Publ. Hlth, Lond. (1975)89, 297-303
Health Care Planning and Computing in Sweden P. d. H e a t h M,Sc,. M.B., Ph.C.
Specia/ist in Community Medicine (Information and Hea/th Care P/anning) Sheffie/d Area Hea/th A uthority (Teaching) During September of last year I was privileged to spend a month studying computerized medical information systems and their relationship to the planning and organization of medical care mainly in and around Stockholm. My trip was financed through a Council of Europe Fellowship, emphasis being placed on systems of data processing with particular reference to their applicability to our own health service following reorganization. This article outlines the organization of medical care in Sweden and its relationship to their system of government and their economy. A description of the Stockholm County Medical Information System then follows, together with a discussion of planning and its relationship to our own planning machinery. The Swedish Health Service The main emphasis of health care in Sweden is placed on hospitals--the number of acute beds provided per unit of population being generally in excess of that in most other countries. Consequently, the expenditure on total provision is high but the proportion devoted tO primary care is somewhat low when matched with economic inputs to health systems in countries at a similar stage of development. At the present time the economic state of the country is good and can sustain expenditure at this level. However, there are signs that they are beginning to feel the effects of inflation and the thoughts of the planners are turning more towards the need to increase the expenditure on primary care and to switch some of their resources away from hospitals. There are difficulties in persuading doctors to practise in areas where the 'population is widely scattered and the hospital facilities are not very extensive; Sweden has a total population of 8.1 millions and a density of 52 persons per square mile, but 90 % of the inhabitants live in the southern half of the country and the population density in the north is therefore very low. This problem is not unlike that found in the Hebrides or in Norway, where it has been largely solved by forms of special incentive to persuade staff to work in the less popular areas. Primary medical care is available at district medical centres, with medical, nursing and associated staff operating from headquarters resembling, functionally, some of our larger health centres in this country. In the greater majority of cases the first contact a patient has with the health services is the district medical or nursing officer, after which he or she may be referred either to the specialist outpatient clinics which operate outside the hospital service or to one of the specialist hospital-based polyclinics or directly to hospital as an inpatient. This system of two levels of outpatient care lessens the significance of the district medical function and hence of primary, non-specialist care as a whole, within the Swedish health service. Sweden has been governed by the Social Democratic Party since 1932 and there has been a progressive decentralization of the health care functions throughout this period. Local government is strongly developed in Sweden; there are at present 24 counties below the
298
P. J. Heath
central government level, each with a governor, presiding over a central board of administration, and for certain functions of a fundamentally municipal character there exists the county council, within which are united the municipalities or Kommuns. There are approximately 270 of the latter at the present time and their functions include housing, basic education, roads, sewerage, water supply, public assistance and child welfare. However, for the centre of health care provision we must look to the county councils, this is their main function and one for which they were formed; the Stockholm County Council provides a model largely applicable throughout the country.
Organization of Stockholm County Council It is the statutory responsibility of the county council to provide both outpatient and inpatient care for illness, injury, deformity and childbirth; the members are elected through a type of proportional political representation every three years and the way in which it fits into the bureaucratic governmental structure is shown in Figure 1. A more detailed breakdown of the organization of the Stockholm County Council is shown in Figure 2. The importance of the medical care function is shown in the expenditure diagram in Figure 3. The major part of this expenditure is raised directly by the County through local taxation of incomes. LEVEL
AUTHORITY
Ministry of Health and Social Affairs National Board of Health and Welfare Health and Medical Care Region County Council
Cabinet National Regional County
I Inpatient
I
care
I
Outpatient care
Figure 1. Organization of Swedish medical care. Council (149 members) I
Central Board (I7 members) I
Eight reporting commissioners Finance I
Personnel
Planning [
Health care
Social matters
Transport
I
I
Education and culture
Real estate
Figure 2. Structure of the Stockholm County Council.
Figure 3. Stockholm County Council operating budget, 1972 (millions of Swedish crowns).
Health care planning and computing in Sweden
299
It is clear therefore, that the provision of health care is very much a local government function, unlike the situation in the United Kingdom where there are specially constituted bodies responsible in a managerial line to the central Department of Health. The organization within the county councils, together with the well-known propensity of the Swedes to collect numerical data about themselves, has resulted in the development of a highly sophisticated computerized medical information system within the Stockholm County.
