Översyn av den offentligt drivna ögonsjukvården i region skåne - avdelningen för...

Koncernkontoret Avdelningen för produktionsstyrning

Karin Ekelund Ledningsstrateg 040 – 67 53032 [email protected]

Datum 2012-08-28

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Postadress: Organisationsnummer: 23 21 00-0255 Besöksadress: Region Skåne, Dockplatsen 26, 211 19 Malmö Telefon (växel): 040 - 675 30 00 Internet: www.skane.se

Översyn av den offentligt drivna ögonsjukvården i Region Skåne

På uppdrag av produktionsdirektör Lars Kristensson har en översyn av den offentligt drivna ögonsjukvården i Region Skåne genomförts. Bakgrunden till översynen har bland annat varit införandet av vårdval inom kataraktverksamheten samt det planerade införandet av vårdval inom den öppna ögonspecialistvården. Medicinskt ansvarig för utredningen har varit professor Anja Tuulonen, Tammerfors, Finland. Bifogat återfinns professor Tuulonens rapport, ”An overview and evaluation of the eye health care i Scania”; Innehåll An overview and evaluation of the eye health care in Scania, sid 1-26 Tables 1-5, sid 27-31 Tables 6, Summary of recommendations, sid 32-34 Appendix 2, Summary of Scania statistics, sid 35-60 Appendix 3, Visited eye care units and discussions, sid 61-62 Appendix 4, Documents delivered during the evaluation, sid 63-64

Tuulonen ‐ August 21, 2012 1

An overview and evaluation of the eye health care in Scania

Professor Anja Tuulonen

Director of Tays Eye Centre

Tampere University Hospital

August 21, 2012

PO Box 2000

FIN-33521

Finland

[email protected]

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Contents Page

1. The assignment - Background of challenges with excerpts from the literature. 3 What is known about: 1.1. The need and demand of services and available resources 3 1.2. Access to care, waiting lists, variations and outcomes 4

1.3. Hospital mergers 5 1.4. Helping successful people to change 6

2. The structure and basis of the present overview and evaluation 7

3. Observations and perceptions

3.1. The reliability of the 2007-2011 statistics on production 7 3.2. Production of Scanian eye health care in 2011 8

3.2.1. Overall production 8

3.2.2. Observations and perceptions in some eye diseases 8

3.2.3. Regional variation 10 3.2.4. Trends in 2007-2011 10 4. Care Guarantee and Choice of Care in cataract surgery vs. chronic eye diseases

4.1. Cataract surgery 11

4.2. Is the current prioritization equitable? 12 4.3. Side-effects of Care Guarantee and Choice of Care 13

5. Personnel 14 6. Merger between Malmö and Lund University Hospitals 15 7. Management and ‘optimal size’ of a hospital 16 8. Economical aspects 17 9. Premises 17 10. Research and education 18 11. Organizational scenarios with their advantages and disadvantages 18 11.1. Keeping Scanian health care structure as it is 19

11.2. Scanian Eye Hospital 20 11.3. The middle way (from ‘either-or’ to ‘both-and’) 20

12. Shared care 21 13. Suggestion for next steps (‘prescription’) to improve Scanian eye care

13.1. Recommendations on care processes (independent of the organizations) 22 13.2. Organizational structure 22 13.3. Leadership 22 13.4. Preferred kick off 23

14. Conclusions 23 15. References 24

Enclosures

Tables 1-6 Appendices 1-4

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1. The assignment - Background of challenges with excepts of the literature The purpose of this brief 2-week evaluation was to create a big picture of the current Scanian eye health care as well as make some holistic and itemized recommendations to be considered in decision making when solving the current and future challenges. Two major Swedish policies to improve access to care and shorten waiting times have been implemented recently: the up-dated Care Guarantee (2005) and Choice of Care (2012). The Care Guarantee confirms that the patient gets the required evaluation and treatment (when it fulfils the national criteria) within a defined period of time. In Choice of Care the money follows the patient who can choose the unit for examination and treatment. The merger of the two university hospitals in Malmö and Lund into Scanian University Hospital (SUS) represents a major local attempt to improve health care.

1.1. What is known about the need and demand of services and available resources

In spite of the fact that the developed countries – more than ever before - spend money and offer services to their citizens (who feel healthier and live longer than ever), the rate of growth in demand of services surpasses the resources societies are able to invest in health care. Although all countries agree that their health care costs are growing too large and too fast, including the US (Sommer 2009), the major cost drivers for rising health care expenditure has been debated for decades (e.g. new technologies, aging, professionals, organizations etc).

In 1940-1990 technological change was argued to be the most important driver for increased expenditure in health care (Newhouse 1992). In spite of the fact that a lot of (un)necessary costs raise from the adoption of inappropriate interventions and technology (Sommer 2009) - nowadays also from massive IT-technology - Getzen claimed that in 1960-88 political and professional choices were far more important in explaining the increase in spending - also when compared to aging (Getzen 1992). In agreement, aging alone induced only 1% increase in the yearly costs of Finnish eye care a decade ago (1/8 of the total increase of costs) (Tuulonen 2009). If professionals and organizations adopt interventions that are not cost-effective, they not only increase demand, needs and expenditures of the services but simultaneously enhance the perception of ‘underfunding’ (Maynard 2001, Muir Gray 2001). E.g. the increase in physician services has been reported to associate more with supply than demand factors (Keskimäki 2001). Thus, health care has a supply-led nature: the more services are produced, the larger is the demand.

By making it seem as if cost increases are inevitable for any external force which are regarded as being beyond ‘our’ responsibility (e.g. aging and developing technology), attention is diverted from the real and difficult choices that we must make when producing services equitably, equally, effectively and efficiently (Evans 2004). Thus, regardless of what might be the most important cost driver, we cannot escape that ‘the problem is us’ (Getzen 1992), i.e. the effects of structures and policies in the health care systems we have constructed.

In countries with national health services, public hospitals provide services with fees below actual costs to the citizens (the public sector’s ‘stakeholders’). With the resources our

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societies have decided to allocate to health care, the systems try to promote well-being and protect citizens by reducing premature death - and taxes (Maynard 2004). In our different roles of the society, as tax payers, patients, different professionals, and decision makers in all levels, we also share the responsibility for problems generated by our system and need become part of the solution. Further development and adoption of new and usually more expensive diagnostic, administrative and IT technologies and treatments will create even further demand for explicit priority setting.

1.2. What is known about access to care, waiting lists, variations and outcomes

In spite of the fact that growth is the major feature of modern medicine, the cure is still believed to be more services and more money. Most people also assume that more medical care must lead to improved health and well-being. However, adding more resources may also have counterintuitive effects (Fisher & Welch 1999). Despite 60 % more services and higher spending in one US region, there was no difference in patients’ access to care, satisfaction, quality of care, or outcomes compared to a lower spending area. The study concluded that 30% savings could be possible in the US without comprising the quality of health care (Fisher et al. 2003a and b). In every-day practice, the challenge lies in the trade-off between the simultaneous over-consumption of care and too little care. The challenges are similar in countries with national health services, like the Nordic countries and Great Britain. Hospital waiting lists, far larger than needed to schedule patients, have been a persistent phenomenon, e.g. in Great Britain at least since 1948 as well as many other European countries (Finland, Norway and Spain) (Table 1). In addition to patients who have succeeded to get to the waiting lists, our health care systems do not find all patients suffering from diseases. As one example of simultaneous under- and over-care, half of glaucoma patients are not aware about their disease while simultaneously up to half of patients are treated for risk of glaucoma without any abnormalities (Vaahtoranta-Lehtonen et al 2007). According to literature, neither health care professionals, health economists, managers nor politicians have succeeded to manage the long waiting-times efficiently (Maynard 2001, Table 1) - nor other significant problems in health care, such as huge medical practice variations and access to care in different regions (not explained by differences in case mix), differences in health between different groups, medical errors, patient outcomes and cost-effective care. Thus, despite increased investments in health services research and managerial efforts, health care delivery is still characterized by problems that have been known and unresolved for decades (Evans 2004, Maynard 2004) Regardless how the health services are structured and financed, the physicians’ millions of decisions on individual patients determine both the patterns and costs of care. It is, particularly, the cumulative effect of small changes to clinical practice (e.g. adding a new diagnostic test or therapy) that has massive impact on health care budgets (Muir Gray 2001). The challenge is how to adjust the joint outcome of these separate decisions with the overall objectives of the system. Focusing only on local autonomy may be harmful for the system a whole (Senge 1999), e.g. a clinician taking ‘the best possible care’ of a single patient even if it would mean that 10 other patients would get no care at all. As physicians, however, practice

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in a fragmented, isolated tradition, they usually do not have (or may not be interested) in reliable administrative information by which they could monitor 1) what they produce in terms of activity, case mix and outcome, 2) how they produce, i.e. what criteria they use to abandon and adopt new treatments and technologies, 3) how much they produce relative to their peers, and 4) to whom they deliver care (Maynard 2004). If a decentralized system is to work properly, every decision maker needs to be able and willing to take all the costs and benefits into account when deciding what to do (Williams 1993).

1.3. What is known about hospital mergers?

Since the first merger in private business in 1895, several merger waves have hit the global markets, e.g. a merger every 18 minutes in 2004 (Choi 2011). Mergers are driven by a complex pattern of motives (stated and unstated) which could be simplified as striving for the improved combined performance (1+1=3), or gaining more with less (Morina et al 2011). The repeated cycles of mergers and their frequent underperformance have established an active field of research. Different schools with ‘hard and soft’ viewpoints try to understand why mergers lead often to up 75% failure in lieu of the desired success (Choi 2011).

Merger trend hit the US health care three decades ago and entered first UK hospitals in Europe, with a number of hospital mergers carried out also in Sweden (e.g. Morina et al 2011, Choi et al 2011). Sahlgrenska (formed in 1997), Karolinska (2004), and Skåne University Hospital (2010) represent university hospitals which have been claimed represent ‘the most complex organizations in human history’ (Choi 2011).

