Regional Agreement between Uppsala University and Uppsala County Council on cooperation in training of doctors, clinical research and healthcare development

Background

On 11 September 2014, the Swedish state and Uppsala County Council entered into an agreement on cooperation in training of doctors, clinical research and healthcare development. This agreement, referred to below as the “Central ALF Agreement”, is to be supplemented with regional agreements between county councils and universities concerned. The Central ALF Agreement enters into force on 1 January 2015. The regional agreements are required to be concluded by 1 May 2015.

The County Council is the authority responsible for healthcare. The University is responsible for education and training leading to the Medical Degree, for education at research level, and for the research conducted at the University.

The kinds of activity in healthcare that are shaped with special reference to the needs of research and education, collectively termed “university healthcare”, are a joint concern for the University and the County Council. To generate favourable conditions for research and education, the University will join in organising and managing university healthcare.

The parties to this “Regional ALF Agreement” are Uppsala University and Uppsala County Council.

Aims

1. Aims for education

The University is the authority responsible for the study programme that leads to the Medical Degree. The County Council is willing, within the scope of this Agreement, to provide premises, staff and other resources for this programme.

The purpose of this study programme in Uppsala is to provide advanced medical education and training for both national and international employment, in a future healthcare and research environment of high knowledge density and dynamism.

The content of the Medicine Programme corresponds to the objectives and requirements reported in the degree system prescribed in the Swedish Higher Education Ordinance.

The parties are agreed that continuous monitoring and evaluation of this medical education and training will take place in accordance with the University’s requirements for clinical supervision and education, and that the trainee doctors will obtain the requisite clinical experience.

The parties are agreed on the importance of interprofessional learning, and that the infrastructural resources such learning may require are set up in the County Council.

2. Aims for research

Research and education are the University’s principal functions. Research and development are also key parts of the work of the County Council, which has a statutory responsibility for assisting in funding, planning and implementation of research work, both clinical and in public health. Achieving sound development of clinical research calls for cooperation between the University and the County Council. The parties have agreed on common objectives, which they will strive to attain, for their efforts in clinical research. This may, for example, be done through jointly agreed investments in infrastructure for research in university healthcare.

The parties agree to strengthen their own position as an internationally leading organisation in university healthcare, and thereby attract the most highly qualified doctors, researchers and teachers worldwide.

3. Healthcare development aims

The County Council will offer good healthcare, in which activities will be systematically and continuously developed and safeguarded. The University will cooperate with the local community and work for research results achieved at the University to be put to use. To strengthen the position of healthcare, regionally, nationally and internationally, university healthcare will contribute actively to dissemination of knowledge, and to development and evaluation of new methods of diagnosis and treatment. Further development of university healthcare is a joint concern for the parties.

4. University healthcare

Section 1 of the Central ALF Agreement prescribes that the core activities of university healthcare, alongside health and medical services, will be clinical research and education, and also knowledge application and dissemination for healthcare development.

Moreover, it is prescribed that the university healthcare will:

  • continuously engage in research of high quality, national and international
  • provide high-quality education
  • monitor international developments in medical research, education and healthcare
  • contribute to evidence-based healthcare through practical application of its own and others’ research results, and continuously evaluate established and new methods convey results from its own activities to other parts of healthcare, and
  • cooperate with businesses and patient organisations.

The Agreement also makes clear that environments are to be characterised by high-quality healthcare; explicit functions in research and education for the authority responsible for healthcare; an innovative culture; and an incentive structure for knowledge development. University healthcare imposes special requirements regarding organisational structure, academic leadership, infrastructure and financing.

The parties are agreed on these starting points for university healthcare. Further, the parties agree on the importance of a clear international perspective for university healthcare.

Section 19 contains provisions on designation of units included in university healthcare.

Organisation

5. Cooperative bodies

The parties agree to set up cooperative bodies at three levels: at management level in the County Council and University; in management of the disciplinary domain and administration; and at department level. The cooperative bodies are named as listed in the table below.