The Stockholm County Medical Information System In Sweden, the use of computers for health service purposes is more advanced than in this country; whereas we might in the past have thought of their use as somewhat of a luxury, the Swedish authorities have tended to regard them much more as a routine facility offering distinct advantages in the processing of large quantities of data. In 1965 it was decided by the Stockholm County Council that there would be a computerized medical information system to fulfil the following criteria: (1) it would cover the whole county and would include all institutions (71 hospitals with 20,700 beds); (2) it would be "real time"; (3) various functional routines could be added progressively at a later stage; (4) it should cover routine administrative, as well as medical and planning, functions. This decision was stimulated by an administrative reorganization of local government, which resulted in the combination, under one administrative body, of the major functional responsibilities of both the city and the county. The starting point for design of the system was the main file, which contains information on all the population in the area, under the following heads: census data--obtained from the central government census bureau and updated at weekly intervals; critical medicaldata--blood group, immunizations, some chronic diseases, etc. previous inpatient care--spells of hospital admission, in summary form, obtained from patient files; previous X-rays--recording the type of examination and the result. It is only possible to maintain a record of this type for such a large population because in Sweden each individiaal is given a unique identification number at birth, which facilitates such complex forms of information recording and linkage. In addition to the main file each hospital or group of hospitals has a special file known as the patient file; at present this is restricted to those hospitals or institutions which currently form a part of the system but it is eventually planned to extend it much further. Like the main file this is on direct access but the information, which is more detailed, is only stored for the period during which the patient is under treatment, and also for 30 days following discharge in order to facilitate the collection of all outstanding laboratory results; after this period a summary of the information is stored in the main file and the patient file itself transferred to the medical record file which at the present time is stored on magnetic tape. It is the patient file which accounts for the major fraction of the information exchange with users of the system.
Patient Administration Routines Information from the main and patient files is accessible by means of visual display units within the hospital, located in relation to wards, outpatient clinics, reception points and
300
P. J. Heath
laboratories; it is handled by trained terminal operators and access to it is by means of a coding sequence. The information is stored at differing levels according to the degree of security involved and staff have access only to that group of data which is appropriate to their security coding. At the present time there are five routines operating within the patient administration system. (1) Outpatient routine The patient is registered in a patient file by feeding his identity number into a terminal, the remainder of the data on that person being transferred automatically from the main file. The routine is in three parts: (a) Registration of consultation: personal data; type of consultation (first or subsequent); hospital; emergency/list case; department; diagnosis. (b) Registration of medical data: name of physician; examinations/treatments; referral source; outcome (home, transfer, etc.); vaccinations/sensitivities. (c) Accounting procedures concerned with direct payments made by patients. (2) Inpatient routine Initial entry procedure is the same as for the outpatient routine described above and other data will already have been fed in as a result of the pre-admission transaction and the automatic transfer from the waiting list routine, such as the examinations required (X-rays, etc.) and the procedures to be performed (for example surgical operations). Various patient lists are produced as a result of this routine and are issued to wards, admission centres, etc.: new patients due the following day (wards); cumulative list of pre-admissions; daily inpatient report (wards); scheduled bed utilization (head physician); detailed list of all inpatients (patients' officer, telephone operators and information desk). In addition to these there are numerous other reports available on activity, usually supplied at monthly intervals. (3) Chemical laboratory routine This is designed to make the maximum use of automated analytical procedures and, at a later stage, of small, specialized computers in laboratories, linked to the main computer. There are three parts to the system: (a) ordering of sample and analysis; (b) collection of data in the laboratorY; (c) reporting on analysis results. Results are fed in at laboratory terminals and are printed out in the form of cumulative lists, with the latest result shown in sequence; they may be presented as: all analyses of one type for one patient; all analyses for one patient; a chosen number of analyses for one ward in one day. Printers are connected to ward display terminals for this purpose. Tests ordered through waiting list and booking routines will be transferred automatically to the laboratory routine. (4) Waiting list routine One of the major aims of this routine is to try and ensure that all the resources in the many hospitals within the county are co-ordinated and used optimally. The referring
Health care planning and computing in Sweden
301
physician fills in a "referral form", to which the admitting physician adds further information when the patient is put on the waiting list. Admission is dependent on many resources, information on each of which is fed into the system and all tests and procedures required during the period of care are ordered and registered in advance. The aim is to optimize the utilization of all the resources required--manpower, equipment, health staffs' time and patients' time--simultaneously conforming to the necessary pattern of care for any one patient. In addition to the main and patient files other--resource--files are needed, containing information about personnel and material resources available within the hospital service. At the point of contact with the physician the patient is told what examinations and/or treatments are needed and this information is sent to the booking centre and fed into the computer; three alternative appointment times are displayed on the terminal for the patient to select the most appropriate one, special provision being made in the case of tests which must be performed in a certain sequence. In this way no delay accrues to the patient and he is able to plan his time in advance. The routine has been developed for both outpatient and inpatient care and at present is operating at 10 hospitals with a total of 8000 acute beds; multiple waiting lists can be produced, classified in many different ways.
