Response to interpellation 2024/25:595 on healthcare administration

Statsrådet Acko Ankarberg Johansson (KD)

Answers to interpellations

Madam Speaker! Anders W Jonsson has asked me what measures the government and I plan to take to reduce the regulatory burden on healthcare.

I would like to emphasize initially that the responsibility for providing health and medical care lies with the primary providers, who are responsible for how the operations are to be conducted within the framework of municipal self-government. The Government and I share Anders W Jonsson's concern regarding the administrative burden and its effects.

The government has in the recent budgets allocated significant resources to strengthen the regions' conditions to offer good, safe, and equal care. This is particularly important given the high inflation, which has affected the regions' finances negatively. It is crucial that the added funds are used effectively and do not entail an unnecessary administrative burden. At the same time, it is important to be able to follow up and evaluate how the common tax funds are used, which is why some administration may be needed.

The Government sees a need for the state to take overall responsibility for the management and monitoring of state funds. To ensure effective management and monitoring of state funds for healthcare, the Government has implemented several changes during recent years. At the end of 2024, the Government decided that two of the previous annual agreements with Sveriges Kommuner och Regioner, SKR, would be replaced by regulation-based state grants. The regulations have been designed from the starting point that the administrative burden for the primary agencies should be as small as possible, while at the same time it must be possible to monitor and ensure that the funds are used in the correct manner.

Furthermore, the government has allocated a total of 11 billion kronor during 2024 and 2025 in a special sector grant targeted at health and medical care. The funds are specifically aimed at strengthening the regions' conditions to provide good, safe, and equal care and are paid out without requirements for reporting back. The regions themselves decide how the funds shall be used within the framework of the health and medical care sector. Thereby, the administrative burden is also reduced.

More money to the regions will however never be the entire solution to the healthcare's problems. The government has therefore also taken several measures to support an efficiency of care and to ensure that patient-proximate activities are prioritized.

The government has, for example, decided to establish an efficiency delegation with the aim of supporting structural changes, strengthening efficiency, and thereby improving the situation within health and medical care. The government has also decided to establish a regional review function at the Swedish Agency for Public Management, ESV, with the primary mandate to review the regions' economic situation. The focus shall be on purposeful resource utilization, cost-effectiveness, and efficiency potential.

The government is also actively working to reform the healthcare's digital infrastructure. One of the goals of the national digital infrastructure is to reduce administration within healthcare, among other things through increased interoperability. This involves, among other things, developing standards and specifications as well as providing various infrastructure components that enable efficient information exchange between healthcare actors and healthcare systems. This will create opportunities to reduce the extensive double documentation that exists today.

Reducing unnecessary administration in healthcare is an important part of improving the working environment for healthcare staff. The Government and SKR have, in the letter of intent on common direction for a coherent and purposeful knowledge management for health and medical care, agreed to reduce the administrative burden for healthcare workers as well as support and facilitate for staff in patient-facing activities. When healthcare resources are freed up for patient-facing work, the supply of competence is strengthened, which contributes to more accessible and secure care for the patients.

I thank Anders W Jonsson for the interpellation and look forward to the debate.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Anders W Jonsson (C)

Madam Speaker! Earlier this year, I read a report that made me very worried. It comes from Kunskapsverket, an exciting foundation that works on producing factual basis in various interesting issues. This time, they had focused on how healthcare is doing. Much of what was in the report was already known, but one figure stood out: During a twelve-year period, the central administration in our regions had increased by no less than 50 percent. Furthermore, the patient-facing administration, which is intended to support doctors and nurses, had decreased by 8 percent during the same period.

I submitted the interpellation to the Minister to get an answer on how the government intends to proceed. This is something that healthcare workers are suffering under. Everyone you talk to recognizes themselves in this picture. One would rather work extra hard with the patients than handle all the administrative requirements that keep coming.

I cannot say that I am entirely satisfied with the answer that the Minister has just given. The Minister began by saying that the responsibility for providing health and medical care lies with the regions; it is implied that it is not the government's responsibility. It is a common misconception that the regions have the entire responsibility. I understand that the Minister has not had time to read the Vårdansvarskommitténs report, but in that, a very good division is made. The system responsibility for healthcare – the responsibility for laws and regulations – is entirely the state's. The financing responsibility is shared between the regions and the state; the state covers up to 30 percent. The provision responsibility lies entirely with the regions. For the execution and operation of health and medical care, we also have private actors.

