År 2010 genomfördes ett ett-årigt utvecklingsarbete rörande prioriteringar som omfattade en utpräglad teamverksamhet, närmare bestämt en habiliteringsenhet i Region Östergötland. I team, särskilt där teammedlemmarna arbetar rollöverskridande, blir det viktigt inte bara med kunskap om den egna professionens insatser, utan även om insatser som utförs av kollegorna. Ett av de viktigare målen för prioriteringsarbetet var därför att skapa en ökad och hållbar medvetenhet och samsyn kring prioriteringar i teamen. Den här rapporten beskriver resultaten från de uppföljningar som gjorts i verksamheten om i vad mån dessa mål uppnåtts och upprätthållits över tid.

Uppföljningarna bygger på enkätundersökningar som gjordes innan prioriteringsarbetet påbörjades, omedelbart efter avslutat arbete, samt 1 respektive 9 år senare. Samtliga teammedlemmar har tilldelats enkäter som innehållit samma påståenden att ta ställning till vid alla fyra uppföljningstillfällen. Påståendena handlade om de anställdas medvetenhet och samsyn om prioriteringar och utgick från den prioriteringsmodell som teamen utgick ifrån. Det innebar bland annat påståenden rörande prioriteringsgrunder som svårighetsgrad, patientnytta och kostnader i relation till vilken patientnytta som habiliteringsåtgärderna i verksamheten förväntades ge.

Resultatet på 11 av 14 påståenden visar en påtaglig ökning av andelen som anser att de är medvetna om teamets prioriteringar och att samsyn råder om dem, en ökning som i huvudsak består över tid men på vissa områden sjunker något efter 9 år. Till de få områden där en lägre andel instämmer, sett över alla fyra uppföljningstillfällen, hör bland annat synen på hur kända teamets prioriteringar är av personer utanför teamet (dvs det som rör den externa öppenheten). Samsynen i teamen beträffande kostnad för habiliteringsåtgärder i relation till patientnytta, är efter 9 år till och med lägre än innan prioriteringsarbetet.

I rapportens avslutande kapitel reflekteras över vad resultat av den här karaktären kan ge upphov till för frågor för en verksamhet att ställa sig för att fördjupa analysen av en uppföljning. I det här fallet rör det frågor om orsaker såväl till att ökad medvetenhet och samsyn kan bestå som att de sjunker över tid. Utöver det lämnas också några avslutande reflektioner över hur det viktiga momentet i ett prioriteringsarbete, uppföljningen, kan utformas och vara en del i att hålla prioriteringsdiskussion vid liv i en verksamhet.

In 2010, a one-year development work was carried out regarding priorities in a team-based organisation, more specifically in a habilitation unit. In a team, especially in transprofessional teams promoting generic working, whereby the interventions of one professional group are expected to be possible to be carried out also by members of another, it becomes important with knowledge also of interventions performed by colleagues. Therefore, one of the goals for the prioritisation process was to create an increased, sustainable awareness and consensus about priorities in the teams. This report describes the results of the follow-ups made in the habilitation unit, in order to see to what extent these goals have been achieved and maintained over time.

The follow-ups are based on a survey conducted before the prioritisation process began, immediately after the work was completed, and one and nine years later, respectively. All team members received a questionnaire, which contained the same statements on all four follow-up occasions, about the respondents' awareness of and consensus on priorities in their team. The statements were derived from the prioritisation model on which the prioritisation work was based. This involved, for example, statements concerning priority grounds such as severity level of conditions, patient benefit and costs of habilitation interventions.

The result of 11 out of 14 statements shows considerable increase immediately after the priority process in the proportion who agree that they are aware of the team's priorities and that there is consensus in the team. The increase lasts over time or decreases slightly in some areas 9 years after the process. Among the few areas where a lower proportion agrees, seen over all four follow-up occasions, is the view of how well-known the team's priorities are by people outside the team (i.e. the external openness). The consensus in the teams regarding the cost of habilitation interventions in relation to patient benefit is, after 9 years, even lower than before the prioritisation work.

