Suchergebnisse

The proposed national model described in this report has been developed by a working group comprised of staff from the National Board of Health and Welfare, the National Centre for Priority Setting in Health Care, and other organisations involved in vertical prioritisation – including the Östergötland County Council, Stockholm County Council, Västra Götaland, the Health Services Region of Southern Sweden, the Swedish Society of Medicine, the Swedish Society of Nursing, and the Swedish Association of Health Professionals. Throughout the process of designing the model, the Swedish Federation of Occupational Therapists and the Swedish Association of Registered Physiotherapists were regularly informed and given opportunities to review and comment on the proposal. Furthermore, the report was reviewed and discussed at a meeting with invited representatives from the other county councils, the Pharmaceutical Benefits Board, and several professional interest groups. Viewpoints were also obtained at a seminar arranged by PrioNet, a network of individuals interested in prioritisation. Potentially, the working model described in Chapter 4 could be used in any context where vertical prioritisation takes place, e.g. activities arranged by the state, county councils, municipalities, hospital departments, and professional groups. This report is designed to be a useful tool for those working on development projects in priority setting. We believe that the contents must be adapted, with the help of relevant examples and some simplifications; to fit the specific needs of different projects or groups. The text must also be adapted to a target group's knowledge and previous experience in dealing with transparent priority setting. It must be the responsibility of each provider and other affected organisation to adapt the material to the given situation and project. The National Centre for Priority Setting in Health Care, the National Board of Health and Welfare, and others who have participated actively in this effort can be helpful to various target groups in adapting this report. When and how to engage in practically implementing vertical prioritisation are questions that need to be answered at the local level. Primarily, it is the duty of the local authorities/providers to take responsibility for implementation. Professional organisations also play an important role. Public agencies, universities, and knowledge centres should be sources of support for the local authorities/providers. The Riksdag's resolution on prioritisation served as the foundation for developing the model. Where there are areas of uncertainty in how to translate these guidelines in practice, or where practical implementation might conflict with the principles, we have pointed this out. Our conclusions and proposals are the following: When facing a choice – regardless of whether it involves allocating new resources for different purposes, or to implement cutbacks – it can be advantageous to rank the possible choices in order of priority. In our model, only the relevant options can be ranked by priority. The consequences of this ranking are not obvious at the outset, but can serve as a basis either to allocate more resources or ration by some means. In vertical prioritisation, it is advantageous to organise the prioritization process starting from a general categorisation of health problems/disease groups. As a rule, these categories cover many organisational units/clinical departments, specialties, or professional groups, thus providing a more multidimensional view of the problem. Furthermore, this allows the process to start from a patient/population perspective, which appears to be more goal-oriented than an organisational/staff perspective. That which is ranked, i.e. one of the choices, we refer to as a prioritization object. We suggest that prioritisation objects consist of different combinations of health conditions and interventions.1 When deciding on the appropriate level of detail, the decision must be based on the context in which prioritisation is carried out. A starting point would be to focus on typical cases, large-volumes services, and controversial care. All forms of vertical prioritisation should be based on the ethical principles that the Riksdag decided should apply in prioritising health services. However, these ethical principles must be made known, clarified, and perhaps complemented before they can be applied to practical priority setting. Furthermore, we believe that the Riksdag's four so-called priority groups should not be part of the model. The human dignity principle, i.e. that all people should have equal value and equal rights to care irrespective of their personal characteristics and function in society, is the undisputed cornerstone in priority setting. When personal characteristics such as age, gender, lifestyle, or function of a group are expressions of the presence of special needs, so that benefits of the interventions are different, these personal