The recent thesis on Karolinska University Hospital merger agrees with previous literature indicating that hospital mergers, too, typically fail in one or several dimensions. Although post-merger cost savings have been reported in the literature with a few mergers, they have been quite limited and may have simply represented one-shot savings rather than sustainable reduction in rates of cost growth. When seven mergers of 17 hospitals in 1992-2000 in Norway were analyzed, mergers showed no significant effect on technical efficiency and had a significant 2-3 % negative effect on cost efficiency. Positive effects on both cost and technical efficiency were found in only one merger. In Karolinska University Hospital, economic problems still existed six years after the merger (Choi 2011), similar to Sahlgrenska University Hospital (Holmberg & Jansson 2008).

Horizontal tension (between units) and vertical tension (between managerialism and professionalism) are probable explanations why hospital mergers are such a difficult task (Choi 2011). The second post-merger year in Karolinska University Hospital revealed a “total war” between management and staff. It was very difficult for management to anticipate and handle strategic organizational differences. Contrary to merger literature’s prescription, initial managerial success seemed to impair the change process further down the organization in Karolinska merger (Choi 2011).

In spite of the initial success in integrating administrative hospital functions, clinical integration is much harder to achieve. Especially in organizations where professional services are based on personal expertise, the merger process is highly dependent on the professionals’ trust and willingness to cooperate. A pure top-down approach may cause professionals with valuable

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knowledge and skills to leave the organization. It takes a long time to rebuild the trust, and to deal with resistance from the medical professionals. In knowledge-intensive organizations, such as a merger between large pharmaceutical companies, it may take 7 to 10 years before potential synergies start to realize (Choi 2011).

Although according to previous literature the failed clinical integration in Karolinska merger was ‘expected’ and a well functioning integration was ‘an anomaly’ (Choi 2011), it shows that success is, however, possible (Table 2). Factors that facilitated integration were the clinical manager‘s approach of “serving two masters” (management and professionals), shared clinical and academic leadership, and the implementation of bottom-up approach for change. The success of shared leadership differs from the “strong individual leadership” which is typically recommended by the traditional merger literature. The shared leadership handled the vertical tension between managerialism and professionalism and shielded the professionals from the pressure ‘above’. The academic leader promoted research success across the two sites. 1.4. What is known about helping already successful people to change Communications during mergers is a tough challenge and never an easy ride (Shaw). Culturally, especially the most higher education institutions are reluctant to accommodate sudden and dramatic change. They also struggle with whole institution loyalty – with academic staff relating most strongly to their department, unit or peer subject group. Professions with higher perceived social status (e.g. physicians, pilots, investment bankers) also tend to have even higher self-assessments relative to their (equally prestigious) peers (Goldsmith). When told to physicians that exactly half of all MDs had graduated in the bottom half of their medical school class, some doctors insisted that this was not possible (Goldsmith).

Marshall Goldsmith (recognized as the #1 leadership thinkers in the world by the Harvard Business Review) refers to Charles Hendy's "paradox of success" which occurs because we need to change before we have to change (Goldsmith) (Table 3). We all have a tendency to revert back to behaviors that were correlated with success in the past. The more successful we are, the easier it is to rationalize this return to past behavior.

Helping successful people change behavior is both an opportunity and a huge challenge. A leader will never be able to win over all those involved to feel engaged - all of the time (Shaw). Although well-intended and constructive suggestions for the future are always welcome and often very useful, leadership is neither a popularity contest (Goldsmith).

A Finnish columnist Aesculapius wrote a conspicuous causerie ‘Sit tibi teer levis’ (Light Composts) of the challenges of a clinical leader. If you want be known as inspiring, expressive, responsible, caring, equitable, and diligent person with whom everybody always feels good and safe because you are stable, tactful, considerate, conscientious and altruistic as well you gain an undivided appreciation and trust from your colleagues as a person constantly supporting others and interested in promoting others’ well-being – you’d better die. No wonder high-potential leaders are claimed to represent one of the greatest sources of value for the organization of the future, a principle e.g. St. Erik’s Eye Hospital in Stockholm.

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2. The structure and basis of the present overview and evaluation

The 2007-2011 statistical data was requested from the eye hospitals. In May 2012, the eye hospitals were asked to deliver the data reported in Appendix 1. Thereafter, their data was summarized and discussed in detail with the experts during the site visits to confirm understanding of the contents. After the visits, the summary of the statistics and figures were mailed to the eye hospitals for comments (Appendix 2)

Visits to the premises of the eye care units (n=8) and discussions with experts (n=31) are listed in Appendix 3.

In addition to reviewing the 2007-2011 production statistics, the views, experiences and perceptions of the experts were discussed using an unstructured format. Views for certain topics were touched, e.g. post-operative cataract controls, choice of treatment in age-related macular degeneration, process of taking visual fields, and shared care. Two physicians who had left (one each in Lund and Malmö) and one nurse who had left Lund were interviewed. In addition, one private clinic was visited. At the end of site visits, all participants were asked what they would do to improve Scanian eye care if they had all the power and money. Of the 32 interviewed experts, 12 represented management above the SUS ophthalmology department (32%)

Other material delivered during the evaluation is listed in Appendix 4.

3. Observations and perceptions

3.1. The reliability of the 2007-2011 statistics on production

At its best, the analysis and decisions should be based on numbers both in every-day practice and management in health care (‘Evidence Base Health Care’, Muir Gray 2001, Maynard 2001). In this brief evaluation, the interpretations of the produced 2007-2011 statistics (especially when trying to analyze trends over time), however, should be considered with utmost caution. Therefore, the interpretations, especially in trends, can be regarded only as suggestively directional and hopefully offer basis for further constructive discussion.

Although the time-table to produce the statistics was limited, Helsingborg was able to report the required information almost completely. In other eye hospitals a lot of data for many years were missing (Appendix 2). Specifically the data prior to the SUS merger were very unreliable. Probably only pre-merger data from Malmö was delivered for this evaluation. Some pre-merger data presented in this evaluation were not received through ‘official’ routes. Individual academic ophthalmologists have kept their own statistical follow-up e.g. from medical retinal diseases and retinal surgeries. The pre-merger need of retinal surgeries was estimated to be around 1000 per year. The estimates for occasions for in-patient care varied from 1000-1400. Thus, similar to reported literature, ophthalmologists in general are not aware what they produce relative to their peers in Scania, nor their case mix and outcome.

There were also differences between the hospitals in the ways of reporting about their production. This indicates that there seem to be no regional definitions what to report on a yearly basis or as trends over the years. For example, some clinics reported initially AMD injections, laser treatments, fundus images and visual as operations. To the contrary, some

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clinics did not register visual fields and fundus images at all. Although there was an effort to straighten up these different interpretations during the site visits, the validity of data remains open for healthy discussion. For example, the high number of operations in Scania (40% higher than St. Erik’s, Table 4) raises suspicions. Quite often, it was also unclear whether the numbers presented visits or patients.

The understanding of the availability of the numbers and their validity was, however, different above the eye department in the management level in Scania, especially in SUS. In quest after the missing numbers, it was confirmed several times that ‘the numbers must be there’. A few administrative people seemed almost offended when hearing that the ophthalmologists do not know, or have all the numbers available. The overall impression was that currently there does not seem to be clarity among clinicians, researchers nor managers about the overall production of eye care services in Scanian region, nor their past trends, and obviously about the scenarios for future neither.

Recommendation for improvement:

– To gain better understanding of the current Scanian production and its trends as well as for systematic national and international bench-marking purposes (e.g. through the World Association of Eye Hospitals, WAEH), it would be beneficial to agree what clinical parameters are important to be followed, how they are reported, who collects the data, who follows them and takes responsibility reacting on them when needed.

3.2. Production of Scanian eye health care in 2011

3.2.1. Overall production

Taken into account the uncertainties in delivered statistics, the total production of eye services in 2011 was around 170 000 (including out-patient visits and operations) (Appendix 2). Compared St. Eriks’s Eye Hospital in Stockholm (Table 4), this is approximately 15 % less than the 200 000 services reported in their 2011 Annual Report (http://www.sankterik.se/sv/om-oss/). St. Eriks’s is the only hospital dedicated solely to the eye diseases in Sweden.

3.2.2. Observations and perceptions in some eye diseases

The production in ophthalmology consists of ‘Big Four’ eye diseases which e.g. in Finland account more than 80 % of costs (cataract, glaucoma, age-related macular degeneration and diabetic eye disease). During the evaluation it was not possible to get an understanding how many patients with the ‘Big Four ‘ and other diseases had visited the eye care units. Overall number of all visits per patient was 1.7 (range 1.2 – 2.0) and the ratio between first and control visits was 2.4 (range 1.9 – 3.0) (Appendix 2). The number of AMD injections seems low compared e.g. to Tampere and Oulu University Hospitals in Finland in 2011. If the Scanian number of injections was similar to these two Finnish university hospitals, the number of injections in Scania would have been approximately 6500 - 8500 in Scania in 2011, i.e. 2-3 times higher than the reported 2500

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http://www.sankterik.se/sv/om-oss/


from last year. The difference is high even though the SUS experts in medical retina reported that – due to high price of the selected medication - the criteria for treatment have been kept strict. Nobody, of course, knows what is the ‘right’ number on injections per population. It is unlikely, however, that the prevalence would differ that much between neighboring Nordic countries. It is, of course, possible that due to reporting problems the actual Scanian actual numbers of injections were higher. In Helsingborg, the medication costs increased over 360 % during 5 years 2007-2011 (Appendix 2). In 2011, the medication for treatment of age-related macular degeneration accounted 86 % of medication costs. The fact that some expenses rise considerable more compared to costs in general has impact to the care of other eye diseases. Their access to care must decrease, both for controls and new referrals. In Finland and in many other countries, an affordable off-label therapy (bevacizumab) has been favored and used since 2008 for treatment for age-related macular degeneration instead of another drug of the same company. This drug is approved for treatment of macula degeneration and is substantially expensive. It has been claimed that drug prices depend entirely on their anticipated demand and have little to do with the cost of the production (Sommer 2009). The Finnish policy has been under debate constantly since 2008 and is again currently under evaluation in Valvira (the highest supervising health care authority in Finland). The more affordable medication has allowed looser criteria for treatment in Finland. The medical directors of all Finnish university hospitals wrote a pro-statement in the Journal Finnish Medical Association for allowing continuing use of bevacizumab for age-related macular degeneration. This policy is estimated to save more than 20 million € every year (170 SEK) per the 5.4 million population in Finland. Although in 20% of cases bevacizumab injections were used in St. Erik’s in 2011, there has not been a national or regional policy promoting the use of the affordable therapy in Sweden. The difference in costs spent between the two drugs was 12-times in St. Erik’s Eye Hospital last year. Recommendations: – To be able to consider current and future care processes and their need for improvement,

knowledge of the number of patients and the number of visits separately would be useful. These data is required also for national and international bench-marking.