Health Care Planning It can be argued that systems of health care delivery need three main inputs for their efficient functioning: (1) resources of manpower, materials, premises, etc.; (2) financial resources; (3) information. Forward planning needs, therefore, to concentrate on deployment of resources in some chosen relationship to demands or needs, using information to predict future states on a basis of past utilization patterns and forward projection estimates. As a socialist country Sweden attaches great importance to planning as a primary means of attaining what the various government agencies, both central and local, regard as desirable ends. If this approach is to be successful then control has to be exercised over the planning activities to ensure uniformity 'of provision and reasonable adherence to policy. There are also facets of planning which are concerned with shifting the emphasis within the total health care system, for instance, the large increase in the intake of medical students a few years ago which is expected to swell the number of doctors from 9930 in 1968 to 16,661 in 1975 and to 21,151 in 1980. My overall impression was that the high degree of independence accorded the county councils in terms of finance and policy decisions enabled them to provide health care to their local populations which need not follow closely any central government policy and which was largely idiosyncratic. In fact there is a marked element of rivalry between counties, which has resulted in duplication of expensive resources and which, I believe, has led directly to the emphasis on hospital care and to the spiralling total of acute beds. Whilst control in the U.K. is exercised centrally through a series of norms of provision, financial allocations and medical manpower planning, in Sweden the main form of central control lies in the regional allocation of medical personnel; although it is possible to argue that the British system of control is too rigid, it is equally arguable that in Sweden the control is too lax. I do not wish to say that I prefer either one or the other approach but it is instructive to look at a few indicators of medical and socio-economic state and compare the Swedish
302
P. J. Heath
performance with that in other countries and to link this performance to financial inputs. The perinatal mortality rate in Sweden is, at approximately 16 per 1000 live births, the lowest in the Western world; the value for England and Wales is around 23. Similarly for infant mortality, where the values are around 11 and 18, and for maternal mortality per 100,000 live births with values of 10 and 19 respectively. Hence, performance judged on these values indicates that the health services are making a better than average contribution to the well-being of the community. (There are data now available, from Dr C. Martini at Nottingham University (personal communication) which indicate that the contribution of health services to these three indices is less than that of socio-economic factors, but that need not affect the main argument in this particular case.) In a report (Maxwell) published in 1974, Robert Maxwell of McKinsey & Company, in discussing the performance of health services in selected countries, concluded that Sweden's performance in terms of acute care was ahead of that of all the other countries, but there were still serious omissions in the care of the elderly and the mentally ill, and I have been able to confirm this by my own observations; there was a need also to grapple with many socio-medical problems, particularly in reducing accidents and violence. However, they point out that the rate of expenditure is very high (it is currently approximately 7 % of the gross national product) and in looking at this in relation to other countries it seems that those with the strongest tradition of general practice, unlike the Swedes, are able to deploy scarce specialist skills to best effect and are generally achieving better value for money. If it were possible to institute a uniform system of collection of information which could be applied to all counties I would suggest that control of the pattern of health care institutions and other facilities thereby promoted would result in a diversion of scarce resources from expensive forms of hospital care to other forms of community-based provision at the level of district and home care. However, since it has never been convincingly demonstrated that community care is less costly than hospital care it is in this field that manipulation of the data base of the Stockholm information system could be of great value, allowing direct comparisons of the economics of care at each level. Discussion A field in which I feel that the Stockholm system has a major part to play is in the direct shifting of emphasis from hospitals to district health centres; there is already one centre with a display terminal and I understand that it is the intention to extend the facility to other centres and districts. This would go some way towards making the district centres more popular places in which to work and would begin to swing the control of individual medical and social care within the health care system more towards the community level. A further possible advantage of this approach would be to reduce the feeling developing amongst patients that the degree of automation currently being practised in Sweden is leading to an unacceptable lack of personal contact. An attempt is being made at present to bring some uniformity into the planning of health care systems by the formation of the Swedish Planning and Rationalization Institute of the Health and Social Welfare Services (S.P.R.I.). Here electronic data processing systems are being devised for patient management, personnel administration, materials, data base and a number of other functions. These systems are to be made available to those counties which have not the resources to develop their own and it may be that this approach will eventually produce a greater degree of control over planning when the eventual upper taxation limit is reached by the local authorities in the not too distant future. If this is so then it might be worth looking at the Stockholm system to extract from it that part of the
