Översyn av den offentligt drivna ögonsjukvården i Region Skåne - Avdelningen för produktionsstyrning

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Inklusive texten "An overview and evaluation of the eye health care in Scania" - Anja Tuulonen - August 21, 2012 Ingen sjukskterska, ingen lkare, ingen underskterska, ingen sktare, ingen kurator, ingen anstlld verhuvudtaget har ftt ta del av texten innan den tvingades igenom av Koncernkontoret, Region Skne.


KoncernkontoretAvdelningen fr produktionsstyrningKarin Ekelund Ledningsstrateg 040 67 53032 karin.i.ekelund@skane.se 2012-08-281 (1)


versyn av den offentligt drivna gonsjukvrden i Region SkneP uppdrag av produktionsdirektr Lars Kristensson har en versyn av den offentligt drivna gonsjukvrden i Region Skne genomfrts. Bakgrunden till versynen har bland annat varit infrandet av vrdval inom kataraktverksamheten samt det planerade infrandet av vrdval inom den ppna gonspecialistvrden. Medicinskt ansvarig fr utredningen har varit professor Anja Tuulonen, Tammerfors, Finland. Bifogat terfinns professor Tuulonens rapport, An overview and evaluation of the eye health care i Scania; Innehll An overview and evaluation of the eye health care in Scania, sid 1-26 Tables 1-5, sid 27-31 Tables 6, Summary of recommendations, sid 32-34 Appendix 2, Summary of Scania statistics, sid 35-60 Appendix 3, Visited eye care units and discussions, sid 61-62 Appendix 4, Documents delivered during the evaluation, sid 63-64

Postadress: Besksadress: Region Skne, Dockplatsen 26, 211 19 Malm Telefon (vxel): 040 - 675 30 00 Internet: www.skane.se

Organisationsnummer: 23 21 00-0255



An overview and evaluation of the eye health care in Scania

Professor Anja Tuulonen Director of Tays Eye Centre Tampere University Hospital

August 21, 2012

PO Box 2000 FIN-33521 Finland anja.tuulonen@pshp.fi




Contents 1. The assignment - Background of challenges with excerpts from the literature. What is known about: 1.1. The need and demand of services and available resources 1.2. Access to care, waiting lists, variations and outcomes 1.3. Hospital mergers 1.4. Helping successful people to change 2. The structure and basis of the present overview and evaluation 3. Observations and perceptions 3.1. The reliability of the 2007-2011 statistics on production 3.2. Production of Scanian eye health care in 2011 3.2.1. Overall production 3.2.2. Observations and perceptions in some eye diseases 3.2.3. Regional variation 3.2.4. Trends in 2007-2011 4. Care Guarantee and Choice of Care in cataract surgery vs. chronic eye diseases 4.1. Cataract surgery 4.2. Is the current prioritization equitable? 4.3. Side-effects of Care Guarantee and Choice of Care 5. Personnel 6. Merger between Malm and Lund University Hospitals 7. Management and optimal size of a hospital 8. Economical aspects 9. Premises 10. Research and education 11. Organizational scenarios with their advantages and disadvantages 11.1. Keeping Scanian health care structure as it is 11.2. Scanian Eye Hospital 11.3. The middle way (from either-or to both-and) 12. Shared care 13. Suggestion for next steps (prescription) to improve Scanian eye care 13.1. Recommendations on care processes (independent of the organizations) 13.2. Organizational structure 13.3. Leadership 13.4. Preferred kick off 14. Conclusions 15. References Enclosures Tables 1-6 Appendices 1-4 2

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1. The assignment - Background of challenges with excepts of the literature The purpose of this brief 2-week evaluation was to create a big picture of the current Scanian eye health care as well as make some holistic and itemized recommendations to be considered in decision making when solving the current and future challenges. Two major Swedish policies to improve access to care and shorten waiting times have been implemented recently: the up-dated Care Guarantee (2005) and Choice of Care (2012). The Care Guarantee confirms that the patient gets the required evaluation and treatment (when it fulfils the national criteria) within a defined period of time. In Choice of Care the money follows the patient who can choose the unit for examination and treatment. The merger of the two university hospitals in Malm and Lund into Scanian University Hospital (SUS) represents a major local attempt to improve health care. 1.1. What is known about the need and demand of services and available resources

