Dr. Marina Tuutma – Head of Delegation

Primary health care in Sweden

Dr Anders Nilsson

Sweden has a population of about nine million. The Swedish healthcare system has by tradition been very hospital oriented, with about 80 per cent of total healthcare expenditures allocated to the hospital sector. In past years there have been financial cutbacks accompanied by structural changes in the healthcare sector. The number of hospital beds has diminished, partly due to more efficient treatments and shorter time spent in hospitals. The number of employees has diminished drastically. This has almost exclusively concerned nurses and nurses’ assistants. The hospitals have been restructured. Smaller hospitals no longer have emergency units for surgery. Highly specialised care is now concentrated to the big regional hospitals. These cutbacks on the hospital side have resulted in the primary healthcare sector receiving an increased and more complex number of cases than before. Primary care in Sweden shall provide the population with the entire basic healthcare, as well as preventive and rehabilitative care that does not demand the medical and technical facilities of a hospital. Today there are about 5000 general practitioners in Sweden. Eighty per cent are employed by the County Councils and 20 per cent are private practitioners. However, in order to work as a private practitioner within the social security system, an agreement with the County Council is necessary. The politicians claim to be open to other ways of organising practices within primary healthcare, as it is the contents of primary healthcare and not the way it is organised that matters.

General practitioners in Sweden are specialists in Family Medicine. All have a minimum of five years specialist training, which starts after the licence to practice has been issued. There are nationally stipulated goals for what the training must include. The specialist training is performed on a specially designed training post, and an individual plan for the training is designed for each trainee. Amongst other things, internal medicine, psychiatry, paediatrics, gynaecology and family medicine are included. Most general practitioners work in group practices, with GP: s working with nurses, secretaries and physiotherapists. Sometimes psychologists and counsellors are employed as well. In addition to their ordinary consulting hours, many general practitioners are also responsible for maternity/child healthcare and for healthcare in schools. Since 1997 there has been a law requiring all doctors to assure the quality of their practice. Today, the referral rate from general practitioners to specialists is less than ten per cent. Some County Councils operate a gatekeeping system. However, a national report states that there should be no compulsory gatekeeping system in primary healthcare. Primary healthcare should be the natural first line choice for the patient because of its competence, quality and accessibility, and not as a result of coercion. There are 20 County Councils in Sweden  They can decide themselves how to organise primary healthcare in their respective areas. Some have a remuneration system per capita and some a budget-based system.

National Action Plan
A National Action Plan adopted by the Swedish Parliament in 2000 had as one of its targets that Sweden should have 6,000 family physicians in 2008; i.e. 1 family physician per 1,500 inhabitants. The Action Plane has proved to be a disappointment, depending on the fact that the County Councils have not fulfilled the intentions of the plan and the extra resources that the government granted the County Councils in this respect have been used for other purposes.
It is also important that primary care is organised in a way that permits the patient to have a continuous contact point in the healthcare system, i.e., with a GP/family doctor.

The biggest problem today is the shortage of specialist doctors which is a very real problem within the specialist field of Family Medicine/General Practice. The average age in the Family Medicine/General Practice population is high and many doctors will reach the retirement age of 65 in the next few decades. This problematic situation might also be aggravated by the fact that many general practitioners have declared that they intend to reduce their working hours from 60 years of age. This is a result of the fact that many general practitioners experience their working situation as unsatisfactory with a high degree of stress, too rapid a working pace and limited possibilities to have a decisive influence on their daily work. Therefore, it is a task of first order to find solutions to these problems.

In 2006 the DLF (the Swedish medical organisation of GP:s) made a thorough analysis of all available statistics on the number of professionally active family physicians, the degree of part time work, retirement age and other work assignments within the health care system (high level head positions e.g. and purely administrative work). We found that today the number of family physicians correspond to 3,900 full time working GPs. DLF has also looked in the rear mirror and found that the net addition per year of GPs has been no more than 48 per year during the last 10 years.

LF has also looked at all those doctors who at the moment are in Family Medicine specialist training in Sweden and when they can be expected to have finalised their specialist training. Taking retirements into consideration, the prognosis show that within a few years Sweden will have a DECREASED number of specialists in Family Medicine. Unless some radical steps are taken we can reach the target of 6,000 specialists in Family Medicine no sooner than in 30-40 years time! There is a clear discrepancy between the national goals and reality.

The Future
Today many counties work with a concept called local health service. The definition of this term is not uniform, however all models work with a base of GP:s who are closely tied to organ specialists. Remuneration models vary.

Since the election in September 2007 the new non-Socialist majority has focused on accessibility and customer choice models. The counties are strong and have the right to act relatively at their own will. The county of Halland has developed the so called Model of Halland which is monitored by other counties with great interest. The Model of Halland rests upon uniform remuneration for all care units and demand authorization from the county. All citizens are listed and the remuneration based upon weighted age interval. Demands to be approved as a care giver are that the unit has a system for guarantee of quality, economical stability, technical ability, capacity etc.

The renumeration comprises all contacts regardless of the care giver of the care unit. This means that there is no special remuneration for visits. Along with the agreement there are defined commitments. There is also a possibility negotiating added commitments. The county monitors accessibility, degree of coverage, medical quality, pharmaceutical prescription an health promoting activities. Seventy per cent of the listed consumption in open primary care is to be performed in the medical health centre that the citizens have selected.

In Stockholm you work with the so called Stockholm model. It was introduced in January 2008 and is based upon a uniform agreement and authorization throughout the county. A very strong driving force in the Stockholm model is that the political majority wants all primary care units to be run privately in a couple of years. The customer choice model that one wishes to introduce in Stockholm prevents that the continuity between doctor and patient is cut off by The Act on Public Procurement. The citizen will, by this model, be the procurer.

The Committee on Public Sector Responsibilities, which after a number of years, handed over a report to the government in February 2007. Among other things, this report suggests that regarding healthcare, the right and the influence of patient shall increase. Citizens shall have the right to have a continuous contact point in the healthcare system, i.e., with a GP/family doctor. However, the statutory claim that this continuous contact point shall be a specialist in Family medicine is to be withdrawn. Furthermore there is a commission working on the right of the patient in healthcare. The results that come out of this commission may have a substantial effect on a primary care in the future.

Many things are happening within Swedish healthcare today, not least within Primary Care and it is of great importance to carefully monitor the development and to find all possible opportunities to keep an ongoing dialogue with the decision makers.

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