Cooperative bodies

Uppsala University

Uppsala County Council

University Medical Board

University management

County Council management

University Medical Board Executive Committee

Disciplinary Domain of Medicine and Pharmacy management

Administrative management

Research, Development and Training (RD&T) group

Department

Department or equivalent

6. Joint participation in regular management bodies

In addition to the cooperative bodies listed above, the parties agree to provide each other with the opportunity to participate in the management bodies comprising units included in university healthcare, and whose decisions may exert influence on university healthcare. For example, this applies to the management groups of the University Hospital Departments, the University Department Boards, the Disciplinary Domain Board for Medicine and Pharmacy, and the University Hospital’s management group or equivalent. How these representatives are to be appointed will be stated in the operational plan.

7. University Medical Board

For cooperation between the University and County Council managements, a University Medical Board is to be set up. This Board will deal with issues of essential common importance for university healthcare, and the education and training of doctors and the clinical research that are integrated into the parties’ work.

The Medical Board will comprise an equal number of members, not exceeding seven, from each party. Each party will appoint its own members, and decide on their term of office. The chairmanship rotates between the parties, and the term of office is one year.

The party that does not have the chairmanship will appoint the vice chair. Minutes on the Medical Board’s meetings will be kept. The Board decides on:

  1. the operational plan
  2. definitions of joint visions and objectives
  3. common areas of investigation and development
  4. the care units that will compose university healthcare
  5. the care units where work-integrated training of doctors is to be conducted
  6. ALF funding in another county council, if any (Central ALF Agreement, section 13)
  7. reallocation, if any, of ALF funds from research to education
  8. prioritisation and allocation of ALF funds
  9. other resources for which the parties agree on joint prioritisation
  10. financial and activity-focused accounting of how the ALF funds are used (Central ALF Agreement, section 14)
  11. impact analysis of recalculating and reallocating the ALF funds (Central ALF Agreement, sections 9 and 12)
  12. repayment, if any, of ALF funds (Central ALF Agreement, section 11) 13. premises and infrastructure for university healthcare
  13. revision of Appendices 1 and 2 to this Agreement.

The Board is entitled to delegate the right to make decisions on various issues. However, points 1, 6, 10 and 14 may not be delegated.

On 15 September at the latest, the Board will decide on a joint operational plan, the University Healthcare Plan, for the years ahead. This joint operational plan will be a practical manifestation of the regional agreement in which the parties define the exact allocation of the ALF funds, but also agree on joint areas of investigation and development. The issues on which the Board delegates decision rights to the University Medical Board Executive Committee should also be specified in the operational plan.

At the beginning of every year, in a separate document, the Board will also report on how the ALF funds were used during the previous year.

8. University Medical Board Executive Committee

For cooperation between the management of the University’s Disciplinary Domain of Medicine and Pharmacy and the administrative management of Uppsala University Hospital, a University Medical Board Executive Committee with an equal number (a maximum of six) members from each party is to be set up. This Committee’s task is to prepare business for the University Medical Board’s meetings and decide on issues that the Board submits to the Committee.

If units in Uppsala County Council, outside Uppsala University Hospital, are selected for inclusion in university healthcare, the administrative management of the University Hospital will, following consultations with the administrative managements concerned, propose members of the University Medical Board Executive Committee.

The parties nominate members of the University Medical Board Executive Committee, who are appointed by the University Medical Board. Each party sets the term of office for its members. The chairmanship rotates between the parties, and the term of office is one year. The party that does not have the chairmanship appoints the vice chair.

Minutes on the Executive Committee’s meetings will be kept.

The Executive Committee works on the tasks assigned to it by the Board, and the Committee draws up documentation for the annual operational plan.

For its work, the Executive Committee can set up working groups of both a permanent and a temporary nature. These groups will include representatives of both parties.

9. University Medical Board Executive Committee’s working group

The University Medical Board Executive Committee has a working group comprising five members appointed by the University Medical Board. One of these will be a representative of the students; otherwise, the parties propose two members each. The working group will prepare business for the Executive Committee’s meetings and, to the extent determined by the Committee, settle questions of a non-fundamental nature.

Minutes of the working party’s decisions will be kept.

10. Research, Development and Training groups

For cooperation at department level in university healthcare, there will be Research, Development and Training (RD&T) groups.

