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«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»

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SWEDEN Main characteristics of the Swedish health care system ► Highly decentralised, with an important role played by regional (county councils) and, to a lesser extent, local authorities (municipalities), also in financial terms ► Providing universal coverage upon the payment of a nominal fee at the point of use ► Mainly public financing of health care – mostly out of regional and municipal taxation ► Mixed service provision – public and private Structure of the system The state is responsible for overall health and medical care policy and legislation but responsibilities for organising health care services lie mostly with regional and local authorities. At the central level, health and medical care is under the Ministry of Health and Social Affairs, supported in its activities by five agencies. The Ministry drafts legislation, shapes policy, distributes resources, monitors implementation and negotiates with county councils and municipalities on issues concerning the delivery of services. Negotiation is through the Swedish Association of Local Authorities and Regions, a body representing the interests of regional and local authorities.

The national health system is based on the decentralisation of responsibilities to the regional and local level; the responsibilities of county councils and municipalities in health and medical care are regulated by the Health and Medical Services Act.

There are 18 county councils and two regions, with different organisational structures but usually organised around district health authorities. County councils are responsible for organising services related to health and medical care. The responsibilities of municipalities usually focus on the care of the elderly, of those discharged from hospitals, and on people with disabilities.

Delivery of services Primary care includes medical treatment, care, preventive measures and rehabilitation and is delivered through doctors, nurses, and other health professionals either working on a private practice basis or as public employees.

Primary care is often delivered through primary care centres whose management has been contracted by the county councils to other providers. Overall, in 2005, some 10% of the total health care expenditure of the county councils was for the contracting of private providers. General practitioners have a gate-keeping function in some counties, while in others patients have direct access to specialist care. Patients can choose their doctor and hospital in any county and region.

Provision of services by the private sector is increasing in outpatient and medical care, but specialist and in-patient care remain dominated by public providers. County medical care provides a second, more specialised level of care through county hospitals including both outpatient and in-patient facilities. Hospitals mostly belong to county councils but may be managed by private companies to which county councils have transferred all or part of operational responsibilities. A third level of care is ‘regional care’, provided in regional hospitals and usually dealing with more complex diseases and injuries.

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Finance and health care expenditure Health care expenditure mainly comes out of general taxation at the national and local level, accounting for 84.9% of total health expenditure in 2005. In 2005, private funding of health care in the form of co-payments accounted for 13.9% of total health care expenditure. The number of those purchasing private health insurance is relatively small but increasing (4.6% in 2008).

Expenditure for health and medical care (and dental care) represents 89% of county council budgets. A very high (71% in 2007) percentage of county council services are financed by county council taxes. Other revenues are from user charges, the sale of services and earmarked state grants (2%).

Expenditure on care for the elderly and disabled represents about one third of municipalities’ total expenditure. Municipalities also generate a high share of their revenues through local taxes, contributing to some 8% of total health expenditure.


- Ministry of Health and Social Affairs website

- Magnussen J. et al. (2009), Nordic Health Care Systems – Recent Reforms and Current Policy Challenges. Open University Press, European Observatory on Health Systems and Policies

- Wadensjö E. and Axelsson R. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Sweden. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms


Main characteristics of the English health care system ►Decentralised to each of the constituent countries; centralised within each constituent country, although organised and administered on a local basis; in England, local authorities (councils) play a role in the delivery and funding of social care ► Providing coverage to ‘ordinarily residents’ in England, largely free at the point of service ► Mainly public financing of health care – out of general taxation and national insurance contributions ► Mostly public service provision Each of the four constituent countries of the United Kingdom (England, Scotland, Wales, and Northern Ireland) has its own, publicly-funded, ‘National Health Service’ (NHS). Since the English NHS covers 84% of the total population of the United Kingdom, more emphasis has been given to its description.

England The Secretary of State for Health bears overall responsibility for public health. It is accountable to the UK Parliament. The Department of Health, run by the Secretary of State and a Permanent Secretary, is responsible for health policy and regulation and for central budget disbursement;

it operates at the regional level through ten Strategic Health Authorities.

Locally, there is a division between commissioning and delivery of services;

health services are purchased by 151 primary care organisations, mainly Primary Care Trusts (PCTs), each with a catchment population of about 340,000 inhabitants. PCTs may also provide some health services directly. General practitioners also play a role in purchasing through practice-based commissioning.

