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The proximity of healthcare in Sweden

According to the Swedish Health and Medical Services Act, healthcare is to be provided to the population according to need and on equal terms. It must also be available for the citizens. Furthermore healthcare should be under democratic control and financed by solidarity, i.e. tax-funded with minor patient fees. Although the state has become more active in regulating and governing healthcare, using national policies and planning as instruments, the Swedish healthcare organization is still considered to be decentralized and the twenty county councils (including three regions and one municipality) to be self-governing (Fredriksson 2012). Soft-law arrangements and concessions to the county councils help to maintain local autonomy. Soft laws refer to rules that are not legally binding as recommendations, agreements and declarations (ibid., p. 24).

The responsibility for healthcare is divided between the national government, the regional county councils (twenty county councils including two regions and one municipality) and the 290 local municipalities. The county councils are responsible for the provision of primary healthcare, specialized healthcare (outpatient and inpatient care) and are together with other county councils coordinated into healthcare regions, which are carrying out regional healthcare. The municipalities are responsible for providing long-term care for the elderly and the disabled as well as for the long-term psychiatric care. In total there are 8 regional hospitals, 65 district hospitals and more than 1.000 primary healthcare centres. A tendency in Sweden is to merge hospitals and to gather strong and efficient medical centers. Three mergers of university hospitals (Sahlgrenska, Karolinska and Skane) were carried out between 1996 and 2011 in order to go further in specialization. Also for county hospitals there have been done mergers (Nordgren 2012 b).

The quality of health care is measured through national open accounting of quality and results, which should be available for all citizens. A system of national quality registries has been established in in the last decades. There are about 70 registries and four competence centers that receive central funding. These quality registries added to scientific studies, have formed the base for good quality of health care in Sweden. Two of the registries exist within orthopedics and were formed, as well as the other quality registries, through cooperation with the university health care. Sweden is presenting very good medical results in terms of prosthetic surgery in hips and knees as an effect of scientific work in the university health care.

A common notion in the Swedish healthcare debate has been that service aspects, as availability of care (Nordgren 2011) has not developed sufficiently in relation to the increase in costs. Waiting-times to care and treatment have been said by politicians and mass media to be long and patient choices to be limited. International studies that compare waiting times and provide evidence of how well Sweden is doing are few and far between, i.e. only a handful of studies based on surveys of patients, hospitals or the general public have included Sweden. These studies have in general found that waiting times in Sweden are relatively long but that the medical results are good. However, the compilation of selected data that is presented in a recent report made by Salar (2011) does not suggest, as has been previously alleged, that the Swedish healthcare system offers significantly poorer availability than other countries.

In order to develop service and availability of care, free choice of healthcare based on a voucher system and a national care guarantee of a limited waiting period has been implemented and fulfilled in recent years. In fact Sweden has gone far in implementing market reforms, especially free choice reforms, in healthcare and in privatization of pharmacies (Nordgren 2010, 2012 a).One effect of these reforms have been an increase of the number of pharmacies and primary healthcare centers located near the population, which is not the same as saying that this increase is a guarantee for increased quality.

Ever since the first care waiting time guarantee was adopted in 1992, a number of attempts have been made to reduce waiting times by means of national healthcare policy. In an effort to improve accessibility, the Swedish Association of Local Authorities and Regions and the government have both agreed to introduce a national waiting - time guarantee with effect from 01-11-2005. On 01-07-2010, the guarantee was incorporated into the Health and Medical Services Act. The promises of the guarantee are summarized in the slogan “0-7-90-90”. The numbers symbolize the amount of days that a patient has to wait for primary care (0), a consultation with a doctor (7 days), a specialist (90 days) and at last treatment (90 days), adding up to maximum amount of 187 days. A problem is that regulations for the guarantee are deemed as difficult to survey for the patients and that there still seems to be a lack of accessible information on the quality of different treatment options available to patients.

Recently there has been an improvement of availability of care in connection with the introduction of a financial stimulus reform entitled “The waiting List Billion”, which means that treatment should be given in 60 days instead of 90 if following the care guarantee. Nine out of ten patients now receive care within the upper limits set by the care guarantee, and availability is approaching the national targets. According to the latest measuring in October 2012 93 % of the patients needing to meet a doctor in primary care, could do this within 7 days. In most of the county councils (16 out of 20) 90% of the patients got their meetings within time the time-limit, which represent an improvement compared with 2006. Moreover, waiting times for specialized care at hospitals have dropped as an effect of the waiting time guarantee and the so called waiting list billion. Sweden's effort to shorten its queues has been assisted by the Waiting List Billion and has been based on the “Care Guarantee Wheel”, which describes the interplay of parallel measures in multiple spheres of activity, including medical indications, process development and handling of referrals.

However compared with what private health insurances (PHI) offer the waiting-times are still high and in order to be competitive with PHI healthcare and to maintain equitable access to healthcare a further increase of availability may be expected.

References

Fredriksson, M., 2012 ‘Between Equity and Local Autonomy’, Acta Universitatis Uppsalaiensis, Uppsala.

Nordgren, L. 2012 b. 'No one wants to get stuck with the losing card - Management conditions in conjunction with hospital mergers', The International Journal of Leadership in Public Services, Vol. 8, Nr. 3, sid. 144-160.

Nordgren, L. 2012 a. ’Guaranteeing healthcare - what does the healthcare guarantee discourse do?’, Financial Accountability & Management. Vol.28, Nr. 3, sid. 335-354.

Nordgren, L. 2011. ‘Healthcare matching - Conditions for developing a New Service System in Healthcare’, International Journal of Quality and Service Sciences, Vol.3 Nr. 3, sid. 304-318.

Nordgren, L. 2010. ‘The Healthcare Voucher - emergence, formation and dissemination’, Financial Accountability & Management, Vol. 26, Nr. 4, sid. 443-464.

Sveriges Kommuner och Landsting (Salar) 2011.  Swedish Waiting Times for Health Care in an International Perspective, Stockholm.

Winblad, U., Vrangbaek, K. and K. Östergren (2010) ”Do the waiting–time guarantees in the Scandinavian countries empower patients?”, International Journal of Public Sector Management. Vol. 23 No. 4, pp. 353-363

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