Every RD&T group will include a head of department from Uppsala University Hospital, or representative appointed by the same, and an academic representative appointed by the Executive Committee of the Disciplinary Domain Board for Medicine and Pharmacy. The management group of every hospital department will include an academic representative, who should preferably be the representative appointed by the Executive Committee of the Disciplinary Domain of Medicine and

Pharmacy. The chair of the RD&T group, who is appointed by the University Medical Board Executive Committee, must have a doctoral degree. The term of office for the chair is two years, with an extension option. The group’s detailed composition and tasks are defined in the operational plan, in section 7 above.

Minutes of the RD&T group’s decisions will be kept.

The RD&T group will allocate ALF funds for research and education, and report on the optimal use of these funds in accordance with the operational plan. The corresponding task applies also to other funds for research and education that are placed at the disposal of the RD&T group, and to reporting on their use in accordance with decisions in the relevant board or equivalent.

11. Decision-making

All decisions within the framework of this Agreement must be made in the cooperative bodies, and these decisions must be unanimous. Decisions are made by agreement among the members present, who are in positions of authority or hold office in Uppsala University and Uppsala County Council, that particular measures are to be taken. Current rules on conflict of interest must be taken into consideration.

Rules on managing differences of opinion are given in section 22.

Operational plan

12. Prioritisation and allocation of ALF funds

The County Council receives funds in two parts, one relating to work-integrated education and training of doctors and one to clinical research. The parties can reallocate funds for clinical research to work-integrated training of doctors. Such reallocation will be decided by the University Medical Board and reported in the annual operational plan.

The operational plan adopted by the University Medical Board will clarify:

  • reallocation of funds from clinical research to education
  • allocation of funds in education
  • allocation of funds in clinical research.

The operational plan will also clarify the allocation to be decided upon in the University Medical Board Executive Committee and the RD&T group respectively.

A proposal for allocating ALF funds for education is submitted by the Faculty of Medicine’s Programme Committee for the Medicine Programme.

13. Use of ALF funds for education

ALF funds for education are intended for work-integrated training of doctors, and will mainly finance supervision and skills training of medical students in outpatient and inpatient care.

“Supervision” means teaching closely associated with healthcare, such as bedside instruction, scrutiny of medical records, teaching rounds and other teaching in close proximity to the patients and requiring no special preparation. “Skills training” refers to hands-on practice in medical procedures or assessment of findings on patient status and investigation results. The County Council undertakes to provide, for this purpose, supervisors, premises, fittings and equipment, and also other services for implementing work-integrated medical education and training. The County Council permits its own employees, besides participating in supervision and skills training, to take part in prepared teaching, such as lectures and group teaching, as well.

Within the framework of the ALF agreement, the County Council permits special teaching units offering healthcare free of charge to be set up.

14. Use of ALF funds for research

ALF funds for research will be used to create the best possible conditions for clinical research. “Clinical research” means the kind of research that requires the care services’ structures and resources, and has the purpose of solving a problem of ill-health or identifying factors that lead to enhanced health. Clinical research is one of the core activities of university healthcare, which is central for the quality and development of clinical research.

The parties are agreed that ALF funds for research may be used for infrastructure, projects, premises and staff. The operational plan may specify the other purposes for which ALF funds may be used.

Cooperation

15. Cooperation with other county councils

Subject to the University Medical Board’s approval, an agreement on cooperation in the areas of education and research may be concluded with another county council, according to section 13 of the Central ALF Agreement. Any ALF funds for these activities will be provided by Uppsala County Council. In the event that the cooperation described takes place, this will be stated in the annual operational plan.

16. Cooperation with other healthcare providers

Besides the points agreed in section 1 of the Central ALF Agreement on broad cooperation with other healthcare providers, the parties agree to engage in efforts to find forms of cooperation with healthcare providers outside university healthcare.

17. Coordinating ALF funds and RD&T funds

The parties agree to endeavour to bring about greater coordination and concentration of resources through joint prioritisation of ALF funds and the RD&T funds made available by the County Council.

Reporting and follow-up

18. Reporting on and following up use of ALF funds

How ALF funds for education and research have been used will be followed up and reported in accordance with section 14 of the Central ALF Agreement. An initial report will be submitted to the University in time for it to be included in the University’s annual report.

The financial statements concerning both education and research will refer to the following discrete cost categories: costs of premises, salary costs and other costs. In the event of decisions being made to reallocate research funds to education, this will be reported. If a surplus or deficit has arisen in a calendar year, the amount will be stated. The Board, Committee and respective group will disclose how the funds have been used.