Primary care is delivered through self-employed general practitioners and their practices, and other structures such as community health services, NHS walk-in centres etc. The primary care system has a gate-keeping function to secondary care. Secondary care is provided through salaried health professionals, publiclyowned hospitals (NHS trusts) and ‘foundation trusts’. Foundation trusts are an example of devolution of responsibilities from the central level for hospital management and governance; they are run by local managers, staff and members of the local community. Private sector provision of services is limited. More specialised tertiary care is provided by NHS trusts. Almost all emergency care is provided by public services within the NHS and funded through public funds;

there are, for example 11 NHS ambulance trusts for the delivery of ambulance services.

Local authorities (councils) are responsible for social care. Social care is the statutory responsibility of 152 Councils with Adult Social Services Responsibilities (CASSRs). Such care is financed through public (local authority budgets, sourced through council taxes and business rates) and private funds (mainly upfront or private insurance contributions). ‘Direct payments’ is another form of support provided by local authorities to individuals for care needs; on the basis of assessment needs, local authorities allocate individual budgets that are used by recipients to purchase the requisite services. Local authorities are also consulted by PCTs in the setting of local priorities and, in particular they participate in the production of a ‘local area agreement’ setting priorities for action and health outcome targets. Additionally, further to the Local Government and Public Involvement in Health Act of 2007, Local Involvement Networks were established in 2008. These networks allow the participation of people in the commissioning, provision and scrutiny of local health and social care services: they are financially and organisationally supported by the local authority, although funding is from the central level.

Services are mainly financed from public sources – primarily general taxation (income tax, VAT, corporation tax and excise duties) and national insurance contributions (as compulsory contributions paid by employers and employees on gross earnings, and by self-employed people on profit). Private expenditure is made up of private medical insurance, user charges or cost sharing for those services not provided or not fully paid for by the NHS, and direct payments for services delivered by private providers. Funds are allocated by the central government to the Department of Health, which passes some 80% of this NHS budget to PCTs. PCTs are responsible for purchasing primary, community, intermediate, and hospital services. Providers are mainly public but may also include some private and voluntary-sector providers. In 2008, more than 82% of total health expenditure was from public sources.

Scotland The Scottish Government Health Directorate is responsible both for the National Health Service (NHS) of Scotland and for the development and implementation of health and community care policy. Primary and secondary health care services are planned through 14 regional NHS Boards. ‘Local Delivery Plans’ are agreed between the government and the boards; these plans are 3-year performance contracts expected to deliver on a series of targets, referred to as HEAT targets (Health Improvement; Efficiency and Governance Improvements;

Access to Services; Treatment Appropriate to Individuals). Boards have statutory obligations with regard to co-operation and public involvement.

Wales The Welsh Assembly Government is responsible for the NHS. The Department for Health and Social Services advises the Assembly Government on health and social care strategies, polices, regulatory and funding issues. Since late 2009, the NHS has been re-structured to include 7 Local Health Boards (LHBs) and three NHS Trusts (the Welsh Ambulance Services Trust for emergency services;

Velindre NHS Trust focussing on cancer-related specialist services; and the Public Health Wales). The LHBs plan, secure and deliver health care services in their areas. Primary care is delivered through general practitioners and other health professionals in health centres and surgeries; secondary and tertiary care is delivered through hospitals. Community care services are usually provided in partnership with local social services.

Northern Ireland The Health and Social Care Board, under the Northern Ireland Government Department of Health, Social Services and Public Safety, has been responsible since April 2009, when it was established, for commissioning health and social services; cooperating with the health and social care trusts that provide the services; and deploying and managing the annual funding received from the Northern Ireland Executive. It operates through Local Commissioning Groups covering the areas of competence of existing HSC Trusts. The Board is expected to achieve engagement with providers, local government, users, local communities, the voluntary-sector and other relevant stakeholders. The peculiarity of the NHS of Northern Ireland is that it combines health and social care administration. Integrated health and social care services are delivered through five Health and Social Care (HSC) Trusts; a sixth Trust is the Ambulance Service, operating throughout Northern Ireland. HSC Trusts manage and administer hospitals, health centres, residential homes, day centres and other health and social care facilities.

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- Boyle S. (2011), United Kingdom (England): Health system review. Health Systems in Transition, 2011; 13(1):1–486, European Observatory on Health Systems and Policies

- Scottish Government Health and Community Care website

- NHS Wales’s website

- HSSPS of Northern Ireland website

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Classifications of health care systems have traditionally been articulated around the types of funding mechanism for health care or on the basis of the prevailing contractual relationships between health care service providers and payers.

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