Select Committee on Health Third Report


28-30 March 2006

Meeting with officials from the Ministry of Health and Social Affairs

Officials gave a brief overview of healthcare in Sweden, followed by a more detailed presentation on pharmaceutical costs and financing.

Healthcare in Sweden is based on the Health and Medical Services Act of 1982. The Ministry does not provide healthcare directly, but oversees the work of Government agencies , monitors and analyses health and medical care and drafts legislation.

Responsibility for the provision of care is decentralised to the 21 county councils and 290 municipalities, which have the right to levy their own taxes. The County Councils provide medical care to all and are responsible for public health; the municipalities are responsible for the personal care of the elderly, disabled and people with long-term mental illness.

9.2% of GDP is spent on health. Charges comprise around 3% of overall resources, with the bulk of the remainder met through taxes (71%) and Government grants for specific projects (18%).

Access charges

Patients pay a charge to see a healthcare professional. It costs less to see a nurse (around £6) than a GP (around £10) or specialist (around £18). A&E visits are charged at around £15 (there is no charge for under-16s). The County Councils set the level of the fee but there is no great variation across the country. There is no difference in charge between privately run but publicly funded hospitals and public hospitals.

There is an annual limit of SEK 900 (£65) for all outpatient care (including A&E visits and the cost of laboratory tests, X-rays etc). Once this level is reached, the County Council meets the cost.

Inpatient care costs 80 SEK (£6.60) per night. There is no annual cap ie. if a patient is in hospital for 3 months, they will pay for 3 months. People do not insure against this charge (only 2% of the population has private health insurance). Social insurance steps in to assist very poor people who cannot afford to pay.

Sweden has at times been criticised for having a pro-rich system, for example in reports by the European Observatory on Health. There is no clear evidence of a deterrent effect of charges in Sweden though. Research by the Swedish National Institute of Public Health has shown that those on very low incomes might refrain from seeing their doctor.


The under-19s receive free dental care, including the provision of braces, as do disabled people. Everyone else pays, with the state making a small contribution. From age 65 the state makes a slightly larger contribution. The state contributes the same to a county or private dentist. There are discussions ongoing on how to reduce the cost of dentistry. Some studies have shown that poor people tend to refrain from seeing a dentist.

Pharmaceutical charges

County Councils pay for medicines given to inpatients and subsidise medicines dispensed to outpatients, through the Pharmaceutical Benefits Scheme. Patients pay a proportion of the cost of prescribed medicines and most of the cost of over-the-counter (OTC) medicines. In total, 21% of total drug budget is met by patient charges. There is an annual limit on expenditure on all drugs. Once a patient, or a family with children (which are considered together), have spent SEK 1,800 (£134.24), the state pays all drug costs for the rest of the year. Pensioners pay the same as everyone else. Medicines given when a patient is admitted to A&E are free.

All medicines, inpatient and outpatient, are dispensed by a branch of the state-owned pharmacy, Apoteket (see below).

Meeting with Parliamentary Committee on Health and Welfare

The Committee met three members of their counterpart committee in at the Swedish Riksdag; Ingrid Burman, Chairperson (Left Party), Gabriel Romanus (Liberal Party), and Conny Öhman (Social Democratic Party). A range of issues of interest to the Committee were discussed.

The Swedish Members pointed out that the access charges levied by the health service encourage patients to see their GP rather than a specialist in the first instance, as GP fees are low in comparison to those of consultants.

They also drew attention to the exemptions to charges, which are minimal in Sweden. Most County Councils exempt children from paying health charges (outpatient care is free up to age 18 or 20, depending on the County Council). Few other groups enjoy exemption from charges but, for poorer patients, the Social and Welfare Authority will meet the costs of healthcare or dentistry. In some cases, the authority will pay the doctor or dentist directly.

The current levels of charges have been in place for the past 5-6 years. The Swedish Committee felt that a large increase in patient charges was unlikely, but that small increases could occur over the next few years.

The rising cost of the health service will be met through an increased percentage of GDP to be spent on health, alongside strategies to encourage better use of GPs and healthcare services in general.

Levels of unemployment are increasing (4.9% at the moment) and the cost of sick leave to the Swedish Government has also doubled in the past few years. The Swedish parliament is now considering whether a proportion of sick leave payments should go directly to hospitals to pay for medical treatment for the sick individual, to ensure they receive the necessary therapy. No decision has been reached yet.

Meeting with Apoteket

There are around 850 community and 80 hospital pharmacies in Sweden. All pharmacies are run by Apoteket, and all medicines are received from one of the branches. There are also 15 Apoteket shops which supply only OTC medicines. Unlike the UK, it is impossible to buy paracetamol, for example, from a supermarket or petrol station. It is Apoteket's responsibility to ensure a good supply of medicines, at the same cost, all over the country.

