Sweden is leading the world in allowing private companies to run public institutions

Sweden is leading the world in allowing private companies to run public institutions

May 18th 2013 |From the print edition

SAINT GORAN’S hospital is one of the glories of the Swedish welfare state. It is also a laboratory for applying business principles to the public sector. The hospital is run by a private company, Capio, which in turn is run by a consortium of private-equity funds, including Nordic Capital and Apax Partners. The doctors and nurses are Capio employees, answerable to a boss and a board. Doctors talk enthusiastically about “the Toyota model of production” and “harnessing innovation” to cut costs.

Welcome to health care in post-ideological Sweden. From the patient’s point of view, St Goran’s is no different from any other public hospital. Treatment is free, after a nominal charge which is universal in Sweden. St Goran’s gets nearly all its money from the state. But behind the scenes it has led a revolution in the relationship between government and business. In the mid-1990s St Goran’s was slated for closure. Then, in 1999, the Stockholm County Council struck a deal with Capio to take over the day-to-day operation of the hospital. In 2006 Capio was taken over by a group of private-equity firms led by Nordic Capital. Stockholm County Council recently extended Capio’s contract until 2021.

St Goran’s is now a temple to “lean management”—an idea that was pioneered by Toyota in the 1950s and has since spread from carmaking to services and from Japan to the rest of the world. Britta Wallgren, the hospital’s chief executive, says she never heard the term “lean” when she was at medical school (she is an anaesthetist by training). Now she hears it all the time.The hospital today is organised on the twin lean principles of “flow” and “quality”. Doctors and nurses used to keep a professional distance from each other. Now they work (and sit) together in teams. (Goran Ornung, a doctor, likens the teams to workers in Formula One pit stops.) In the old days people concentrated solely on their field of medical expertise. Now they are all responsible for suggesting operational improvements as well.

One innovation involved buying a roll of yellow tape. Staff used to waste precious time looking for defibrillator machines and the like. Then someone suggested marking a spot on the floor with yellow tape and insisting that the machines were always kept there. Other ideas are equally low-tech. Teams use a series of magnetic dots to keep track of each patient’s progress and which beds are free. They discharge patients throughout the day rather than in one batch, so that they can easily find a taxi.

St Goran’s is the medical equivalent of a budget airline. There are four to six patients to a room. The decor is institutional. Everything is done to “maximise throughput”. The aim is to give taxpayers value for money. Hospitals should not be in the hotel business, the argument goes. St Goran’s has reduced waiting times by increasing throughput. It has also reduced each patient’s likelihood of picking up an infection. However, scrimping on hotel services means that it has to invest in preparing patients for admission and providing support after they are released.

The hospital has helped to change the way Swedes receive health care. Ms Wallgren likens it to a hare that sets the pace of a dog race. The hare can run fast because its staff think of themselves as part of a team, and because managers emphasise collective learning. But St Goran’s is also a symptom of a wider change.

Sweden has gone further than any other European country in embracing the purchaser-provider split—that is, in using government money to buy public services from whichever providers, public or private, offer the best combination of price and quality. Private firms provide 20% of public hospital care in Sweden and 30% of public primary care. Both the public and private sectors are obsessed with lean management; they realise that a high-cost country such as Sweden must make the best use of its resources.

St Goran’s also acts as a hare for Capio, one of Europe’s largest health-care companies, with 11,000 employees across the continent and 2.9m visits from patients in 2012. Sweden is Capio’s biggest market, accounting for 48.2% of its sales (France comes second with 37.6%). The firm performs 10% of all Swedish cataract operations, and much more besides. Capio thinks it can make huge savings in other countries by transferring the lessons it has learned in Sweden. The average length of a hospital stay in Sweden is 4.5 days, compared with 5.2 days in France and 7.5 days in Germany. Sweden has 2.8 hospital beds per 1,000 citizens. France has 6.6; Germany, 8.2. Yet Swedes live slightly longer.

Capitalists under the bed

Spreading efficiency will not be easy, however. Europeans instinctively recoil from private companies making money from health care. British placards protest against modest reforms with pictures of fat cats helping the health minister to disembowel a patient labelled “NHS” (National Health Service). Even in Sweden, the mood has grown more hostile since some private-equity companies were embroiled in scandals at nursing homes.

The public-health business is hardly alluring for investors, either. Cash-strapped European governments are striking hard bargains. Leif Karnstrom, a senior figure at Stockholm County Council, is excited about a new system of “outcome-based health care” that allows him to claim his money back if providers perform poorly. Most people in the private-equity business think there are easier ways to make money than taking over bits of the state.

This is a pity. Private health-care companies have several advantages over public organisations. They have more incentive to make services more efficient, since they typically keep some of the savings. They are better at persuading their employees to adopt new ideas. And they are better at spreading new ideas across borders. Europe should be proud of its public-health services. But if it wants them still to be affordable in the future, it should allow more private companies into the mix.