HealthManagement, Volume 5 / Issue 1 2003 (English)

Crises of Success : Elder Care in Sweden

Crises of Success : Elder Care in Sweden
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JoAnne Girard

An Interview with Lennarth Johansson, Associate Professor, Research Leader, National Board of Health and Welfare, Stockholm, Sweden Sweden has been successful in creating social conditions that have achieved one of the longest lifespans in the world.


Their welfare system provides health care and social services according to needs. Now they must manage the increasing demand for elder services created by their success. The ability to provide services is challenging due workforce shortages and financial constraints. Anew vision of what caring for the elderly means must be created in order to sustain the benefits for the Swedish recipients yet to come.


What are the Principal Goals for Care of Elder Care in Sweden?

Sweden has been the forerunner of health care and social services. The pension system provides economic security for everyone, so no one has to abstain from necessary service and care, due to economic reasons.

There are four aims for the National policy as defined in 1998. They include:

-To be able to live actively and to have influence in society and over there everyday lives.

-To be able to grow old securely and with independence preserved.

-To be treated with respect.

-To have access to good caring services.


Swedish people pay more or less half of their salary in taxes, of which a substantial part is used to finance health and social services. Swedes have equal access to those services regardless of their income. Naturally people have high expectations for those services to continue at current levels.


How are the Elder Services Organized?

There are three levels of government with health care responsibility in Sweden: the National Government, the 21 counties, and the 290 municipalities. At the national level, the Parliament and the Government set out policy aims and directives by means of legislation and economic steering measures. At the regional level, the county councils provide hospital and primary care. The social services, such as home help services, home nursing care and housing (institutional care), are provided at the municipal level. Both the county councils and municipalities may set priorities and eligibility requirements within the limits prescribed by existing legislation. Some 80% of services are financed locally and the municipalities are very independent in their functions.


Are there Variations in Services Among the Different Municipalities?

The type and amount of services can vary greatly due to many factors such as local economy, availability of personnel, and percentages of elderly population. Generally, there is shortage of able and qualified personnel, but the shortage is more severe in rural communities. There are increased demands on the municipalities for services at home or in special housing such as nursing homes as a result of decreased hospital beds. As a consequence, municipalities have increased beds in municipal nursing homes, for example, to provide for terminal care; and that has negatively impacted their resources. Cost is also a factor, especially in sparsely populated communities where it is possible to have 33% of the population at or over age 65. If a community has a weak economy and large elderly population, the social services are limited by the funds available. These differences in funding levels, personnel available, and priorities set by the region and local governments have inevitably resulted in variations of care and service across the country. This division responsibilities and incentives have led to tension between the regions and municipalities over funding and coordination of services. The public has also taken great interest in the variations and quality of service.


Just last week the government formed a committee to study the issue of local independence versus national government in general, and with special regard to variations in the standard of public services and overall expected equality. The trend is for the national government to take a stronger role in setting standards and monitoring quality. For example, in 2001, financial floor and ceiling limits were put in place to establish standards for municipal services and care.


There Seems to be a Shift Toward Care Outside the Hospital. What are Some of the Services are Provided in the Municipal Setting to Ease the Burden on Families?

The elderly are the dominant users of short-term hospital care. In 2000, 54% of the total bed days were used by the population 65 years and older. Since reforms were implemented in 1992, however, the number of hospital beds has decreased and some have expressed concern that the average lengths of stay are too short. Despite those concerns, there is an obvious trend toward moving care outside of the hospital. Provided that there is qualified personnel and adequate funding available, many would agree that care outside the hospital promotes independence and a higher quality of life for the elderly.


The most important of the services provided outside the hospital is home help services. Home help services give the elderly assistance with daily activities as well as personal care. In 2001 about 7.9% of the population over age 65 received home help services. Of these, about one third also received home nursing care. In the age group 80 years and older, 18% received home help.


Another important service is special housing (institutional care). Special housing comprises nursing homes, old age homes, service houses, and group homes (for the demented). In 2002, 20% of people 80 years and older received special housing services.


Many programs have also been put in place to assist families who care for the elderly. These services include economic assistance, respite care, as well as counselling and personal support. In 1999 the National Action Plan on Policy for the Elderly set forth a programme that increased block grants to the municipal elderly care. In the Action Plan the government established a three-year plan (10 million Euro annual funding) to stimulate local governments to develop and infrastructure of services targeting family caregivers. The issue of family support continues to receive much public attention and groups have been formed to lobby local and national government for increases in family assistance and support.


Is the Workforce an Issue in Expanding Home-Based Services?

That is the “mega” issue. Many areas currently lack sufficient numbers of fully trained personnel and this has been the subject of many media exposés. Sweden currently has about 320,000 people employed, serving the elderly in the health and social services sector, but they too, are an aging population. The number of personnel on long-term sick leave is increasing and the drop off due to retirement is coming. If Sweden is to continue to expand elderly services, health care careers must be attractive to those entering the workforce over the next 15 years. Factors such as working conditions, recruitment, and training must be remodelled so that they provide the basis for an attractive lifetime career.


Can the Economic Pressures be Met?

Solving the economic issues depends on a new vision. We must define how we should serve our elderly and the division of responsibility between the state and the family. And for example, the retirement age is just one factor that must be addressed for the provision of equal resources to everyone. Currently people tend to leave the workforce earlier, at an average of 60.5 years of age, and it has been suggested that people should remain productive for a longer period of time to contribute to a sustainable economy. Innovative programs with a preventative approach that support the elderly in their homes must continue to be explored. Programs to educate, counsel, and support families must be expanded.


Sweden can create a modern view or serving the elderly with independence and respect. To continue success we must provide the vision for larger workforces who are attracted to elderly care by attractive working conditions and economic security. Sweden must remodel the system of services just as the pension system was remodelled. The pension system redesign took 12 years so it will be a long journey, but success can be achieved. Both the citizens of Sweden and the other countries ofEurope will share the benefits of a modern paradigm for the elderly.

«« Coordination of primary health care and hospital health care reduces readmission in patients with COPD

Author JoAnne Girard An Interview with Lennarth Johansson, Associate Professor, Research Leader, National Board of Health and Welfare, Stockholm, Swed

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