EXPLAINED: What a new healthcare watchdog report tells us about Sweden's care homes and Covid-19
Almost half of the people who died in Sweden of Covid-19 (more than 2,800 out of a total 6,400 deaths) lived in nursing homes.
The majority of these deaths took place in spring, peaking at around 300 deaths per week in April. During September and October there were few Covid-19-related deaths in Sweden's care homes, but in November the number has risen again, with 40, 47 and 35 people's deaths reported during the three most recent weeks with data available.
Swedish authorities acknowledged early on that significant failures had been made in the country's effort to protect the elderly, a central tenet of its coronavirus strategy. A new report by healthcare watchdog IVO reveals the extent of these failures.
One in five were not assessed by doctors
One in five people in care homes did not receive an individual assessment from a doctor, and around 40 percent of this group (meaning around 8 percent of the total) did not receive an individual assessment from a nurse either.
"It is important not to just see this as numbers. It's about people," said IVO director Sofia Wallström. "Such a high figure [of people not receiving individual assessments] is not acceptable."
In the cases where doctors did give an individual assessment, it was rare for this to happen in person. Instead, most assessments took place over the phone.
Wallström emphasised that in Sweden everyone has a right to individual assessments, and said: "I don't think any of us would accept being the subject of a group assessment."
Other key findings
IVO named four key conclusions from the report, the first being that elderly care home residents did not receive care based on their individual needs.
The watchdog found that both elderly people and their relatives received insufficient information about their care, and were not involved in decisions on care and treatment.
Furthermore, IVO said "decisions on and implementation of end-of-life care have not been made in accordance with current regulations during the Covid-19 pandemic for the elderly who live in special housing".
And the watchdog had some difficulties carrying out its investigation because of "deficiencies" in patient records for elderly care home residents with suspected or confirmed Covid-19.
Healthcare in Sweden is managed by the country's 21 administrative regions (whereas elderly care homes as such are generally managed by its 290 municipalities), and IVO said, "no region has taken full responsibility for ensuring an individual needs-based care and treatment" when it came to Covid-19 in elderly care homes.
"There are serious shortcomings that emerge in the report [...] Even though we understand the challenge of providing care during a pandemic, we see that the minimum level in the regions' overall way of taking their medical responsibility is too low," said Wallström.
IVO General Director Sofia Wallström. Photo: Anders Wiklund/TT
Could lives have been saved?
It is difficult to translate the report's findings into concrete figures and the report did not look at this specifically.
But Wallström said that the flaws had "dramatic and serious consequences" and that the watchdog does believe lives could have been saved if correct procedures had been followed.
She said that there were examples of doctors taking decisions to offer palliative care to a patient without having access to their primary care records, for example.
Why is this being revealed now?
Sweden's failure to protect care home residents became apparent at an early stage in the country's epidemic.
IVO carried out inspections into around 1,000 care homes in the spring, and detected "serious flaws" in around one in ten homes. This prompted it to launch the nationwide probe, which included reviewing primary care records, interviews with doctors, nurses, and others in the sector, and information from tips or reports made to IVO.
The watchdog strengthened their tip-off and reporting functions early on in the pandemic with the aim of "reducing the threshold" for care and medical workers to report problems, and received thousands of tips.
The umbrella association for Sweden's municipalities and regions also published a report in summer into the obstacles faced. This showed, among other things, that those municipalities and homes which acted quickest – for example in introducing early visit bans and sourcing their own protective equipment – were most successful in limiting the spread of the virus.
What happens next?
Sweden's regions have been set a deadline of January 15th to report back on what actions they have taken to improve the situation, and what they plan to do in future.
IVO will also carry out further reviews to check that these changes are actually put into practice. And in December it will make further decisions related to municipalities and private care providers, aimed at making it clearer who is responsible for different areas.
What have those in charge said?
Health and Social Affairs Minister Lena Hallengren described the report as "very serious", but said that she did not think it showed a need for new legislation or changes at the national level.
"We are very keen that you get the care you need, regardless of where in the country you live or at what address you live," she said, and also noted: "It is important to say that even if criticism is directed at all regions, which needs to be taken very seriously, it is not said that they have failed in all respects."
State epidemiologist Anders Tegnell, the figurehead for the country's response to the pandemic, said IVO's findings were an "eye-opener".
