Resolving health care's difficult choices : survey of priority setting in Sweden and an analysis of principles and guidelines on priorities in health care

This project report is the product of an extensive survey and analysis by Sweden’s National Centre for Priority Setting in Health Care. The project was commissioned by the National Board of Health and Welfare, which shall report to the Swedish Government on the priority setting activities of local governments (eg, county councils and municipalities) and assess how well they comply with the intent of Sweden’s Health and Medical Services Act and the Riksdag’s (Swedish parliament) resolutions on priority setting. We were also assigned to analyse problems in applying the guidelines on priority setting and to propose changes and clarification. The National Centre for Priority Setting in Health Care has been engaged in the complexities of prioritisation issues for many years. We welcomed the Government’s initiative and gladly accepted this assignment. Our ambition has been to describe the situation throughout Sweden from multiple perspectives. We reviewed the literature on studies and follow-ups related to the Riksdag’s guidelines. In studying the experiences of local governments in establishing healthcare priorities we focused on county council leaders, but complemented the study by interviewing representatives of major personnel categories. We also interviewed a smaller sample representing Swedish municipalities. Based on over 150 interviews, we describe current activities, plans for priority setting, and perceptions towards the current guidelines. Karin Bäckman served as coordinator for this part of the project. Other contributors from the National Centre for Priority Setting in Health Care included: Mari Broqvist, Per Carlsson, Peter Garpenby, Catrine Jacobsson, Per Johansson, Erling Karlsson, Sven Larsson, Karin Lund, Per-Erik Liss, and Ann-Charlotte Nedlund. In addition to the interview study, and under the leadership of Per-Erik Liss of the National Centre for Priority Setting in Health Care, we conducted an ethical analysis of principles and guidelines in priority setting. Anders Melin reviewed international ethical guidelines and principles in priority setting. A separate chapter presents a summary of this work. The ethical analysis also includes proposals for improvement, eg, reinterpretation and description of the ethical principles in the current platform, the addition of another ethical principle, and suggestions concerning the role of health services. Preliminary versions of the analysis were discussed at seminars with ethicists and individuals experienced in transparent priority setting and representing the National Board of Health and Welfare, the Pharmaceutical Benefits Board, the Swedish Association of Health Professionals, the Swedish Association of Registered Physiotherapists, the Swedish Federation of Occupational Therapists, and the Swedish Medical Association. Katrin Lindroth conducted literature reviews and edited the report. Elisabeth Furberg, Gustav Tinghög, Niklas Ekerstad, and Peter Wahlberg from the National Centre for Priority Setting in Health Care also contributed valuable perspectives. Appendix 3 presents the staff of the National Centre for Priority Setting in Health Care. Preliminary versions were discussed with the Board of Directors of the National Centre for Priority Setting in Health Care, who offered many constructive viewpoints. I would like to express my sincere appreciation to all who contributed valuable input and perspectives throughout the process. It is my hope that our collective effort will lead to improvement in regulations and work methods and will generate greater understanding for the importance of transparent priority setting in health care. Linköping, Sweden March 2007 Professor Per Carlsson Director of the National Centre for Priority Setting in Health Car