The concluding chapter reflects on what kind of questions that results of this nature can give rise to, in order to help an organisation to deepen the analysis of a follow-up. In this case such questions primarily concern reasons why increased awareness and consensus persist or decrease over time. In addition, there are also some concluding reflections on how the important element in a prioritisation process, the follow-up, can be designed and be a part of keeping the priority discussion alive in a health care organisation.

Vem ska få tillgång till intensivvård om platssituationen blir ansträngd? Kommer respiratorerna att räcka till, och om inte, hur ska bristen hanteras? Allt sedan covid-19 pandemin drabbade Sverige har media, genom daglig rapportering, satt prioriteringar inom hälso- och sjukvården på agendan för allmänheten. Men det är inte bara media som kommunicerar till medborgarna, reaktionerna från allmänheten har också varit intensiva i tidningarnas kommentarsfält på sociala medier. Att studera uppfattningar om prioriteringar är inte sällan en utmaning, då ämnet upplevs som känsligt. Att göra studier av nätet, i form av netnografi, har gett en möjlighet att få inblick i vilka reaktioner på prioritering i vården under covid-19 som kan finnas där. De kommentarer som studerats är hämtade från 18 artiklar i våra största dagstidningar, artiklar som relaterar till Socialstyrelsens nationella principer för intensivvård under pandemin. Resultatet bygger på 1096 kommentarer, som postats av 645 användare, och som analyserats såväl kvalitativt som kvantitativt.

Kommentarerna kan delas in i positiva respektive negativa reaktioner på Socialstyrelsens prioriteringsprinciper för intensivvård. Här finns kommentarer som handlar om att principer inte skulle behövas om inte vården nedrustats eller om människor följde Folkhälsomyndighetens restriktioner. Oro uttrycks för att prioriteringar enbart kommer att baseras på kronologisk ålder, eller att äldre skulle få en lägre prioritet enbart av samhällsekonomiska skäl. Ungefär lika stor del av materialet består av positiva kommentarer, t ex när det gäller biologisk ålder som prioriteringsgrund. En positiv reaktion gäller också öppenheten kring vilka prioriteringar som ska råda, vilket anses ge en viktig påminnelse om allvaret i situationen.

Ett annat syfte har varit att studera interaktionen på nätet när principerna diskuteras. De som har kommenterat interagerar genom att förklara för varandra vad som uppfattas som missuppfattningar. De kritiserar varandras inlägg men uppmuntrar också varandra genom att försöka skapa lugn, de utmanar varandra med prioriteringsdilemman samt diskuterar känslan av ett ställningskrig gällande prioriteringar i form av ”vi-och-dem”.

Denna studie är ett axplock av reaktioner i sociala medier i en tidig fas av pandemin. I enlighet med vad som anges i Världshälsoorganisationens riktlinjer för kriskommunikation understryker resultatet värdet för beslutsfattare av att vara medvetna om debatten i sociala medier. En sådan debatt kan informera om missförstånd som behöver förtydligas, men också lyfta fram relevanta farhågor om hur prioriteringsprinciper kan tillämpas felaktigt i praktiken. Att anta att sociala medier bara är ett forum för missnöje är en alltför grov förenkling. De kan likväl ses som plattformar där åsikter utmanas och argument formas om vad som är rättvisa grunder för resursfördelning i vården.

Who will have access to intensive care if the situation becomes strained? Will the access to respirators be sufficient, and if not, how will the shortage be handled? Ever since the covid-19 pandemic hit Sweden, the media, through daily reporting, has put priority setting in healthcare on the agenda for the public. But it is not just the media that communicates to the citizens, the reactions from the public have also been intense in the newspapers' commenting fields. Studying reactions to priority setting is often a challenge, as the subject is perceived as sensitive. Using netnography, has provided an opportunity to gain insight into reactions to prioritization in healthcare that could be found in social media during covid-19. The comments studied are taken from 18 articles in our largest dailies and relate to the National Board of Health and Welfare's national principles for intensive care. The result is based on 1096 comments, posted by 645 people, and analyzed both qualitative and quantitative.

