ANNEX 2: HEALTH COMMITTEE VISIT TO SWEDEN
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.
Dentistry
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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