sou · H0B333 · 2012-05-15 00:00:00 — Vi redovisar flera skäl för denna bedöm- ning, men framförallt anser vi att skapandet av ett samlat kunskaps- stöd är en nyckelfaktor som förloras i dessa alternativa lösningar. De nya myndigheterna föreslås inleda sitt arbete . Till dess att den nya strukturen är etablerad har de nuvarande myndig- heterna fortsatt ansvar för sina uppgifter. Utredningen bedömer att det krävs cirka nio månaders förbere- delse från det att organisationskommittéer och generaldirektörer är utsedda tills dess att den nya strukturen är etablerad. Vi föreslår därför att regeringen överlämnar särpropositionen till för beslut , för att säkerställa införandet . Ur beredningssynpunkt kan drygt uppfattas som , men för verksamheterna och de berörda medarbetarna skulle en mer utdragen genomförandeprocess riskera att leda till bland annat kompetensförluster, osäkerhet och produktionsbortfall. Eftersom så många myndigheter berörs behöver ett samlat ansvar för omvandlingen pekas ut tydligt. Utredningens föreslår att en omvandlingsledare utses på departementet. Omvandlingsledaren blir länken mellan den nya och gamla myndighetsstrukturen och till departementsledningen. I direktiven till organisationskommittéerna bör regeringens val av lokalisering för de nya myndigheterna framgå. I direktiven bör regeringen vidare ange ledningsform och huvudsakligt uppdrag för de nya myndigheterna samt ge dem i uppdrag att ta fram slutligt förslag till instruktion och regleringsbrev. Avvecklingen av nuvarande myndigheter bör hanteras av en gemensam för de nuvarande vård- och omsorgsmyndigheterna. Utredningsförslaget får konsekvenser för majoriteten av de befint- liga myndigheterna i sektorn. Förslaget innebär inga förändringar av det statliga åtagandet, men många uppgifter ska skötas och vida- reutvecklas med utgångspunkt från nya förutsättningar och ambit- ioner. Den nya myndighetsstrukturen ger sammantaget möjligheter till besparingar, både för staten och för vården och omsorgen i sin helhet. Förslaget beräknas leda till att de långsiktiga kostnaderna för de statliga verksamheterna sänks med . Bespa- ringen på statsbudgeten beräknas till . Förslaget beräknas minska antalet årsarbetskrafter med cirka 550. I nedanstående tabell sammanfattas utredningens översiktliga bedömning av de nya myndigheternas resursbehov, uttryckt som summan av anställda och inhyrda årsarbetare. I förslaget ingår att det administrativa stödet för de nya myndigheterna förläggs till . De nya myndigheterna finansieras i huvudsak på samma sätt som dagens myndigheter. För att få en enhetlig finansiering av kunskapsstödet om läkemedelsfrågor till vården och omsorgen föreslås att staten övertar finansieringsansvaret från industrin. Detta motsvarar en kostnadsökning för staten motsvarande cirka 70 årsarbetskrafter eller , och motsvarande kostnadsminskning för industrin. För statsbudgetens del blir besparingen . Nedanstående tabell visar utred- ningens bedömning av statens kostnader , inklusive avvecklingskostnader: Konsekvenser för myndigheternas medarbetare Cirka 2 700 årsarbetare, varav ungefär 1 950 kvinnor och 750 män, berörs av förslagen. Utredningens bedömning är att det för merparten av personalen i de myndigheter som avvecklas sker en verksamhetsövergång till befattningarna i de nya myndigheterna. Bemanningen av de nya myndigheterna ska ske med beaktande av reglerna i 6 b § lagen 5 Utredningens översiktliga bedömning. (1982:80) om anställningsskydd. Vid övertalighet blir det statliga tillämpligt. Konsekvenser för folkhälsoarbetet och funktionshindersfrågorna Utredningens förslag innebär integration av arbetet med folkhälso- frågor och funktionshindersfrågor, både på övergripande samhälls- nivå genom Myndigheten för välfärdsstrategi och i det praktiska vård- och omsorgsarbetet, via . Dessutom kvarstår sektorsmyndigheternas ansvar för integrering av perspek- tiven inom ramen för sina respektive ansvarsområden. Sammantaget bedömer utredningen att integrationen av dessa frågor kommer att ge ökad genomslagskraft. Konsekvenser för vården och omsorgen Förslagen kommer på flera sätt att förenkla för vårdens patienter, brukare, anhöriga, professioner, verksamhetschefer, entreprenörer och huvudmän. Förslagen kommer i sig inte att lösa sektorns problem, men de medför att vården och omsorgen kan möta en statlig verksamhet som är mer sammanhållen, tydlig och enklare att samarbeta med. The health care and social services sector faces a number of chal- lenges. Differences in the level of service and quality provided are becoming increasingly visible and at the same time are less accepted. Patients, service users, relatives and carers are making ever greater demands for information and influence on their own health care and social services. Knowledge is being developed in the sector in an increasingly international context and at an ever- quickening pace. Increasing needs for health care and social ser- vices and new technical capabilities are accentuating the need for priority-setting and effective working practices. Greater diversity in forms of organisation and operation may be one way of meeting the needs for modernisation, but also requires new demands on overarching governance. Patients and service users who need most health care and social services often have multiple needs. These people must be met with integrated support and preventive efforts adapted to their circum- stances. is a small country. Our health care and social services system must work coherently and effectively. Skills that today are dispersed in many different agencies need to be utilised more effectively in the future. The Inquiry considers the challenges to pose a great need for changes in the sector in the years ahead. and more questions will necessitate cooperation at national level. In our interim report in October 2011, we identified some areas where such national cooperation is becoming increasingly important: health care and social services on equal terms, support for empowering patients and service users, quality enhancement, IT coordination, knowledge management, priority-setting and leadership. We also pointed out that health-promoting and disease-preventing efforts need to have a greater impact in practical health care and social ser- vices. All these areas will gradually need to be addressed, for many years to come. Many EU Member States are working on similar issues. Several countries are currently implementing radical changes of system in order to meet the challenges. As far as is concerned, a great deal can be achieved through changes in the present structure and by enhanced interaction between the national, regional and local level. For the central government level, the Inquiry proposes a focus on four main tasks: Knowledge Support that supports successive improvement efforts, Regulation and Supervision that ensure an acceptable quality in all providers, Infrastructure for IT and Communications and . The Inquiry proposes a new government agency structure based on these four main tasks: A knowledge agency responsible for all types of knowledge sup- port for health care and social services. Here we also propose enhanced cooperation with service providers and responsible authorities at regional and local level. An inspection agency responsible for permits, licences to prac- tice, approvals of drugs and other medicinal products and super- vision. This agency is to be given greater resources for supervision than exists in the presents agencies. An agency that, together with other stakeholders, manages and develops the IT and communication solutions the sector needs. An agency that monitors the overarching development of public health, disability issues, healthcare and social services – and in so doing strengthens the of strategic governance The Inquiry also proposes the special legislation on Drug Thera- peutic Committees to be abolished, to make it easier for all relevant areas of expertise to be integrated in knowledge management. The proposal presents a long-term sustainable central-government structure that can meet the needs of the providers and the demand. The new structure does not, in itself, answer all the questions, but will make it easier to tackle the issues the sector faces. The Inquiry's remit has been to ... review how central government, through its agencies, can promote a long-term sustainable system of health care and social services focused on health-promoting and disease-preventing efforts with the aim of promoting health and reducing ill-health and future care needs and bring about equal health care and social services throughout the country. The focus in the Inquiry's terms of reference is on bringing about a clearer distribution of responsibilities and improved effi- ciency in the central-government parts of the system of health care and social services, both between the agencies and for national gov- ernment as a whole. The terms of reference highlight the need of an integrated and systematic approach, in order to provide a better basis for collective priority-setting, be able to resolve problems that are common to several agencies and improve the for coordination between agencies. The role and functionality of are to be elucidated in par- ticular, but the Inquiry has otherwise focused on a comprehensive system approach, not primarily on functions and effectiveness of individual agencies. The Inquiry has also been tasked with suggesting how the pro- posed changes should be implemented. An important basic premise has been that the prevailing distri- bution of responsibilities between national, regional and local gov- ernment should be fixed. Our interpretation of the remit The citizens perspective is highlighted in our remit as taking prec- edence. This has guided our work, so that analysis and our pro- posals have been consistently linked to the combined effects for citizens, the service providers and the professions. The remit has a long-term perspective. The present-day strengths and weaknesses of the current agencies provide an important background picture, but our proposals are based on more long-term assessments of what the service providers and the sector as a whole need. Our analysis of the current situation Increasing need for national coordination There is demand from healthcare and social services for greater national coordination in several important areas. This need for national coordination can be understood in the light of the signifi- cant changes that healthcare and social services are going through: The development of knowledge is becoming increasingly inter- national. It is becoming ever simpler – and therefore also necessary – to spread best available knowledge effectively. This is partly a matter of effectively spreading knowledge developed by individual experts, but it is largely also a matter of systems for data capture and analysis where knowledge is developed successively on the basis of broad experience. This trend necessitates greater na- tional and international cooperation. The growth of information and communication technology has created greater opportunities for comparing quality and efficiency in health care and social services. Differences between different ends of the country, units and sometimes also individual practitioners are becoming increasingly apparent. The steadily increasing transparency applies to health care and social service providers, but also to overarching factors such as public health and conditions for people with disabilities. Issues concerning health care and social services on equal terms are becoming clearer and need to be addressed collectively. Increasing needs for health care and social services and greater expectations from patients, service users, relatives and carers, combined with increasing opportunities to provide treatment and assistance, are accentuating the need for priority-setting and effective working practices. The challenge is accentuated when pri- ority-setting becomes increasingly visible to the public. Additional to this, the need for coordination and joint development is in- creasing. Some responsible authorities see greater diversity in forms of organisation and operation as a way of meeting the needs for modernisation. However, new forms of organisation and operation make new demands on regulatory frameworks and routines. The Inquiry regards these long-term changes to have great sig- nificance for many years to come. Many initiatives are gradually being taken to respond to the increasing needs for cooperation, but far more needs to be done. The providers, the professions and the elected representatives in health care and social services need knowledge bases that are user- friendly in both content and form. Service users and patients have similar needs based on their particular circumstances. The present structure, in which several different agencies provide knowledge support in their specialist fields, slows down the development of comprehensive material that integrates different perspectives. The large number of agencies contributes to knowledge support to the sector being fragmented and unclear. The providers do not receive the needs-based and user-friendly support they need. Healthcare and social services for individual patients and service users are becoming less coherent than they could be. This fragmentation is supported by the special legislation on re- gional Drug Therapeutic Committees, under which county coun- cils have to organise knowledge support on pharmaceutical issues in special committees. Supervision is too weak Central government has difficulty guaranteeing the levels of quality that are to apply in all service providers. There are obvious defi- ciencies in the supervision of health care and social services in particular, but there is also criticism of the supervision aimed primarily at the pharmaceutical industry and the pharmacy market. Some of the problems can presumably be solved in present agencies, but there are also structural problems: the balance between audit and providing advice and guidance is unclear. is the supervision sufficiently adapted to the increasing diversity in provision and rate of change, where supervision has to be aimed at different players and both directly at service providers and at their constituents/purchasers. Supervision generally needs to be strengthened. Inadequate impact for guidelines Guidelines should drive development forward, but actual change is what is important. Advice and guidelines need to be developed and updated faster than they are today, based on the issues that arise in practical work. Advice and guidelines must also be based on the practical and financial circumstances of the providers to have an impact. At pre- sent there is a lack of clear forms in which to link work on guide- lines to the specific circumstances of the responsible authorities and providers. Inadequate dialogue with the research and education sector Supply of skills in the sector is a key issue. This involves, among other things, training a sufficient number of people with the needed skills. Research, development and innovation are also key issues in long-term. There is a clear need for better regular communication between various representatives of the sector and universities and colleges. Lack of coordination of IT structure and communication channels There is an increasing need for a national infrastructure for IT so- lutions and communication channels in the health care and social services sector. There are several dimensions to this task, including creating a basic structure and standards, for example through uniform terms and concepts, , managing and successively developing in- frastructure for data management and , managing and suc- cessively developing integrated communication channels for prac- titioners and the general public. Many stakeholders, both public and private, have taken and are taking initiatives in this area, but to face up to the continued chal- lenges central government needs to be represented by some kind of authority with a comprehensive mandate in this field. for enhanced strategic management Management by the Government in recent years has been done increasingly through strategies, which in several cases are linked to agreements with the Authorities and Regions. In several ways success has been achieved in strengthen- ing the ties between the Government and the political leaderships of municipalities and county councils. The large number of parallel initiatives and unclear distribution of responsibility between the Government Offices, agencies, the Authorities and Regions has, at the same time, posed certain prob- lems. does the Government have sufficient support from an overarching knowledge base for long-term policy. The present agencies develop basic documentation in their particular specialist areas, but none of them has been commissioned to prepare a knowledge base that integrates several different areas and provides a collective picture of the state of, and challenges faced by, the sector. National policy could have a greater impact by focusing on a smaller number of issues and knowledge and analysis support that can relieve the Affairs of operational tasks. The Inquiry proposes a clearer focus on four principal tasks of central government: Supporting the development of the sector, through support for effective development and dissemination of knowledge. Ensuring acceptable quality in all service providers, through effective management of approvals, permits and licences to practice, as well as efficient supervision Coordinating and taking responsibility for strategic key func- tions with regard to information and communications technol- ogy Managing strategically on the basis of a broad approach to the state of and challenges faced by health and welfare sector Support for development of the