characteristics could be addressed in a priority at the group level. Further discussion is needed regarding the question of how external effects (i.e. the effects of an intervention on families and groups other than the individual directly affected by the intervention) should be valued in priority setting. The concept of need in health care includes both the severity level of the condition and the expected benefits of intervention. As a patient, one needs only those interventions that can be expected to yield benefits. Based on this definition of need, a person does not need an intervention that does not improve health and quality of life, i.e. an intervention with no benefit. In such cases, health services have a responsibility to refer people who seek care for some type of problem, to other appropriate services. The Riksdag's guidelines regarding the cost-effectiveness principle (applied to individual patients) are too limited to provide guidance for vertical prioritisation at the group level. From the outset, the Government's bill (Priority Setting in Health Care) highlighted the importance of differentiating a cost-effectiveness principle that applied to choices among various interventions for the individual patient (where the principle can be applied as the Commission of Inquiry proposed) and the aim of health services to achieve high cost-effectiveness in health care generally. Here we also refer to the Riksdag's directive to the Pharmaceutical Benefits Board. In its decisions on subsidising (prioritising) a drug, the Board should determine, e.g. whether the drug is cost effective from a societal perspective, which requires comparing the patient benefits of the drug to its cost. In such decisions, the cost effectiveness should be considered along with the needs and solidarity principle and the human dignity principle. The proposed working model essentially concurs with the working model used by the National Board of Health and Welfare in developing national guidelines. In describing a national working model, it is not possible to include every aspect that might be considered. Hence, one must start from the model and decide which other relevant aspects should be included. For instance, the International Classification on Functioning, Disability, and Health (ICF) can be used as guidance to describe the severity of health conditions. Due to the wealth of variety in outcome measures for different activities, and the limited experience in working with explicit threshold values, we believe would be premature to recommend standardised categories, e.g. risk levels. However, it is important that those working with prioritization describe their reasoning. Primarily, the categories applied by the Swedish Council on Technology Assessment in Health Care (SBU) to grade the scientific evidence of an intervention's effects should be used. Local prioritisation projects with limited resources at their disposal should describe (text) their appraisal of the scientific evidence and reference the scientific sources used. The strength of evidence should be expressed in numbers only when supporting a conclusion of a systematic review by SBU, or other literature reviews of good quality. Prioritisation projects having access to health economic evaluation should, until further notice, adhere to the approach used by the National Board of Health and Welfare and present cost-effectiveness on a scale from low to very high cost per life-year gained or cost per quality-adjusted life-year. Economic evidence should be presented according to the principles applied by the National Board of Health and Welfare. In local projects with limited resources, or problems in consistently acquiring information on cost effectiveness, we recommend that the authors at least discuss cost effectiveness in cases where the priority ranking would be decisively affected when costs are weighed in. A 10-level ranking list should be used. The ranking list should be complemented by a "don't do" list for methods that should not be used at all, or not used routinely, and a research and development (R&D) list for methods where the evidence still insufficient to motivate their use in standard practice. In the absence of an objective quantitative/mathematical method, a qualitative method should be used in the appraisal. Here too, we believe that it is not yet possible to establish standard criteria to determine within which ranking level a prioritisation object should fall. Results should be presented as a ranking list. The parameters used as a basis for prioritisation should also be presented in a uniform manner in ranking lists that are shared with other parties. For pedagogic reasons, details concerning language and format need to be adapted to the respective target groups. Thresholds for what constitutes an acceptable coverage of need (care quality, volume, and percentage of the patient group with access to services) are regional and local issues, and hence are not included in the national model.

