News article
Hot potato in the healthcare sector
Poor collaboration between healthcare and social services causes unnecessary suffering for the most vulnerable patient groups. The so-called Collaboration Act was supposed to solve this problem, but responsibility remains unclear. “It becomes a hot potato logic,” says Ulrika Winblad, who has researched the implementation of the law.
What happens when an elderly person breaks a femur and is ready to go home after a few days in the hospital? First, the home may need adjustments: a raised toilet seat, perhaps a chair in the shower, and other assistive devices. Medications need to be procured.
– There are many assistive devices that need to be arranged; in some cases, it can be as simple as someone needing to come and unlock the door, says Ulrika Winblad, Professor of Health and Healthcare Research at Uppsala University.
Individually, these are simple but necessary measures. Taken together, however, they form a complex puzzle that must be solved to ensure patient safety and a manageable work situation for staff.
– It is very stressful for staff if, for example, a medication list is not available, Ulrika adds.
Primary care lacks the means to coordinate
In a Forte-funded project with three sub-studies, she and her colleagues Paula Blomqvist, Douglas Spangler, and Wilhelm Linder have investigated how collaboration works in Swedish healthcare.
The starting point is a new Collaboration Act from 2018, which requires that each patient needing services from both healthcare and social services should have a coordinated individual plan, abbreviated SIP. According to the law, primary care should “hold the baton,” as Ulrika puts it, and initiate SIP meetings.
– We see major shortcomings in implementing this part of the law, but understanding the exact reasons is difficult. In interviews with staff, we found that knowledge and willingness exist, but primary care still does not take the coordinating role the reform requires.
– I believe this is because they are accustomed primarily to outpatient work. To manage coordination, they would need to work more proactively and even hold SIP meetings in patients’ homes, she explains.
This does not happen due to understaffing, unclear collaboration agreements, and a lack of financial incentives to cooperate.
– Collaboration agreements are often poorly designed. They do not clearly specify what should be done or how collaboration should proceed, says Ulrika.
There are many assistive devices that need to be arranged; in some cases, it can be as simple as someone needing to come and unlock the door.
Ulrika Winblad
Professor of Health and Healthcare Research, Uppsala University
Sweden stands out – despite a top-notch welfare system
She describes the situation as three circles: one for the region, one for the municipality, and a third for the collaboration that should connect the two.
– The problem is that the collaboration part has no budget, so it becomes a hot potato logic where no one wants to take responsibility for coordination.
Despite good intentions and one of the world’s most advanced welfare systems, Sweden stands out as a country where collaboration often fails.
– Many countries struggle with collaboration; it’s not just Sweden. But the problems are bigger here because we have a different administrative model, Ulrika explains.
While healthcare is primarily the responsibility of the regions, municipalities are responsible for care services, such as home care.
– The division of responsibility between municipalities and regions makes collaboration problematic. A large region like Västra Götaland, for example, must coordinate with 49 municipalities. Privatization has further fragmented healthcare and social services – the more actors, the harder it is to collaborate.
The diversity of actors increases the risk that individuals fall through the cracks. Another organizational obstacle in the Swedish model is privacy regulations, which prevent healthcare providers in different organizations from accessing each other’s records.
Fragmentation affects both young and old
In her research, Ulrika has focused on older patients with multiple illnesses, but they are not the only group affected by the decentralized and fragmented Swedish welfare model.
– Other affected groups include young people with mental health problems. School refusers, that is, children and youth not attending school, are hit hard by collaboration issues when responsibility is spread across schools, social services, and psychiatry.
Part of the problem, highlighted in Ulrika’s research, is that project follow-ups often fail and that national statistics on collaboration are lacking. She has therefore had to rely on secondary sources, such as regions’ and municipalities’ own audit reports, to get an overview of the situation.
There are currently no figures on the societal cost of poor collaboration in healthcare, beyond the individual suffering.
– I am convinced it is a significant cost to the system when patients fall through the cracks.
Collaboration requires more than goodwill
Despite the extensive problems, Ulrika is “cautiously optimistic” that things can improve. She sees willingness among both staff and politicians.
Many of the difficult issues she has highlighted in her research are also highly relevant in the ongoing reform to person-centered care.
– Collaboration is a key factor in person-centered care. The problem is that collaboration is a soft value – much stricter governance and structured cooperation are needed.
Rakel Lennartsson (English translation by Forte)