– In addition to total number of AMD injections (age related macular degeneration), it would be important to know how many patients are referred per year for evaluation of AMD therapy and require imaging, what percentage of them are selected for treatment, the criteria for therapy and follow-up (including number of follow-up images), the number of injections of patients and in how many patients therapy is withdrawn due to unsuccessful outcome. These data helps to estimate future increase in demand.

– By using the affordable therapy for age-related macular degeneration, based on the cost data of St. Erik’s, it would have been possible to save roughly 20 million SEK in Scania in 2011. Or alternatively, to give over 3 times more injections if indicated (up to 8500 which would correspond the number of injections in two Finnish university hospitals). This kind of choice of therapy typically requires bold system-level decision making and responsibility because of the exceptionally heavy marketing pressure on physicians.

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– The injection rate for age-related macular degeneration could be improved also by delegating the injections to nurses which would save ophthalmologists’ time to decision making in diagnostics and follow-up as well as surgery.

– It would also be helpful to know how many patients per year are treated for glaucoma, how many visits they have to the eye clinics, how many visual fields and images are taken per patient per year, and what is the yearly increase in referrals for glaucoma.

– Similarly, knowing the total number of diabetics would be helpful when evaluating the adequacy of current screening on one hand and get an estimate of the number of imaging and future needs. The national and pharmacy registries of patients using diabetic and glaucoma medications would be useful - if available - for regional planning purposes and for gaining some basis to estimates of future needs.

3.2.3. Regional variation Similar to differences between countries, there seemed to be regional differences in Scania regarding the case mix of the ‘Big Four’ eye diseases (Appendix 2). The differences in the proportion of visits were up to 5-fold in cataract surgery, 2-fold in AMD, 4-fold in glaucoma and 5-fold in diabetic eye disease. The differences could be partly explained by case mix as SUS offers also near services to its serving area. In addition, the care of some patient groups is concentrated to SUS which accounts approximately half of the total Scanian eye care production and population. 3.2.4. Trends in 2007-2011

Although the reliability of the trend data is questionable, some discussion might be useful. It looks like the post-merger production of SUS has decreased 20 % compared to combined pre-merger production in Malmö and Lund (89 000 in 2008 vs. 68 000 in 2011 with difference over 20 000 visits). One wonders whether this drop can truly be real, or whether the drop is due to differences between pre- and post-merger reporting. Simultaneously to this drop, however, the production in other Scanian eye hospitals increased by about 11 000 visits (of which very roughly one third each in Helsingborg, Kristianstad and Ystad-Trelleborg combined). A separate document indicated a total number of 6851 operations in Malmö and Lund in 2006 (Appendix 4). This was 650 (10%) more than 5 years later. During 2009-2011, the number of operations in Kristianstad and Ystad increased by 1370. This is probably at least partly due to a post-merger shift of patients and staff to other hospitals in Scania. The number of cataract operations in SUS decreased by 900 (23%) from 2005 to 2011 and by 280 in Helsingborg from 2007 to 2011 (altogether -1180 operations). As Kristianstad increased cataract operations in 2009-2011 by 630, the total decrease of cataract operations was somewhere around 550. However, the biggest drop of 44 % (about 450 operations – please, note the comment about validity of numbers) was reported in the number of retinal operations, from pre-merger estimate of maximum of 1100 in 2008 (847 in Lund from a separately delivered 2008 report, Malmö 130 and Kristianstad 130) to 635 in 2011. This drop was reported to relate directly to the post-merger period when several retinal surgeons left Lund.

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The postoperative controls at public sector after eye operations accounted about 10 % (range 5 -18 %) of the out-patient visits in 2011 and showed a decreasing trend in 2009-11 the hospitals which reported these data (Appendix 2) . The largest decrease in post-operative controls was seen in Ystad and Kristianstad which simultaneously increased the number of cataract operations. Obviously, the post-operative controls were turned out-side of these hospitals. The fact that postoperative controls in the Choice of Care (vårdval) are referred back to public hospitals will probably increase again their proportion - at the expense of other eye diseases. Currently, in some units nurses are taking care for post-operative controls after cataract surgery.

In Finland, the current practice is to direct the patients after uneventful cataract operations to optometrists in private sector to gain spectacle correction. Although the optometrists are health professionals, in Finland they cannot (contrary to Sweden) currently refer patients directly to public sector (in Finland only via health care centers). The Finnish patients can, of course, choose to see a private ophthalmologist – at their own expense – to gain post-operative spectacle correction. Also this current policy (post-operative cataract controls at optometrists’ offices) is under evaluation in Valvira (the highest supervising authority in Finnish health care). If Valvira decides to change the current policy which have been implemented since 2007, there would be increase of 50 000 visits in the country – and decrease the number of visits for other eye diseases with the same extend. Recommendations Retinal surgery – The revival of retinal surgery should be on top of the list in improving the Scanian eye

care. A team of Scanian experts and managers need to establish the regional goal and estimate for the need of surgeries and road map how to get there.

Cataract surgery – It would be worthwhile to consider increasing and setting a goal to bilateral cataract

surgery (e.g. to 30-40%) in order to improve efficiency and access to care for surgery. – Regarding explicit prioritization it would be imperative to consider discussing whether the

post-operative controls after uneventful surgery (majority of cases) could be referred to private optometrists. This would save both physicians’ and nurses’ time to vision saving tasks.

4. Care Guarantee and Choice of Care (vårdval) in cataract surgery vs. chronic eye diseases

4.1. Cataract surgery

The improvement of access to care through national Care Guarantee has been both in need and successful. According to a separately delivered report, the median waiting time in Scania for cataract surgery was 8-10 months in 2005-06 compared to maximum three months after Care Guarantee became valid. If the number of cataract surgeries has, however, truly decreased in Scania, it could be postulated that the improvement is mainly based on stricter criteria.

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A similar phenomenon was also found in Finland after 2005 Care Guarantee which defined the national criteria for cataract surgery. In the entire country, the number of patients on the waiting list dropped from 24 000 to 12 000 between years 2000 and 2007 (Tuulonen 2009). This happened in spite of fact that the number of operated cataract patients did not increase during the same period of time. However, bilateral surgery increased from 3% in 2001 to 29% in 2007 which increased the efficiency of cataract surgery. Although one goal of the Finnish national criteria was also equalizing the indications to therapy, large variations have now appeared in the frequency of bilateral surgeries which range from 0 to 70%. It is again a matter of definitions and decisions, what would represent the ‘right’ number of cataract surgeries and bilateral operations. In Scania, the numbers for bilateral surgery were not reported, presumably because bilateral surgery is a not a current policy and therefore probably not promoted e.g. through reimbursements rules. 4.2. Is the current prioritization equitable? As mentioned earlier, even if all public money would be spent on health care, we would not get rid of waiting lists. Such an investment would neither be very profitable because health care accounts only 10-20 % of the improved well-being of the citizens, compared e.g. to many other important infrastructural services, such as education, safety at work and traffic, etc. Thus, we must make choices in health care by explicit prioritizing (rationing) all interventions, including diagnostics tests, treatments, care processes, practices, management models - and also IT technologies. Although cataract is the only one among the ‘Big Four’ eye diseases which does not cause permanent visual disability, it is of interest to notice its leading role in Care Guarantee and Choice of Care, also in Sweden as in many other countries. One possible explanation is its nature as a ‘once-in-a-life-time’ (maximally twice) procedure. It is easy to measure what gets done compared to chronic life-long diseases which may damage vision permanently over variable times. Once these patients with chronic disease get a (right or wrong) diagnosis, they will – contrary cataract - stay within the system until death. Thus, their number increases constantly with new cases and extended life expectancy. The number of new referrals was about 37 500 in 2011 (Appendix 2). With about 10 000 cataract operations performed in 2011, most of them were due to diseases other than cataract. Contrary to cataract, one would expect that age-related macular degeneration (causing most visual disability in the elderly) and glaucoma (on the second place in the elderly) and diabetic eye disease (causing most visual disability at working age), would be on the top of the list in Care Guarantee. Although there is now treatment to one form of age-related macular degeneration which require testing and treatment within a few weeks time, the national policies to improve the access to care in Sweden are not obvious. If the delivered numbers are correct, the number of treated Scanian patients with AMD seems low suggesting possible considerable under-treatment. Simultaneously, during 2009 -11 the visits of glaucoma patients in Scania decreased 2 % in spite of the new diagnosed cases. The number of glaucoma operations has decreased to half during six years (196 in 2006 to 98 in 2011). In addition, 50 patients

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with diabetic eye disease were reported as Lex Maria cases June 2012 due to delayed control visits and may have suffered permanent visual loss. From the perspective of explicit prioritization, getting all cataracts operated within three months is not equitable. 4.3. Side-effects of Care Guarantee and Choice of Care

In spite of gains in improved access to care, the Care Guarantee and Choice of Care – as all policies – have also counterintuitive side-effects. The dual current structure, i.e. the lack of trained ophthalmologists in public sector in Scania (due to overall shortage in Sweden and post-merger escape from SUS) as well as national guarantee to receive and select unit for cataract surgery within 3 months time, the only thing ophthalmologists need to do is to sit and wait for 3 months to confirm the demand in private sector. This might also back the rising claims especially within the younger generation in some hospitals to request working at both public and private sector. As was reported already in 1987 and confirmed by many others later, failure to cope with the public sector work-load might be financially advantageous (Yates 1987, Martin 2003, Tuulonen 2005, Table 1). Thus, the problem – again – is ‘us’, the structure we have created. It is extremely difficult to persuade physicians to adopt cost-effective practices if the incentive structure opposes such behavior. In the long-run, however, it is very difficult to conclude what is finally cause and effect. This is demonstrated in the causal-loop which explains the Finnish structural 23 % -shortage (range 16 -31 %) of ophthalmologists in public sector since 1986 (Table 5). There is no evidence that an increase in salaries leads to better productivity (Tuulonen 2005). In the US, medicine is composed of individual physicians who are paid each time they treat patients for a disease, mostly on a fee-for-service basis which pay for ‘disease work’. If you pay for piecework, you will get more piecework (misplaced incentives) (Sommer 2009), i.e. fee-for-service system creates incentives to over-produce services and rewards unnecessary as well necessary care. In stead, Sommer suggested a system where pay would depend on the infrequency of patients going blind from eye diseases.

