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A Swedish approach to integration
Connecting the dots with a Swedish approach to integration

With an increasing drive to join-up health and social care services, and evidence showing the results it can yield, both sectors need to look at their systems. Sweden’s Esther Project has been proving its efficacy for several years – but could it work on a larger scale? Spencer Gardner from Coffin Mew shares details of the project here.

Health and social care systems are designed in a traditional, functional way. Each link in the care-giving chain – the GP, hospital, care provider and pharmacy – acts independently according to its function, and this can act as a barrier to personalised and co-ordinated health and social care.

Overcoming this traditional divide has long been the goal of the NHS and social care departments, but we are yet to find a solution that works across systems. Sweden’s Esther Project is an inspiring example of how the power of a patient story can start to dissolve these boundaries and enable services to begin moving towards a more integrated, patient-centred system, ultimately, improving health and adult social care outcomes.

Who is Esther?

In 1997 in Sweden, Esther, aged 88 years old, developed breathing difficulties. She phoned her daughter in a nearby town, who told her to call her district nurse. The nurse visited and told her she needed to see her GP. Esther visited her GP, who told her she needed to go to the hospital, and an ambulance was called.

At accident and emergency, she was greeted by a nurse and waited for three hours to see a doctor, who examined her and sent her for an x-ray. She was admitted to a ward and treatment began.

During her five-and-a-half-hour journey through the system, Esther saw a total of 36 different professionals and had to re-explain her symptoms and history at every point.

Esther found herself lost in a system built around the provider, not the person. Limited value was created from Esther’s interactions before and during her admission to hospital. The episode highlighted significant wastage in the system, which was due to the links in the care-giving chain not fitting smoothly together.

Furthermore, Esther’s lack of knowledge of what to do and who to contact when faced with her health issues created a delay in her treatment and added to the workload of the nurses, which could have been prevented.

The Esther Project

Esther’s experience gave inspiration to a team of physicians, nurses, and other providers who joined together to improve patient flow, integration and co-ordination of care for elderly patients in Höglandet, Sweden.

The team, led by Mats Bojestig, the then head of the medical department of Höglandet Hospital, initiated an extensive series of interviews and workshops between 1997 and 1999 to analyse people’s care journeys in order to identify redundancies and gaps in the system, and to develop an action plan to reshape it.

During this time, Esther came to represent any older person who had needs requiring co-ordination between hospital, primary care and social care. Creating a persona in the form of ‘Esther’ helped health and care professionals to focus on the needs, preferences, hopes, and concerns of real people who needed care.

The series of interviews and workshops gave rise to a series of best practice questions professionals could ask themselves. Asking questions such as ‘What’s best for Esther?’ and, ‘What could we have done better for Esther?’ at every stage of an older person’s care, from their first interaction with them, helped Mats Bojestig’s team focus on the needs, expectations, priorities and fears of people entering and moving through the system.

The team identified from their interviews and workshops that people felt healthcare personnel did not have enough time to listen, and that too many people were involved in their care.

The Esther model aims to combat these issues, using continuous quality improvement, cross-organisational communication, problem-solving, and staff training to provide the best care for older people with complex care needs.

“I think it is very important that we call this work Esther. It helps us focus on the patient and her needs. We can each imagine our own ‘Esther.’ And we can ask ourselves in our work, ‘What’s best for Esther?'”– Mats Bojestig, MD, Chief of the Department of Medicine at Höglandet Hospital, Sweden.

How Swedish integration works

Traditionally, each provider in the care pathway – whether of health or care services – acts independently. ‘But Esther needs it to all fit together,’ states Bojestig. ‘It needs to flow like an organised process,’ he says, so each provider can take advantage of what others have already done or will do.

The result of a lack of co-ordination is that, while Esther’s care or social worker knows all about how Esther lives, for example, ‘Still her GP asks her how she lives, and she tells it, and the hospital asks her, and she tells it again, and so on.’ Lack of co-ordination of information, particularly where medications are concerned, causes considerable redundancy and waste. In the worst cases, it can lead to medical errors.

The Esther Project, which Bojestig initiated, includes a set of goals for both ‘Esther’ and providers to improve the co-ordination between services and enable the best care for older people. These goals are:

Goals for Esther

  • To get care in or close to home.
  • To experience care from multiple providers as if it were from the same provider.
  • To have care uniformly available throughout the region.
  • To know to whom to turn when problems arise.