"[Elderly care homes] are not easy operations to protect. It is a difficult problem to solve and I hope that we have come closer to a solution," he said.
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The majority of these deaths took place in spring, peaking at around 300 deaths per week in April. During September and October there were few Covid-19-related deaths in Sweden's care homes, but in November the number has risen again, with 40, 47 and 35 people's deaths reported during the three most recent weeks with data available.
Swedish authorities acknowledged early on that significant failures had been made in the country's effort to protect the elderly, a central tenet of its coronavirus strategy. A new report by healthcare watchdog IVO reveals the extent of these failures.
One in five were not assessed by doctors
One in five people in care homes did not receive an individual assessment from a doctor, and around 40 percent of this group (meaning around 8 percent of the total) did not receive an individual assessment from a nurse either.
"It is important not to just see this as numbers. It's about people," said IVO director Sofia Wallström. "Such a high figure [of people not receiving individual assessments] is not acceptable."
In the cases where doctors did give an individual assessment, it was rare for this to happen in person. Instead, most assessments took place over the phone.
Wallström emphasised that in Sweden everyone has a right to individual assessments, and said: "I don't think any of us would accept being the subject of a group assessment."
Other key findings
IVO named four key conclusions from the report, the first being that elderly care home residents did not receive care based on their individual needs.
The watchdog found that both elderly people and their relatives received insufficient information about their care, and were not involved in decisions on care and treatment.
Furthermore, IVO said "decisions on and implementation of end-of-life care have not been made in accordance with current regulations during the Covid-19 pandemic for the elderly who live in special housing".
And the watchdog had some difficulties carrying out its investigation because of "deficiencies" in patient records for elderly care home residents with suspected or confirmed Covid-19.
Healthcare in Sweden is managed by the country's 21 administrative regions (whereas elderly care homes as such are generally managed by its 290 municipalities), and IVO said, "no region has taken full responsibility for ensuring an individual needs-based care and treatment" when it came to Covid-19 in elderly care homes.
"There are serious shortcomings that emerge in the report [...] Even though we understand the challenge of providing care during a pandemic, we see that the minimum level in the regions' overall way of taking their medical responsibility is too low," said Wallström.
IVO General Director Sofia Wallström. Photo: Anders Wiklund/TT
Could lives have been saved?
It is difficult to translate the report's findings into concrete figures and the report did not look at this specifically.
But Wallström said that the flaws had "dramatic and serious consequences" and that the watchdog does believe lives could have been saved if correct procedures had been followed.
She said that there were examples of doctors taking decisions to offer palliative care to a patient without having access to their primary care records, for example.
Why is this being revealed now?
Sweden's failure to protect care home residents became apparent at an early stage in the country's epidemic.
IVO carried out inspections into around 1,000 care homes in the spring, and detected "serious flaws" in around one in ten homes. This prompted it to launch the nationwide probe, which included reviewing primary care records, interviews with doctors, nurses, and others in the sector, and information from tips or reports made to IVO.
The watchdog strengthened their tip-off and reporting functions early on in the pandemic with the aim of "reducing the threshold" for care and medical workers to report problems, and received thousands of tips.
The umbrella association for Sweden's municipalities and regions also published a report in summer into the obstacles faced. This showed, among other things, that those municipalities and homes which acted quickest – for example in introducing early visit bans and sourcing their own protective equipment – were most successful in limiting the spread of the virus.
What happens next?
Sweden's regions have been set a deadline of January 15th to report back on what actions they have taken to improve the situation, and what they plan to do in future.
IVO will also carry out further reviews to check that these changes are actually put into practice. And in December it will make further decisions related to municipalities and private care providers, aimed at making it clearer who is responsible for different areas.
What have those in charge said?
Health and Social Affairs Minister Lena Hallengren described the report as "very serious", but said that she did not think it showed a need for new legislation or changes at the national level.
"We are very keen that you get the care you need, regardless of where in the country you live or at what address you live," she said, and also noted: "It is important to say that even if criticism is directed at all regions, which needs to be taken very seriously, it is not said that they have failed in all respects."
State epidemiologist Anders Tegnell, the figurehead for the country's response to the pandemic, said IVO's findings were an "eye-opener".
"[Elderly care homes] are not easy operations to protect. It is a difficult problem to solve and I hope that we have come closer to a solution," he said.
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