What is best for Esther? What Canada can learn from the Swedish health care service

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What is best for Esther? What Canada can learn from the Swedish health care service

Ali N. Damji, MD, MSc, Göran Henriks, and Martin Rejler, MD


Health care systems in Canada and Sweden are facing increasing challenges to do with access and wait times for non-emergent issues. Both are seeing the erosion of single-payer health care systems as a consequence of these challenges, and both are emphasizing moving care out of hospitals into community and home care. Sweden has moved ahead in this area and Canadians can learn two key lessons from its experience. First, rather than thinking in terms of what’s best for the system or the provider, the Jönköping region in Sweden emphasizes the perspective of “Esther,” a hypothetical patient with a life beyond the walls of the institution. Second, viewing patients as copilots in their care has patients learning treatments, such as self-dialysis, with benefits to themselves and the system.


KEY WORDS: health system transformation, coproduction, patient-centred care, Esther


As an experiment, at your next staff meeting, pose this question: “What kind of industry do we work in?” Based on my experience, most clinicians will answer, “health care” or “biomedical.” Others may say “teaching” or “research.” Almost no one will say, “a social industry.” Now, ask that same question in a Swedish hospital or primary care centre, and prepare to be amazed. Top


Canadians may be proud of our health care system, but its quality ranks 17th in the world.1,2 Meanwhile, Sweden ranks fourth.1 Learning from other jurisdictions may very well be one of the most important contributors to the future advancement of our system. This article focuses on two important lessons we can learn from the Swedish health care service.


Similarities and differences


Sweden shares many similarities with Canada — not just the cold climate. Both countries have universal single-payer health care systems that emphasize providing care to citizens based on need rather than ability to pay. Both have rural and remote populations that suffer health inequities compared with their urban counterparts, in addition to health disparities that disproportionately affect refugees, asylum seekers, people of lower socioeconomic status, and Indigenous populations.2-4 And both are under intense fiscal pressure as health care is consuming increasing tax dollars: in Canada, health care spending is 10.4% of the gross domestic product; in Sweden it’s 10.9%.5

The Jönköping region of Sweden is one of 21 landstings (counties) and has 353 000 inhabitants, 46 health care centres, and three hospitals. Delivery of health care takes almost 90% of the county’s budget.6 Like health care systems in Canada, the Jönköping system is facing increasing challenges to do with access and wait times for non-emergent issues.2,7 Both are seeing the erosion of single-payer health care systems as a consequence of these challenges, exacerbating health inequities at the population level. Top


In Canada, wealthy citizens are now seeking care in other countries or paying additional fees to access “concierge medicine,”8-11 while in Sweden, because of similar access-related issues, “private doctors” have been allowed to bill outside the public system for their services as a means to entice them to work in underserviced areas.7,12 Currently, 10–20% of Swedes have private health insurance, which they can purchase through their employers, and this is projected to increase as access challenges grow, particularly in primary care.12 This gives Swedes with the ability to pay quicker access to services, increasing health inequity. In response to these challenges, both countries are putting a stronger emphasis on moving care out of hospitals into community and home care. However, implementation of that vision remains challenging in Canada.


Delivery of health care differs. In Sweden, health care funding and delivery are almost entirely determined by regional governments, with 5% of care nationalized for specific disease categories (e.g., transplant care).7 Sweden’s regions are much smaller than Canadian provinces. Top


The Swedish health care system’s coverage is far more comprehensive than its Canadian counterpart. Universal pharmacare, home care, long-term care, equipment, and allied health services (physiotherapy/occupational therapy, psychology, acupuncture, social work, and others) are all funded under the public system.7 A broader policy directive on addressing the social determinants of health has been adopted in Sweden, including generous parental leave policies (approximately 500 days per child that can be used at any time in the child’s life), and free postsecondary education.13 Moreover, recent changes in Swedish law have mandated that patients must be involved in the design of personalized care plans, leading to a fundamental transformation in how care is delivered.14 Patient care is seen as a partnership, rather than a unidirectional relationship.


What can we learn from the Swedish system?


Lesson 1: It’s all about flipping your perspective

In Jönköping, one of the key ingredients in the success of the health care system is a flipped perspective on quality improvement and change. Rather than thinking, “what’s best for the system?” or “what’s best for me, the provider?” the question is always, “what’s best for Esther?” Esther is a hypothetical patient, but she is also a person with a life beyond the walls of the institution. She is elderly and frail. She has complex health needs. She lives alone. If she lacks effective primary care, or transitions from the hospital back to home without support, she does not do well.15,16


The Esther network has several key features. It is interorganizational and brings together patients, municipalities, social services, hospitals, and primary care centres to address challenges that exist in transitions between sectors. There are informal “cafés” that bring together these organizations, professionals, and patients to allow for sharing and learning. These cafés happen regularly and in person to strategize and address problems, together.16 Top


Clinicians are also trained as “Esther coaches,” who support projects at the frontline, introduce new ideas, motivate others in their organizations, and introduce a culture of quality improvement. They receive training from Qulturum, the region’s quality improvement centre.15,16


On the ground, this has led to several unprecedented innovations in the region. In primary care, this mentality led to the advent of team-based care, where patients are followed by an entire team of nurses, physiotherapists, physicians, social workers, and dietitians, who work collaboratively and fully use their scope of practice and skills to serve their patients.