If one tries to make an analysis of what is causing this rapid development of the central administration, it is my and many others' opinion that it is the two state parts that are driving it. The first concerns the system responsibility. It is about laws enacted here in the chamber, ordinances from the government, and not least all the regulations from the authorities that regulate in detail how one should act. All those regulations have come into being in the best of faith to create better healthcare. But what one never sees from the state authorities – Läkemedelsverket, Ivo, Socialstyrelsen, and Folkhälsomyndigheten – is how this collectively increases the administrative burden. Here is an important reason why the central administration has increased.

The second part of the state's responsibility concerns the financing. The regions finance healthcare through income tax. It does not involve much administration for them; that is handled by the Swedish Tax Agency. But the tradition we still have in Sweden of providing a number of specially designated grants from the state to the regions constantly requires additional administration.

Here I believe we have the two absolutely strongest drivers. It is not the regions that can influence them, Madam Speaker, but the state. The government could facilitate this through mandates to its agencies and through actions regarding the appropriations, so that the regions do not constantly have to build up the central administration at the expense of the patient-proximate administration. In this way, one could reduce the administrative burden. This is not something that anyone wants to sit and deal with.

I want to ask the Minister again: What is the Minister's analysis of this? What is the reason for the incredibly rapid development with an increase of 50 percent of central administration in health and medical care? You then land on some other proposals that I will return to.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! Thank you, Member, for the interpellation!

I share the member's concern that administration takes up such a large part of the work close to healthcare. However, I have read the committee's report and am halfway through the annex section. I have read it with great interest. There is much useful material to be gathered from it. It is a large and solid piece of work that has been done.

Let me begin by linking back to all these years that the member refers to. That time when everything began, or had been ongoing for a while, was characterized by fragmentation as a result of new public management, where one wanted to know in detail what one had done in order to be able to follow up. It was quite a lot of a check in some box for having done the one thing and the other.

There is a small part in this that might seem good. When I know that I have done what is expected of me, I can feel secure as an employee, know that I have done what is expected and go home in peace. But quite quickly, the healthcare workers see that the checkboxes do not reflect reality. The patients remain, and we do a lot of things that are not purposeful.

That is why I am very happy that we have moved away from new public management and instead see how it turns out. We are more interested in the result and not always in the way it has been done, but it is about achieving the results.

That is the reason why we have reorganized and included several earmarked state grants into two large boxes. One contains 3.7 billion for good close care. The other contains 8 billion for increased care capacity.

There are short descriptions of what is to be achieved. It is about increased accessibility and an improved working environment for staff. But how to do it is decided by the staff and the operations themselves. I believe that is the way forward.

It is about what one wants to achieve, but there is a large space to shape it on one's own. One does not request detailed descriptions of everything but looks at the result. The path there can look different. Furthermore, it needs to do so in our elongated country.

The development we have made from the government's side is a transition from very detail-oriented agreements with very many details to short, precise regulations that also have a simplified reporting. I believe that is the way forward.

We need to go into depth regarding why all this administration arises. I assess that some of it is policy-driven. As politicians, we want an account: How is it going with that issue, and how is it going with that issue?

Every time we have asked for it, it creates a process that ultimately affects the nursing assistant who has to fill in something after every visit and the doctor who has to fill in even more boxes.

Finally, we have filled in all this mass of detailed information that is rarely purposeful in the aggregate. We sometimes need to refrain from requesting policy-driven administration.

The second is that which is born directly in the operations. One wants, just as the member says with good will, to ensure that it has turned out well and that we do what we are supposed to do. Therefore, the government, together with SKR, has issued a letter of intent. It concerns working with the entire partnership where all agencies and SKR are involved.

We decided that we must collectively reduce the regulatory burden. We know that much happens at the clinic level and the regional level. But it also happens at the authority level and at the government level. We must collectively reduce the regulatory burden and decrease the administrative routines. We had a first follow-up now in April this year. It looks promising, but substantial steps forward need to be taken.

It also turned out that some of the needs that arise for follow-up are linked to the fragmentation and that we are becoming increasingly specialized in each activity. It requires even more administration to put it all together.

We will, of course, retain all the deep knowledge we have in healthcare. But we need to get better at the holistic perspective and instead gather around what the patient needs.

We perhaps need less administration and more of the staff being able to decide: What is best for the patient in front of me? Therefore, the statement of intent is also a link in the work that the government is doing.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Anders W Jonsson (C)

Madam Speaker! I also realize that the management of a region has a responsibility for this. That is obvious. But the state and the government also have a great responsibility. There are some positive steps that have now been taken in that one has moved over to regulation-based state grants. But there is very much more that must be done.

