Response to interpellation 2023/24:566 on preventive and health-promoting measures for public health
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
The debate concerned preventive and health-promoting measures for public health. KD argues that society needs to pool its efforts and that the government has invested heavily in preventive work within primary care 1. KD wants to strengthen primary care and increase resources for preventive and rehabilitative work 2. KD emphasizes that social outcome contracts can mobilize private capital for long-term goals and innovation 3. KD wants to create a support structure for municipalities and regions to enable these models 2 and argues that they create a pressure to use evidence-based methods 4. S argues that primary care suffers from a lack of resources 5 and questions why resources do not go directly there 5 6. S argues that coherent measures require continuity 7.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Socialministern Jakob Forssmed (KD)
Madam Speaker! Anna Vikström has asked me whether my ambition is to only strengthen the preventive work of private and independent actors within the field of public health and not the preventive work carried out by public healthcare providers, for example primary care in public hands, and if so, why. Anna Vikström has also asked me which actors I mean in my statement regarding private and independent actors, besides private companies. Anna Vikström has further asked me what type of work I refer to in my statement regarding the preventive work that private and independent actors shall perform. Anna Vikström has finally asked me what measures I intend to take so that the preventive work that primary care shall provide from a patient perspective shall function together with separate private and independent actors who shall work preventively.
Society needs to pool its resources to reach the public health policy goal of creating societal conditions for good and equal health in the entire population and closing the addressable health gaps within a generation, by 2048. At the current pace, the goal will not be reached, and there are no signs of reduced relative inequality in health. Therefore, an active policy is required to reverse the development. If we want to see different results, we need to do things differently.
Since public health work is cross-sectoral, a great deal of commitment and cooperation between actors in all of society is required, such as public and private actors, independent actors, the voluntary sector and civil society organizations. Furthermore, it is required that the measures taken are purposeful and cost-effective.
The Government has initiated a major effort to promote health-promoting and preventive work within primary care and throughout society. The Government has, among other things, decided on major health-promoting and preventive initiatives regarding a leisure card for children and young people, physical activity on prescription, FaR, expanded home visit programs within child healthcare, as well as preventing and counteracting involuntary loneliness. During 2024, a total of approximately 1.2 billion kronor has been allocated to these initiatives.
In addition, the government has tasked Socialstyrelsen to develop a national health program for children and young people which, among other things, aims to achieve a coherent, regular and equitable health monitoring, regardless of where in the country the child or young person lives.
The government has recently appointed two important inquiries that are expected to further contribute to health-promoting and preventive work. On 13 February 2024, the government decided to task a special investigator to propose how the current monitoring system for public health policy can be developed with complementary health economic analyses (dir. 2024:21). On 7 March 2024, the government decided to task a special investigator to, among other things, analyze and propose how school health can be strengthened in order to better meet the students' needs (dir. 2024:30).
As Anna Vikström emphasizes, primary care has an important role in health-promoting and preventive work. Primary care needs to work more health-promoting and preventive, from a holistic perspective that includes both physical and mental care needs.
Right now, the transition of healthcare towards good and close care is underway. With an expanded primary care, hospital care can also be used more effectively. The Government therefore allocates 3 billion kronor annually for the purpose of supporting the transition towards a close and accessible care with a focus on primary care, where a part is precisely the health-promoting and preventive work. In addition, the Government has allocated an additional 43 million for a reinforced investment in an expanded primary care during 2024. The reinforcement is estimated to amount to 544 million kronor for 2025 and 389 million kronor for 2026.
The government also intends to strengthen the national support to municipalities and regions to enable and stimulate the use of innovative models for social investments, such as social impact contracts. This is a way to open up opportunities for different actors in society to jointly address specific societal challenges, such as preventive and promotional work, with the aim of achieving improved social and health outcomes. The goal is that society's resources can be used more effectively. Interventions are followed up and made more accurate by focusing on specific and predetermined outcomes. In these innovative models for social investments, both private and independent actors can contribute and new collaborations are stimulated.
Furthermore, within the framework of the work to prevent and break involuntary loneliness, the government has tasked Socialstyrelsen with allocating 98 million kronor to non-profit organizations, non-profit foundations, religious communities, collaborative bodies, and parishes so that these can contribute in different ways to breaking involuntary loneliness, a factor for promoting health and preventing ill health. Through this initiative, we also want to encourage the strengthening of local collaboration between actors.
Regarding issues of loneliness, we also believe that the business sector has an important role to play, as the power and creativity that exists in the Swedish business sector is needed to meet the challenges we face. It is a sector with great opportunities to contribute to solving societal problems.
Anna Vikström (S)
Madam Speaker! Thank you very much, Minister, for the answer to my interpellation! In the answer, it is stated, among other things, that the government continues the investments in primary care that our government initiated. What is new are the innovative models for social investments such as social outcome contracts, which the private providers are to contribute with. I have some remaining questions. Is this about evidence-based measures? How is it to be measured? Why do primary care services not receive the mandate and the money?
It was the Minister's statement in today's press that private and independent actors should be able to be let into the preventive work and, together with municipalities and regions, be paid for their work based on long-term health gains that made me write this interpellation. I actually did not understand what it was about.
That these actors are to be let in implies that they do not already exist in the preventive work today, but they do; they exist, for example, in primary care. Primary care has a central role in the health-promoting and preventive work at the population level, but we know that there are problems with keeping up with their mandate.
Since 2021, there has also been a clear regulation regarding the primary care's basic mandate in the Health and Medical Services Act. It states, among other things, that regions and municipalities, within the framework of primary care, shall specifically provide preventive interventions based on both the population's needs as well as the patient's individual needs and circumstances.
This is a task that it is natural for primary care to have, while at the same time it is largely not managed to the extent that is needed because there is a resource shortage in primary care. Doctors have too many listed patients, and district nurses from all over Sweden testify to how they do not have time for the preventive work, which is pushed aside when the economy becomes increasingly pressured. The health center managers assess that the lack of economic conditions is the primary obstacle for preventive work, according to a survey by the Agency for Health Analysis.
One could say that there is knowledge and a will to work preventatively, but that there are insufficient resources to work as the law prescribes. These conditions appear to be worsening for primary care in today's healthcare crisis. For example, Region Sörmland had a deficit of over 1 billion in 2023. There, the moderately led government has made a decision to completely close 12 out of 15 district nurse clinics.
The elderly and families with children are particularly hard hit by this in rural areas and in smaller towns. District nurses are one of the professional groups that have a very clear mandate to work preventatively and health-promoting in primary care and also have that competence in their education and job description.
What I wonder is: Should private contractors be funded because primary care does not have sufficient resources? I mean other private actors. Why, in that case, do the resources not go directly to primary care?
Socialministern Jakob Forssmed (KD)
Madam Speaker! I thank Anna Vikström for the clarification regarding what prompted the interpellation. It also makes it easier for me to answer in an even better way, I believe. I apologize if I have contributed to confusion through my statement in today's press.
What I said refers to the social outcome contracts. It is not private actors in primary care behind this mainly, I imagine, but it is primarily private capital that can be mobilized around this. It exists in other countries. It exists in the United Kingdom under the name social impact bonds. An investor – it can be an institutional investor or a private investor – enters into a specific project where there are no resources available with our short-term models that we apply for governance. There, one can step in and make an intervention, and then someone can perform that intervention – it can be a municipality, a non-profit organization, a public health center, or something else that performs the intervention itself. If it then leads to the results that were agreed upon from the beginning and one can see this by producing robust models for evaluation, the investors can get their money back with interest.
I find this interesting, and I want us to create more robustness around this. I know it occurs in some municipalities and regions, but one is somewhat forced to reinvent the wheel when one wants to make this type of social investment and work in this way to create more long-term perspective and more innovations in order to manage to complete some things that perhaps do not fit into the ordinary operations, which however should fit, one might think.
