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Sweden
Sweden has a population of about nine million people. The
main responsibility for financing and providing healthcare services
in Sweden rests with the 20 County Councils. The County Councils
present a political level between the municipal districts and the
national government levels. Elections to the County Councils are
held on the same day as the general elections to Parliament and to
the municipal districts.Traditionally the Swedish healthcare system
has been very hospital oriented.A new health political view made its
appearance some 20 years ago and at this time we could witness a
political thrust on Primary Healthcare as the main basis for the
future healthcare delivery system.
Despite the political will, it
took several years before the focus on and the resource allocation
to the PHC system really gained momentum. As late as ten years ago
the number of general practitioners (GP) in Sweden amounted to only
2,000. Today there are about 4,500 GPs. The total number of
professionally active doctors in Sweden is approx. 27,500. This
means that one doctor out of six is working as a GP, today. The
doctor/population ratio for all doctors is 1/320 and the GP/population
ratio 1/1,955.
It is also of interest to note that 39 per cent of
the GPs today are women and that 25 per cent of the GPs are working
part-time.As mentioned above, primary healthcare has been a major
political issue in Sweden in recent years. In 1994, eg, a bill on
the introduction of a Family Practitioner system was passed by
Parliament. This system was based on the principle that each
inhabitant could voluntarily register themselves with a particular
GP. The income of the GP was mainly to be based on capitation
fees. With the change of government that occurred in the autumn of
1994, this legislation was revoked as of 1 January 1996. The
consequence of this is that today the County Councils can decide
themselves how to organise the PHC in their areas. If they want to
use a list system this is acceptable; if they want to organise the
GP services in some other way, this is also possible.As of today
there are basically two different modalities for working as a
GP.
One is that the GP is employed by a County Council. This is by
far the most common one. More than 80 per cent of Swedish GPs are
employed by the County Councils, while just about 1 7 per cent
perform their work basically as private practitioners, which is the
other option. But in order to work as a private practitioner, an
agreement is needed with the County Council concerned, since it is
the County Council that will reimburse the private GP for the
services rendered. The patients are also charged a fee, but the
amounts resulting from the patient's payment are marginal.Private
medicine does exist but on a very limited scale. Some 90 per cent of
Swedish doctors in total are employed by the County Councils,
leaving some seven per cent of all doctors to work in private
practice, either as GPs or as specialists in other medical
disciplines. Lately though there are indications that the political
interest and willingness to consider private alternatives inside the
health insurance scheme and also to be openminded about other
possible organisational forms for rendering the medical services
might be on the rise. It remains to be seen what concrete results
this might have on the healthcare system.The most common way for GPs
to work today is in group practices, where three to four GPs work
closely together with district nurses, physotherapists, occupational
therapists, midwives, secretaries, etc.
It should also be noted that Swedish GPs are medical specialists
in Family Medicine on the same level as other specialists (surgeons,
internists, etc). All Swedish GPs have passed through a specialist
training period of at least five years.The training period starts
after graduation from medical school and after complete
pre-registration training of a minimum of 18 months.After many years
of struggle for increased resources for the PHC, we are happy to
note that PHC and General Practitioner Services have made
substantial progress. But this process must continue in order to
obtain a more favourable GP/population ratio than today. The present
PHC struggles with many problems some of which are that the
reduction of inpatient services has left the PHC and the GPs to care
for patients with more complex medical situations than before. An
increasingly ageing population staying as long as possible in their
own homes or in various types of service or nursing homes also
demand more time and help on the part of the GPs. The number of
doctors, including GPs, who feel more and more stressed and show
various degrees of burn-out symptoms tend to increase. More GPs are
clearly needed in the years to come to safeguard both good medical
services and acceptable working environments for the heallhc are
personnel.
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