The cost of healthcare has increased substantially since the start of the new millennium. A limit must eventually be reached. There are, quite simply, not enough money, personnel or care places for everybody. This has led to an increase in interest for ethically difficult questions in recent years. Which patient groups are to be given priority, and which ones not?
The National Centre for Priority Setting in Health Care at Linköping University conducts research into questions related to difficult choices of priority in healthcare. The centre is a Swedish resource and was established at the start of the new millennium. It spreads knowledge about setting priorities within the health and social care sectors, and supports decision-makers within Swedish government agencies, regions and municipalities.
Lars Sandman. Photo credit Charlotte Perhammar“It is now medically possible to help increasing numbers of patients, but the resources required to provide all the care that is possible are not available. This means that we have to choose how medical care resources can be best used. Essentially every day, the healthcare system faces choices about what is to be given priority and what must be left without resources”, says Lars Sandman, professor in health and medical care, and director of the National Centre for Priority Setting in Health Care.
Discussions about setting priorities started in earnest in Sweden as early as the 1990s. The Swedish parliament at that time determined that priorities in health and medical care should be based on three principles:
- The human dignity principle, which states that all people have equal worth, and have the right to care independently of age, gender, education, social status or economic resources.
- The needs and solidarity principle, which makes it clear that those with the most severe diseases are to receive care first.
- The cost-effectiveness principle, which requires that there be a reasonable relationship between the cost and the effect of treatment.
“There is broad political consensus around these principles. However, as the costs for healthcare increase, the politicians must make more definitive priority choices, which includes also denying care and in this way setting a limit to welfare. This is, of course, politically sensitive”, says Lars Sandman.
Priorities today differ between county councils and regions. For example, some offer more treatment rounds to involuntary childless people than others. In some places in Sweden, more resources are invested in treating mental ill-health in young people than in other places.
As needs increase more rapidly than the resources available, an awareness is growing about the importance of setting priorities. This is particularly the case among decision-makers, but can also be seen in healthcare personnel.
“More national expert groups are being established, such as those for new drugs, and this means that we are approaching greater national consensus”, says Lars Sandman.
There are, however, pitfalls that must be avoided. It may be easier for powerful patient organisations to make their voices heard by politicians and healthcare personnel than people who may not have a patient organisation at all, such as, for example, elderly multimorbid patients.
Some conditions, such as cancer, for example, have a higher status in the research world. As more research results are produced, a risk arises that such diseases are given priority, at the expense of diseases or conditions that are not the focus of so much research, such as mental health conditions.
Operations and results
The mission of the National Centre for Priority Setting in Health Care is to support actors in the healthcare system when setting priorities. The researchers at the centre (approximately five full-time equivalent posts) carry out traditional research that concerns legitimacy and openness around these questions. Various models for setting priorities are developed, based on the knowledge that has been built up. The Swedish model for open priorities, for example, was developed by the centre in the early years of the millennium, together with the National Board of Health and Welfare and other actors in the health and medical care system. The model has been widely established, and is used at various levels in several health and medical care regional units.
The research carried out by the National Centre for Priority Setting in Health Care is continuously advancing and the knowledge gained is continuously expanding. The centre in this way contributes to new solutions and ideas for the progress of work with setting priorities throughout Sweden. Implementation of the new knowledge is rapid, and it arouses considerable interest.
“The principal focus of the National Centre for Priority Setting in Health Care is to provide benefit for society. The research projects we conduct depend on the societal challenges we recognise. We find concrete examples of issues of priority that the health and medical care system is grappling with and seek to answer them”, Lars Sandman says.
The centre plays a central role in national questions that concern setting priorities in health and social care, and has carried out several commissions for governmental inquiries. As the corona pandemic started to affect Sweden, for example, the National Board of Health and Welfare adopted guidelines for setting priorities within intensive care with respect to COVID-19 patients. Lars Sandman was head of the inquiry that led to these guidelines.
The National Centre for Priority Setting in Health Care has close collaboration with several health and medical regional units in Sweden, with actors in clinical operations in the healthcare system, with several medicine boards, and with several government agencies, including the National Board of Health and Welfare.
Mattias Fredricson is head of unit at the National Board of Health and Welfare with responsibility for guidelines and recommendations in national screening programmes.
“We are in close contact with the National Centre for Priority Setting in Health Care. The centre is a powerhouse that generates research, knowledge and practical support in issues of priority. Its operations are highly valued, and its profound knowledge in the field enables the centre to contribute to our operations in many ways”, he comments.
The centre also collaborates with researchers both within LiU – including those at the Centre for Medical Technology Assessment, CMT – and at other Swedish and international bodies, including universities in Norway, Italy and Great Britain.
An increasing interest in questions relating to setting priorities in recent years has also led an increase in media attention. The National Centre for Priority Setting in Health Care has in this way achieved increasing significance for the knowledge of the general public of questions around setting priorities.
Report + article that form the basis for the change in the policy of the Dental and Pharmaceutical Benefits Board for pharmaceuticals:
The national model – most recent revision:
Report to the National Board of Health and Welfare about care that cannot be deferred – i.e. for people who lack the right of residence in Sweden: