How we wish to be cited:
Norberg B. Leadership and ownership. The Swedish crisis of health care [health]. Rondel 2002; 12. URL: http://www.rondellen.net

The Swedish crisis of health care

By tradition, criminal care produces jobs and crimes, the development and training of virgin criminals into professional criminals. Likewise, health care produces jobs, diagnoses, and interventions. The registered activities of health care are thought to reflect a promotion of health. The basic assumption is that diagnoses reflect morbidity and mortality, every intervention a step toward better health for each patient.

Up to 1970, there was a moment of private profit in the health care of Sweden. All patients, who could be managed in the outpatient clinic, had to pay the doctor a fee. When the doctor had to refer the patient to hospital care, the doctor had no fee. It was a system devoid of human dignity; few of us regret it.

In 1970, the doctors of Sweden became employees without fees from their patients (cf 2-4). The idea was that physicians should work eight hours a day and 40 hours a week, like ordinary people, and give the patients the time needed for solving their problems. Although an improvement, the system has not appeared satisfactory to many patients, relatives, and health care workers. One basic reason is that time takes all of us in due course (5, 6). The personal problem of aging and dying remains unsolved.

By 1950, factories and manual switchboards in telephone communication provided jobs for women. Gradually, most of them joined the expanding health care. Hospitals replaced the primary health care 1950-90 (2-4), providing jobs. From about 1970, primary health care expanded again.

The re-structuring and slimming of health care under financial press from about 1990 meant harder work, and more qualified, for elder nurses and white-collars. The jobs became unsafe, the staff burnt-out. The patient queues grew. The cells and corridors teemed with functional white-collars, fathoming papers and pretending to nurse human individuals.

The development of the administrative staff within health care in the period 1950-2000 provides a fruitful subject for many disciplines of history. I can only define some working hypotheses, based on 50 years of class journey over most parts of Sweden.

The first fragments of firm facts dawned during a lecture of medicine in the early 1960´ies in Lund in the south part of Sweden. The lecturer, a gray-haired professor, had to attend his own lecture. He improved production by making confession in class. He tried to organize the company secrets of the hospital, safe in his conviction that all student minds were asleep, pen and hand noting. A main part of the hospital production then was located to specialist outdoor clinics. The fees from the patients were an appreciated fringe benefit of the specialists.

"One might wonder, how the patient finds his way to the right specialist at a hospital of this size. The question has, in fact, been addressed in a non-published investigation. The answer is that the porters direct the patients to a suitable specialist. Everybody appears to be satisfied with this free and informal counsel."

I happened to be awake. I bore the information with me in subsequent years, when I played football (soccer) with the porters in the hospital team and in my contacts with porters 1960-2000. Gradually, a picture of a process emerged.

The role of a porter in Swedish health care was ambiguous and variable in the period 1940-2000. He was an autodidact, trained by his predecessor. At best, he had a formal training as craftsman or non-commissioned officer, before he became a porter. As corpse carrier and autopsist, he had a lower standing than that of the cleaner in the hierarchy of health care. "Death is defeat in the health game" (cf 7). On the other hand, he could be treated as a respected college by the consultants in front of a defiant apparatus.

It is reasonable to assume that porter counsel of confused patients had its golden age between 1950 and 1970. The porters had an overview of resources and staff rivaled only by the insight of the brightest cleaners. By kind advice, they gained a social approval from lay and learned, from poor and rich.

The porters were driven out from patient sorting about 1970. In the previous two decades, health care had expanded with nurse aids, assistant nurses, and nurses and doctors of various degrees. Some of the aids and assistants had developed back pain, joint pain, or a sore soul. They were recycled into health care as typists and clerks and took over patient guiding from the porters about 1970.

The clerk sway of health care proved a disaster, scrupulously hidden in the wardrobes of history (cf 8). The aids and assistants changed into authorities, the chiefs of the patients, during their transfer from clinic to office. Furthermore, a bad back or a bad temper is a bare background for a career as adviser and servant of anxious patients. The situation soon became unbearable. At strategic points of patient contact, nurses replaced the clerks.