Designation of units in university healthcare

19. How units in university healthcare are designated

Units in university healthcare are designated by the University Medical Board according to established criteria. This can take place ahead of every new decision on an operational plan. A unit included in university healthcare is evaluated every four years. The evaluation will be based on the criteria laid down in Appendix 1. In conjunction with the evaluation, a decision will be taken on whether the unit is to remain part of university healthcare.

For evaluation, the University Medical Board appoints a review group that includes external assessors.

Criteria to be met by units in university healthcare are defined in Appendix 1 to this Agreement. This Appendix will be revised and adopted by the University Medical Board annually.

Units in university healthcare will be regarded as being the kinds of designated unit (for medical training and research) that are referred to in the Swedish Higher Education Ordinance, Chapter 4, Section 2. In addition, the operational plan can specify which other units should be regarded as the kinds of designated unit referred to in Chapter 4, Section 2 of the aforesaid Ordinance.

The University Medical Board, University Medical Board Executive Committee and RD&T groups govern activities relating to education and research in university healthcare. The funds for these activities are derived from ALF, the County Council (including RD&T funds), the Faculty and external sources. The University Medical Board, the University Medical Board Executive Committee and the RD&T groups also control activities relating to development.

20. Joint appointments

Provisions on joint (academic and clinical) appointments may be found in Appendix 2 to this Agreement.

21. Termination of previous agreement

The parties are agreed that, with the signing of the new regional agreement, the following agreement will cease to apply: the previous regional agreement between Uppsala University and Uppsala County Council on cooperation in basic training of doctors, medical research and healthcare development (UFV 2003/39, CK 2003-0036).

22. Managing conflicts of opinion

If differences of opinion arise and cannot be resolved in a cooperative body, they will be referred to the level immediately above. A dispute at department level will be referred primarily to the RD&T group concerned. If a dispute persists, it can be taken to the University Medical Board Executive Committee and thereafter to the University Medical Board.

Differences of opinion in the University Medical Board occasioned by this Agreement will be resolved primarily in negotiations between the parties.

23. Validity of Agreement

This Agreement is to enter into force on 1 May 2015 and every part of the Agreement will apply with effect from 1 January 2016. Conditions for the validity of the Agreement are laid down in the Central ALF Agreement between the Swedish state and the county councils concerned. A cancellation of this new Agreement will come into effect from the calendar year-end that takes place three years after the Agreement was cancelled.

This agreement has been drawn up in duplicate and the parties have each taken one copy.

For Uppsala County Council

For Uppsala University

Börje Wennberg

Eva Åkesson

Chair, County Council Executive Committee

Vice-Chancellor

Appendix 1. University healthcare

The functions of university healthcare are defined in the Central ALF Agreement. The features of the units composing university healthcare under this Agreement are characterised by:

1. Research of high quality by national and international standards

The unit will have structures, organisation, skills, incentive structures and resources for conducting clinical research that yields publications in international peer-reviewed journals, and will assist in providing education at research level. To be able to engage in these functions, the unit will have joint appointments and/or co-options to the University (where the employee must normally have at least docent status) with an explicit research function.

2. High-quality education

In applicable cases, the unit will provide workplace training places and supervision for medical degree studies and other care sciences study programmes. The unit will contain teachers or county council employees, in both cases with supervisor training, tasked with leading workplace training within the unit. The unit will supervise students continuously (every semester) and, where necessary, be able to receive students who, during a semester, take up residence within the University’s exchange programme. Normally, there must be teachers with joint appointments who have overall responsibility for education.

3. Healthcare of high quality and systems for continuous care development

The unit provides healthcare based on science and proven experience, and plays an active part in promoting development in the unit’s speciality. This part comprises skills and time set aside for participation in relevant national quality registers, and for taking part in drawing up national and regional guidelines. The unit will monitor and implement development of diagnostics, treatment and care, with a system for evidence-based, ordered introduction.

4. Staffing and patient base

The unit will possess skills and staffing that permit implementation of its tasks in research and education, as well as healthcare and knowledge development, and a sufficient number of patients to enable clinical research and education to take place. The unit will have a clear staffing plan for each function.