Health care planning and computing in Sweden
303
whole which is particularly applicable to district care and to consider making it more widely available. It would be inappropriate to consider direct application of the Stockholm system in this country, both from the economic and from the functional viewpoints. In terms of its geographical area and the spread of population Stockholm County might be said to approximate to one of our larger new area health authorities, which will in future be setting up their own information systems. The absence of a unique identification number precludes the use of a similar data base but there is an argument for the adoption of a modification of the booking routine, probably in batch mode (currently under investigation at Nottingham University) and for a series of terminals at area headquarters connected to the regional computers for retrieval and analysis of inpatient data currently available under the Hospital Activity Analysis scheme (later perhaps to be extended to outpatient data). I propose to explore this further and hope to initiate a small trial in my own aiea along these lines and to report on its feasibility. References Martini, C. J. Health Care Research Unit, University of Nottingham (Personal communication). Maxwell, R. (1974). Health Care: The Growing Dilemma. New York: McKinsey & Co. Inc.
Health Care Planning and Computing in Sweden P. d. H e a t h M,Sc,. M.B., Ph.C.
Specia/ist in Community Medicine (Information and Hea/th Care P/anning) Sheffie/d Area Hea/th A uthority (Teaching) During September of last year I was privileged to spend a month studying computerized medical information systems and their relationship to the planning and organization of medical care mainly in and around Stockholm. My trip was financed through a Council of Europe Fellowship, emphasis being placed on systems of data processing with particular reference to their applicability to our own health service following reorganization. This article outlines the organization of medical care in Sweden and its relationship to their system of government and their economy. A description of the Stockholm County Medical Information System then follows, together with a discussion of planning and its relationship to our own planning machinery. The Swedish Health Service The main emphasis of health care in Sweden is placed on hospitals--the number of acute beds provided per unit of population being generally in excess of that in most other countries. Consequently, the expenditure on total provision is high but the proportion devoted tO primary care is somewhat low when matched with economic inputs to health systems in countries at a similar stage of development. At the present time the economic state of the country is good and can sustain expenditure at this level. However, there are signs that they are beginning to feel the effects of inflation and the thoughts of the planners are turning more towards the need to increase the expenditure on primary care and to switch some of their resources away from hospitals. There are difficulties in persuading doctors to practise in areas where the 'population is widely scattered and the hospital facilities are not very extensive; Sweden has a total population of 8.1 millions and a density of 52 persons per square mile, but 90 % of the inhabitants live in the southern half of the country and the population density in the north is therefore very low. This problem is not unlike that found in the Hebrides or in Norway, where it has been largely solved by forms of special incentive to persuade staff to work in the less popular areas. Primary medical care is available at district medical centres, with medical, nursing and associated staff operating from headquarters resembling, functionally, some of our larger health centres in this country. In the greater majority of cases the first contact a patient has with the health services is the district medical or nursing officer, after which he or she may be referred either to the specialist outpatient clinics which operate outside the hospital service or to one of the specialist hospital-based polyclinics or directly to hospital as an inpatient. This system of two levels of outpatient care lessens the significance of the district medical function and hence of primary, non-specialist care as a whole, within the Swedish health service. Sweden has been governed by the Social Democratic Party since 1932 and there has been a progressive decentralization of the health care functions throughout this period. Local government is strongly developed in Sweden; there are at present 24 counties below the
298
P. J. Heath
central government level, each with a governor, presiding over a central board of administration, and for certain functions of a fundamentally municipal character there exists the county council, within which are united the municipalities or Kommuns. There are approximately 270 of the latter at the present time and their functions include housing, basic education, roads, sewerage, water supply, public assistance and child welfare. However, for the centre of health care provision we must look to the county councils, this is their main function and one for which they were formed; the Stockholm County Council provides a model largely applicable throughout the country.