The clerk catastrophe paved the way for another catastrophe. There is a Marxism belief that the workers know best how to run a factory and a company. In general, this concept has not been accepted by the stock market. Nevertheless, an analogous assumption stated that nurses and doctors were more suitable than professional administrators to organize health care. By now, Swedish health care is mainly administered by amateurs, the professional nurses or physicians of past.

Admittedly, a few nurses and doctors are excellent administrators and leaders, guided by instincts and interest. However, most are not. The switching of a good nurse or a good physician into a mediocre administrator represents a destruction of human capital. Now trained administrators consider a nursing degree in order to improve their chances of promotion.

The patient queues represent a conspicuous sign of malfunction in Swedish health care. It is reasonable to assume that the queues reflect chaotic administration rather than true lack of staff and resources. Several production lines are entangled – education, research, emergency medicine, routine interventions.

European football (soccer) provides a model of the production game (9). A toe-kick may be more efficient than anything else in a close combat. Ankle-kick, volley or side-foot may be more efficient in other contexts. However, a goal by a toe-kick is as valuable as a goal by more spectacular methods. Likewise, health care shod provide the intervention needed by the patient. Unnecessary attributes slow the process and create queues.

A footballer is expected to move, and perform transactions, without aid of other tools than head and feet – he is a skilled craftsman. Scientific tools might be used in search of new knowledge about footballing, but scientific tools would hamper tempo and performance in the field and are not allowed in matches. Likewise, medical practice should not repeat clinical research programs. Instead, simple solutions should be sought whenever possible.

The queue system of Swedish health care was introduced about 1970 in order to provide a fair distribution of health care according to individual need. The departments with the longest queues were rewarded with more resources and manpower. Thus, the system provided leaders with a lever for projecting their own personality and strength into resources and manpower. "A large population is a king´s glory; but without subjects a prince is ruined" (Prov. 14:38). Leaders expanded by queues.

The last decade has been ten lean years for Swedish health care. Since employees still are the glory or the ruin of a leader (10), all leaders try to preserve personnel (cf Gen. 14:21). The patients are spared in a queue in order to save staff. The basic meaning of the maneuver is a passive opposition against change. The consequence is that current development of methods and tools cannot be cashed as adequate treatment of patients in need; patients are locked up in queues, where a fraction are in immediate need of help. For most patients, the queue serves as a shelf of maturation for the moment of intervention.

It should be emphasized that the situation is unsatisfactory for both leaders and staff; they are frustrated in their genetic flock behavior of "actualizing themselves" and crop the social approval of their patients and of their society. In tangles of different production lines and different hierarchies, their influence over their situation is limited. My working hypothesis is that the scenario depicted provides the biosocial background of burnout and sick-listing in Swedish health care.

Often the interest of the patient and the interest of society are identical. A hip prosthesis provides a big and risky surgical procedure. The artificial hip has limitations and restrictions. Nevertheless, at a certain degree of invalidity, risks and limitations are worth while. At that point, the society may also benefit by an adequate intervention.

The political promises of more money and manpower to health care may be a smart way of reducing unemployment in other branches. However, the main deficit of present health care is structure and competence. Employees and leaders are entangled, "offside". The only moving part is the owner, society. As a voter and a patient, I feel free to make a few suggestions for the future.

The decision of for example an artificial hip should stay with the patient, his family, and his general practitioners. When these actors agree about an artificial hip, the surgical procedure should be bought from a suitable producer, preferably from one of our numerous small hospitals, which are fit for clean elective surgery in office hours. The education and training of students should be located to primary health care, where most of them will work as future professionals. Advanced surgery, emergency surgery, and obstetrics should be concentrated to five university hospitals with resources and competence day and night.

It appears that health care to some extent has produced jobs and health problems, much like the production of jobs and crimes by criminal care. The owner only can break the vicious circles and turn the activities towards the solution of problems and the promotion of health.