Goals for service providers

  • All personnel to be committed to giving Esther’s needs primacy.
  • Commitment to mutual support to achieve the best for Esther.
  • Increased competence through the care chain.
  • Continuous quality improvement.

Because many of the problems experienced by Esthers usually involve more than one organisation, a central issue in creating the initiative was bringing together people from different levels and organisations. To achieve the aim of reducing fragmentation and improving co-ordination, the team developed multiple avenues allowing providers to come together and co-design a vision for a system that ensured Esther remained central to their work:

  • A yearly steering group: A committee of community care chiefs of municipalities, hospitals, and primary care who discuss challenges seen across organisations.
  • Quarterly Esther cafés: Cross-sector, multi-agency, client experience meetings held to share learning from the experiences of recently hospitalised patients who had continued on to homecare or other services.
  • Ongoing training: Inter-organisational education sessions on palliative care, nutrition, fall prevention, and other topics to facilitate collaboration and understanding.
  • An annual ‘strategy day’: Nurses, doctors, coaches, managers and Esthers coming together for team-building exercises, to identify priorities and generate ideas for addressing problems in the care chain.

Most importantly, each meeting involved at least one ‘Esther’ to guarantee that the clients’ experience was always included.

Driving change

In 2006, the program began to train ‘Esther coaches’ across the participating organisations. Coaches were most commonly nurse assistants and nurses, but they also included physical and occupational therapists, social care workers, and administrators. Coaches were not paid extra – the work formed part of their jobs.

To become a coach, employees received eight days of structured training over eight months in problem analysis, quality improvement, and client focus. In their own organisations, coaches were expected to support improvement projects at the front-line, introduce ideas to improve competencies, make connections between daily work and performance improvement, inspire and motivate colleagues to improve, and introduce ‘lean thinking’ – that is, using the right resources in the right place at the right time to minimise waste, retain flexibility, and make workflows smoother.

International impact

The Esther model proved inspirational. During the project, the team was able to achieve significant results across health and social care services.

Admissions to the medical department of Höglandet Hospital declined, from 9,300 in 1998 to 6,500 in 2013. Closer working between health and social care reduced lengths of hospital stay for surgery between 2009 and 2014 (from 3.6 to 3.0 days) and rehabilitation (from 19.2 to 9.2 days); and hospital readmissions within 30 days for patients aged 65 and older dropped from 17.4% in 2012 to 15.9% in 2014.

The reputation of this initiative has also crossed the Swedish border, with the model gaining international recognition for its success in making and sustaining large-scale improvements. Esther has spread across the globe – from Toronto to Singapore – with the approach becoming ever-more popular.

Esther also expanded to two systems in the UK in 2016. Now, in South Somerset, Esthers attend cafés every other quarter to report on progress they have seen. In Kent, cafés take place every two months, and around 1,400 care workers, social workers, chefs and administrators have been trained as Esther coaches.

A shift in culture

The Five Year Forward View outlines a number of models of care that could help integrate health and social care, including a ‘chains of care’ approach to smooth the care transition.

In recent years, investing in well-thought-out prevention campaigns has taken a backseat because of the immediate financial challenges facing both social care and the NHS. If we are to draw further inspiration from Sweden’s long-term approach to public health and care, the lack of a long-term strategic framework for integration, which arises from a lack of investment, will need to be reviewed.

The Esther model is less about structural changes and more about ingraining a culture of quality-improvement with a seamless network of care around people who need the services. Consistent, clear communication between health and care organisations is crucial, as well as an understanding of the importance that each stage of the health and social care pathway can play.

Taking a system approach to meeting the needs of the elderly may seem odd at first glance. However, when viewed from the personal perspective of Esther, we begin to see how a more personalised approach can work. The Esther model depends on the power of people’s stories. These stories, when elicited, give professionals vital insight into what is required to improve health and social care outcomes for all Esthers.

Spencer Gardner is a Lawyer in the Care & Protection group at Coffin Mew. Email: spencergardner@coffinmew.co.uk Twitter: @CM_SpencerG

What are your thoughts on the Esther Project? Could it be a route to integration in the UK? How could it be explored here? Let us know what you think in the comments section below.

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Georgina Walton

Great piece, we have been on the ESTHER journey in Kent and Medway for a number of years and very happy to share more on our experience and learning.

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