Organization of Stockholm County Council It is the statutory responsibility of the county council to provide both outpatient and inpatient care for illness, injury, deformity and childbirth; the members are elected through a type of proportional political representation every three years and the way in which it fits into the bureaucratic governmental structure is shown in Figure 1. A more detailed breakdown of the organization of the Stockholm County Council is shown in Figure 2. The importance of the medical care function is shown in the expenditure diagram in Figure 3. The major part of this expenditure is raised directly by the County through local taxation of incomes. LEVEL
AUTHORITY
Ministry of Health and Social Affairs National Board of Health and Welfare Health and Medical Care Region County Council
Cabinet National Regional County
I Inpatient
I
care
I
Outpatient care
Figure 1. Organization of Swedish medical care. Council (149 members) I
Central Board (I7 members) I
Eight reporting commissioners Finance I
Personnel
Planning [
Health care
Social matters
Transport
I
I
Education and culture
Real estate
Figure 2. Structure of the Stockholm County Council.
Figure 3. Stockholm County Council operating budget, 1972 (millions of Swedish crowns).
Health care planning and computing in Sweden
299
It is clear therefore, that the provision of health care is very much a local government function, unlike the situation in the United Kingdom where there are specially constituted bodies responsible in a managerial line to the central Department of Health. The organization within the county councils, together with the well-known propensity of the Swedes to collect numerical data about themselves, has resulted in the development of a highly sophisticated computerized medical information system within the Stockholm County.
The Stockholm County Medical Information System In Sweden, the use of computers for health service purposes is more advanced than in this country; whereas we might in the past have thought of their use as somewhat of a luxury, the Swedish authorities have tended to regard them much more as a routine facility offering distinct advantages in the processing of large quantities of data. In 1965 it was decided by the Stockholm County Council that there would be a computerized medical information system to fulfil the following criteria: (1) it would cover the whole county and would include all institutions (71 hospitals with 20,700 beds); (2) it would be "real time"; (3) various functional routines could be added progressively at a later stage; (4) it should cover routine administrative, as well as medical and planning, functions. This decision was stimulated by an administrative reorganization of local government, which resulted in the combination, under one administrative body, of the major functional responsibilities of both the city and the county. The starting point for design of the system was the main file, which contains information on all the population in the area, under the following heads: census data--obtained from the central government census bureau and updated at weekly intervals; critical medicaldata--blood group, immunizations, some chronic diseases, etc. previous inpatient care--spells of hospital admission, in summary form, obtained from patient files; previous X-rays--recording the type of examination and the result. It is only possible to maintain a record of this type for such a large population because in Sweden each individiaal is given a unique identification number at birth, which facilitates such complex forms of information recording and linkage. In addition to the main file each hospital or group of hospitals has a special file known as the patient file; at present this is restricted to those hospitals or institutions which currently form a part of the system but it is eventually planned to extend it much further. Like the main file this is on direct access but the information, which is more detailed, is only stored for the period during which the patient is under treatment, and also for 30 days following discharge in order to facilitate the collection of all outstanding laboratory results; after this period a summary of the information is stored in the main file and the patient file itself transferred to the medical record file which at the present time is stored on magnetic tape. It is the patient file which accounts for the major fraction of the information exchange with users of the system.