In the autumn of 2003 the County Council of Östergötland went all the way in terms of working with transparent horizontal priorities, and was the first county council in the country to do so. Preparations had then been underway for a number of years. The aim of this report is to describe the political decision making process during the work with priority setting in Östergötland in 2003, and to analyse the process based on a condition that is of importance if a decision making process is to be considered fair and legitimate. Some of the questions we initially had were: Are the politicians going to set any transparent priorities? What is the process like? What actors take part in the decisions? How do the politicians reason in order to arrive at decisions? What do the politicians take into account when making decisions? What are the obstacles to transparent priorities? What are the success factors? Our method is based on acquiring information from many sources: Direct observation at the Public Health and Medical Services Committee's (PHMSC) two practical priority setting exercises in March and in May 2003 Direct observation at the PHMSC's information meetings, working meetings and conferences, and the medical advisors' meetings during September - October 2003. Interviews with participating politicians, medical advisors, public officials, the Health Care Director, and health professionals during December 2003 - January 2004. Examination of directives, background material, supporting documents for the decisions, and internal and external documents from the county council. Focus groups and a before-after questionnaire at the citizens' meeting in January 2004. An additional study focuses on how the priority setting process was reflected in daily newspapers during the autumn of 2003. The results of this study will be reported in an upcoming report. Our observations and interviews show that the procedure for priority setting used in Östergötland functioned relatively well but that there were also shortcomings. In addition, we found that with respect to many points the decision making process fulfilled the required conditions for a decision making process to be considered fair and legitimate  reasonable and accepted by the majority  while several conditions were poorly dealt with. 1. The institution where the decisions are made In accordance with current regulations for the County Council, decisions are made by the PHMSC following recommendations from its Presidium. The priority setting decisions were made in a legitimate organisational context with a mandate to make this type of decision. 2. The persons who participated in the decisions Only politicians on the PHMSC took part in formal decision making, but during the preparatory phase with development of proposals for decisions, the Presidium of the PHMSC had the support of medical advisors, public officials, the Health Care Director, as well as administrative assistance. When making decisions, the politicians' behaviour was consistently supportive. This contributed to making a joint political decision possible despite differences in political views and different opinions. Supporting documents in the form of vertical ranking lists and descriptions of consequences were furnished by the health professionals. When developing these documents for use in decision making, however, representation of professional groups other than physicians was often missing, as was that of "users", i.e. patients and citizens. The perspectives of many interested parties were represented, while others that could have contributed were missing. 3. Factors considered in the decisions Different individual factors that shaped the decisions are found in the priority setting model that was established in the County Council. The priority setting model is based on ethical principles established by the Swedish Parliament and contains components that are important to consider in priority setting. The politicians had a high level of awareness concerning principles and factors they should consider in their decisions, but in practical discussions they seldom referred directly to individual factors in the model for priority setting. 4. Reasons for the decisions The politicians had not written down their reasons and motives at an early stage, which made transparent discussion difficult concerning both results and their underlying motives. The individual factors the politicians considered during their discussions were weighed together into different composite pictures, clusters of facts, that formed the reasons and motivations for the decisions. As a rule, reasons for decisions did not rest on individual factors, but on a total appraisal of facts. 5. The decision making process The work fulfilled a number of conditions for the decision making process itself within a decision making group that contribute to fairness. We consider that there was great transparency within the decision making group, while there was less transparency toward other politicians and toward other actors in the priority setting process. There was also relatively great outward transparency toward the public. The supporting documents and the final document were published on the Internet. Although a large part of the material was available on the Internet, few knew that it was there and could interpret and understand its content. In other words, although the material was accessible it was nevertheless "inaccessible" to the public. 6. Mechanisms for appealing decisions The intention of the County Council was that it would be possible for its first decisions to be appealed if new facts and arguments emerged. In this first round, however, there was no prepared mechanism for appealing decisions if new facts or arguments emerged. The areas where we think there is the greatest need for improvement: Representation of groups other than physicians is needed in order to elucidate problems regarding the entire care chain, from prevention to care to rehabilitation. Greater representation or dialogue with "the users", i.e. patients and citizens, is needed to obtain their perspective regarding health care policy priority setting and to assure that the priority setting procedure is considered to be fair and legitimate. However, it is necessary to identify appropriate problems about which to carry on a dialogue. An established routine in the decision making process is needed to assure that those who take part in the decisions consider all the components in the County Council's model for priority setting. Concerning transparency in the decision making process, we consider it important for supporting documents to be developed by means of an transparent internal process that includes health care staff at many levels in order to attain as high internal legitimacy as possible. Sound information must therefore be given to participants' own organisation: initially concerning the priority setting process, differentiation of roles, guidelines and timeframe; and at the conclusion of the priority setting process concerning what decisions mean in practice for the clinical areas. Guidelines for who should do what, how it should be done, and when it should be done must be clear. Information also needs to be given to the public: initially concerning how the work is carried out, and at the conclusion of the priority setting process concerning the decisions that have been made and a description of possible consequences. The information that is dispersed externally should as far as possible be well adapted and contain information about actual decisions, or preliminary positions the politicians want to convey for public debate. A mechanism for appealing decisions if new knowledge or new arguments emerge is lacking and should be created. Above all, transparency must increase with respect to decisions and reasons for decisions. The possibility of assessing and discussing priority setting decisions increases greatly if the decisions are well-motivated so that facts, values and the weighing of pros and cons are reported.

"Det demokratiska samtalet och människors acceptans av nödvändiga prioriteringar förutsätter kunskaper om på vilka grunder prioriteringar görs, vilka möjligheter man som patient har att påverka dessa och vilka vägar man kan gå om man inte är nöjd med den gjorda prioriteringen. Hälso- och sjukvården har en skyldighet att utveckla metoder för att sådan information finns tillgänglig både för dem som är patienter idag och för dem som kan förväntas bli patienter i framtiden". Detta citat är hämtat ur den proposition som innehåller riktlinjerna för hur prioriteringar ska gå till inom hälso- och sjukvård. En ökad öppenhet kring de prioriteringar som alltid sker i sjukvården kräver instrument både för att kommunicera prioriteringar till medborgarna och för att kommunicera etiska överväganden och olika ställningstaganden mellan personer som ska göra prioriteringar. Behovet av ett systematiskt och enhetligt arbetssätt att göra prioriteringar på växte fram i slutet av 1990-talet i Landstinget i Östergötland. I samband med att Socialstyrelsen påbörjande arbetet med de första nationella riktlinjerna (för hjärtsjukvård) blev behovet av att ytterligare precisera och tydliggöra metoden för prioriteringar än mer tydligt. De allmänt beskrivna prioriteringsprinciperna i propositionen var inte tillräckliga för att vägleda mer praktiska arbeten och röster höjdes om en mer konkret beskrivning av arbete med att rangordna tillstånd och behov. Med tiden växte också ett behov fram i enskilda landsting och verksamheter att kunna använda erfarenheter från Socialstyrelsens sätt att ta fram prioriteringar i lokala prioriteringsarbeten. En arbetsgrupp med företrädare från Socialstyrelsen och Prioriteringscentrum, andra organisationer som arbetat med prioriteringar såsom Landstinget i Östergötland, Stockholms läns landsting, Västra Götaland, Södra sjukvårdsregionen, Svenska Läkaresällskapet, Svensk sjuksköterskeförening och Vårdförbundet tog 2006 fram det ursprungliga förslaget till en nationell modell för öppna vertikala prioriteringar. Förslaget förankrades hos myndigheter, yrkesförbund och personer med särskilda kunskaper inom området. ; The national model for transparent prioritisation concerns a systematic method of interpreting and implementing the Riksdag's guidelines and ethical platforms in practice. The model may be used for prioritisation, primarily at group level, by all types of publicly funded health care providers, within county councils, municipalities and privately managed health care. The prioritisation model is applicable in both vertical and horizontal prioritisation. The national model for transparent prioritisation aims to increase the systematic application of the Riksdag's guidelines in order to ensure that a greater proportion of resources are allocated appropriately and efficiently to the care of those in greatest need of it, enabling and facilitating transparent prioritisation. The model does not, however, stipulate how the actual work of priority setting shall be organised.