This has been tested, not least by a number of Social Democrats in Sweden. Lars Stjernkvist has been one of the pioneers when it comes to working with this type of models. We have, of course, had many conversations with him about this. There are also others testing this in Sweden.
What I want to do is to see if we can create a clearer model for the impact assessments so that we create a robustness around such a model so that we do not have to reinvent it from scratch every time. We are now working on being able to produce such a model to stimulate innovation.
I hope this brings some clarity that this is not a way to target only private actors - really not! I envision a breadth of actors, not least non-profit organizations. I know that today there are those who work in exactly this way with funding, outcomes, and providers, where everyone becomes a winner by doing this preventive work that we know is needed but that does not always happen.
Anna Vikström (S)
Madam Speaker! I thank the Minister for the clarification of the answer.
I have tried to read up on this and have then seen that the government intends to strengthen the national support to municipalities and regions to enable the use of innovative models. I have also read that 10 million are promised. Is that correct, and what will they be used for in the first instance?
I also want to say that what the Minister said in his previous answer regarding the government having developed a directive and appointed an investigator when it comes to more efficient public health interventions through health economic analyses is very positive. I want to agree with that. When it comes to the specific investments for private and independent actors, I am, however, still a bit puzzled.
If one is to have external capital – which it seems to be mostly about – it could also be the case that external actors are to come in and perform some of these tasks. How are care and preventive work to function together if different actors are to take care of measures that should be coordinated for the same residents and patients? It does not seem to be a purposeful division.
An important part of the transition to good and close care is to strengthen the health-promoting and preventive work. When the investigator Anna Nergårdh was interviewed in connection with the release of one of the reports, she said that we must think more about health than illness and that both preventive work and rehabilitation are therefore important parts of the health and medical care system. She said that the staff in primary care, where the relationships are often long, have the best conditions to manage this. I think this is a very important point. Person-centered care and long relationships are significant for the preventive work.
The problem today is the resources for preventive care. A district nurse recently wrote in a letter to the editor: I did not train to be a district nurse to sit as a gatekeeper on the phone. I trained to be a district nurse because I want to help patients and work preventively. We need to be more.
This is the running point in the preventive work. The district nurses, who in their job description have a very important mission to work preventively in their profession, have become fewer in primary care in Sweden instead of more over the last 15 years. It is at least district nurses in the private primary care, across all of Sweden, unfortunately. It is probably about compensation and economics for the individual provider.
An example that I would like to bring up here is that a previous M-led government funded healthcare providers that were more or less separate from existing primary care and which, in some regions, stepped in and performed certain measures for patients. After 6 billion and eight years, the Swedish National Audit Office concluded that it had not had the intended effect, partly because it was not part of the regular primary care.
I mean that there is a great deal to learn here when it comes to continuity, competence, and working with evidence-based measures. I don't quite think I have received an answer to my question: Will this be built on evidence-based measures?
Socialministern Jakob Forssmed (KD)
Madam Speaker! I thank Member Anna Vikström for supplementary questions and comments regarding this.
We must not mix apples and pears here. The organization of primary care, which is primarily the responsibility of my State Secretary colleague Acko Ankarberg Johansson, is very important. We want to strengthen it. We want to strengthen good and close care.
They have received a clarified mandate to work more preventatively and rehabilitatively. It is very important. My perception, which I share with the government and Acko Ankarberg Johansson, is that they work too little preventatively. Far too few of the resources are allocated for this.
I believe that we need to think differently here moving forward if we are to manage the health challenges we face. The government and I share the view that resources are required. Therefore, we have also allocated very large amounts, both in the autumn budget and in the year-end budget, when it comes to this.
Let us leave that discussion and go into social outcome contracts a bit more. It is about interventions that would not be made, which are innovative and where funding is lacking in the usual way. It concerns short budget horizons but where one makes an intervention now that can pay off powerfully and well further ahead. There are deficiencies in the way we work and the budget systems we have.