Patient Administration Routines Information from the main and patient files is accessible by means of visual display units within the hospital, located in relation to wards, outpatient clinics, reception points and
300
P. J. Heath
laboratories; it is handled by trained terminal operators and access to it is by means of a coding sequence. The information is stored at differing levels according to the degree of security involved and staff have access only to that group of data which is appropriate to their security coding. At the present time there are five routines operating within the patient administration system. (1) Outpatient routine The patient is registered in a patient file by feeding his identity number into a terminal, the remainder of the data on that person being transferred automatically from the main file. The routine is in three parts: (a) Registration of consultation: personal data; type of consultation (first or subsequent); hospital; emergency/list case; department; diagnosis. (b) Registration of medical data: name of physician; examinations/treatments; referral source; outcome (home, transfer, etc.); vaccinations/sensitivities. (c) Accounting procedures concerned with direct payments made by patients. (2) Inpatient routine Initial entry procedure is the same as for the outpatient routine described above and other data will already have been fed in as a result of the pre-admission transaction and the automatic transfer from the waiting list routine, such as the examinations required (X-rays, etc.) and the procedures to be performed (for example surgical operations). Various patient lists are produced as a result of this routine and are issued to wards, admission centres, etc.: new patients due the following day (wards); cumulative list of pre-admissions; daily inpatient report (wards); scheduled bed utilization (head physician); detailed list of all inpatients (patients' officer, telephone operators and information desk). In addition to these there are numerous other reports available on activity, usually supplied at monthly intervals. (3) Chemical laboratory routine This is designed to make the maximum use of automated analytical procedures and, at a later stage, of small, specialized computers in laboratories, linked to the main computer. There are three parts to the system: (a) ordering of sample and analysis; (b) collection of data in the laboratorY; (c) reporting on analysis results. Results are fed in at laboratory terminals and are printed out in the form of cumulative lists, with the latest result shown in sequence; they may be presented as: all analyses of one type for one patient; all analyses for one patient; a chosen number of analyses for one ward in one day. Printers are connected to ward display terminals for this purpose. Tests ordered through waiting list and booking routines will be transferred automatically to the laboratory routine. (4) Waiting list routine One of the major aims of this routine is to try and ensure that all the resources in the many hospitals within the county are co-ordinated and used optimally. The referring
Health care planning and computing in Sweden
301
physician fills in a "referral form", to which the admitting physician adds further information when the patient is put on the waiting list. Admission is dependent on many resources, information on each of which is fed into the system and all tests and procedures required during the period of care are ordered and registered in advance. The aim is to optimize the utilization of all the resources required--manpower, equipment, health staffs' time and patients' time--simultaneously conforming to the necessary pattern of care for any one patient. In addition to the main and patient files other--resource--files are needed, containing information about personnel and material resources available within the hospital service. At the point of contact with the physician the patient is told what examinations and/or treatments are needed and this information is sent to the booking centre and fed into the computer; three alternative appointment times are displayed on the terminal for the patient to select the most appropriate one, special provision being made in the case of tests which must be performed in a certain sequence. In this way no delay accrues to the patient and he is able to plan his time in advance. The routine has been developed for both outpatient and inpatient care and at present is operating at 10 hospitals with a total of 8000 acute beds; multiple waiting lists can be produced, classified in many different ways.