Among specialists, it was most important for patients to be seen as efficiently as possible. Thus, for example, gastroenterologists have trained nurses to enhance their scope of practice to meet the needs of the population. Consequently, nurse-endoscopists perform routine colonoscopies, freeing up time for the more serious cases for gastroenterologists — a change led by the clinicians themselves in partnership with their nursing colleagues. Top


In the community, thinking about the patient’s lived experience led to the development of a mobile geriatrics unit. This team provides specialized geriatrics consultations and rapid investigations in the home setting to prevent unnecessary emergency department visits. Patients’ frustration with needing to repeat their stories over and over again to providers led to more streamlined direct admissions to hospital and the advent of case conferences regarding complex patients.15


Transitions have been streamlined through telephone and email communication between patients and their physicians. A family physician is able to speak directly with an admitting consultant, thereby being able to admit a patient and bypass the emergency department.15 All specialty clinics have admitting consultants available to speak to family physicians during regular office hours and book same-day appointments for patients.17


Patients are given a “safety receipt” at the time of discharge that functions as a checklist to ensure that a comprehensive plan has been made.15 There is systematic follow up of all hospitalized patients within 72 hours.15 Newly passed legislation now mandates that within 24 hours of a patient’s discharge from hospital, home care or long-term care services must be set up by the municipality. Failure to do so results in the municipality shouldering the cost of the additional days spent in the hospital.7 The system is described as one that moves around the needs of the patient, rather than putting the onus on the patient to navigate the system.7 For complex patients, a support worker or team is often sent to the home on the day of discharge to ensure the patient is well set up for the transition by making sure necessities, such as a clean bed, food, and the right equipment, are present in the home — even a dog walker if needed.15 Top


At the system level, artificial boundaries between health and social services and between layers of government have been torn down. Funding is mobile and flows easily between sectors to meet the needs of the patient. For example, in response to challenges regarding the placement of patients in long-term care homes, the county responded by transferring funds to the municipalities to enable this.15


These efforts appear to have paid off. Since the introduction of the Esther project, Jönköping’s hospital admissions have decreased from 9300 to 7300, total length of stay for all heart failure patients fell from 3500 to 2500, and wait times for specialists decreased from 48–85 to 14 days over three years.15,17 Over the same period, hospital readmissions within 30 days dropped from 17.4% to 15.9%, and rehabilitation length of stay fell from 19.2 to 9.2 days.15 As a testament to its success, the Esther network has also been adopted in the United States, United Kingdom, and Singapore.16 Top


Lesson 2: With that flipped perspective, be a copilot with your patients

We’ve all heard the buzzwords: patient-centred, patient engagement, patient experience. But what about patients as partners?


Batalden et al.18 describe the concept of coproduction in health care as a system where patients and providers are participants. Their relationship is predicated on civil discourse, shared planning, and shared execution. The ultimate outcome is coproduced high-value health care and better health care for all in society. Simply put, this means that patients and clinicians produce better outcomes when the system supports collaboration and true partnership in care.18


One example of such an approach is the self-dialysis clinic at Ryhov Hospital.19 This a world-renowned example of coproduction that began with the courage to try something different despite the possibility of failure.


The story began with a single patient. One day, he asked his nurse if he could learn to do his own hemodialysis, as he found the long sessions made him feel helpless and he hated the side effects. He wanted to take his care into his own hands. Rather than shut him down, the nurse began to educate the patient, gradually giving him more and more independence under her close watch. Initially the patient struggled, but eventually he learned and began to coach other patients, with the nurses, to do the same.19


Today, in collaboration with patients, clinicians assess their confidence and competence and coach patients toward greater independence in their hemodialysis. Typically it takes 4–8 weeks from start to finish for a patient to feel comfortable performing dialysis completely on their own. The unit is open to patients 24/7, and those who become confident and competent in their own hemodialysis can use their own access cards to come into the unit and dialyze themselves when it is most convenient for them, even without supervision. They even set up and shut down their own machines and draw their own blood. So far there have been only three documented cases of patients needing to return to supervised dialysis from the self-dialysis program, and currently 60% of all dialysis patients are a part of this model.19 The rates of infection associated with dialysis have dramatically decreased since the introduction of the program.19  Top


In the pediatric setting, by law, Swedish children should receive relevant information when a decision must be made about them. The laws stipulate that the parents, children, and entire interprofessional team across all sectors including social services must work together to design a care plan that is individualized to the child. After coming up with this shared plan, it is revisited by the interdisciplinary team. Any member (including the child and parent) has equal authority to make changes to this plan, and it is done in a collaborative fashion.20