The comments can be divided into positive and negative reactions to the prioritization principles. Among the negative comments are those that say that principles would not be needed if healthcare had not been disarmed or if people followed the Public Health Agency's restrictions. Concerns are also expressed that priorities will be based primarily on chronological age, or that older people would be given a lower priority solely for financial reasons. However, positive comments regarding biological age as a basis for prioritization are about as common. A positive reaction also applies to the transparency about which priorities should prevail, a transparency that can provide an important reminder of the seriousness of the situation.

Another purpose with this study has been to explore the interaction online when discussing the principles. The posters interact by lecturing each other on their interpretations of the principles and by trying to explain the “correct” interpretation.

They criticize each other´s standpoints, both calming and challenging each other with prioritization dilemmas and discuss these in terms of "we-and-them".

This study is a snapshot of reactions on social media in an early phase of the pandemic. In line with the World Health Organization's guidelines for risk communication, the results underline the value for decision-makers of being aware of the debate on social media. It can inform about misunderstandings that need to be clarified, but also raise relevant concerns about how prioritization principles can be applied incorrectly in practice. Assuming that social media is only a forum for the dissatisfied is an oversimplification. Instead, it can be seen as a platform where arguments are sharpened in dialogues about what are the fair bases for resource allocation in care.

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term’s colloquial uses.

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term’s colloquial uses.

Allt sedan riksdagen fastslog riktlinjer för prioriteringar i hälso- och sjukvården har behovet av att utveckla metoder för prioriteringar mellan olika typer av hälsoproblem återkommande diskuterats. Ett steg i den riktningen är att försöka utveckla metoder för så likvärdiga och jämlika svårighetsgradsbedömningar som möjligt mellan olika typer av ohälsa. Som ett led i den utvecklingen redovisas här en studie av svårighetsgradsbedömningar som gjorts i Socialstyrelsens riktlinjearbete. Syftet har varit att undersöka om vissa aspekter haft större betydelse än andra för hur svårt ett hälsotillstånd ansetts vara. Ifyllda så kallade Svårighetsgradsmatriser från riktlinjer för hjärtsjukvård, stroke, epilepsi och schizofreni har ingått i studien, vilket innebär att 215 hälsotillstånd analyserats. De åtta aspekter av svårighetsgrad som analyserats omfattar funktionsnedsättning, aktivitetsbegränsning, delaktighetsinskränkning, varaktighet, frekvens, risk för framtida allvarlig ohälsa, risk för förtida död och livslängdspåverkan. Data har analyserats med deskriptiv statistik samt med icke-parametriska test, kompletterat med en enkät till projektledare på Socialstyrelsen.

Högre svårighetsgrader är helt dominerande bland de 215 tillstånden. En knapp majoritet av dessa saknar dock bedömning på en eller flera av aspekterna, eller har fått ett spann av grader istället för en specifik grad, vilket gör grunden för svårighetsgraden mindre transparent. För materialet som helhet verkar dock svårighetsgraden för ett tillstånd påverkas av a) vad majoriteten av aspekterna i Svårighetsgradsmatrisen getts för grader och/eller b) medelvärdet för bedömningarna i tillståndet (även där bedömningarna varierar stort). Däremot finns inte fog för att säga att en viss aspekt avgör svårighetsgraden. Det är istället olika aspekter i de olika sjukdomsgrupperna som har starkast samband med svårighetsgraden. I en sjukdomsgrupp är det triaden funktionsnedsättning, aktivitetsstörning och delaktighetsinskränkning som har det starkaste sambandet, i en annan är det risk för förtida död. Sammantaget styrker fynden tanken om att hur svårt ett tillstånd är kan bero på flera olika aspekter, och att en avvägning mellan olika aspekter måste göras. Denna bild förstärks av enkätsvaren från projektledarna.