I can understand and accept that targeted state grants are needed in situations where we suddenly get a pandemic or something else that requires special measures with state funds. But there must be a transition to general state grants on a significantly larger scale. They do not generate administration in the same way that the targeted state grants do.

Furthermore, the state authorities are not free from blame. A large part of the central administration is rendered by the fact that from various sector authorities, a need is seen to further micro-manage the operations. This, in turn, leads to the regions having to build up a central administration, and ultimately it falls on doctors and nurses.

All these changes are made with the best of intentions. One wants to improve healthcare. But one does not see that all these small streams of new additions actually break the healthcare staff.

The matters that have been raised here concern what the government is doing concretely. One establishes a state efficiency delegation. The belief is that one can have a delegation in Stockholm that is to streamline healthcare and in some way reduce administration. The risk is obvious that it will have the exact opposite effect.

Furthermore, the digitalization of the infrastructure is highlighted. That is absolutely correct. One must look further into that. But a description from reality is that a large part of Sweden's regions are today introducing new digital healthcare systems such as Cosmic. They entail increased administration for nurses and doctors.

Due to regulations from authorities, it is stated that in those systems there are a number of tasks that a medical secretary could previously handle but which must now be performed by the individual doctor.

Regarding the digital infrastructure, data is transferred from medical assistants to doctors due to the authorities' desire for control. It is directly counterproductive. The result of that is only less time with the patient.

Finally: That one shall again make an agreement with SKR so that they shall do something to reduce healthcare administration is a good idea. But here, sharp decisions from the government's side are required.

Regarding the regulatory burdens on the business sector, governments have previously stated that it is an order to our state agencies to reduce the regulatory burden on the business sector and the companies. It concerns ensuring that the administrative burden decreases and does not increase. A concrete goal has even been set for a reduction of 25 percent.

It is something equivalent that we must also do in healthcare. It is a matter of ensuring that our state authorities understand that the administrative burden leads to poorer healthcare and not to better.

It also applies if an additional regulation may have the ambition to further strengthen a certain part of patient safety. One must look at the total workload that doctors and nurses have in healthcare regarding administrative burdens.

Just the figure of a 50 percent increase in central administration over twelve years is an alarm bell that means the government should act in a significantly sharper way than with the three measures that are proposed here.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker! Thank you, Member, for the additions!

I assume that the member has read what the efficiency delegation is to do. That it meets in Stockholm during its five to six meetings a year is less interesting. The important thing is that it is established to provide support to those regions that themselves want to enter into long-term work to increase efficiency.

Then they can receive financial support for this. In practice, it will be a committee, a delegation, that makes decisions on how much money they receive. It is the efficiency delegation's task. It is not that it itself shall dictate what a region should do. It is the region itself that submits proposals on what it wants to do and how much support it wants for it.

It is precisely the choices that the regions themselves make when they enter into new journal systems that do not always turn out well. It is a choice that every region makes. Should it be a medically knowledgeable person who notes it, or should it be a medical secretary who is knowledgeable in their area who notes it?

I believe we have had an imbalance here. I have noted that several regions that are now introducing new digital [solutions] immediately reduce the number of healthcare administrators who work close to the healthcare. I do not believe that is the right way to go. The different competencies that exist have been overlooked.

Those who are medically skilled are good at one thing; medical secretaries are skilled in another. This is a choice that every region makes. My opinion is that the regions could have made other choices when they decided which systems they should have. I believe that better efficiency could have been achieved in that way.

Unfortunately, I have heard far too many horror stories about the new systems that the regions have, including from professional associations. I believe there is a learning to be made between regions when it comes to how one orders systems and what promotes good care.

Let me highlight a very good thing that the member himself is the reason we are doing today. Anders W Jonsson wrote a motion to the Committee on Health and Welfare some many years ago now regarding the development of national standards for digital healthcare information. It is precisely that work that the government is now doing. Thanks to the member's motion, which received support from everyone in the Riksdag, we have been able to take these steps forward.

It is not just about a new system that becomes cumbersome, but about a system that reduces double reporting. If something has been entered once, it should then be automatically forwarded to other places. It is a very important task. I am very pleased that the member wrote the motion, that it received full support in the chamber, and that we now as a government have taken the initiative for the work.

What is it then that, in practice, results in so much administration? I believe it is the connection between old mindsets, new public management and fragmentation, and on the other hand, the goodwill, just as the member himself highlights. Then one must dare to question if one needs anything, and that is what we have done from the government's side. That is why we have removed so much of the detailed management in the state grants, grouped them into larger boxes, and allowed a greater scope of freedom when it comes to how one does this. I believe that is the way forward.