On the wards, patient care has been transformed into a more coproduced format. Instead of traditional rounds, where the hospital team discusses every case in a secluded area and then discusses the plan with the patient, who is in bed, a new approach has been adopted. Every morning, hospital patients are invited to participate in morning rounds with the health care team where they contribute to the discussion regarding their care plan in real time. All the people in the room are introduced as equals. Furthermore, the medical history and social needs are walked through as each participant adds to the story. In the end, the consultant summarizes medical, nursing, and social needs, so that all are informed and ready to act before moving on as the next patient enters the room.  Top




Sweden and Canada share many similar challenges, and learning from the former’s approach to finding cost savings by doubling down on patient-centredness may yield some insights into future directions for Canada. Seeing the health care system as a social industry that responds to the needs and preferences of its users and supporting coproduction are key ingredients in Jönköping’s success. Although championing the needs and power of the “health care consumer” runs the risk of being told things we may not want to hear, that approach has led the Jönköping region and the Swedish health care system down an exceptional path where they have engaged and happier physicians, a better patient experience, lower costs, and improved population health.


Health care, at its heart, is about people. Flipping our perspectives, challenging our traditional practices, and bringing patients with us to lead transformation together are effective ways to make meaningfully improvement in our system, so that it can best help people — not just treat disease.


This novel mentality has to start with everyone, whether clinician, leader, or patient. We all have a role to play. To get started, let’s take a page from the Swedish playbook, and ask the most important question, at every chance we can: “What is best for Esther?”


The answers may surprise you. After all, we are a social industry. Top



1.GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017;390(10091):231-66.

2.Martin D, Miller AP, Quesnel-Vallée A, Caron NR, Vissandjée B, Marchildon GP. Canada’s universal health-care system: achieving its potential. Lancet 2018;391(10131):1718-35. DOI: 10.1016/S0140-6736(18)30181-8

3.Silburn K, Reich H, Anderson I (editors). A global snapshot of Indigenous and tribal peoples’ health: The Lancet–Lowitja Institute Collaboration. Melbourne, Australia: Lowitja Institute; 2016.

4.Devaux M. Income-related inequalities and inequities in health care services utilization in 18 selected OECD countries. Eur J Health Econ 2015;16(1):21-33.

5.Health spending. Paris: Organisation for Economic Co-operation and Development; 2017.

6.Staines A, Thor J, Robert G. Sustaining improvement? The 20-year Jönköping quality improvement program revisited. Qual Manag Health Care 2015;24(1):21-37. DOI: 10.1097/QMH.0000000000000048 Top

7.Healthcare in Sweden. Stockholm: Government of Sweden; 2018.

8.Private clinics and the threat to public medicare in Canada: results of surveys with private clinics and patients. North York, Ont.: Ontario Health Coalition; 2017.

9.Allen-Dicker J, Auerbach A, Herzig S. Perceived safety and value of inpatient “very important person” services. J Hosp Med 2017;12(3):177-9. DOI: 10.12788/jhm.2701

10.Assessing the patient care implications of “concierge” and other direct patient contracting practices. Ann Intern Med 2015;163(12):949-52. DOI: 10.7326/M15-0366

11.Reid L. Concierge, wellness, and block fee models of primary care: ethical and regulatory concerns at the public–private boundary. Health Care Anal 2017;25(2):151-67. DOI: 10.1007/s10728-016-0324-4

12.Swedes buy insurance to skip long health queues. The Local 2014;17 Jan.

13.10 things that make Sweden family-friendly. Stockholm: Government of Sweden; 2018.

14.Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovish K, Born K. Jonkoping County Council. In High performing healthcare systems: delivering quality by design. Toronto : Longwoods Publishing; 2008:121-44.

15.Gray B, Winblad U, Sarnak DO. Sweden’s Esther model: improving care for elderly patients with complex needs. New York: Commonwealth Fund; 2016.

16.The Esther network. Jönköping, Sweden: Region Jönköpings Ian; 2018.

17.Improving patient flow: the Esther project in Sweden. Ottawa: Institute for Healthcare Improvement; 2015.

18.Batalden M, Batalden P, Margolis P, Seid M, Armstrong G, Opipari-Arrigan L, et al. Coproduction of healthcare service. BMJ Qual Saf 2016;25(7):509-17.

19.A patient directs his own care. Ottawa: Institute for Healthcare Improvement; 2012.

20.Hedberg B, Nordström E, Kjellström S, Josephson I, Lee A. “We found a solution, sort of” — a qualitative interview study with children and parents on their experiences of the coordinated individual plan (CIP) in Sweden. Cogent Med 2018;5(1). Top



Ali N. Damji, MD, MSc, is a chief family medicine resident at the University of Toronto and Trillium Health Partners, Credit Valley Hospital. As part of his graduate studies, he completed a seven-week practicum in Jönköping, Sweden, under the supervision of

Goran Henriks and Martin Rejler.


Goran Henriks is chief executive of learning and innovation at Qulturum, Jönköping County, Sweden.


Martin Rejler, MD, is a staff gastroenterologist at Eksjo Hospital in Jönköping County and is completing an improvement science fellowship at Jönköping University.


Correspondence to:,,


This article has been peer reviewed.