NHS European Office

Is Sweden’s model of integrated care a beacon of light for the NHS? | Elisabetta Zanon

older man looking out of the window

The Five Year Forward View sets out how the health service needs to change. Central to its vision is overcoming the traditional divide between primary, community and hospital services, which is increasingly acting as a barrier to the personalised and coordinated healthcare patients need. 

The document outlines a number of new models of care that could help local health communities dissolve these traditional boundaries and move towards a more integrated, patient-centred and sustainable delivery of care. 

As one of the most unified health systems in the world, developing new models of care isn’t something that necessarily comes easily to the NHS. Thankfully though, the Forward View acknowledges that some of these new models have already been tried out or developed in other countries, and that there is much NHS leaders could gain from looking at successful international experiences. 

One of the models referenced in the document is ‘chains of care’, which has been implemented in Sweden over the past 15 years. It focuses on two elements: patient-centredness and shifting care out of hospitals by strengthening the development of primary and preventive care; and reducing variations of quality of care across the country.

The concept of ‘chains of care’ relies on a strong focus on patient needs and the use of evidence-based care pathways. In practice, it means that care is delivered by a variety of providers through a multi-disciplinary team approach, crossing the traditional boundaries between providers.

While the founding principles of the model are the same across the country, different county councils in Sweden have implemented it in different ways across their local geographies, achieving different results. 

One of the most successful experiences is that of Jönköping County Council, in the south of Sweden. The county has 34 primary care centres and three acute hospitals, with a total health workforce of 9,500, serving a local population of 350,000 across 11 municipalities. 

A key element of the reform programme in Jönköping was the acknowledgment that a major cultural change was needed to move from a provider-centred approach to a patient-centred one. A multi-disciplinary team composed of physicians, nurses, social workers and other professionals from the range of local providers, was set up to look at how care for chronic disease patients could be improved. 

The team conducted more than 60 interviews with patients and providers from across the system. Interestingly, the team worked on the case of a theoretical patient, whom they called ‘Esther’ – an elderly woman with complex health needs – looking at practical ways of improving patient flow and coordination of care through the complex network of providers. Check out the short video, below, on the Esther project.

This exercise provided an excellent starting point for identifying and working on improvements in the way patients flow through the care system. A lot of work was done to align capacity with demand and to strengthen coordination and communication among providers. Examples of changes made include: 

  • a redesigned intake and transfer process across the continuum of care
  • open-access scheduling
  • team-based telephone consultation
  • integrated documentation and communication processes
  • and an explicit strategy to educate patients in self-management skills.

The ‘Esther Project’ proved inspirational for the team, which was pushed to focus specifically on the patient and her needs. Mats Bojestig, the chief of the Department of Medicine at Höglandet Hospital and one of the developers of the project, said this: "It is very important that we called this work ‘Esther’. It helped us focus on the patient and her needs. We can each imagine our own 'Esther.' And we can ask ourselves in our work, what is best for Esther?”.

The initiative led to significant improvements towards seamless patient care, by overcoming fragmentation between providers of primary, hospital, home and social care. This resulted in impressive improvements over a three-to five-year period, including:

  • an overall reduction in hospital admissions by over 20 per cent (9,300 to 7,300) and a redeployment of resources to the community
  • a reduction in hospital days for heart failure by 30 per cent (from 3,500 days per year to 2,500) 
  • a reduction by more than 30 days of wait times for referral appointments with specialists, such as neurologists. 
This is an exemplary case of how leadership and a new working culture has led to health system transformation, with significant benefits for patients, while at the same time allowing improvements in efficiency. The success of the project led several other county councils across Sweden to work in a similar way.

The reputation of this initiative has crossed the Swedish border, with the model gaining international recognition for its success in making and sustaining large-scale improvements in healthcare. At a time when the NHS is looking at new models of healthcare delivery, I am convinced that this experience can offer inspiration to NHS leaders looking for successful examples of healthcare system transformation.

Elisabetta Zanon is director of the NHS European Office, a part of the NHS Confederation. Follow the organisation on Twitter @NHSConfed_EU.

Dig deeper

Anna Carlbom, medical office nurse and Esther coordinator visited London in April 2015 to talk about Jönköping’s Esther model to a range of health and care colleagues. Here she speaks to the NHS European Office about the Esther project.

Find out more about the Esther model and contact anna.carlbom@tranas.se to register to receive the Esther international newsletter.

Want to know more about international models of care?

Read Elisabetta’s post on the Alzira model, a Spanish model of care that offers great lessons for the NHS: The Alzira model gives us a great deal to think about.

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