National sections

Primary health care in Sweden

Dr Carl-Eric Thors

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 has 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 all the 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 4,500 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. However, in most County Councils the climate for establishing a private practice has been most unfavourable.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 four or five GPs closely 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 newly published 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.

The future
In 1997 the Swedish Medical Association decided that an increase in the number of general practitioners in Sweden from 4,000 to 6,000 was appropriate to meet the new demands in primary hcalthcare. Emphasis has also been placed upon the importance of cooperation between hospitals, specialists outside of hospitals, and general practitioners. 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, ie, 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 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.