If the number of cataract surgeries would hypothetically be set e.g. at high level of 1% of population, the need of cataract operations in Scania would be 13 000 per year, 3600 operations (38%) more than in 2011. If 30% of them would be bilateral surgeries, the number of operated patients would be 9100. If we count 200 full working days per year and perform 10 cataracts per day in one operating room (current reported number is 12 per day), all 13 000 Scanian cataract operations could be performed in 7 operating rooms. However, there are currently 17 operating rooms in public sector in Scania (compared e.g. to St. Erik’s 9). When we add the 10 operating rooms in the private sector available through Choice of Care, the number rises to 27 operating rooms in Scania. As the private sector units are at the top of the list on the Choice of Care web site, this mean that there is a generous overcapacity of the operating rooms in Scania in both public and private sector. The Choice of Care allows purchasing of operations with very low rates (e.g. 100 cataracts per year per surgeon). Obviously, operating theatres as facilities are not the key factor in long waits, except currently in Malmö after the merger. Similar to history again (Table 1), the hospitals trusts with more had more patients with prolonged waiting (Martin 2003, Tuulonen 2003).

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Recommendations

– In priority setting, the eye diseases causing permanent visual disability (age-related macular degeneration, glaucoma and diabetic eye disease as well many other smaller patients groups, including children) should be prioritized before cataract which does not cause irreversible blindness even with longer waits than 3 months.

– The incentive structure should be based on preventing visual disability from eye diseases and taking long-term responsibility of continuity of care of patients with (chronic) eyes diseases in stead of fee-for-service.

– If purchasing services from private sector increases as well as part-time working in public and private sector gets political leverage, they cannot be expected to solve the physician shortage nor waiting times (Tables 1 and 5).

– The Scanian eye health care structure should be structured to work more efficiently.

5. Personnel

Although the number of 18-36 new ophthalmologists by 2020 (depending on the source 2-4 residents graduating per year) may be enough for replacing the number of 21 retiring specialists by 2020, many hospitals would need to hire more physicians immediately. After SUS merger several specialists (mainly from Lund) left to other hospitals (within and outside of Scania), and to private practice. A new phenomenon seems to be the request for part-time working in both public and private sector. This creates increased further pressure to residency program as for every position in public sector, more than one ophthalmologist needs to be trained. On the other hand, this affects also other specialties. Although ophthalmology is an important specialty, patients’ other diseases need care as well. In Finland, the part-time working in public and private sector has been implemented since 1990’s. It has not solved the problems of waiting lists or physician shortage. Work load of Scanian specialists per year was reported approximately 1600 per year which is on the same level as in Finland (Tuulonen 2005).

The statistics revealed that approximately 63 % are physician visits (range 60 - 67 %). According to a separate report, this proportion was over 70% in 2005-06 indicating increase in shared care. Nurses take care of pre-operative measurements, and in some units also post-operative controls in cataract surgery as well as control visits for ocular hypertension and glaucoma. Interestingly, in some units nurses read the referrals which is a task decreed by law solely to physicians in Finland. In Scotland, nurses have distant clinics in remote locations as well as perform minor lid surgery and laser treatments (laser iridotomy, laser trabeculoplasty and yag-capsulotomy). In Bristol, half of the acute cases are seen by a nurse only. Mobile unit is used northern Finland to offer services for diabetes and glaucoma in remote regions (Hautala et al 2009).

Many units were concerned about the lack of nurses and ortoptists in addition to lack of ophthalmologists. If the shared care would be developed further which would be practical, this lack could be increased further. However, currently the nurses who have academic grade in

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Sweden, are doing many things which could be delivered to technicians. So far no optometrists are working in Scanian public sector compared to 10 optometrists St. Erik’s Eye Hospital.

Recommendations

– Automated examinations (performed with an instrument), like visual fields, imaging, automated refraction and visual acuity can be taught to non-medically trained technicians and save the nurses’ skills to more demanding tasks.

– All Scanian eye hospitals should copy the SUS process of one person taking visual fields in 2-4 patients simultaneously.

– Optometrists who have education on visual system could be recruited to work in public sector in many different tasks, e.g. measurements and examination prior to cataract surgery, follow-up of glaucoma, strabismus, contact lens fitting, rehabilitation etc.

6. Merger between Malmö and Lund university hospitals

The purpose of this brief evaluation was not to describe and analyze the SUS merger process. This would not have even been possible during the very short evaluation period. Although there were different views about the SUS merger process, all interviewed experts unanimously agree on one thing, i.e. that the merger in ophthalmology has failed. In addition to post-merger problems with organizing patient care and premises as well a resignation of staff, deep hurt feelings were openly or silently expressed, such as disappointment, sadness, loss of motivation, passivity, frustration and hostility etc together with open and silent resistance.

Many features described in the unsuccessful case (Table 2) could be recognized from the process, together with a few features of the successful case as well. Although the goals of the merger were widely acknowledged and accepted in Malmö and Lund and the merger was implemented ‘by the book’ top-down (with focus group discussions, interview of personnel, written questionnaires, mapping the structure, goals, personnel, collaboration and economics etc), the result was unfortunately – according to literature – an expected failure.

It seems that especially the horizontal (academic) tensions between Malmö and Lund have been significant in the merger. The two units are historically very different in nature. According to their cultures, both units also reacted to the organizational change differently.

Recommendations

– In stead of concentrating energy to what has happened, and trying to find or punish scapegoats, there are opportunities to learn from the successful case described in Table 2 and experiences of how to get successful people change (Table 3).

– As the initiative for change is assumed to depend upon the trust and the willingness of individual autonomous experts, the recruitment should concentrate on professionals who are genuinely motivated by the overall task of public eye care: 1) Acknowledge and

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accept the constantly widening discrepancy between resources and opportunities in care, 2) In spite of this gap, be inspired to take the valuable and important responsibility in coordinating the eye care and trying to reduce visual disability in Scania, 3) Support and coach each other in patient work, research and education as well as leadership in order to create a friendly innovative and inspiring atmosphere for patients and staff.

7. Management and ‘optimal size’ of a hospital

Although it is a common belief that ‘Big is beautiful’, it is worthwhile to consider what might be an optimal size of an (eye) hospital, at least consider how big is ‘too big’ and what is ‘too small’ (Lundbäck & Söderström 2002). Compared to a small hospital, a larger hospital could potentially e.g. attract more specialized doctors and other professionals to one facility, offer better opportunities to develop expertise in clinical work, research and education in a larger population, offer support and collaboration with colleagues and other professionals as well as improve clinical and administrative efficiency. If the hospital becomes ‘too big’, however, its administration and management expand with development of new organizational levels and silos – often not aware of each other’s doings, the focus on the practical core mission fades, increasing time is spent in meetings, more time is spent caring the IT systems instead of patients, the staff loses contact to leaders and stresses in front large flows of patients, the care becomes non-personalized and patients need to travel longer distances to get the services. Compared to a large hospital, the structure of a smaller hospital in easier to understand, commitment in a smaller group or team induces cohesion and flexibility, the staff knows each other and the leaders, the patient flows feel controllable and reasonable, patients get near-services and may learn to know the their care givers who change less frequently. On the other hand, if the unit is ‘too small’ it becomes vulnerable because the loss of one expert may paralyze, or even finish the services, the sight and interest of being part of the health care system is lost, the lack of experts may overburden the remaining workers and give rise to an atmosphere of giving up and induce unhealthy competition, the operating costs may rise, workers do not want to live in smaller places and do not like travelling etc. During the site visits, several observations and subjective perceptions suggested that that Scanian University Hospital – in spite of gaining from its grandiosity - also suffers from its big size both above and at the eye department level. Atmosphere and management in smaller sites gave a more comprehensible perception of their mission, goals and doings which may explain their attraction among the ones who decided to leave after the SUS merger. Probably due to stressful merger process, the turn-over of managers in different levels in SUS has also been considerable.

The core business in health care is to promote well-being. All other disciplines (management, research and education) are serving this core business and would not exist or be meaningful without it. Although the role of SUS is to offer specialized ‘university level’ eye services, educate ophthalmologists (who hopefully would like stay in Scania) as well as produce scientific innovations to promote both patients’ well being and sustainable health care, its role as a leading Scanian hospital remained hazy. Maybe due to problems with the merger, the status of the regional eye care in Scania did not seem to be of interest in SUS.

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In most sites outside SUS, the current leaders are both clinically and academically exceptionally committed and very experienced. It was not possible to gain an understanding during the short evaluation what will happen when their valuable silent knowledge and holistic understanding disappears after their retiring, i.e. what is the level of interest to continue their work among the younger ones and are there on-going recruiting and coaching programs for the new generation to take over the leadership. 8. Economical aspects

The income of Scanian hospitals in 2011 was 337 million SEK and the expenses 281 million SEK. According to another source the income was 383 SEK out of which 67 million SEK accounts for production in private sector (18%). The income divided by the number of all services was about 2000 SEK both in Scania and in St. Erik’s. The staff expenses accounted for 46 – 56 % of the costs, medications costs 10 – 13 %, rents 4 – 7 % and internal services 1 – 9 % of the total costs in SUS, Helsingborg and Landskrona. The staff costs increased in 2010-11 in Landskrona by 10 %, Helsingborg by 6 % and SUS by 2 %. The medications cost increased in 2010-11 by 22 % in SUS and 13 % in Helsingborg. The rent costs decreased in SUS by 4 % and Helsingborg by 12 % but increased by 114 % in Landskrona. Internal costs decreased in SUS by 2 % but increased in Helsingborg by 271 % and 60 % in Landskrona.