Om inte vissa aspekter av hur svår en ohälsa är bör viktas högre (eller lägre) oavsett vilken ohälsa det gäller, finns det då andra vägar att gå för att skapa svårighetsgradsbedömningar på mer lika grunder i riktlinjearbetet? En sådan möjlighet skulle kunna vara att utveckla Svårighetsgradsmatrisen så att samtliga sjukdomsgrupper kan ha samma definition av vad de olika graderna står för, vilket inte är fallet idag. Frågan är öppen för diskussion.

Ever since the Swedish Riksdag established guidelines for priorities in health care, the need to develop methods for priority setting between different types of health problems has been repeatedly discussed. One step in this direction is to try to develop methods for as equal assessment as possible between different types of ill health when it comes to the severity level. This report presents findings from a study of what role different aspects of severity play in how severe a health condition should be considered to be. Severity assessments in four guidelines (Heart, Stroke, Epilepsy and Schizophrenia) from the National Board of Health and Welfare have been analyzed, in total a study of 215 health conditions. The eight aspects of severity analyzed, documented in a Severity framework, include physical and psychological disability, activity limitation, participation restriction, duration, frequency, risk of future severe ill health, risk of premature death and life expectancy. Data have been analyzed with descriptive statistics and with non-parametric tests, complemented with a questionnaire to project leaders from the authority.

Among the 215 conditions, higher levels of severity are dominant. A scarce majority either lack judgment on one or more of the aspects, or has a range of grades rather than one specific grade. This makes the grounds for the severity level less transparent for these conditions. For the material as a whole the severity level for a condition seems to depend on a) what grades the majority of the aspects has been given and/or b) the average of grades. However, there is no justification for saying that some specific aspect determines the severity level. Instead, different aspects in the four disease groups are most strongly associated with the severity. For one disease, the triad of physical and psychological disability, activity limitation and participation restriction are decisive, in another it is the risk of premature death. All in all, the findings reinforce the idea that how severe a condition is can depend on several different aspects, and that a balance must be made between different aspects. These findings are reinforced by the survey responses from the project leaders.

If certain aspects of ill health should not be weighted higher (or lower) when assessing severity level, are there other ways to make the assessments on more equal grounds, in priority-setting contexts as national guidelines? Could perhaps one possibility be to develop the Severity framework further so that all disease groups can have the same definition of what the different grades represent, which is not the case today? The issue is open for discussing.

Alltsedan 1997 då den etiska plattformen för resursfördelning introducerades i den svenska hälso- och sjukvården har metodutveckling pågått i syfte att stödja vårdens aktörer i de svåra avvägningar som prioriteringar ofta innebär. Fokus har varit på de stora frågorna, om resursfördelning på regionnivå och policybeslut i olika verksamheter, men det stora antalet prioriteringar görs på daglig basis i mötet mellan personal och patienter.

Den här rapporten vänder sig till er som vill arbeta med att göra prioriteringar på individnivå på mer likvärdiga grunder i linje med de riktlinjer om prioriteringar som riksdagen beslutat om. Här presenteras ett verktyg, Beslutsstöd för prioriteringar på individnivå, som syftar till att styra insamlandet och analys gällande vårdbehov så att behovs-solidaritetsprincipen och kostnadseffektivitetsprincipen i riksdagens riktlinjer för prioriteringar beaktas vid bedömningen. Beslutsstödet är resultatet av ett mångårigt utvecklingsarbete, byggt på erfarenheter framför allt inom hjälpmedelsverksamheter i flera olika regioner. Utöver att användas vid hjälpmedelsförskrivning är beslutsstödet även tänkt att kunna prövas för andra typer av hälso- och sjukvårdsåtgärder.