This report is the first of a two-part report addressing different aspects of the priority setting process. The priority setting process includes standpoints, choices, information acquisition, information interpretation, decisions, and activities to win support for the various steps in this type of process. Setting priorities for collective resources requires conscious choices between different options, it takes place at different levels in a society, and it involves different types of actors (politicians, administrators, health care personnel, patients, and the public). This report presents several broad strategies from the body of international literature on priority setting in health care. The muddling through elegantly strategy dissociates itself from general rules or formulas for allocating resources in health care since these tend to make the process static. Rather, health care personnel should have substantial freedom to make decisions about the distribution of resources. The public has limited insight into the priority setting process, but is given the opportunity to judge the results. In the strategy for rational decision making, the acquisition of information is a key activity – usually the most important. Only the best available information, preferably acquired through scientific methods, should serve as a foundation for making decisions. Decision makers at different levels are expected to act rationally, i.e. guided by the available information they seek the optimum solution without allowing themselves to be influenced by extraneous factors. The strategy for pluralistic bargaining implies that priority setting involves the ability to make socially acceptable decisions, and that this bargaining process must be repeated again and again. According to this strategy, we reach the best possible solution to the prioritisation problem through transparency, participation of many different parties in the process, the ability to consider and analyse opposing arguments, and finally viewing the decision as being "reasonable". The community approach strategy assumes that strain on society will increase to gigantic proportions if we attempt to finance all potential medical interventions. There is a risk that along the way we will stray from the essential values of what constitutes a "humane society" and a "good life". A broad discussion should be initiated in the community to deal with the "impossible" value systems that lead in the wrong direction. The public should participate in this discussion, whereupon politicians and administrators need to develop "categorical standards" that are applied by health care personnel. The model of health care requirements combines elements of the rational and the pluralistic strategies. It includes the clarification of goals and principles, the utilisation of good information, and the understanding that prioritisation must be a continuous process at different levels that also considers the viewpoints of lay persons (consultation of patients and the public). Explicit and implicit decision making refers to the situation where elected officials are forced to explicitly indicate what should be financed while implementation of decisions at other levels involves an implicit process of prioritisation (not so much a conscious choice as a compelling condition). The transparency at one level serves as "protection" for the concealed process that must be carried out at other levels. If we focus solely on the transparency issue, the strategies themselves do not appear to differ substantially, except on a few points. However, such a conclusion would be entirely erroneous – substantial differences begin to appear as we carefully scrutinise the various strategies. This review suggests that we are not dealing with a single priority setting process, but rather with two processes – one concerning internal legitimacy and another concerning external legitimacy. Only when we make this sharp distinction does the content of the different strategies become truly apparent. The process of internal legitimacy is characterised by the ability to identify a knowledge base (scientific) and arguments for establishing priorities based on that knowledge. This is the only way that knowledge-based organisations like health services can begin to gain trust for the priorities. The model of health care requirements describes a reasonable model for establishing internal legitimacy in a priority setting process. Pluralistic bargaining, the community approach, and muddling through elegantly are priority setting processes concerned with improving the conditions for external legitimacy. However, they present two fundamentally different perspectives: to prospectively (ex ante) build confidence through guiding principles and a transparent and pluralistic decision making process, or to retrospectively (ex post) provide an opportunity to review and revise the results. Of the strategies reviewed, two emerge as being more attractive in regard to developing a priority setting process for health services in Sweden. These are the model of health care requirements to assure internal legitimacy and pluralistic bargaining to enhance the conditions for external legitimacy. ; This report is a translation from the Swedish report Prioriteringsprocessen Del I: Övergripande strategier with the same serial number 2003:3.