Staff moving post-merger from SUS to other hospitals may partly explain the trends. The expenses of facilities were low compared to staff and medication costs. Interestingly large increases were seen in internal services Helsingborg and Landskrona. If non-patient related costs increase more rapidly than total costs, this obviously creates pressure to decrease costs in the core business.

9. Premises

All buildings except for Landskrona were reported requiring renovation. The total area for the use of ophthalmology is about 15 000 -17 000 square meters (Appendix 2). SUS accounts about 67 % of the premises and 52 % of the population. SUS is expected to offer highly specialized services to entire Scania.

In the SUS merger, after many different phases, it has been decided to concentrate all eye services to Malmö. However, the premises are still divided and scattered between the sites and the final solution is open. There are opposing views whether all out-patient services would fit and would be practical to move altogether to Malmö. The estimate for need of operating theatres in SUS is seven, based on former clinic head‘s statement and St. Erik’s statistics. If the estimate (1000 vårdtillfälle, 2400 vårddagar) for the need of in-patient care is correct, about ten beds would be required in ophthalmology if the practice would be similar to St. Erik’s. This would mean minimally 5 rooms, maximally and preferably 10 rooms considering the MRSA prevention. It has been emphasized that the operating unit as well acute and in-patient care would be located close to each other to improve efficiency. These rough estimates represent, however, the current need and do not take into account any future increase in demand at all.

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10. Research and education

As the requested list of publications from Lund and Malmö in 2007-11 was not delivered, some excerpts are cited from the bibliometric analysis in 2002-07 (the Leiden report) and a separate report from 2004-2008 (Appendix 4). One indicator (JPP/FCSm) compares the research unit’s papers to the research unit’s journal set globally. When simplified, the ratio above 1.0 means better than the global comparisons. Although in 2002-07 the number of 118 publications in Lund was double than that of 50 papers in Malmö, the citation indicator of 2.1 in Malmö was clearly above the average as well as exceeded that of 0.8 in Lund. In years 2004-2008, the mean number of 19 papers per year in Malmö was now slightly more than the mean of 16 per year in Lund. Again the Malmö papers were cited about twice more often than the Lund papers. The higher citation rates reflect also in the higher h-indices of the academic researchers in Malmö compared to Lund. Although according also to Leiden report, impact and scientific quality are by no means identical concepts and are effected e.g. by time delays (in this case also by excluding ‘past performance), they citation-based indicators give a picture about international research activities.

In the 2008 SPUR evaluation of the Swedish residency programs in ophthalmology Helsingborg hospital received the highest points in Scania (17 out 18). Only one hospital received full 18 points in Sweden (Su/Mölndal). Malmö and Kristianstad received 16 points, Ängelholm 14 and Lund 13 points.

The approaches in education of medical students are different in Malmö and Lund (about 100 students in each site). Malmö has developed a computerized self-guiding curriculum with systematic feed-back and evaluation of learning which has been copied to some other universities in Sweden as well. Lund offers a traditional type of education with emphasis on teaching skills during patient contacts.

Recommendation

– To improve attractiveness and image of SUS and Lund University, the development of collaboration and communication in research and education would be of crucial. The emphasis would be in framing clinical everyday work within the international scientific context as well as promote basic, translational, clinical and health services research.

– A systematic recruitment and training program to attract residents needs to be created.

11. Organizational scenarios with their advantages and disadvantages

Most of the previous recommendations of this report could be implemented within any organizational structure. This chapter discusses with different models for organizing the care and the premises in future. The presentation starts from the extremes, the current decentralized system and totally centralized system, and ends up in the middle way. The presentation order does not represent ranking order of recommendations. The conclusions and a suggestion for next steps (‘prescription’) to improve Scanian eye care are presented in Chapter 13.

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While in difficult times people yearn for change, they simultaneously hope that everything would stay exactly the same it was before. The common expectation (that all other people and units should change) contradicts the reality, i.e. we can only change our own behavior. As the collective is made of the individual and the individual is made of the collective, however, our change will have impact on those around us as well. If one wants to start a change from the center of the world, a look at a mirror offers the best help.

The greatest opportunity within all health care systems is how to make them more cost-effective. To reach this objective, two approaches are available. The narrower one with making the existing system work better, and broader one is concerned with changing the system (Williams 1993).

11.1. Keeping Scanian health care structure as it is

After the wearing post-merger experiences, it is important to consider what should be done differently in order to not to make the same mistakes again. After learning about the general difficulties in gaining success after mergers, refraining from further organizational changes may, therefore, seem more warranted and practical than ever in order not to lose any more energy in resisting change. As the production, safety, efficiency and image of the SUS eye department has decreased after merger, wise and sustainable decisions and actions are, however, required how to proceed with the SUS unfinished merger process in order to improve the situation.

A fundamental issue is to clarify whether there are enough practical square meters and premises in Malmö in order to take care of all Scanian eye services. If there is, the next step is to figure out the (political) willingness to finally implement the decision which – according to the best understanding - is already made. The debate is actively going on in the media (Appendix 4). If the answer to one of the previous questions is ‘no’, the division of tasks between two units needs to be finalized. It is obvious that one location would promote efficiency of services, allocation and planning of resources, cultural change and management. However, from Lundian patient perspective this solution impairs the near services and increases travelling. Because of the prevailing cultural differences, concentrating services in one physical unit in Malmö may also lead to further resignations of some experts in Lund and thus plunge the department even deeper for some time. On the other hand, if the production of services continues in two sites, the cultural differences and problems related to that would survive and strengthen. This would be no good news either to the patients both in Lund and Malmö.

There are also several factors which might not support status quo. Regardless whether the eye services in SUS will be finally produced in one or two locations, the current model to produce eye services in Scania is extremely decentralized, especially if further decentralizing of the care with privatization through Choice of Care continues and expands. Decentralization to private practice does not improve the current underuse of capacity in operating theatres both in public and private sector, and if expanded further in future, underuse of other premises will probably also follow, too. In addition, if the image and production in the public

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sector does not improve, demand of services in private sector are strengthened which in turn affects the shortage of ophthalmologists and their training in public sector negatively – and increases costs (Table 5)

11.2. Scanian Eye Hospital

Instead of services scattered and fragmented in different hospitals under separate leaderships, an option to the opposite extreme would be to differentiate eye units from their current organizations and combine them (similar to Scanian Psychiatry, or St. Erik’s) into one ‘Scanian Eye Hospital’. It would be about 15 % smaller to St. Erik’s Eye Hospital in Stockholm (Table 4). This would, of course, be even a bigger merger. At best – envisioned and built together with the current partners - a flow could be created ending in a successful, efficient and well-functioning entity. Efficient processes could be developed to guarantee best possible access to care with allocated resources, emphasis would be on preventing permanent visual disability, efficiency would improve, variations in practice patterns would decrease, collaboration in research and education could flourish and the image would attract professionals to work and train in the ‘Scanian Eye Hospital’. The negative scenario would, of course, be a total collapse if ‘Lund disease’ (resignations) would transmit to all eye hospitals.

To the specialty, a separate Scanian Eye Hospital, would probably feel as recognition of its importance and help to start from scratch after the painful post-merger experiences. For the hospital management, it would give more time to solve the SUS merger problems in other departments.

11.2.1. One (old or new) hospital building and / or a network of old premises

If one continues to loosen the thinking beyond the current realities, instead of renovating the old premises, in a pipe dream enough resources would appear to build a brand new hospital somewhere in the middle of Scania, within good access to public transportation and plenty of parking space for those wanting to drive. This was the solution between Boden and Luleå in Sunderby hospital merger (Morina 2011).

The next version as a possible location for Scanian Eye Hospital would look whether there would be a current location where the eye services could be fit (provided that the current tasks from them could be moved somewhere else). At least for the time being in SUS, the square meters maybe scarce even for moving all Lund services to Malmö. However, Landskrona has at least about 17-19 000 square meters (plus premises for psychiatry, primary care and gynecology), is located centrally, can be reached public transportation and has parking space. Even if a centrally located Scanian Eye Hospital in new or old premises would be possible, the disadvantage would be increased travelling both to the patients and staff.

11.3. The middle way (from ‘either-or’ to ‘both-and’)

The big question is how to optimize the organization, management and premises in such a way which would combine the best features of large and small hospitals, minimize their side-effects and – most importantly – would serve the patients best. The decision does not necessarily be made ‘either-or’ (between an ‘a super-market’ or net of ‘boutiques’). Instead, a ‘both-and’ middle-way model could be constructed in delivering near services in patients’

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neighborhood by creating a network for keeping chronically ill patients well. As low cost comes from focus and to improve the current overcapacity of scattered operating rooms, ‘once-in a life-time’ high volume services (like cataract surgery) could be centralized geographically in a Scanian Cataract Hospital (e.g. in Landskrona). The Cataract Hospital could have permanent nurse staff to guarantee high efficient flow for the surgeons who could also come to operate from different eye hospitals. The pre-operative measurements would be offered as near services. If cataract surgery would be performed in Cataract Hospital e.g. in Landskrona, Malmö would have enough premises for all high level services as well as near services to Malmö-Lund region. Naturally highly specialized, research and education care should be centralized as well although part of training could well be given in smaller hospitals as well. Cataract Hospital would be responsible for training cataract surgery.

The definition of an optimal size eye hospital is, of course, very much culture dependent. In the largest eye hospital in the world (Aravind, South India) visit half a million out-patients every year and physicians operate over 100 000 patients per year (over 70 000 cataracts) in one hospital. It is regarded as an excellent training center also among foreign residents who maybe doing 60-70 cataracts per day. The maximum rate of the Chief Administrative Officer is an amazing 12 cataracts per hour compared to current Scanian 12 per day which is regarded quite reasonable in Nordic countries. The Aravind concept has been reviewed in business school reports (e.g. Prahalad 2004) and has received Bill Gates Award. Without intention to copy Indian practices one-to-one to the west, their attitude to succeed certainly gives food for thought in a country spending 2 % of Gross Domestic Product in health care in a 1.2 billion population. In spite of extremely high efficiency, the operating rooms have a feeling of serenity.

