
- On the basis of the areas for development and challenges identified in this study, the county councils should identify the most important challenges within their own organisation to the more effective use of staff resources.
There are major differences both among and within the county councils in terms of administrative requirements and procedures, IT support, the division of work tasks and the work being done on production and capacity planning. In the report, we provide a number of specific pieces of input to the continuing work of the county councils.
- The county councils should identify and prioritise the improvement measures at regional/local level that may help to achieve a more effective use of the staff resources.
The prioritisation of measures should be done on the basis of expected effect and the complexity of implementation. Some initiatives will probably need to be drawn up locally, while other measures are common to the whole county council.
Vårdanalys has one recommendation to the Swedish Government:
- The Government should, on the basis of the areas for development and challenges identified in this study, identify and prioritise the improvement measures at national level that may help to achieve a more effective use of the staff resources.
Any prioritisation of improvement measures must be based on a holistic view and an awareness of the mutual relationship between the various areas for development. In the same way, an analysis is required of the relationship between the national and regional level within each area for development. In carrying out this work, it is not unlikely that the county councils may identify improvement measures that will need to be addressed at national level. There should therefore be a continuous dialogue between the regional and the national level, thus making it easier for the county councils to raise the issue of improvement measures that require national initiatives where this is necessary. Finally, it is important to consider the time perspective and consider which challenges should be prioritised in the short, medium and long term. In the report, we have drawn up a number of questions that may help to provide valuable guidance to the work on identifying conceivable improvement measures at national level.
The Government has decided to appoint a national coordinator for more effective use of resources in the healthcare and medical care services once this study is complete. This study may be regarded as a possible starting point for the work of the national coordinator.
The Swedish healthcare and medical care services are facing major challenges and the need for healthcare initiatives will increase. If the demands are to be met, the healthcare services need to succeed in attracting, recruiting, developing and retaining committed and skilled staff. Good working conditions are a prerequisite for this. This includes allowing doctors and other staff to use their expertise fully. They should not be devoting their time to aspects of work that are quite simply unnecessary or that should be carried out by a different professional group. A more effective use of the time and expertise of doctors and other staff may therefore lead to more attractive working conditions and generally create the conditions needed to cope with the challenges being faced by the healthcare and medical care services.