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Primary Care in Sweden
Cecilia Björkelund, MD PhD & Andy Maun, MD
Department of Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Primary care in the Swedish health care system
Sweden with its 9.4 million inhabitants of which more than 80% live in urban areas has three independent levels of government all involved in the health system: national, county and municipality. The health system is primarily funded through national and local taxation (80%) and is equivalent to 9.9% of gross domestic product (GDP) (2009).
Primary care forms the foundation of the health care system. Primary care, delivered by more than 1100 public (owned by the county councils) and private (mostly owned by companies or cooperation) primary care units throughout the country, involves services that do not require advanced medical equipment and is responsible for guiding the patient to the right level within the health system. Team-based primary care facilities with four to six GPs, and other staff categories (district nurses, nurses and often physiotherapists, occupational therapists, psychologists, and social welfare counselors), is the most common form of primary care practice in Sweden. Private practices with only one GP exist but are rare.
Payment to primary care providers is generally based on capitation for registered patients, complemented with their estimated 'illness burden', fee-for-service and performance-based payments.
Primary care constitutes around 20% of the total health care budget. Every year around 13-14 million people make a visit to the GP, and more than 30 million telephone calls concerning medical advice, guidance or counseling are dealt with by primary care nurses. Since 2010 patients can register with any public or private provider accredited by the local county council and registration based on latest visit or shortest geographical distance is practiced in most county councils for individuals who do not make an active choice of provider. Irrespective of registration, however, primary care has no formal gate-keeping role in most county councils and patients are free to contact specialists directly. Accessibility is emphasized in the primary care system. Home-nursing service is in most cases not run by the county councils but by the local municipality authority.
Inter-professional collaboration in primary care
During the last twenty years, inter-professional collaboration in primary care has expanded, but since the reforms in 2010 with the freedom of establishment and increased privatization of providers, the expansion seems to have ceased. Nurses, and especially district nurses, have a central role in primary care together with the GP, but e.g. social welfare counselors have been a diminishing part of primary care professionals, due to economic reasons of the individual Primary Care Centre.
General practice in medical schools and vocational training
In Sweden, Family Medicine and General Practice is taught at all seven universities, but it is not a main domain as e.g. in Norway. Usually, Family Medicine departments teach both general practice and consultation methods, as well as take a good part of professional skills teaching. Totally, general practice/family medicine answers for 3-6 months of around in all 40 months of clinical medical education. In most other health care educations, e.g. nurses, primary care is not included in the basic education, only in further education. In intern medical training, general practice is a main domain together with medicine, surgery and psychiatry during a 2-year period. Specialist vocational training in family medicine/general practice in Sweden is five years, mostly in primary care, but also medicine, paediatrics, psychiatry, surgery and gynaecology. We would prefer both medical students and other health care professionals to have more of their basic training in primary care, both to enhance the knowledge as well as the understanding of the vast areas of activity in primary care in Sweden.
There are more than 30 000 physicians in Sweden, and around 5 000 (17%) work as GPs, most of whom are specialists in general practice, and almost all work in group practices. Around 46% are women.
Research in general practice
Research in general practice/family medicine in Sweden is expanding and recruiting research students from all primary care professions. Both clinical primary care research projects as well as epidemiological health care and population based research are expanding, as well as qualitative research. In the last years, cooperation on a national basis between the universities has started and made way for more extensive primary care research projects concerning e.g. chronic illness as diabetes care and hypertension. A joint project for building a national primary care database for quality and research has started, supported by national funds. A Swedish national research school with 50 PhD students (and planning for further 10 students) from the whole of Sweden has been created in the recent years supported by national funds. GPs as well as nurses, physiotherapists and psychologists are represented in the national research school.
The threat for the future development of primary care research is that the present payment system to primary care providers does not include well defined incentives for primary care research. The responsibility to drive primary care research as an important part of health care research as a whole is not identified by the county councils or the present health care economic and political system.
Glenngård AH, Hjalte F, Svensson M, Anell A, Bankauskaite V. Health systems in transition. Sweden. WHO, on behalf of the European Observatory on Health Systems and Policies. 2005;
Smith PC, Anell A, Busse R, Crivelli L, Healy J, Lindahl AK, u. a. Leadership and governance in seven developed health systems. Health Policy. 2012;106(1):37.