12. Shared care

As there is and will be limited availability of professionals, their expertise should be carefully allocated according to their education. Physicians’ time should be allocated to clinical problem solving and decision making on individuals and groups of patients (Christensen 2009). After the patient has diagnosis, the next decision deals with what is done and by whom, e.g. if the required time is 5 minutes or we can allocate 100 SEK to do the next step. In the network care model of chronic diseases, the role of nurses, ortoptists and optometrists will carefully be defined and learn from the current nurses’ glaucoma clinics. E.g. nurses can pre-read diabetic and OCT images, inject and follow patients with age-related macular degeneration etc. If the patients with glaucoma have an individual follow-up plan, their intraocular pressure could also be followed by local optometrists, or in the future preferably by the patients themselves with home tonometers, which would save nurses time to other tasks. Nurses are also currently doing things which could be done technicians. The basic aim is to figure out how complicated and expensive products and services can be transformed into simple and affordable ones (Christenson 2009).

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13. Suggestion for next steps (‘prescription’) to improve Scanian eye care

13.1. Recommendations on care processes presented in sections 1-10 (independent of the organizations)

– Consider whether applicable.

– The choice of medication and nurse injections in macular degeneration are most urgent. If succeeded, they would free resources to other important purposes.

13.2. Organizational structure

a. Find out whether the idea of a Scanian Eye Hospital is attractive, reasonable and possible to different stake-holders: patients and professionals, political and management decision makers,

– If out of the question, continue to step b.

– If attractive, collect a group of partners (‘equals’) and stakeholders to consider different models: 1) ‘super-market’ model (everything under one roof in an old or new building), 2) services would be produced in current premises which would form a common regional network organization, 3) ‘middle way’ model with one centrally located Scanian Cataract Hospital together with centralized specialized services in SUS and current near services outside SUS, 4) some other model.

– If no gains, continue to step b. – If one (or two) models are worth further evaluation, create a process with time tables. – Regardless of the model, the SUS merger needs to be finalized. The SUS premises are

dependent on the selected model.

b. If the concept of a regional eye hospital is not possible, finalize the SUS merger process within the current premises.

– Figure out how the regional eye hospitals can work together and help each other instead of competing about staff and resources.

13.3. Leadership – Find clinical and academic leaders who will be committed to lead the chosen model with

heart, mind and skills. – Finds the ones who want and can succeed, regardless of the model, and helps them to

succeed. – Recruits and coaches the next generation to take over

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13.4. Preferred kick off

The SUS merger needs to be finalized (all services to Malmö?) – most urgent.

Initiate investigation of Scanian Eye Hospital (‘middle way’) model: 1. Centralized specialized services in SUS (Malmö) plus near services to Malmö-Lund region, 2. One centrally located Scanian Cataract Hospital (Landskrona), and 3. Near services e.g. for chronic eye diseases, day-time acute cases and other appropriate services etc. in current premises outside SUS (also considering nurse and mobile clinics in remote regions).

The summary of recommendations is presented in Table 6.

14. Conclusions

The reason for citing the literature in this report was to comfort and show that the challenges in health care have been the same for decades. Several principles how to manage them have also remained the same - in spite of the increasing evidence that the results have often been short-termed and even counter-intuitive (Tables 1 and 2) –– not only in Scania but in all countries.

When trying to understand why we all have failed, we need to understand better the structure of our system and try change that. If one tries to find and punish individuals (scapegoats), the structure with its side-effects will remain unchanged. Every system has a very powerful, underlying structure which creates behavior in individuals within system (Senge 2005). If we bring new people to the existing system, it will have only temporary impact. As the system is ‘never’ in balance, the imbalance creates forces to change the structure - which the system attempts to resist.

When the system becomes very complex and large, we may lose the sight of the essential, i.e. in health care, how to deal with the fact with limited resources and exponentially increasing opportunities in care. Our system (we) are contributing and responsible for both of them. A former US governor joked that to cut the health care costs in the US, they should borrow a trick from the agricultural sector. ‘Land banks’ pay farmers to keep prime land idle - a ‘doctor bank’ would pay doctors not to practice medicine (Sommer 2009). Waiting list formation actually represents way of reducing costs which are increasing too rapidly.

Thus, the complexity perceived even by experts is only apparent (Senge 2005). Different professionals (managers, health care professionals, researchers etc) just look the system from different view points. The essential in eye care is 1) to prevent visual disability with affordable costs, and 2) develop the system to identify the citizens with highest risk and prevent them from becoming blind, i.e. treat right patient at a right time in a right place by a right professional. The success starts with the belief that together we can and will succeed reaching this goal.

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Morina G, Shekshaeva o, Wendahl Sa. A Swedish Hospital Merger - The Case of Sunderby Hospital. Bachelor Thesis in Business Management, Jönköping Uniebersity, May 2011. http://hj.diva-portal.org/smash/record.jsf?pid=diva2:431560

Muir Gray. Evidence-based healthcare. How to make health policy and management decisions. London: Churchill Livingstone ⁄ Harcourt Publishers Limited, 2001

Newhouse J. Medical care costs: how much welfare loss? J Econ Perspect 1992;6:322.

NIKE http://www.cataractreg.com/Cataract_Sve/forstasida.htm

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Prahalad CK. The Aravind Eye care System. University of Michigan Business School. Wharton Publishing 2004.

Senge P. The fifth discipline. The art and practice of the learning organization. Mackays and Chatham PLC, Chatham, Kent, 1990

Shaw J. What is the best way to communicate mergers and change in HE? The Guardian, University mergers. http://www.guardian.co.uk/education/universitymergers

Sommer A. Getting what we deserve, health & medical care in America. The Johns Hopkins University Press ISBN-13: 978-0-8018-9387-2, 2009

Sterman JD. Business dynamics. Systems thinking and modelling for complex world. Boston: Irwin McGraw-Hill Companies, 2000

Sterman J. All models are wrong: reflections on becoming s systems scientist. System Dynamics Review 2002;18:501-31

Tuulonen A. Can we get rid of waiting lists for cataract surgery? The statistics of eye health care in Finland in 1984-2000. The Finnish Medical Journal 2003;58:2657-2663

Tuulonen A.The effects of structures on decision making policies in health care. Perspectives in ophthalmology, Acta Ophthalmol Scand. 2005 Oct;83(5):611-7

Tuulonen A, Salminen H, Linna M, Perkola M. The need and total cost of Finnish eyecare services: a simulation model for 2005–2040 Acta Ophthalmol. 2009: 87: 820–829

Vaahtoranta-Lehtonen H, Tuulonen A, Aronen P, Sintonen H, Suoranta L, Kovanen N, Linna M, Laara E & Malmivaara A. Cost effectiveness and cost utility of an organized screening programme for glaucoma. Acta Ophthalmol Scand 2007;85: 508-518

Väntetider i Vården (tillgänglig vård) http://www.vantetider.se/

Williams A. Priorities and research strategy in health economics for the 1990’s. Health Economics. Quest Editorial. 1993;2:295-302 Yates J (1987): Why are we waiting? An analysis of hospital waiting lists. New York: Oxford University Press.

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http://www.guardian.co.uk/education/universitymergers

Table 1. Why are we waiting? Excerpts from literature about waiting lists and physician shortage. Waiting times are stable regardless of number of procedures and physicians 1980 The mean waiting time to general surgery remained constant for 25 years. After a

delay of approximately two years, an increase in physician manpower led to a similar increase in the waiting list (Frost 1980).

1987 Ageing may affect the utilisation of services and waiting times much less 01-09 than claimed (Yates 1987, Keskimäki & Häkkinen 2001, Tuulonen 2009) 2005 In spite of a 10-fold increase in cataract operations in 1980-2000, the average waiting time for cataract remained at 7 months (Tuulonen 2005) Incentive structure does not support short waiting times 1987 Failure to cope with the public sector work-load might be financially advantageous. There

might be motivation to induce demand if it guarantees higher income level (Yates 1987) 1993 If the waiting time has a positive influence on the hospital’s budget, there is an incentive to

maintain long waits. Everybody complains about the wait, but within the structure nobody has incentives to change actions. (Iversen 1993)

1999 Extending the working day to the afternoon with a fee-for-service system creates incentives to maintain long lists artificially (Busto-Gonzales 1999).

2003 A positive association was detected between private sector activities and prolonged waiting in ophthalmic and general surgery (Martin 2003).

Increase of resources does not shorten waiting times 1980 A policy where a temporary increase in resources is expected to reduce waiting lists is wrong

(Frost 1980). 1987 No relationship in regional variations between waiting times and shortage of resources (beds,

surgeons or theatre provision). (Yates 1987) 1999 General surgery waiting lists could not be reduced in the long-term by applying more resources

(Busto-Gonzales 1999). 2003 The trusts with more resources (surgeons, anaesthetists, and beds) had more patients with

prolonged waiting. (Martin 2003) Indications for treatment are needed but not explicitly applied 1976 Systematic admission criteria should be developed including both clinical and social

judgements (Culyer and Cullis 1976) 2001 In spite of the substantial effort being devoted to health care rationing, there is little clarity

about the views of the health care professionals and citizens. The rationing should become more explicit (Coast 2001).

Standardized statistics is needed 1987 The health care authorities need to know what work is being done. Information gathering

should be improved and decided what definitions should be used. (Yates 1987) Physician shortage and work effort 1930-2000 (Cooper 2002)

Increase in gross domestic product (GDP) with a lag of several years - causes health care pending to rise and outpace GDP by a ratio 1.5/1. The existing trends are all in the direction of reduced work effort, eg. Decrease in hours worked.

1986-2000 (Tuulonen 2005) Finland has suffered from a chronic structural 23% (range 16-30%) shortage of ophthalmologists in the public sector since 1980’s. The shortage is independent of a low burn-out rate and high income levels of ophthalmologists, short working hours (part-time) and the fact that the ophthalmologists are allowed to work simultaneously both in public and private sectors.

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Table 2. Description of the ‘expected’ unsuccessful and ‘anomalous’ successful clinical mergers in Karolinska University Hospital (Choi 2011). Both clinical departments belonged to the same division. The assignment to the newly appointed heads of the clinical departments was the same: – to integrate the units within the same medical specialty into single a entity under a common

management structure – to reduce costs by 10 % The ‘expected’ unsuccessful case – The clinical manager was recruited externally by top management. He initiated large, rapid top-

down changes ”by the book”. As one unit had experienced previous leadership inadequate, this was felt appropriate. However, a strong and popular leader in another unit protested vividly against the clinical manager’s “dictatorial” style.