Denna rapport har tillkommit som en del av ett projekt om prioriteringar i den dagliga vården som drivs av Kommunal och Vårdförbundet. I projektet har Landstingen i Västerbotten och Halland samt kommunerna i Lycksele och Halmstad deltagit. Syftet med att genomföra intervjustudien var att öka kunskaperna om patientnära prioriteringar som vårdpersonalen gör och att öka kunskaperna om vilken betydelse ledarskapet har i prioriteringsprocessen. Följande frågeställningar belyses i rapporten: Vad handlar prioriteringar om? Vilka faktorer påverkar prioriteringar inom omvårdnadsområdet? Vilka olika former har prioriteringsbeslut? Vilka faktorer påverkar resursanvändningen? Vad utgör grunden för de prioriteringar som vårdpersonalen gör? Vilka grupper och verksamheter är högt respektive lågt prioriterade? Vilken betydelse har ledningen, på olika nivåer, för prioriteringsarbetet? Hur ser vårdpersonalen på det framtida prioriteringsarbetet? Metoden har sin utgångspunkt i ett brett angreppssätt för att belysa frågeställningarna. Datainsamling har genomförts som fokuserade gruppintervjuer, så kallade fokusgrupper. Både homogena och heterogena grupper avseende t ex profession, verksamhet och huvudman har förekommit. Sammantaget har 16 fokusgruppsintervjuer genomförts med i huvudsak undersköterskor/-vårdbiträden och sjuksköterskor, men även andra yrkesgrupper har varit representerade. De vardagliga prioriteringarna i vården handlade om att rangordna brukarnas (patienter/vårdtagares) behov, att skapa balans mellan olika prioriteringar och att dämpa negativa konsekvenser av oönskade prioriteringar. En del av dessa hade sin grund i det delade huvudmannaskapet inom vården som flertalet deltagare på ett eller annat sätt ställde sig kritiska till. Deltagarna återkom ofta till ansvaret för att göra rätt bedömning och att fatta svåra beslut och många upplevde att yrkesrollen splittras mellan det patientnära arbetet och andra arbetsuppgifter. Många val som den enskilde medarbetaren gör i sin vardag är beroende av prioriteringar som andra gör - vilka de inte har inflytande över. Det kan vara politiska beslut, andra huvudmäns prioriteringar, organisatoriska faktorer och beslut och val som andra professioner gör. Ökade krav från brukare och deras anhöriga skapade rädsla för att bli anmäld till Hälso- och sjukvårdens ansvarsnämnd vilket ibland leder till att beslut om prioriteringar som den enskilde medarbetaren står inför påverkas. En mängd andra beslut på olika nivåer påverkar omvårdnadspersonalens möjligheter till att göra prioriteringar som uppfattas som rimliga. Politiska beslut och beslut på förvaltningsnivå uppfattades ofta som pålagor och differens mellan de besluten och vad man på enhets- eller avdelningsnivå ansåg borde prioriteras var inte ovanligt. Det förekom också att politiska beslut om vårdgaranti och valfrihet uppfattades som oförenliga med tillgången på läkare och annan vårdpersonal, och ibland också på vårdplatser. Deltagarna framhöll också vikten av effektiv resursanvändning för att frigöra tid för arbetsuppgifter som de utifrån sin yrkesroll borde prioritera högre än vad som görs idag. Ett exempel var att överföring av arbetsuppgifter mellan sjuksköterskor och undersköterskor via delegeringar i kommunens äldreomsorg kunde utvecklas mot effektivare användning av kompetens och resurser. De etiska principerna i riksdagens prioriteringsbeslut var endast kända av några få deltagare. Som grund för prioriteringar framhölls istället etiska principer och riktlinjer i Hälso- och sjukvårdslagen och/eller Socialtjänstlagen samt den professionella kunskapen. Prioriteringar sker ibland också oreflekterat och bygger på intuition eller på rutiner som byggts upp inom verksamheten. Beslut om prioriteringar sker på ett flertal sätt, uppifrån utan delaktighet, hierarkiskt/professionellt, genom egna vardagsnära beslut och/eller i dialog med berörda. Områden som deltagarna ansåg behövde prioriteras högt upplevdes inte alltid tillräckligt högt prioriterade av huvudmannen. Detta gällde t ex demensvården och rehabilitering av de äldre. Främst prioriterades akuta insatser, basbehov och omvårdnadsuppgifter och deltagarna upplevde att det oftast inte fanns tid för något utöver det. Även om diskussioner om hur arbetet skulle bedrivas förekom nästan dagligen, saknade deltagarna generellt sett strukturerade diskussioner om prioriteringar. Uppfattningen om att det var ett långt avstånd mellan politiken och den praktiska situationen i verksamheten var generell och mer gemensamma diskussioner önskades. Långsiktighet och systematik genom framtagandet av gemensamma riktlinjer för prioriteringsarbetet framhölls som avgörande för att arbetet med prioritering utifrån prioriteringsbeslutets riktlinjer skulle bli framgångsrikt, d v s få genomslag i verksamheterna. En förutsättning för att resurserna till vård och omsorg ska användas på bästa sätt är att kunskaperna om prioriteringar ökar. Utvecklingsarbeten behöver startas och enligt deltagarna fanns utrymme för att utveckla, både vårdformer, arbetsmodeller och arbetsformer. Särskilt framhölls samarbete både mellan huvudmännen och mellan olika verksamheter som förutsättningar för ett bra arbete med prioriteringar. I det arbetet har ledning på olika nivåer stor betydelse bland annat för att skapa förutsättningar för prioriteringsarbetet och att skapa arenor där dessa frågor kan diskuteras.