Electronic prescribing is used all over Sweden both in primary care and in all hospitals. Over 55% of new outpatient prescriptions are handled electronically. The information is stored in a database for 15 months (patient consent is not required to store information, but only the pharmacist, prescriber and patient can view the record) and medicines can be dispensed by any pharmacy or posted to patients. Prescribers and pharmacists need the patient's consent to view the record. All pharmacies are linked to the same IT system. Patient records are therefore available at every outlet.

The Pharmaceutical Benefits Board administers the Pharmaceutical Benefits Scheme and decides which medicines and devices will be covered by it. For a medicine to be included on the scheme, it must be proven to be cost-effective. Patients must pay the full price of medicines not included in the scheme. Some medicines are included on the list but their use is 'limited', ie. there are rules that apply before they are included, (eg. to be prescribed Xenical a patient must reduce their body mass index to a certain level). Otherwise the patient meets the full cost of the drug.

Sweden operates a 'stair' model for the County Councils' contribution to the cost of medicines. A greater proportion of the drug cost is paid initially by the patient, but this falls as more medicines are purchased. Up to SEK 900 there is no discount; between SEK 900 and 1,700, there is a 50% discount; between SEK 1,700 and 3,300, there is a 75% discount; and between SEK 3,300 and 4,300 there is a 90% discount. After the cost of the medicines exceeds SEK 4,300 (and the patient has actually paid SEK 1,800) a card is issued which states that all future medicines for the rest of that year should be dispensed free of charge.

The most a patient has to spend on medicines in one year is therefore SEK 1,800, but it is possible that they would have to spend this on the first prescription, if the drug was expensive. Patients may arrange a credit agreement with the pharmacy and pay SEK 150 each month for a year (rather than pay high immediate costs until the discount threshold is reached. Apoteket does not check their income, and this system is used by many people for practical reasons). Patients who have previously had problems paying their bills are blocked from the system. There has been some criticism of this, but those who are really poor can in most cases get their medication paid through the social security system.

Generic substitution has been in place since October 2002. Pharmacies are obliged to substitute prescribed medicines with the least expensive equivalent medicine available. If the patient chooses to have the branded medicine dispensed, in most cases they must pay the price difference.

Although medicines funding is met by the County Councils, the Councils may negotiate with the state for extra funding if there are many costly patients in a particular area.

Meeting with Director of Stockholm County Council

Mr Sören Olofsson, Director of Stockholm County Council, outlined how Council members are elected, and their role, before discussing specific areas of health charging, particularly dentistry, with the Committee.

Stockholm has a regional parliament with 149 members who are elected every 4 years. Healthcare, transport (rail, bus and water) and regional planning are the main responsibilities of the County Council.

Mr Olofsson said that there was no tradition of accessible GPs in Sweden, although this is now changing; surgeries are open later to allow patients to see their doctor after work. A&E is over-used (it costs a similar amount to see a consultant as to visit A&E). It has been suggested that the annual cap on outpatient charges should be raised as a result but this move is not expected in the near future.

Mr Olofsson stated that the current pharmacy system, run by Apoteket, is popular with users, in contrast to the system in Norway. The pharmacies in Norway were privatised, which led to much criticism there.

Regarding dentistry, adults meet 70% of costs. A check-up costs approximately SEK 600 (£43.50) and the price of any treatment required is added to this. Prosthetic treatment can be extremely expensive, even with a cap that is in place for pensioners. Older patients pay a maximum of around SEK 7,510 (£544) for dentures. The maximum charge for dental implants is SEK 37,570 (£2,724). This is an issue for many Swedes.

Meeting with the Swedish Association of Local Authorities and Regions

The Swedish Association of Local Authorities and Regions represents the municipalities and County Councils of Sweden, and supports the authorities in their service development. The Committee met Roger Molin, deputy health of the Healthcare Division. Mr Molin outlined some recent charges in healthcare policy in Sweden before discussing sight tests and the consequences of charging.

As in the UK, there has recently been a move towards providing more care outside hospitals. There has been a reduction in the number of full-scale emergency hospitals and hospital beds. The number of maternity units has fallen alongside levels of infant mortality. Now more women are cared for in larger and more effective units. This means that many women have to travel long distances.

Sight tests

Sight tests for adults are all carried out privately; there is no contribution from the state for either spectacles or the test. Patients visit an ophthalmologist for an eye examination, and pay the same charge as to see any other medical specialist.

Children receive a free basic eye check before they start school. Once at school, they receive a free yearly check with a nurse. There are some subsidies from County Councils for glasses for children up to the age of 18, but uptake is reportedly low.

Consequences of charges

Overall, the impact of patient fees is unknown but around 2.4% of the population do not get medicines dispensed because of cost. These are reportedly mainly medicines for pain and asthma. This is more common among those on low incomes, and among people aged 20-54 rather than older individuals.

Only small differences in inpatient care are observed between those on high and low incomes and car parking charges are not an issue for Swedish patients.

Mr Molin stated that patient charges for health services represented a means of 'steering' patients rather than generating income. The system of charges is well accepted overall, but Mr Molin felt that dental charges are likely to change in the next few years.

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Prepared 18 July 2006