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Procedurrättvisa och praktisk prioritering: tre fall från svensk hälso och sjukvård
Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment. Linköping University, Faculty of Health Sciences.ORCID iD: 0000-0002-3300-5516
2006 (Swedish)Report (Other academic)
Abstract [sv]

Prioritering av vård väcker starka känslor bland många människor. Prioritering likställs ofta med nedskärningar av offentlig service. Ändå är prioritering det mest naturliga man kan tänka sig inom ett hälso- och sjukvårdsystem som finansieras kollektivt genom skatter. När prioritering sker öppet blir frågan dock känslig i ett skattefinansierat sjukvårdsystem eftersom solidariteten mellan medborgare med olika medicinska behov sätts på prov. En sjukvård organiserad efter den generella principen rymmer inslag av omfördelning, mellan frisk och sjuk, mellan lite och mycket sjuk, mellan rik och fattig och ofta mellan ung och gammal. När sjukvårdens möjligheter expanderar utan att samhällets ekonomi riktigt hänger med i svängarna kommer ett sådant system lätt i obalans. Frågan blir då hur mycket solidariteten tål – denna problematik möter våra politiker. Hur mycket omfördelning går egentligen att visa upp för medborgarna.

I rapporten undersöks tre fall med anknytning till prioritering. De är hämtade ur vardagen inom svensk hälso- och sjukvård under senare år och illustrerar en problematik som kommer att bli mer och mer påtaglig. Rapporten pekar på både möjligheter och problem.

I rapporten redovisas resultaten från delstudie 2 i projektet ”Svåra beslut vid prioriteringar i hälso- och sjukvård – kan ’rättvisa processer’ stärka legitimiteten?” Projektet har erhållit finansiering genom Det nationella forskningsprogrammet om sjukvårdens förändringar, Tema 2: Prioriteringar i praktiken (bakom forskningsprogrammet står Landstingsförbundet och ett antal landsting och regioner).

Författaren riktar ett tack till finansiärerna samt till alla personer inom tre icke namngivna landsting (eller motsvarande) som frikostigt delat med sig av erfarenheter, kunskap och åsikter.

Abstract [en]

In the health care sector, priority setting often takes the form of rationing (i.e. waiting lists) or even the exclusion of treatment for which there are inadequate funds.  This  situation  is  notoriously  difficult  for  decision-makers  to  handle, whether they are clinicians or elected politicians.

In this study we have used a well-known ethical framework for "fair" priority setting (accountability for reasonableness) to analyse three cases drawn from the regional  health  care  service  in Sweden.  The  aim  was  to investigate  to what extent "procedural justice" can be applied to "real-life" cases of priority setting and rationing. The cases used in the study are cosmetic surgery, the allocation of disability aids and infertility treatment (IVF). In addition, the local politicians responsible for health care in three local authorities were asked to express their views on issues such as legitimacy and fairness in relation to priority setting.

It is important to take into consideration that priority setting in the public health care system consists of at least four different processes, i.e. those that can be regarded as internal (within the health care delivery system itself and between the delivery system and political decision-makers)  and those that are external (between the delivery system and patients and between the public provider of health care and the general public).

The intention was not to grade the three cases with regard to the "fairness" of the  priority-setting  process.  Nevertheless,  it  can  be  noted  that  in  case  A (cosmetic surgery) very little focus was given to the element of "publicity" i.e. information  to  or  dialogue  with  patients  and  the  general  public  about  the priority-setting process. In case B (new policy for disability aids) we noted that the internal legitimacy was far better, although the medical staff responsible for prescribing disability aids found it difficult to develop their own procedures for priority setting. The final case C, (infertility treatment) represents the traditional way to handle the gap between demand and supply in the public sector. In the local authority studied, the political level of decision-makers  had delegated all the  priority-setting  decisions  to  the  clinical  level,  but  instead  of  adopting  a "muddling  through  strategy",  the  clinicians  in  charge  had  spent  time  on developing procedures for disseminating information to patients (publicity) and for ensuring fairness (equal rights).

The interviews indicate that Swedish local politicians responsible for health care have a relatively good understanding of  the problems related to limited resource and the need for priority  setting.  They are trying  to find new solutions,  and above all to develop a better dialogue with the general public. Most politicians appreciate  the  importance  of  "internal  legitimacy"  i.e.  the  interrelationship between the different decision-making levels within the local authority, and the need for a clear-cut message to patients and the public. On the other hand, the politicians are not in agreement about how the responsibility for communicating the information about priority-setting should be divided between the clinicians and themselves.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2006. , 63 p.
CMT Report, ISSN 0283-1228 (print), 1653-7556 (online) ; 2006:4
Keyword [no]
Prioritering inom sjukvården
National Category
Social Sciences
URN: urn:nbn:se:liu:diva-36918ISRN: LIU CMT RA/0604Local ID: 33051OAI: diva2:257767
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2014-10-27Bibliographically approved

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Garpenby, Peter
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