Method
The assignment from the National Board of Health and Welfare consists of three related parts. Part one presents different interpretations of the concept “care that cannot be deferred” based on an analysis of how the concept is used in the government bill and the wording of the Act. Several criteria are used to specify these interpretations. Part two analyses the interpretations of the concept “care that cannot be deferred” discussed in part one. The analysis is based on the ethics platform for priority setting. Part three aims to analyse how the concept “care that cannot be deferred” relates to the National Model for Transparent Prioritisation in Swedish Health Care and discuss whether it can be used to support prioritisation and rationing. The theoretical analysis is complemented by several examples of practical decision-making situations, as described by clinicians, that involve the care of non-registered individuals.
Analysis
In this report we have formulated several criteria that the concept “care that cannot be deferred” must fulfil according to the law (2012/13:407).
These criteria address: Care need: The individual has a care need – i.e. a discrepancy exists between the desired and actual condition, which can be influenced by a care intervention.
Limitations: The provider may place limitations on “care that cannot be deferred” delivered to non-registered individuals in Sweden and who are 18 years of age or older. Such limitations should be based on considerations involving:
- Severity of the condition (current ill health, risk for future ill health, or special needs arising from previous assault and trauma).
- Effect of the intervention if it is provided now compared to deferred intervention.
- Cost-effectiveness of the intervention if it is provided now compared to deferred intervention.
Limited responsibility: When applying the concept “care that cannot be deferred” the provider should assume that the individual is expected to be in Sweden for a limited time, but it is not necessary to consider the person’s opportunities to receive care once he/she is no longer in Sweden.
Expanded responsibility: When applying the concept “care that cannot be deferred” the provider should assume that the individual is expected to be in Sweden a limited time, but should also consider the person’s opportunities to receive care once he/she is no longer in Sweden.
Conclusions
Based on the care need criterion, we conclude that non-registered individuals who seek care should be adequately evaluated in each case so the provider can determine whether a care need exists.
We conclude that the limited responsibility criterion conflicts with the human dignity principle when it comes to limiting care based on chronological age and national registration. Further we conclude that the rationing of care implied by the limited responsibility criterion does not appear to be based on limited resources, but that the non-registered individual does not have the same right to health services as the nationally registered population does.
We conclude that in choosing between the limited and the expanded responsibility criteria, the latter is preferable in light of the ethical platform since, to a greater extent, the expanded responsibility criterion allows consideration of relevant aspects (e.g. severity level, effect of intervention, and cost effectiveness) similar to the way the registered population is treated. Further, we conclude that the time limitation of the responsibility criteria is difficult to address since in many cases it is highly uncertain how long a person can remain in Sweden without necessary authorisation.
We conclude that the factors presented for determining how to define “care that cannot be deferred” are basically the same as those in the national model for priority setting – i.e. severity of the condition (current and potential), effect of the intervention (and how it changes over time), and cost effectiveness. Concurrently we point to several contradictions in defining the definition, and in the law generally, that conflict with the ethical platform and the national model for priority setting. This includes the cases where specific diagnostic or treatment areas are explicitly noted, regardless of severity level, effect of intervention, or cost effectiveness.
Further, we conclude that it is possible to point to several general combinations of severity level, effect of intervention, and cost effectiveness that can define “care that cannot be deferred” – so these combinations are very difficult to apply at the individual level. The reason is that it is difficult to determine individual risks and effects. As regards the registered population, a normal way to determine risks or effects would be either to provide treatment “for safety’s sake” or to wait, thus providing the opportunity for the patient to return if the condition deteriorates or for the provider to call the patient for a return visit. If the provider decides that care can be deferred, usually there is an opportunity for a new evaluation at the initiative of the patient or provider. Since it is less certain that patients in the non-registered population can return for a new evaluation, it might seem reasonable to offer treatment more often for safety’s sake. Concurrently, this must be balanced against the risks associated with treatment and the opportunities to follow up on these risks wherever the individual resides.