This paper discusses current administrative reforms in the SwedishHealth Care System. More specifically, changes in cost accounting,principles for resource allocation and criteria for evaluation ofresults in health care. Diverse and still developing models arereviewed and discussed in the light of what research inaccounting, infused with constructivist social theory, has arguedin later years.The reform ambitions can be categorized under two labels;panopticon and the market metaphore. Many of the well-knownproblems related to sophisticated management accounting seem toemerge also in the context of health care. Apart from those, wepropose that health care has some intrinsic characteristics thatcreate special problems. The social goals in terms of health,which motivate the entire system, cannot be measured in economicfigures and hence not used for cost-revenue purposes, which is thebase for much of management accounting. It is also problematic toapply the industrial logic of separation on medical staffs,patients, treatments and results, which intermingle in severalways in health care. Further, health care as a social field isconstituted by and through the medical profession and its praxis.Medical action and discourse are based on quite different forms ofcategorization, judgement and values compared to management ofproduction by economic figures.The merging of management accounting and medicine isconnected both to conceptual and moral problems. The politiciansand administrators pushing for administrative reforms are probablyfacing unintentional effects due to two factors.First, they overestimate management accounting as a means toeliminate or suppress micro-politics, opportunism and self-seekingguile. Second, they underestimate management accounting as aconstituting and transforming mechanism. They adopt a traditionalview that regards accounting as a neutral device, operating on aself-sufficient material world. In the long-run, the merging ofmanagement accounting and medicine can transform our conception ofhealth and health care in ways unpredictable today.

I Sverige kan förebyggande sjukpenning lämnas till den som genomgår medicinsk behandling eller medicinsk rehabilitering i syfte att förebygga sjukdom, förkorta sjukdomstiden, eller helt eller delvis förebygga eller häva nedsättning av arbetsförmågan. Syftet med förmånen är således att en enskild ska kunna vara frånvarande från sitt arbete i den utsträckning det behövs för att medverka i medicinska insatser som kan förebygga att arbetsoförmåga på grund av sjukdom alls uppstår. Genom detta förebyggande syfte är förmånens ersättningsvillkor i hög utsträckning knutna till prognostiska bedömningar i flera steg. Försäkringskassan, som är den myndighet som ska administrera ersättningen, ska bland annat bedöma om det finns en risk för sjukdom, om den medicinska behandling som erbjuds kan förkorta eller förebygga sådan sjukdom i det enskilda fallet, samt om sjukdomen i sig kan förväntas sätta ner arbetsförmågan – vilket placerar förmånen mycket nära hälso- och sjukvårdens medicinska expertis. I artikeln visas att dessa omständigheter har förklaringsvärde för att Försäkringskassan samt hälso- och sjukvården uppvisar vissa brister i samsyn när det gäller hur begreppet vetenskap och beprövad erfarenhet ska förstås samt om förmånens syfte och funktion – och att detta inverkar på hur förmånens förebyggande (profylaktiska) syfte får genomslag i rättstillämpningen samt i sjukförsäkringen.