sector The Inquiry proposes that the work of central government on knowledge support be made more coordinated and better adapted to the needs of the users, with regard to both content and form. Observations made in supervision are also used as support in the gradual development of knowledge. The Inquiry also proposes that the local and regional authorities be given a clearer place in the work on guidelines and other knowledge bases that contain priority-setting. In addition, the Inquiry proposes that procedures be developed for a continuous dialogue between local and regional authorities, universities and other players on the training needs of the sector and its need for research. It is proposed that the legislation on regional specific Drug Therapeutic Committees be abolished. Ensuring quality in all providers The Inquiry proposes that the supervisory activity of central gov- ernment be strengthened and enhanced. The balance between strict audit on the one hand and advice and guidance on the other is to be clarified. An integrated and strengthened supervisory function should ensure that laws and regulations are complied with. Coordinating and supporting key functions for the sectors information and communication needs The Inquiry proposes that central government brings together and strengthens its initiatives to support the needs of the health care and social services sector for joint IT and communications solu- tions. Central government needs to coordinate its own efforts in the area and also be a party to the interaction with other players that are involved in national solutions. The Inquiry proposes that central government establish a function that provides a basis for broad and long-term political assessments and priority-setting in health care and social services. The Inquiry also proposes that the interaction between the Government and the responsible authorities be given a structure that facilitates a long-term approach and focus. Among other things, the process that leads to agreements should be given a clear form that is supported by both knowledge base and practical sup- port. To facilitate modernisation, the Inquiry proposes a collective or- ganisational approach in which a new agency structure is shaped according to the needs of tomorrow. The Inquiry therefore proposes that ten current government agencies1, a non-profit association2 and a state-owned company3 be replaced by four new agencies: the for Public Health, Health Care and 1The , the , the Dental and , in Health Care, , , the for Health and Analysis, Handisam, the Swedish Intercountry Adoptions Authority and the Inspectorate of Public Health, Health Care and Social Ser- vices the for Public Health, Health Care and the Agency for Welfare Strategy It is proposed that these four agencies be given a joint overarching remit to work in cooperation to promote the health of the popula- tion and ensure good health care and social services for those who need them. Two of the agencies, the and the Inspec- torate will work with health care and social services as their princi- pal target groups: professions, responsible authorities, patients and service users etc. Both will have important roles to play in the con- tinuous development of the sector, where continuous learning and development lead to successive improvements. for Public Health, Health Care and So- cial Services supports the development of the IT and a communi- cation structure of the whole sector and also assists the other three agencies in the health care and social services sector with IT sup- port and communication channels. for Welfare Strategy supports strategic overview and policy. Three of the agencies, the , the Inspectorate and the , will be operational. for Health Strategy will be given a more strategic way of working. The remits of all four agencies will include successively developing work content and procedures. New ways of working All four agencies are to develop procedures that make it possible to use skills throughout the country. It is proposed that all the agencies should develop various forms of employment and procedures that make it possible to engage staff in several places. The opportunities for decentralised ways of working provided by new technology create important conditions for mod- ernisation. The Inspectorate, at least, needs a regionalised organisation adapted to the division proposed by the Regions Inquiry4. If the chooses a regional division, it should be co- sited with the Inspectorate's regional organisation. The head offices are to be co-sited to facilitate interaction be- tween the agencies. Consequences for the activities of present agencies Our proposal is based on how central government could better support the future needs and challenges of health care and social services. The area of knowledge appears as a hub in this work. It is therefore the agencies that have the task of developing knowledge in various parts of health care and social services that are most af- fected by our proposals. The agencies we propose should be phased out are: , the , the Dental and , in Health Care, , , the for Health and Analy- sis, , Handisam (the for Disability Policy Coordination) and the 4 Review of central government regional administration etc. Terms of Reference 2009:62 Swedish Intercountry Adoptions Authority. It is also proposed that be phased out. The skills and work tasks of the organi- sations would be transferred to the new agencies. The Inquiry has considered a number of alternative organisational solutions that could respond to our fundamental ambitions and proposals. The Inquiry has, among other alternatives, examined the idea of forming an Inspectorate, and IT agency and a strategic authority to allow knowledge support to remain in the present agencies. This could be done by dividing off 's supervision to a new independent agency, creating a new IT agency and broadening the remit of the for Health and Analysis.