Beslutsstödet som används för att avgöra hur prioriterat en persons hälsoproblem och en tänkt åtgärd bör vara består av ett bedömningsformulär och en manual. Svårighetsgrad, patientnytta och patientnytta i relation till kostnad bedöms där i ett antal bedömningspunkter som styr bedömningen mot en prioriteringsgrad.

Ett syfte med beslutsstödet är att skapa prioriteringar på mer lika grunder. Infört på ett välorganiserat sätt, kan det bidra till att skapa förståelse och acceptans för gemensamma grunder och en större öppenhet i prioriteringar. I den här rapporten ges ett exempel på en genomtänkt implementeringsprocess från hjälpmedelsverksamheten i Region Jönköpings län. En viktig slutsats av det arbetet är att stöd från ledning och politiker, metodstöd till användarna av beslutsstödet samt uthållighet är huvudingredienser för att lyckas i ett sådant arbete.

Since 1997, when the ethical platform for resource allocation was introduced in the Swedish health care system, methods have been in development with the aim of supporting the healthcare providers in the difficult decisions of assigning priorities. The methodological focus has been on the major issues, on the allocation of resources at regional level and policy decisions in various activities, but the large number of priorities are made on a daily basis in interactions between health care staff and patients.

This report is addressed to those who strive to prioritize at individual level on more equal and explicit grounds, in line with the guidelines on priorities that the Riksdag has decided on. The tool presented here is called Decision support for priorities at the individual level. It aims to guide the analysis of the persons´ health care needs so that the need-solidarity and the cost-effectiveness principle are taken into account in the assessment. It is the result of many years of development work and tested in practice in Center for assistive technology in different regions for several years. In addition to being used in prescribing such technology, decision support is also possible to test for other types of health care interventions.

The decision support consists of an assessment form and a manual. Severity, patient benefit and patient benefit in relation to costs are the variables that should be assessed and direct the health care staff in assigning a priority.

One aim of using the decision support is to facilitate priorities on more equal grounds. Introduced in a well-organized manner, it can contribute to, but not alone, create such priorities. In order to create mutual understanding and acceptance for grounds and transparency in priorities, a thought-out implementation process is also required. In this report, such an example is given from Region Jönköpings län and prescribers of assistive devices. The main ingredients for succeeding in such work seem to be support from the management and political level, methodological support and constant perseverance.

Resource allocation in publicly funded healthcare systems is inevitably linked with priority setting between different patient groups and between different service areas, so-called meso level priorities. Behind every priority-setting decision (investments, reallocating or rationing), are values affecting both the content of the decisions and how the decisions are made. The importance for priority-setting to reflect social values, has been emphasised for the legitimacy of the healthcare systems and the decision makers. Also important, if supposed to provide enough guidance in practice, is that content values, expressed in ethical principles and criteria, are further operationalised. Few studies exist where Swedish citizens have been asked about priority setting and rationing at meso level, and findings from other countries cannot automatically be transferred to the Swedish context.

The overall aim of this thesis is to extend and deepen the knowledge of the Swedish citizens´ views on acceptance of rationing in healthcare, on appropriate decision makers for rationing, and on the severity criterion for priority setting. Two qualitative and one mixmethod study were conducted, where citizens were interviewed. Citizens´ views on severity were also compared, both with a Severity Framework, derived from parliamentary-decided ethical principles and used for resource allocation, and with health professionals´ and politicians´ ranking of different aspects of severity in a quantitative, survey study.

Study I shows that citizen participants perceived that acceptance of rationing at meso level is built on the awareness of priority-setting dilemmas between patient groups. No such spontaneous awareness was found. Depending on reactions of self-interest or solidarity, acceptance was also perceived to be built on acceptable principles for rationing and/or access to alternatives to public care. Study II shows that awareness of the meso level forms the basis for awareness of different risks of unfairness, linked with potential decision makers (even health professionals). Collaborative arrangements were promoted in order to control for such risks, especially the risk of self-interest. Politicians, in contrast to previous studies, were favoured as final decision makers for rationing healthcare. In study III, citizen participants identified the same severity aspects as health professionals and experts had done in the Severity Framework. They contributed with some possible refinements, but also promoted aspects not in line with established ethical criteria for priority setting in Sweden. Study IV shows that citizen respondents differ to a larger proportion compared to politicians´ ranking of severity aspects, than with that of health professionals´. The greatest number of significant differences was found between politicians and health professionals.