We are now trying to help catalyze what is happening in municipalities and regions and help with how one can initially agree on what is to be achieved and whether there is support that this will be achieved, in order to answer the question of evidence and knowledge. If a private investor wants to put in money, it will probably want to see knowledge and evidence because it will likely lead to this.
It can be a long series of measures. It can be specific measures that lead to more people completing school by receiving a specific support that enables them to get through school. It can be special measures aimed at the group that neither works nor studies and who today easily fall between the chairs in many different systems.
Everyone is convinced that if one introduces specific targeted measures there, results can be achieved - saving human suffering and making socio-economic gains. But sometimes we do not succeed because our models are not quite rigged to promote this. Then we must think a bit differently, and that is what we are trying to do. It is about contributing to the new thinking that nevertheless exists within this sector and about being able to perform social health-preventive interventions in new innovative ways. It is politicians of different colors, I want to say, who have been involved in that work and who see the potential in this.
Our 10 million is about creating a support structure so that this will be easier to use for municipalities, regions, and other actors who may be involved in this work, so that one does not have to reinvent the wheel – we are not finished with that work.
This has been driven by, so to speak, enthusiasts. But I want more than just the pioneers to be able to utilize such models. I believe everyone would benefit from it, not least vulnerable groups who do not always receive quite the interventions that we believe could help them.
Anna Vikström (S)
Madam Speaker! I still have some questions. For example, I have not received an answer regarding this matter of the money. I also wonder if these socially innovative models are evaluated. Is there evidence that this is a way of working that works?
I have personally tried to find answers to this and have asked around quite a bit, but have not succeeded in finding research that supports that this way is a good way to work. Maybe it is. Does the Minister think that the measures to be carried out should be evidence-based? We have, over time, concluded that it is very important when it comes to public health work. It would not be, it would be unfortunate.
Then there is this matter of the focus being on specific and predetermined outcomes. How are those effects to be measured and by whom? We have a discussion about there being a very large amount of administration in healthcare and about whether we need to reduce it. Is there a risk that the measurements will involve a lot of data collection that the funders consider very important to obtain so that they know whether they are being paid for their interventions? Who is going to do this? I also wonder how it is going to work.
I am not entirely convinced that this is a purposeful way to work, especially not now when we have a healthcare crisis where 12 of 15 district nursing clinics are forced to close in ordinary care. I mean that primary care needs more resources directly and that funding should instead go to the entire primary care. Then both public and private providers could take part in this and work more preventatively. I am not entirely sure that it is that which will be financed by these private capital owners.
Socialministern Jakob Forssmed (KD)
Madam Speaker! I thank you for further questions. I think a general problem is that we focus too little on outcomes and too much on hopes. We make investments that we hope will lead to certain results. We do not follow up on it to a sufficient extent.
That is what is done in these models. One agrees on something from the beginning: This is what we are going to achieve. We believe that this is the way to achieve it. Then you follow up and see if you have achieved this. It creates a pressure from the beginning to use evidence-based methods so that you can be reasonably sure that you reach a certain outcome. You must at least believe in the idea enough that you are prepared to stake your money on the fact that it will lead to a certain outcome. In that way, the model evaluates itself in some sense – does it work, or does it not work? If it doesn't work, no one will stake the money. It is that simple. That is what is clever about this way of working.
One does not exclude the other. I want a strong primary care and more resources for primary care so that they can do their very important work and, not least, focus further on preventive work.
But I also see that there is a need for the more long-term measures, not least those targeted at children and young people who risk ending up on the wrong track. There, we should take advantage of the models that we can utilize to create this. We want to support exactly with that. How should the impact assessments be done? Yes, a long row of municipalities have now created their own models for this. But if we can create greater robustness around this so that more can be involved in that work, I believe that would be very good. It is a contribution that we can give from the government to get more collaborations in place for better health and fewer social problems for children and young people than we see today.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.