Health Care Planning It can be argued that systems of health care delivery need three main inputs for their efficient functioning: (1) resources of manpower, materials, premises, etc.; (2) financial resources; (3) information. Forward planning needs, therefore, to concentrate on deployment of resources in some chosen relationship to demands or needs, using information to predict future states on a basis of past utilization patterns and forward projection estimates. As a socialist country Sweden attaches great importance to planning as a primary means of attaining what the various government agencies, both central and local, regard as desirable ends. If this approach is to be successful then control has to be exercised over the planning activities to ensure uniformity 'of provision and reasonable adherence to policy. There are also facets of planning which are concerned with shifting the emphasis within the total health care system, for instance, the large increase in the intake of medical students a few years ago which is expected to swell the number of doctors from 9930 in 1968 to 16,661 in 1975 and to 21,151 in 1980. My overall impression was that the high degree of independence accorded the county councils in terms of finance and policy decisions enabled them to provide health care to their local populations which need not follow closely any central government policy and which was largely idiosyncratic. In fact there is a marked element of rivalry between counties, which has resulted in duplication of expensive resources and which, I believe, has led directly to the emphasis on hospital care and to the spiralling total of acute beds. Whilst control in the U.K. is exercised centrally through a series of norms of provision, financial allocations and medical manpower planning, in Sweden the main form of central control lies in the regional allocation of medical personnel; although it is possible to argue that the British system of control is too rigid, it is equally arguable that in Sweden the control is too lax. I do not wish to say that I prefer either one or the other approach but it is instructive to look at a few indicators of medical and socio-economic state and compare the Swedish
302
P. J. Heath
performance with that in other countries and to link this performance to financial inputs. The perinatal mortality rate in Sweden is, at approximately 16 per 1000 live births, the lowest in the Western world; the value for England and Wales is around 23. Similarly for infant mortality, where the values are around 11 and 18, and for maternal mortality per 100,000 live births with values of 10 and 19 respectively. Hence, performance judged on these values indicates that the health services are making a better than average contribution to the well-being of the community. (There are data now available, from Dr C. Martini at Nottingham University (personal communication) which indicate that the contribution of health services to these three indices is less than that of socio-economic factors, but that need not affect the main argument in this particular case.) In a report (Maxwell) published in 1974, Robert Maxwell of McKinsey & Company, in discussing the performance of health services in selected countries, concluded that Sweden's performance in terms of acute care was ahead of that of all the other countries, but there were still serious omissions in the care of the elderly and the mentally ill, and I have been able to confirm this by my own observations; there was a need also to grapple with many socio-medical problems, particularly in reducing accidents and violence. However, they point out that the rate of expenditure is very high (it is currently approximately 7 % of the gross national product) and in looking at this in relation to other countries it seems that those with the strongest tradition of general practice, unlike the Swedes, are able to deploy scarce specialist skills to best effect and are generally achieving better value for money. If it were possible to institute a uniform system of collection of information which could be applied to all counties I would suggest that control of the pattern of health care institutions and other facilities thereby promoted would result in a diversion of scarce resources from expensive forms of hospital care to other forms of community-based provision at the level of district and home care. However, since it has never been convincingly demonstrated that community care is less costly than hospital care it is in this field that manipulation of the data base of the Stockholm information system could be of great value, allowing direct comparisons of the economics of care at each level. Discussion A field in which I feel that the Stockholm system has a major part to play is in the direct shifting of emphasis from hospitals to district health centres; there is already one centre with a display terminal and I understand that it is the intention to extend the facility to other centres and districts. This would go some way towards making the district centres more popular places in which to work and would begin to swing the control of individual medical and social care within the health care system more towards the community level. A further possible advantage of this approach would be to reduce the feeling developing amongst patients that the degree of automation currently being practised in Sweden is leading to an unacceptable lack of personal contact. An attempt is being made at present to bring some uniformity into the planning of health care systems by the formation of the Swedish Planning and Rationalization Institute of the Health and Social Welfare Services (S.P.R.I.). Here electronic data processing systems are being devised for patient management, personnel administration, materials, data base and a number of other functions. These systems are to be made available to those counties which have not the resources to develop their own and it may be that this approach will eventually produce a greater degree of control over planning when the eventual upper taxation limit is reached by the local authorities in the not too distant future. If this is so then it might be worth looking at the Stockholm system to extract from it that part of the
Health care planning and computing in Sweden
303
whole which is particularly applicable to district care and to consider making it more widely available. It would be inappropriate to consider direct application of the Stockholm system in this country, both from the economic and from the functional viewpoints. In terms of its geographical area and the spread of population Stockholm County might be said to approximate to one of our larger new area health authorities, which will in future be setting up their own information systems. The absence of a unique identification number precludes the use of a similar data base but there is an argument for the adoption of a modification of the booking routine, probably in batch mode (currently under investigation at Nottingham University) and for a series of terminals at area headquarters connected to the regional computers for retrieval and analysis of inpatient data currently available under the Hospital Activity Analysis scheme (later perhaps to be extended to outpatient data). I propose to explore this further and hope to initiate a small trial in my own aiea along these lines and to report on its feasibility. References Martini, C. J. Health Care Research Unit, University of Nottingham (Personal communication). Maxwell, R. (1974). Health Care: The Growing Dilemma. New York: McKinsey & Co. Inc.