– The conflict escalated with political decision to close both an emergency unit and an elective care ward. When the ward was closed, key staff members left, and the unit “collapsed” into “complete chaos” due to inadequate staffing.

– The clinical staff forced the new clinic manager - a scapegoat - to leave. – After a long and troublesome search, a new clinical manager from a private hospital was

appointed. – In the meantime, senior physicians at each site took over the operational leadership informally.

They were later appointed site managers. – Three years post-merger, an additional management level had been added to the departmental

structure contrary to top management’s goal of reducing administration levels and costs. – Perhaps most significantly, physicians and nurses from both sites perceived the distance as “the

perimeter of the earth minus 30 km”. – Six years post-merger, the situation was reported to be status quo. The anomalous ‘successful’ case – The two clinical managers (‘equals’) at each site formed shared leadership from the very

beginning. One of them was formally appointed clinical manager, the other one was his deputy. – They showed responsiveness to opinions from senior physicians and listened to the view of the

staff, and constituted a bottom-up process. – To down-size a latent “horizontal” tension between the professionals at the two sites, both clinical

managers attended all meetings together. Eventually, the deputy manager was able to return to his clinical position.

– The leadership was also supported by an informal leader, a professor who forcefully emphasized the benefits of the merger in terms of improved conditions for research and placed the clinical everyday work in an international scientific context.

– The professor placed the clinical everyday work in an international scientific context and encouraged collaboration between all staff categories of the two sites, which even contributed to spontaneous integration.

– In practice, the clinical manager and the professor defined that they had two constituencies to serve: top management “upwards” and clinical staff “downwards”. By dividing these managerial duties, the professor took the strategic role in the merged department “downwards”, whereas the clinical manager dealt with the economic and operational issues “upwards”.

– The cost savings and an integrated department were achieved within allocated time, the staff and manager turnover was low, and group cohesion was reportedly strong six year post-merger.

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Table 3. How could we understand successful people and promote further success? The views and statements are from Marshall Goldsmith whose experience is based on working with top successful leaders in the world. Paradox of success – When things are going well, we often feel no reason to change. As we become more

successful, it seems even harder to change. o One of the greatest mistakes of successful people is the assumption:

‘I am successful. I behave this way. Therefore, I must be successful because I behave this way.’

o The disconfirming input is often denied if delivered by a ‘non-equal (‘it ‘doesn't count’), the input is inconsistent (‘incorrect’) with their self-image (the other person is ‘confused’), or even if agree with the input, assume that the behavior must not be that important since they are successful.

o The same commitment that had brought a huge success in the 1980s, may lead to a huge challenge at the turn of the century.

– While most of us can easily see the need to change the behavior of others, we often have great difficulty in changing ourselves.

– Successful people have a unique distaste for feeling controlled or manipulated. If they feel they are being judged or manipulated, they will tend to become hostile to the process and quit trying.

‘Letting go’ of the past and focusing on the future – ‘Make peace’ with the fact that we cannot ‘make’ successful people change. We can only help

them get better at what they choose to change. o The ultimate motivation for change has to come from the person being coached - not

the coach. – If successful people feel that they are being encouraged and supported by the people around

them, they will be much more likely to "stick with it" and achieve positive, long-term behavioral change.

– If successful people respect the source of information, they will be much more likely to learn and change.

o Finding and coaching leaders who have a personal commitment to the mission and work with their hearts as well as minds will also be effective in attracting and developing fellow ‘believers’ who choose to succeed and want to get the job done (the ‘clan’).

– The ‘clan’, in turn, attracts more people who believe that they can succeed and see opportunities where others see threats.

– Although the executives should listen to the experts with attention and respect, they should not be expected to do everything that their colleagues suggest.

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Table 4.

Comparison of some statistics between the summary of Scanian eye hospitals and St. Erik’s Eye Hospital* in 2011.The St. Erik’s numbers include 6159 from foreign countries as well patients from all over Sweden (including Scania, e.g. retinal operations).

Year 2011 Scanian St. Erik’s

estimate Annual Report**

Out-patient visits 157 596 165 436

Acute visits 16 000 34 888

Operations 14 364 10 262

Operating theatres 17 9

Cataract operations 9 339 5 042

Retinal surgeries 755 1 984

Glaucoma surgeries 98 407

Other surgeries 4 1 72 2 829

AMD injections 2 474 4 276

Fundus photos 20 527 21 562

Employees 287 360

Income / turnover* (million crowns) 337 410

Population (million) 1.3

Beds 16

In-patient occasions (vårdtilfälle) 1000*** 1656

* St. Erik’s Eye Hospital is run as a limited liability company owned by the Stockholm County Council of (Stockholms läns landsting).

** http://www.sankterik.se/sv/om-oss/ *** Estimate

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http://www.sankterik.se/sv/om-oss/

Table 5. An example of causal-loop between shortage of ophthalmologist and their turnover rate within and between public and private practice, in which it is difficult to conclude what if finally cause and effect. The model is based on Finnish eye care structure (Tuulonen 2003a). In Finland, many ophthalmologists are working part time in public and private sector. The country has had a structural 23 % physician shortage (range 16 -31 %) of ophthalmologists in public sector since 1986.

Shortage of ophthalmologists in public sector – turnover rate – The shortage of ophthalmologists increases the supply of benefits in order to get the positions

filled. – The shortage shifts the work load to those still working in public sector and decreases their

satisfaction and motivation. – When the differences in earnings escalate and satisfaction deteriorates, the physicians emphasize

even more money and benefits. – Differences in income, workload and dissatisfaction increase the turnover rate from one public

sector hospital to another or from public to private sector. – The increased turnover decreases the number of ophthalmologists in public sector and shortage

does no fade, or may even increase in spite of education. – When shortage increases, the public sector hires ophthalmologist working part-time. Shortage

remains, or increases further which in turn increases the supply in income and benefits.

– And the loop continues… . The number of physicians – Waiting lists – Budget – The shortage of ophthalmologists decreases production and waiting lists become longer. – When physicians turn to private practice, the number of referrals to specialized care increase and

the waiting lists enlarge further. – The longer waits raise the pressure on decision-makers to increase budgets in order to shorten

waiting. – On the other hand, if the waits can be shortened, the budget resources are allocated to other

diseases with longer waits. – Higher budget allows to hire new ophthalmologists and the waits shorten. – Larger budget allows also higher salaries and benefits, which increase turnover which, in turn,

provoke shortage and longer waiting.

– And the loop continues…

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Table 6. Summary of recommendations

A. Statistics: production, bench-marking and scenarios for future needs

To gain better understanding of the current Scanian production and its trends as well as for systematic national and international bench-marking purposes (e.g. through the World Association of Eye Hospitals, WAEH), it would be beneficial to agree what clinical parameters are important to be followed, how they are reported, who collects the data, who follows them and takes responsibility reacting on them when needed.

– To be able to consider current and future care processes and their need for improvement, knowledge of the number of patients and the number of visits separately would be useful. These data is required also for national and international bench-marking.

– In addition to total number of AMD injections (age related macular degeneration), it would be important to know how many patients are referred per year for evaluation of AMD therapy and require imaging, what percentage of them are selected for treatment, the criteria for therapy and follow-up (including number of follow-up images), the number of injections of patients and in how many patients therapy is withdrawn due to unsuccessful outcome. These data helps to estimate future increase in demand.

– Similarly, it would be helpful to know how many patients per year are treated for glaucoma, how many visits they have to the eye clinics, how many visual fields and images are taken per patient per year, and what is the yearly increase in referrals for glaucoma.

– Knowing the total number of diabetics would be helpful when evaluating the adequacy of current screening and get an estimate of the number of imaging and future needs. The national and pharmacy registries of patients using diabetic and glaucoma medications would be useful - if available - for regional planning purposes and for gaining some basis to estimates of future needs.

B. The Scanian eye health care should be structured to work more efficiently.

a. Age-related macular degeneration – By using the affordable therapy for age-related macular degeneration, based on the

cost data of St. Erik’s, it would have been possible to save roughly 20 million SEK in Scania in 2011. Or alternatively, to give over 3 times more injections if indicated (up to 8500 which would correspond the number of injections in two Finnish university hospitals). This kind of choice of therapy typically requires bold system-level decision making and responsibility because of the exceptionally heavy marketing pressure on physicians.

– The injection rate for age-related macular degeneration could be improved also by delegating the injections to nurses which would save ophthalmologists’ time to decision making in diagnostics and follow-up as well as surgery.

– The choice of medication and nurse injections in macular degeneration are most urgent. If succeeded, they would free resources to other important purposes.

b. Cataract surgery – It would be worthwhile to consider increasing and setting a goal to bilateral cataract

surgery (e.g. to 30-40%) in order to improve efficiency and access to care for surgery. – Regarding explicit priorization, it would be imperative to consider discussing whether

the post-operative controls after uneventful surgery (majority of cases) could be

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referred to private optometrists. This would save both physicians’ and nurses’ time to vision saving tasks.

c. Examinations

– Automated examinations (performed with instruments), like visual fields, imaging, automated refraction and visual acuity can be taught to non-medically trained technicians and save the nurses’ skills to more demanding tasks.

– All Scanian eye hospitals should copy the SUS process of one person taking visual fields in 2-4 patients simultaneously.

C. Incentive structure, part-time working and private sector

– The incentive structure should be based on preventing visual disability from eye diseases and taking long-term responsibility of continuity of care of patients with (chronic) eyes diseases in stead of fee-for-service (as currently in private practice).

– If purchasing services from private sector increases as well as part-time working in public and private sector gets political leverage, they cannot be expected to solve the physician shortage nor waiting times (Tables 1 and 5).

D. Shared care

– Optometrists who have education on visual system could be recruited to work in public sector in many different tasks, e.g. measurements and examination prior to cataract surgery, follow-up of glaucoma, strabismus, contact lens fitting, rehabilitation etc.

E. SUS post-merger actions

In stead of concentrating energy to what has happened, and trying to find or punish scapegoats, there are opportunities to learn from the successful cases (Table 2) and experiences of how to get successful people change (Table 3).