This thesis has several implications. Politicians ought to strive for greater public awareness of the priority-setting dilemma at the meso level in healthcare, both according to the process and the content values behind the decisions. Social values not in accordance to the parliamentary decision indicate a need to facilitate an ongoing dialogue, reason-giving activities and promotion of content values of solidarity. To capture social values on priority setting and rationing, ambitious public deliberation is not the only way. Methodologically stringent research, with a variety of study designs, could contribute in many important ways.

The importance for governments of establishing ethical principles and criteria for priority setting in line with social values, has been emphasised. The risk of such criteria not being operationalised and instead replaced by de-contextualised priority-setting tools, has been noted. The aim of this article was to compare whether citizenś views are in line with how a criterion derived from parliamentary-decided ethical principles have been interpreted into a framework for evaluating severity levels, in resource allocation situations in Sweden. Interviews were conducted with 15 citizens and analysed by directed content analysis. The results showed that the multi-factorial aspects that participants considered as relevant for evaluating severity, were similar to those used by professionals in the Severity Framework, but added some refinements on what to consider when taking these aspects into account. Findings of similarities, such as in our study, could have the potential to strengthen the internal legitimacy among professionals, to use such a priority-setting tool, and enable politicians to communicate the justifiability of how severity is decided. The study also disclosed new aspects regarding severity, of which some are ethically disputed, implying that our results also reveal the need for ongoing ethical discussions in publicly-funded healthcare systems.

IntroductionIn order to meet the challenges presented by increasing demand and scarcity of resources, healthcare organizations are faced with difficult decisions related to priority setting and resource allocation (PSRA). Tools to facilitate evaluation and improvement of these processes could enable greater transparency and more optimal distribution of resources. Resource Allocation Performance Identification Tool (RAPIT) is a tool for identifying the performance of PSRA. RAPIT was first developed in Canada (RAPAT - Resours Allocation Performance Assessment Tool) and then further developed in Sweden where items from the original tool were edited, likert scales were added, aiming to also identify areas of improvement. RAPIT was applied in the Regional Health Authority of Dalarna – ”Landstinget Dalarna”, Sweden, and administered to both middle and senior managers in the regional health authority Dalarna at baseline. In addition to answering the questions themselves, respondents were also asked to rate the value of each question with respect to PSRA performance relevance. Results were then presented to the senior managers. In this step, the senior mangers were asked to assess the value of information that they received from both the middle and senior managers responses. The senior managers also assessed the value of using RAPIT itself as an input for improving their PSRA process.ResultRAPIT revealed variations in the understanding of PSRA across management levels and individuals. 94% of the questions was given a very high value by the middle manager, 65% by senior manager. Some of the low ranked questions generated high valued information. In several cases, after seeing the result of RAPIT, senior managers changed their assessed value of ech question. Concerning incentives to participation for example, the senior mangers valued the question low but after seeing the result they valued the information very high.ConclusionsRAPIT is useful for identifying areas of improvement in a PSRA process: • Useful for education and promoting discussion – what does our PSRA process really look like? • Useful for motivating a more explicit PSRA process • Useful for mutual discussion when PSRA is perceived differently by involved actor. • Useful for a longitudinal perspective on the improvement on targeted areas • Useful as a collection of questions that can be adjusted to a specific context • Useful as an evaluation tool • Useful for comparative studies, not least for international comparisons. RAPIT is applicable in multiple contexts, and enables decision makers at different level to identify opportunities to improve their own PSRA processes.