The Independent View: The merits of Swedish-style localism in improving UK healthcare

Swedish flagDebate about NHS reform has been intense in 2013 as the service has entered its historic 65th year and the need for greater accountability has become apparent in response to lapses in care such as those at Mid Staffordshire.

In light of this, it is important to learn from what is already established practice abroad and one of the best examples is Sweden, a nation with a word-class healthcare system with a history and ethos closely comparable with our own revered health service.  It was developed after the war by a reforming social democratic government, it is financed from general taxation, it is universally accessible and it was traditionally provided by the state.  On closer inspection, however, there are significant differences in both design and performance which may be instructive for the UK.

As I detail in a new report for the think tank Civitas, health outcomes in Sweden are consistently far better than in Britain on most measures – this includes amenable mortality, which to some extent measures deaths preventable by the health system itself. Sweden performs better in international rankings and satisfaction surveys and polls there often give the system high ratings.

Crucially, rather than being a single centralised ‘National Health Service’, the system is run by elected county and municipal governments and is funded from local taxes, keeping services responsive and accountable.  Central government provides extensive oversight and a quarter of health funding, providing critical state-local balance and a sense that the system is national. Localism fosters a stronger sense of ownership and engagement, making citizens willing to pay for better services

As in the NHS, market reforms have been brought in to enhance patient choice and drive up standards – these have intensified since 2006.  There is early evidence that in some areas, reform has improved accessibility, productivity and satisfaction.  The reforms have also brought non-profit organisations back into healthcare and to some extent enjoy consensus political support.  Localism has also aided reform, allowing communities to go at their own pace and learn from each other’s experiences.

All in all, there is much we can learn from Sweden.  Its progress with market reforms, sometimes said to be an inspiration for the UK coalition’s current NHS agenda, is worth watching closely.  But while competition tends to be an ideological dividing line in British health policy debates, a replication of Sweden’s long-standing, admirable and carefully-structured commitment to localism could potentially be a far easier point for consensus in the UK.

The main Westminster parties are already committed to some form of health localism.  The Liberal Democrats pledged in 2010 to put new “elected Local Health Boards” in charge of commissioning, the coalition has pursued localism by putting commissioning in hands of GP-led Clinical Commissioning Groups and Labour are discussing putting council-run Health & Wellbeing Boards in charge of joint health and social care commissioning.

Since there is already something of a cross-party agreement on the merits of localism, Sweden offers a powerful case study for how we can successfully bring about such a system and radically devolve power to communities and patients in the UK.



* Elliot Bidgood is research fellow in health reform for the think tank Civitas.

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This entry was posted in The Independent View.


  • And as long as all three main parties continue to accuse the other two of “wanting to destroy the NHS”, when any of them talk of reform, nothing will improve.

  • Peter Davies 22nd Oct '13 - 9:15am

    There may already be “something of a cross-party agreement on the merits of localism” but the three parties have very different definitions of the word. The Tory version certainly doesn’t include democratically elected councils having real control of local services funded by local taxes.

  • Graham Martin-Royle 22nd Oct '13 - 10:29am

    Once you start talking about localism you will get scare stories about post-code lotteries in the health care system. Unfortunately you can’t have it both ways, localism will mean that each area will prioritise different things.

  • I was impressed with the Swedish system when I visited and met politicians of across the spectrum some years ago.
    But as always simple comparisons from other countries need many caveats.
    Localism for English Councils means more freedom to manage very large budget cuts but less freedom to raise money locally. Finacial constraints I never saw on local government whether in Sweden or the USA.
    Health Care localism in Sweden also means the freedom to raise money locally, via locally elected political systems -and of course a much higher starting tax base than in the UK.

  • Surely the key message is that the Swedish Government trust and empower Local Government. The Coalition and Labour before it have gradually reduced the powers of local Government particularly in Education. The localism Bill is another example.

  • I believe Herbert Morrison proposed something similar within Attlee’s government but Nye sound-of-a-bedpan-dropping Bevan won the argument.

    One of the main problems with healthcare is the artificial divide from local government, so that officers in what used to be called social services and NHS managers spend a lot of time liaising with one another, hampered by different targets and rules that may work against one another.

  • Malcolm Todd 23rd Oct '13 - 1:19pm

    Whilst I agree with the thrust of the argument here, I’d have to disagree with this statement: “the coalition has pursued localism by putting commissioning in hands of GP-led Clinical Commissioning Groups”. There is nothing “localist” about replacing PHTs with CCGs. The old trusts, after all, were overseen and staffed by people local to the area they served. All that happened was that the management of the bulk of NHS provision was removed from publicly appointed bodies (some modicum of democratic control, albeit exercised at several arms’ length and through national government) and handed over to completely unaccountable private businesses. Who for the most part (sensibly enough) promptly employed exactly the same people to do the actual managing and administering.

    I’m afraid that the poster is also too optimistic that local democratic control will do away with accusations of “postcode lotteries”. I have seen the phrase just as often applied to social services, which have always been run by local government…

  • Spencer Hagard 23rd Oct '13 - 9:00pm

    @ BrianD
    It’s not a case of the Swedish Government trust(ing) and empower(ing) Local Government. Sweden has a separation of central and local powers embedded in its written constitution as do many other countries. That’s a sine qua non for achieving and sustaining local democratic control and accountability in the UK. It’s also Liberal Democrat party policy.

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