ICU Management & Practice, ICU Volume 11 - Issue 1 - Spring 2011
Author
Providing healthcare for just under 9.5 million people (www.scb.se), the Swedish national healthcare system is regularly ranked as one of the best in the world and continues to improve through innovative solutions and investment in the latest technology.
Health in Sweden
Sweden boasts high life expectancy rates – 79 years for men and 83 years for women, high cancer survival rates, as well as one of the lowest infant mortality rates in Europe, with an average of 3 death per 100, 000 children born (2008). It has the EU's highest rate of physicians per capita, at 3.3 per 1,000, which allows patients to have quick and easy access to healthcare professionals and a well-established and efficient preventative healthcare service. Compared to many other EU member states, Sweden also has a very high rate of efficiency in healthcare service delivery, despite restrictions in state funding and investment. However, like many other industrialised countries, Sweden also has a low fertility rate, which has resulted in negative natural population growth since the late 1990s, although real population growth is on the rise due to positive net migration into Sweden. Today, Sweden has one of the world's oldest populations, with more than 17% of the population being aged 65 years or older and 5.2% aged 85 years or older. Although mortality due to diseases of the circulatory system has been significantly reduced during the last 30 years, this remains the leading cause of mortality, accounting for over a third of all deaths. Chronic diseases that require monitoring and treatment and often life-long medication also place great demands on the healthcare system. One positive fact is that Sweden has relatively few smokers – almost 85 percent of Swedes are non-smokers, which is reflected in the low rates of certain smoking related cancers.
Managing National Healthcare
In Sweden there are three independent governmental levels, which are elected every four years – the national government (Riksdag), the county councils (Landsting) and the municipalities (Kommuner) – and all three are involved in healthcare. Health policy in Sweden is a national-level responsibility, however it is a highly decentralised system, which is based on three simple principles: Equal access, care based on need, and cost effectiveness.
The Swedish healthcare system is organised into seven sections: Proximity or close-to-home care (this covers clinics for primary care, maternity care, outpatient mental healthcare etc.), emergency services, elective care, hospitalisation, out-patient care, specialist treatment and dental care. The national system is administered by 21 councils, of which 18 are at the county level and three are regional. The population in these 21 areas ranges from 60,000 to 1,900,000. The 21 councils are responsible for hospitals and GPs, while the 290 municipalities provide municipal care through smaller clinics, nursing homes and home care services. There is no hierarchical relation between municipalities, county councils and regions, since all have their own self-governing local authorities with responsibility for different activities. The councils and the municipalities have considerable freedom in planning for the delivery of care, which is one explanation for regional variations.
Services Provided
Sweden has 60 hospitals that provide specialist care, with emergency services 24 hours a day. Eight of these are regional hospitals where highly specialised care is offered and where most of the teaching and research is based. The eight regional hospitals are located in Sweden's six healthcare regions, which are coordinated by the Committee for National Specialised Medical Care (Rikssjukvårdsnämnden) within the National Board of Health and Welfare.
The new Karolinska University Hospital is the largest hospital in Sweden with about 15,000 employees and 1,600 patient beds and is the result of a 2004 merger between the former Huddinge University Hospital (Huddinge Universitetssjukhus), south of Stockholm, and the Karolinska Hospital (Karolinska Sjukhuset) in Solna, north of Stockholm. It is associated with the Karolinska Institutet (KI), one of Europe's largest medical universities and Sweden's largest centre for medical training and research.
The counties own all the emergency hospitals and whilst specialised treatment is usually provided by the regional hospital service, healthcare services can also be outsourced to contractors. Usually either an executive board or an elected hospital board at the county level determines the management structure of hospitals within each county. County councils also have similar authority over primary healthcare centres, which differ from hospitals in that they are responsible for providing most outpatient care.
Municipal governments are left with the responsibility of overseeing patients who have been discharged from a hospital and need public nursing homes or home care. Although municipal authorities have a smaller role to play, it is becoming increasingly important with an aging population.
Private Healthcare
In Sweden, the county councils and municipalities are the main providers of healthcare with only about ten percent of health services delivered by private providers. Private funding, beyond user fees, therefore only plays a small role in Swedish healthcare. In 2007, less than 3 percent of the Swedish population had supplementary health insurance, with the primary benefit being the ability to avoid long waiting lists for treatment. However, private insurance has risen by 50 percent from 2004 to 2007 as Swedish hospitals are now permitted to operate at a profit and Swedish companies begin to offer employees private health insurance policies.
Financing the System
Over the past 20 years Sweden has had an average annual investment of around 9.2 percent of its GDP on healthcare. Most of the public financing comes from county council taxes (proportional income tax), which accounts for just over 70 percent of the healthcare costs. Health services for the elderly and disabled provided at home or in special residential settings are financed mainly by municipal (local) taxes. National subsidies cover approximately 20 percent of the costs.
Patient fees (out-of-pocket) account for approximately three percent of the total healthcare costs. The out-of-pocket fees for physician visits (including primary care) and for most visits to other providers are set by the individual county council, however, there are uniform national ceilings on the total amount that a patient pays during a 12- month period. Health services for children and adolescents up to 19 year of age are free of charge.
Patients also pay part of the pharmaceutical costs but an out-of-pocket ceiling also applies to pharmaceutical costs. All Swedish pharmacies are interconnected with a nationwide network, which means prescription drugs can be picked up from any pharmacy in the country.
Another service incorporated into the social welfare system is sickness pay. When a physician declares a patient to be ill (by signing a certificate of illness/unfitness), the patient is paid a percentage of their normal daily wage from the second day. For the first 14 days, the employer is required to pay this wage, and after that the state pays the wage until the patient is declared fit. The state also reimburses patients for travel costs to and from the clinic or hospital.
Healthcare Reform
The Swedish healthcare system has undergone a number of reforms and changes but, in general, the basic structure of the system has been relatively stable. The major reforms since 1970 have been result of demographic changes, with increasingly ageing population and increases in the number of people with complex non-communicable diseases. One of the main changes in healthcare and social services came in 1992 when responsibility for elderly care was transferred from county councils to local authorities (municipalities). Since hospital treatment is more costly, the aim was to care for elderly persons as far as possible in their own homes or in settings within primary healthcare. Since 1995 the municipalities have also taken over the responsibility for persons with long-term mental illness and all kinds of disabilities. Over the last decade, GP visits have steadily grown while specialist interventions have fallen. Sweden has also sought to drive patients more quickly through the hospital system, which has allowed more investment into community services and primary healthcare.
Since 2003 Swedes have enjoyed free choice in healthcare, which has allowed patients to choose to be treated at any facility in the country, under the same conditions as in their home county. By January 2010, all county councils adopted what is known as the primary choice system in primary care, which allows patients to choose whether they would prefer to go to a private or public health centre.
Specialist Projects
In June 2009, Sweden saw successful deployment of the first stage of the Swedish National Patient Summary Project (NPO). The Örebro County Council and the Municipality of Örebro healthcare region in central Sweden have connected to the NPO in the first stage of a project to create a Swedish national health record. The NPO solution, which has been extended to more than 500 doctors, nurses and occupational therapists, makes real-time patient information available on a national level to county councils, local authorities and private healthcare providers. The project was temporarily suspended, following concerns about the amount of information patients are receiving but was resumed at the end of 2010 and has been extended nationwide. Sweden is currently developing online access to electronic medical records by patients.
1177: This number is known in Swedish as Sjukvårdsrådgivningen - the healthcare advice line, for non-emergency health advice. It connects patients with a qualified nurse who has received training in telephone-based healthcare. The service is available 24 hours a day, 7 days a week.