F. Overall task - the basis on recruitment

– The recruitment should concentrate on professionals who are genuinely motivated by the overall task of public eye care: 1) Acknowledge and accept the constantly widening discrepancy between resources and opportunities in care, 2) In spite of this gap, be inspired to take the valuable and important responsibility in coordinating the eye care and trying to reduce visual disability in Scania, 3) Support and coach each other in patient work, research and education as well as leadership in order to create a friendly innovative and inspiring atmosphere for patients and staff.

– To improve attractiveness and image of SUS and Lund University, the development of collaboration and communication in research and education would be of crucial. The emphasis would be in framing clinical everyday work within the international scientific context as well as promote basic, translational, clinical and health services research.

– A systematic recruitment and training program to attract residents needs to be created

G. Organizational structure and premises

Figure out how the regional eye hospitals can work together and help each other instead of competing about staff and resources.

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The SUS merger needs to be finalized (all services to Malmö) – most urgent.

Initiate investigation of Scanian Eye Hospital (‘middle way’) model:: 1. Centralized specialized services in SUS (Malmö) plus near services of Malmö-Lund region, 2. One centrally located Scanian Cataract Hospital (Landskrona), and 3. Near services e.g. for chronic eye diseases, day-time acute cases and other appropriate services etc. in current premises outside SUS (also considering nurse and mobile clinics in remote regions).

Future increase in demand if services should be taken into account in planning for premises.

H. Leadership – Find clinical and academic leaders - committed to lead with heart, mind and skills. – Recruit and coach professionals who want and can succeed and helps them to

succeed. – Recruit and coach the next leader generation to take over.

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Summary of Scania statistics

Appendix 2

35

Scania

production in 2011Per day (200

working days / yr)

Visits 157 596 788

Fundus images 20 527 77

Glaucoma 15 345 103

AMD injections 2474 12

Operations 14364 72

Cararact 9339 47

Retina 755 4

Glaucoma 98 0,5

Others 4173 21

Total services 171 960 860

Referrals 37421 156

Patients 94283 393

36

Visits

Control/First 2,4

Per patient / year 1,7

Physician visits 63 %

Operating rooms 17

Operations / OR / day 4,2

Square meters 15718

Visits per sq meter 10

Sq meters per person (pts+staff) 23

Personnel 287

Services / physician (n=83) 1 381

Services / other personnel (=207) 351

Services / personnel (=290) 599

Physicians 83

Retiring by 2020 21

New specialists by 2020 36

Scania

production in 2011

37

Total number of visits

09‐11

10‐11

09‐11Excl L & Y38

Control visits / first visits

39

Total number of referrals

Without LWithout ML & L

40

Without T

42

Acute visits

44

Without L & Y

45

Without L

Number of fundus

photos

46

Number of AMD injections

48

2009‐11,Excl ML &L49

Personnel

53

2010‐11

Income

54

Malmö-Lund costs

56

Other factors

58

Diagnostic profile among 10 most frequent diagnosis

59

0

200000

400000

600000

800000

1000000

1200000

1400000

Helsingborg 170000 13 %

Kristianstad 170000 13 %

Ystad 100000 8 %

Landskrona 55000 4 %

Trelleborg 95000 8 %

Malmö‐Lund 670000 53 %

Total 1260000 100 %

Population Per cent

Scanian population

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Appendix 3. Visited eye care units and discussions with experts during June 7-15, 2012

June 4 Lars Kristensson, produktionsdirektör, koncernledning Rita Jedlert, biträdande medicinsk director, koncerkontoret, kunskapstryrning och FoU Karin Ekelund, ledningsstrateg

June 7, Helsingborg Peter Olsson, verksamhetschef Alexandra Jörgren, överläkare Lena Brenner, specialitetsföreträdare Annika Lindberg, chefssjuksköterska

June 8, Ystad Karin Björklund, områdeschef Håkan Stjernqvist, enhetschef och medicinskt ledningsansvarig

June 8, Kristianstad Åsa Olofsson, verksamhetschef Anders Felix, medicinskt ledningsansvarig Lolita Jönsson, enhetschef

June 11 and 13, Malmö facilities June 11, Lund June 13 Harald Roos på fm den 11/6 i Malmö Roger Sidestam, verksamhetschef

June 11, Landskrona Märtha Hjelmer, verksamhetschef Patrik Schatz, överläkare Carina Westerlund, avdelningschef

June 12, Lund Jan-Erik Magnusson, hälso-och sjukvårdsstrateg, avdelning för hälso- och sjukvård, koncernkontoret Harald Roos, docent, divisionschef Sven Blomé, divisionscontroller Maria Gustavsson, produktionscontroller

June 12, Malmö Elisabet Agardh, Professor

June 13, Lund Sven Oredsson, medicinsk rådgivare i Region Skåne

June 13, Trelleborg Anitha Algotsson, verksamhetschef Ulla Norling, ögonläkare

June 13, Malmö Peter Åsman, lector

June 14, private unit Ingela Nilsson, enhetschef, Capio Meducolar, Malmö Patrik Svensson, optometrist, Capio Meducolar, Malmö

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June 14, Lund Åsa Berling, hälso- och sjukvårdsstrateg, Koncernkontoret Marie Nilsson, tillgänglighetshandläggare

June 15, Lund Ingemar Petersson, professor, Epi-centrum Skåne

June 19 Anders Heijl, Professor, Malmö (discussion in a meeting in Copenhangen)

June 27 E-mail material and comments from Berndt Ehinger, Professor Emeritus, University of Lund

62

Appendix 4. Documents delivered during the evaluation.

Anmälan Enlight Lex Maria. Utkast 25.6.2012

Artikel i Sydsvenskan. Läkarna kritiska mot fusionen. 12.8.2012

Avseende verksamhet för operation av gråstarr inom vårdval Skåne 2012. VSEENDE Förfrågningsunderlag enligt Lag om valfrihetssystem 2008:962, Fastställt i Hälso- och sjukvårdsnämnden den 5 december 2011

Material from Lars Kristensson – Region Skånes förvaltningsdrivna hälso- och sjukvår (Power Point presentation) Material from Åsa Berling – Remisser från optiker, Stor-SPESAK, 31.5.12 – Ansvar för remisshantering I Region Skåne – Regionalt tilllägg til SOSFS2004:11 – Praxis för samordning av patient I Region Skåne, 15.9.11 – Samverkan för ökad tillgänglighet ögonmottagningarna I Region Skåne, del rapport

augusti 2008 – Process Analysis: Principles, tools and methods. Better steering of health organisation

through analysys of the flow of patients, the Ophthalmology Clinic, Malmö University Hospital, 3.3.2006

– Vårdagarantin – sammanfattande bakgrund (Power Point presentation) Material from Elisabet Agardh

– Reports and plans from Medical Retina in 2007-11

Material from Roger Sidestam – Lokalbehov Ögonkliniken SUS Material from professor Ehinger – Berndt Ehinger. Considerations on how to develop eye care in the Region Skåne

County, 9.7.2012 – Berndt Ehinger. Merging the department of ophthalmology in Lund and Malmö (the

PROLUMA process and subsequent actions), June 2012 – Bent Christensen. Sjukhuschefens bedömning av status för sammansalgning av

universitetssjukhjusen i Lund och Malmö. 15.9.2010 – Delprojetkgrpp Ögon Malmö. Kommentar till styrgruppens bedömning och förslag för

delprojekt Ögon.13.11.2008 – Britt Beding-Barnekow, Peter Åsman, Anette Lindström, Elisabeth Pranter, Anders

Heijl, Helena Samuelsson, Andreas Wohlquist. Proluma delprojekt – Ögon, UMAS, 17.10.2008

– Ledninsbolaget i Skandinavien (Mari Vallin, Klas Görna Brege, lena Olsson, Jan Thorling). Slutrapoort. Ledningsstöd. Ögonkliniken Malmö/Lund. 17.12.2009

– PROLUMA Analysfas omgång 1 B – beslutunderlag, 7.11.2008 – Prolomagruppen Ögon Lund, Ögonkliniken USiL. Fördjupad analys av förslaget om

samordning av ögonsjukvården USiL/UMAS och alternativt förslag, 17.10.2008 – Karin Christensson,hälso- och sjukvårddirektör. Ansvar för etablering och ledning av

Region Skåne Högspecialierat KompetensCentrum i ögonsjukvården med inriktning bakre segmentkirurgi, 11.12.2007

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– Anders Bergström, Karrin Sjöström. Förslag angående HKC Ögon, 7.6.2007 Kompetensbeskrivning legitimerad sjuksköterska med specialisering inom ögonsjukvård. Riksföreningen för ögonsjukvård & svensk sjuksköterskeförening. 2009

Lundstöm M. Medicinsk revision av kataraktkirurgi i Stockholms Läns Landsting för perioden 1/7 2009 – 30/6 2010, Nationella Kataraktregistret

Målbeskrivningar i läkarnas nya ST http://www.socialstyrelsen.se/ansokaomlegitimationochintyg/bevis,specialistkompetens/omlakarnasnyast/malbeskrivningar

Operation codes in Helsingborg hospital

Research Report to the Lund University. Bibliometric Study of Lund University, 2002 – 2007, ECM Noyons, Centre for Science and Technology Studies, Leiden University

SPESAK, letter of eye clinic heads to SUS hospital directors

SPUR förbättrar kvalitet (ögonkliniker). Läkartidningen 2008;105:2889-90.

ST-sammanställning, 2011

Vårdgaranti och väntetider. http://www.skane.se/sv/Lattlast/Halsa-och-vard-i-Region-Skane/Dina-rattigheter-i-varden/Vardgaranti-och-vantetider/

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http://www.socialstyrelsen.se/ansokaomlegitimationochintyg/bevis,specialistkompetens/omlakarnasnyast/malbeskrivningar

http://www.socialstyrelsen.se/ansokaomlegitimationochintyg/bevis,specialistkompetens/omlakarnasnyast/malbeskrivningar

http://www.skane.se/sv/Lattlast/Halsa-och-vard-i-Region-Skane/Dina-rattigheter-i-varden/Vardgaranti-och-vantetider/

http://www.skane.se/sv/Lattlast/Halsa-och-vard-i-Region-Skane/Dina-rattigheter-i-varden/Vardgaranti-och-vantetider/