What are the challenges and rewards of working as a foreign doctor in Sweden?
The good things are that the countryside is beautiful and empty, the cities are clean and efficient, outdoor life-styles are easily pursued; people speak good English (though for their job doctors will have to learn Swedish), Sweden has some of the best medical research traditions in the world, hospital equipment is modern and hospitals and clinics make their often Victorian NHS equivalents look intolerably shabby and chaotic. As in Australia or New Zealand, the population is fluent in British culture, yet it is only an hour away from the UK.
But the system is not perfect.
There has historically been a shortage of doctors, with brought in from abroad, but salaries are not as good as for instance the UK – the country increasingly has to attract foreign talent on quality-of-life measures. And foreign doctors will have to be aware of various challenges facing the system. Sweden’s past success came from having a highly educated, homogenous population benefiting from a great sense of solidarity, but since the 1990s, there has been an influx of largely unassimilated and mostly unemployed population of Muslim immigrant origin which is growing fast, and so there are fewer working people able to carry the burden of the ageing indigenous population – the world’s oldest. And there are healthcare management difficulties connected to the structure of its NHS-like universal access system.
Here Sweden’s top health policy academic Johan Calltorp, professor of health policy advising Sweden’s western hospital region, gives the background to the political, social, demographic challenges facing Swedish healthcare…an essential rundown for anyone thinking of working there….
How do you deal with having the world’s oldest population?
Some people think the whole thing will go to hell by 2020, with an ever lower taxbase having to pay for a growing geriatric population. I don’t think so, I am positive, but there are intense discussions going on about this at the moment.
A taxation-based health system depends on a kind of national solidarity – you pay in enormous amounts until the age of 75, then draw a lot. But twenty percent of the population is of immigrant stock, and there is high unemployment. How much they are able to pay for an ageing population – and how much next generation of Swedes is prepared to pay for ageing immigrants – is a highly sensitive issue
Is that why Sweden has the western world’s highest sick-leave rates?
Yes, partly. There is the feeling: if you are unemployed, we will take time off sick.
There is also the problem of incentivisation, when compensation for being off sick as so high as it is in Sweden. Doctors will be called upon to sign a lot of sick-leave notes…..
What other challenges are there?
The Hjertqvist report on European health systems, published last month in Brussels, rated the Swedish system the third best in Europe, but noted that Sweden performed poorly on service and access.
There waiting lists, as you have in common with all the other centrally funded systems. They are getting longer. These waiting lists are a problem of poor management, because a lot of the patients nominally on the list have recovered or died, but they are also used a political weapon by doctors to demand more money.
Partly it is just a problem of situation. The country is so huge, by European standards, with a low population density, yet there is this commitment to provide a universally high quality of healthcare, which becomes very expensive the northern, Arctic areas, which are also suffering from depopulation and an increasingly large number of elderly people. You do need an oversupply of care everywhere. But if you depopulate Lapland and resettle old people in the cities – what then? Turn it into a complete wilderness?
Do the immigrants have problems getting jobs in care?
There is a long tradition of taking in doctors from abroad; but in a broader society, the country is grappling with the problems of multiculturalism. There was a case a few days ago when a hospital banned a Muslim nurse from wearing a hijab for medical hygiene reasons, but the health ombudsman overturned this as a case of discrimination. There is a lot of ongoing debate about these issues….
Sweden doesn’t have any GPs….so what sort of environment can a foreign doctor expect?
In earlier decades Sweden had quite a good house doctor system; now there is a tradition of going straight to specialists or to emergency wards. This has meant long waiting lists for specialists and – especially old people – clogging up the emergency wards unnecessarily.
It is a matter of tradition. In the 1950s and 1960s politicians wanted to build big hospitals – it was their monument, their “Aswan dams” This is particularly true in the big towns; in smaller urban communities you have multiple doctor care centres, which are a bit like GPs’ practices.
Where else can Sweden improve?
The Hjertqvist report on European health systems, published last month in Brussels, notes that Sweden performed most poorly on service and access.
There waiting lists, as you have in common with all the other centrally funded systems. They are getting longer. These waiting lists are a problem of poor management, because a lot of the patients nominally on the list have recovered or died, but they are also used a political weapon by doctors to demand more money.
Partly it is just a problem of situation. The country is so huge, by European standards, with a low population density, yet there is this commitment to provide a universally high quality of healthcare, which becomes very expensive in Lapland, which is also suffering from depopulation and an increasingly large number of elderly people. You do need an oversupply of care everywhere. But if you depopulate Lapland and resettle old people in the cities – what then? Turn it into a complete wilderness
What is the culture of doctors like?
There is an efficiency culture of doctors – they can be a bit remote, not friendly; instead there is a premium on the role of being efficient and competent.
We are not as good as the UK as giving out information – there are no 24 hour helplines, and there is a point systems based on specialty and hospiatsl , but public awareness of this is not as developed.
The pharmacies are all state-run, are hardly ever open, and they seem expensive
Opening hours have been quite restrictive compared to the rest of Europe, but hours are being expanded.
The pharmacies, along with the alcohol shops, are a state monopoly, and are very characteristic for Sweden. Last year the European court of justice said the monopoly might have to be dismantled to allow competition under the single market rules.
The idea of controlled pharmacies was to en able a gatekeeper – the pharmacist – to be on hand to advise on medicine.is less relevant now that you have the internet.
What does Sweden do well?
We have very good patient outcomes.
There is good access to drugs, emergency care is so good, and we have very good public health indicators; our smoking rates are the lowest in Europe. Obesity is growing, but is still low internationally..
What makes the Swedish funding system different?
Our system is more decentralised than the UK one. It is funded through a local tax, by county councils or regions. In fact there is whole local tier of government, with its own elections, devoted entirely to health administration. These local taxes can very greatly, but the health issue as a regional political football becomes obscured by national politics – the tier above – and municipal election s – the tier below, devoted to issues like schools and public transport. . In a few years time these councils will consolidate into larger regions along the European model – we already have two, and I was the boss of one of those, for west Sweden including Gothenburg - although it is unlikely that these regions will have non healthcare political powers. Sweden is quite a centralised country and our governments are traditionally wary of the European regional power model.
What new policies were the result of the election in September last year?
Health is a very unideological issue in Swedish politics, all the parties think the same. We have this “care guarantee” policy promoted by the liberals but which has now being pushed by the ruling social democrats; it will guarantee treatment to anyone within three months, or they can receive treatment in another part of Sweden.
Or abroad?
Not yet! Though I understand EU legislation on this is in the pipeline. There are some initiatives for social and elective care collaboration with Denmark – now linked by bridge to Sweden – and Norway, in the border areas. The EU has argued that healthcare is best dispensed at a regional level, and there are a lot of cross border initiatives in Belgium, Holland and Germany. In Scandinavia most collaboration happens in research and in the pharma industry, not between hsealth systems.
Isn’t Sweden a bit too efficient at times?
The Danes are very different. They smoke more, drink more, eat less healthily and take less exercise. It is true Sweden can seem a bit over regulated. Danes die much younger; but they have more fun.