I note that there is a desire to know what the money is used for. When investigating that, one must design the follow-up in a way that makes it sensible. I believe quite a lot in the dialogue form. It may sound vague, but I believe that this form – to listen to those who have worked with the systems and hear how it is going – can provide much more than reading a paper where someone has answered survey questions.

Now we are testing some different forms of follow-up to see in what way we learn more. Just today I received a report from the National Board of Health and Welfare on how they work with learning in the competency supply. It has been too much micro-management, too many checkboxes that one has to fill in and too little space to also learn within the organization.

That is a bit strange. Healthcare has a constant learning process when it comes to medical knowledge. One tries new things, and one develops them. But when it comes to organization and the parts that the member raises, it often happens that we get stuck and do as we have always done. There, I wish for more learning and that we dare to question whether things are needed.

The authorities are on board. They have already received notification from the government that they are to reduce the administrative burden. It is stated in all our decisions where it is relevant, so it is truly included.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Anders W Jonsson (C)

Madam Speaker! I hear what the Minister says. There is a will from the government to constantly shift the responsibility in these matters to the regions and say that it is there that the decisions lie.

But just take the example that the Minister raises with digitalization and healthcare information systems. It is not the regions that sit there in a world of their own and build this up together with a company, but one is completely dependent on the legal requirements that exist and not least on the regulations that exist from authorities.

When healthcare staff ask the person who delivered the system why it is in a certain way, they are told that there is a regulation that governs it. Then we are back again to the responsibility that the administrative burden has increased in healthcare and that we have 50 percent more central administrators. It is not the regions themselves that bear this responsibility entirely, but the government also has a part of it.

I have pointed out two important parts in this. The government answers one of them. It concerns the specially designated state grants and the follow-up of them, which renders an enormously large central administration.

The second is the government's way of governing the authorities. I have full respect for the fact that it is very important to have a dialogue with the authorities. But it is also the government that decides what the authorities shall do. When it comes to demanding reporting, who are those who have reduced the administrative requirements on healthcare? When a new regulation comes from Socialstyrelsen or Läkemedelsverket, requirements should be made that corresponding ones are removed somewhere else so that one does not just add burden to the Swedish healthcare system.

I do not think that dialogue is enough. It has previously been shown that the authorities see their area of responsibility as so important. Therefore, sharp steering from the government's side is required to reduce the administrative burden in healthcare.

The speech at riksdagen.se, in Swedish (opens in a new tab)

Statsrådet Acko Ankarberg Johansson (KD)

Madam Speaker and members! The dialogue is with the healthcare sector and not with the authorities. The dialogue is with all operations to see how we have succeeded in reducing the regulatory burden and the administrative systems. It was that dialogue I intended and no other.

I am a bit surprised if the member thinks it is difficult with legal requirements. The laws are enacted by this assembly. One of the requirements that I think is very concerning that we do not follow is the healthcare guarantee, which states that the patient shall have the right to an operation that a doctor has assessed that they need within a certain time. It is deplorable that we have not been able to fulfill the healthcare guarantee in its entirety since it was introduced. It is clear that we must have stronger governance of this. There is no doubt that patients should receive the care they need.

But when one does this, one must consider in what form it is done, and that is something we do all the time. That is why the requirement from the government is included in all decisions that are relevant, that one must reduce the regulatory burden and administration. It is included in our mandates to the authorities.

It is also about finding new forms of follow-up. It was not least this that Socialstyrelsen reported today. They have moved and today work much more operationally close, when it is relevant, than they did just three years ago. If one goes out and asks the healthcare managers, healthcare directors and others, I believe they can tell that in recent years there has been a shift from Socialstyrelsen's side. I welcome it, and we have pushed for this. If our agencies – this also applies to the others – work closer to the operations, one knows better what is needed. One captures all that which does not always come into words.

I therefore welcome this, and the government will continue to push so that one works closely with the operations, close to healthcare, and is well informed about what needs to be done.

I note with gratitude the clear messages coming from the Care Responsibility Committee regarding strengthening state governance and even going as far as sanctions. If one issues a sanction, one must of course first know what one has received.

I think that this is an exciting assignment. It is about ensuring that it becomes a purposeful administration – not an unnecessary administration. What is to be captured is whether the patient has received care or not. That, Madam Speaker, is my assignment.

The interpellations debate was hereby concluded.

The speech at riksdagen.se, in Swedish (opens in a new tab)