In spite of the fact that the developed countries more than ever before - spend money and offer services to their citizens (who feel healthier and live longer than ever), the rate of growth in demand of services surpasses the resources societies are able to invest in health care. Although all countries agree that their health care costs are growing too large and too fast, including the US (Sommer 2009), the major cost drivers for rising health care expenditure has been debated for decades (e.g. new technologies, aging, professionals, organizations etc). In 1940-1990 technological change was argued to be the most important driver for increased expenditure in health care (Newhouse 1992). In spite of the fact that a lot of (un)necessary costs raise from the adoption of inappropriate interventions and technology (Sommer 2009) nowadays also from massive IT-technology - Getzen claimed that in 1960-88 political and professional choices were far more important in explaining the increase in spending - also when compared to aging (Getzen 1992). In agreement, aging alone induced only 1% increase in the yearly costs of Finnish eye care a decade ago (1/8 of the total increase of costs) (Tuulonen 2009). If professionals and organizations adopt interventions that are not costeffective, they not only increase demand, needs and expenditures of the services but simultaneously enhance the perception of underfunding (Maynard 2001, Muir Gray 2001). E.g. the increase in physician services has been reported to associate more with supply than demand factors (Keskimki 2001). Thus, health care has a supply-led nature: the more services are produced, the larger is the demand. By making it seem as if cost increases are inevitable for any external force which are regarded as being beyond our responsibility (e.g. aging and developing technology), attention is diverted from the real and difficult choices that we must make when producing services equitably, equally, effectively and efficiently (Evans 2004). Thus, regardless of what might be the most important cost driver, we cannot escape that the problem is us (Getzen 1992), i.e. the effects of structures and policies in the health care systems we have constructed. In countries with national health services, public hospitals provide services with fees below actual costs to the citizens (the public sectors stakeholders). With the resources our 3



societies have decided to allocate to health care, the systems try to promote well-being and protect citizens by reducing premature death - and taxes (Maynard 2004). In our different roles of the society, as tax payers, patients, different professionals, and decision makers in all levels, we also share the responsibility for problems generated by our system and need become part of the solution. Further development and adoption of new and usually more expensive diagnostic, administrative and IT technologies and treatments will create even further demand for explicit priority setting. 1.2. What is known about access to care, waiting lists, variations and outcomes

In spite of the fact that growth is the major feature of modern medicine, the cure is still believed to be more services and more money. Most people also assume that more medical care must lead to improved health and well-being. However, adding more resources may also have counterintuitive effects (Fisher & Welch 1999). Despite 60 % more services and higher spending in one US region, there was no difference in patients access to care, satisfaction, quality of care, or outcomes compared to a lower spending area. The study concluded that 30% savings could be possible in the US without comprising the quality of health care (Fisher et al. 2003a and b). In every-day practice, the challenge lies in the trade-off between the simultaneous over-consumption of care and too little care. The challenges are similar in countries with national health services, like the Nordic countries and Great Britain. Hospital waiting lists, far larger than needed to schedule patients, have been a persistent phenomenon, e.g. in Great Britain at least since 1948 as well as many other European countries (Finland, Norway and Spain) (Table 1). In addition to patients who have succeeded to get to the waiting lists, our health care systems do not find all patients suffering from diseases. As one example of simultaneous under- and over-care, half of glaucoma patients are not aware about their disease while simultaneously up to half of patients are treated for risk of glaucoma without any abnormalities (Vaahtoranta-Lehtonen et al 2007). According to literature, neither health care professionals, health economists, managers nor politicians have succeeded to manage the long waiting-times efficiently (Maynard 2001, Table 1) - nor other significant problems in health care, such as huge medical practice variations and access to care in different regions (not explained by differences in case mix), differences in health between different groups, medical errors, patient outcomes and cost-effective care. Thus, despite increased investments in health services research and managerial efforts, health care delivery is still characterized by problems that have been known and unresolved for decades (Evans 2004, Maynard 2004) Regardless how the health services are structured and financed, the physicians millions of decisions on individual patients determine both the patterns and costs of care. It is, particularly, the cumulative effect of small changes to clinical practice (e.g. adding a new diagnostic test or therapy) that has massive impact on health care budgets (Muir Gray 2001). The challenge is how to adjust the joint out