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Local autonomy key to improving health outcomes

Engagement and accountability can be challenges in the NHS. This year, Mid Staffordshire and other hospital care scandals have brought both these issues and the general question of standards into particular focus.

In a new report for the think-tank Civitas, I have set out how the Swedish healthcare system may offer some sound lessons as we go about tackling these problems. The history and core ideals of their system are similar, in that they have a universal public system, developed in the post-war era and financed from general taxation. However, there are crucial differences in performance and structure, mostly relating to decentralisation and local autonomy.

Health outcomes in Sweden are better in terms of life expectancy, infant mortality and potential years of life lost (PYLL). According to a Lancet study this year, Sweden has the fewest preventable child deaths among 15 European nations, while Britain has the most. Sweden also performs better on mortality amenable to healthcare, the best available measure of deaths preventable by healthcare intervention. Sweden’s system is also rated highly in both international rankings and national surveys.

One compelling explanation for some of these differences is the placement of both day-to-day provision and broad taxation powers in the hands of county councils, which handle healthcare services, and municipal councils, which handle public health and social care. Over 70% of funding comes from local taxation. It is felt that this makes services flexible and more accountable to local electorates, strengthening engagement and creating pressure to ensure standards.

It may also explain their high turnouts in local elections, which allow Swedes to shape health services more than our general elections do, and the willingness of Swedes to pay more in tax and fund Sweden’s higher per-head health spending, since the value for money link is clearer.

Also comparable is the fact that Sweden has seen internal market and patient choice reforms, intended to improve efficiency and standards. However, these are more entrenched in Sweden, and have accelerated since 2006. Despite issues and a need for more evidence, Swedish patients have appreciated choice and it appears that in some areas, reform has improved accessibility, responsiveness, productivity and satisfaction.

Also crucial is the role that decentralisation has played in allowing localities to shape the reforms, innovate and learn best practice from each other.

A continual concern about decentralisation of course relates to the fear of “postcode lotteries”, hence why the Swedish state still provides extensive oversight and guidelines, as well as a quarter of all health funding, ensuring critical balance.

But we must also remember that centralism in the NHS has never truly stamped out variance and that democratic local control means that service differences are not a haphazard ‘lottery’, as they are shaped by local service users.

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