An incentive structure, to ensure that research education and docentships provide useful qualifications, must be clear and self-evident. Completed midterm review, completion of a

PhD, a docentship and Distinguished University Teacher status will confer salary increments. Research expertise and teaching skill will also be advantageous in appointments to all positions in university healthcare.

5. Infrastructure

Within the unit, there will be premises with basic equipment that permits clinical research and education. There will also be access to advanced research infrastructure, including advisory functions, a regional support function for clinical studies, cooperative structures for companies and patient organisations, innovation systems etc. Moreover, lecture halls and premises for clinical skills training will be available.

6. Quality assurance system

The unit will have systems for documenting, following up and assuring quality in implementation of all three of the principal functions, and for open reporting of the results.

Appendix 2. Joint appointments

Joint appointments are currently regulated in the Swedish Higher Education Act (1992:1434), Chapter 3, Section 8; the Swedish Higher Education Ordinance (1993:100), Chapter 4, Section 2; the Swedish Act (1982:764) on some doctors' employment at designated units etc.; and in local regulations.

Chapter 3, Section 8 of the Swedish Higher Education Act states (unofficial translation):

The Government or the agency nominated by the Government may issue regulations whereby a teaching position at a higher education institution is combined with an appointment as a doctor or dentist with specialist training, or with an appointment other than as a doctor at a healthcare unit designated for medical training and research. A joint appointment may be held only by a person who fulfils the eligibility requirements for both appointments.

The regulations applying to a teaching position also apply to the appointment that is to be combined with the teaching position.

Before anyone is appointed as a teacher, the authority responsible for healthcare must be given the opportunity to express views on the matter, if the position is to be combined with an appointment at a healthcare unit. Ordinance (1997:797).

Chapter 4, Section 2 of the Swedish Higher Education Ordinance states (unofficial translation):

A higher education institution may, with the consent of an authority responsible for healthcare as referred to in Chapter 3, Section 8 of the Higher Education Act (1992:1434), decide that an appointment as a professor or senior lecturer at the institution will be combined with an appointment at a healthcare unit designated for medical training and research. Training and research at such a unit includes training and research in odontology. Ordinance (2010:1064).

Ahead of a decision on recruitment to a position as professor, senior lecturer or lecturer that is combined with clinical practice, an agreement must therefore be reached between the University and the authority responsible for healthcare. Where the position is as professor, the agreement is signed by the Vice-Rector or Dean and the Hospital Director or person to whom the matter has been delegated. Agreements on other joint appointments are signed by the head of department concerned and the Hospital Director or person to whom the matter has been delegated. The agreement is written in duplicate.

The agreement regulates:

  1. The University’s intention to recruit a holder of a position in the defined subject combined with clinical practice.
  2. Consent from the authority responsible for healthcare for the position to be combined with clinical practice, with a specified hospital unit as the place of work.
  3. Intended organisational placement of the holder.
  4. Costs of the position concerned, including overheads, and their division between the two authorities.
  5. Distribution of working time between the authorities.
  6. Provision of resources for the employee’s work.
  7. Confirmation that the agreement will continue to apply if the holder is promoted to professor or senior lecturer.
  8. Coordination of certain issues of staff administration between the University and the authority responsible for healthcare.
  9. Coordination of measures to be taken in the event of misconduct.
  10. Influence, if any, of the position on the healthcare organisation and premises concerned.
  11. Time frame of the agreement.
  12. Procedure in the event of a dispute.

The authority responsible for healthcare is given the opportunity to attend the recruitment group’s meetings when joint appointments are discussed. If the authority responsible for healthcare is absent, it will be given the opportunity, after the meeting, to express views on the clinical expertise of the person whose appointment is proposed.

Ahead of an appointment decision, an agreement must be reached between the University and the authority responsible for healthcare. For a professor’s appointment, this agreement is signed by the Vice-Rector or Dean and the Hospital Director or the person to whom the case has been delegated.

Agreements for other positions are signed by the head of department concerned and the Hospital Director, or the person to whom the case has been delegated. The agreement is written in duplicate.

The agreement regulates:

  1. the proposed holder of the position
  2. the scope of the clinical work and extent of remuneration for the position 3. the provision of information on employment terms and conditions to the holder
  3. the time frame of the agreement.

To coordinate the work of the University and the authority responsible for healthcare regarding issues of staff administration and labour law, there is a joint working group for issues of labour law.

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