In 2018, the Swedish government proposed the initiative “God och Nära Vård” (Good and Close Care) - where primary care should act as the primary hub of Swedish healthcare. At that time, a current situational analysis determined the work of primary care as unsynchronized and unclear in relation to the work of hospitals, and called for new ways of working to offer patients personalized and co-ordinated care. This would more easily meet the demand for both psychological and physiological care throughout Sweden.
The Authority for Care and Care Analysis (Myndigheten för Vård- och Omsorganalys) has published reports on how this transition has gone. Five reports have been made so far, and the final report is due at March 2025. In this report, which was published in the spring of 2023, the experiences seen though the lens of the general managers participating in this transition from primary care centers, has been the focus. A majority of the country's health center managers have participated in an extensive survey, and data has been obtained from the International Health Policy Survey 2022, to complement the employees views. The report concludes with a closer look at three counties undergoing transformation at a regional and municipal level. The data has also been analysed with regard to socio-demographic differences in different areas with health centres, as well as sparsely populated areas.
“God och Nära Vård” overview
So far, the government has put in 28 billion SEK for this investment, through Sweden's Municipalities and Regions (SALAR). 86% of all funds have gone to regions. Regions can organise their own primary care - where citizen must have open access to care of all levels or illnesses. In terms of costs, the regions spend about 90% of their expenses on the health centers themselves, which are a central part of primary care, and that is what the survey is focused on.
In the surveys to business managers, different themes appear.
The care centers are considered understaffed in relation to their care needs. Although the number of psychologists, for example, has increased, more are needed to meet the demands of the general managers. Due to both finances and personnel availability, it is difficult to increase the supply of skilled workers.
The largest occupational category in health centers are specialist doctors - about 18% of all staff, followed by various forms of nurses and medical secretaries. Together, this group makes up 69% of all staff in healthcare centres. Psychologists and psychotherapists account for only 6% of the total staff in the health center. Almost all - 94% - of psychologists are permanently employed, while only 80% of specialist doctors are. Specialist doctors have the highest rate of service on average - 76%. For psychologists, the figure is 66%. The lowest are dieticians at 31%. 82% of all health care centers have a psychologist permanently employed. Lower than, for example, 94% of health centers with assistant nurses, but higher than licensed doctors at 50%. Specialist doctors have an employment rate of 91%.
The number of specialist doctors with a general medicine specialty has decreased, and instead other professional categories have increased, and psychologists have been one of these categories. The benchmark of 1,100 listed patients per specialist doctor is not followed, and is currently just over 2,000 listed patients. Many operational managers feel dissatisfied with this development. The shift of a lower rate of specialist doctors has generally meant an increased rate of other types of employees such as dieticians, or psychologists. The health centers have become more generalised in their competencies.
Among the professional categories that business managers need to hire, 77% report the need for more more specialist doctors, and 46% for more district nurses. 27% are looking for more psychologists. Calculated in the number of full-time positions per health center in need, there is a need for another 1.95 specialist doctors, 0.85 nurses and 0.34 psychologists per health center.*
Although 77% of healthcare centers feel the need to hire, only 44% report that they have the space to do so.
A majority of doctors in primary care report stress in connection with fulfilling the requirements for their work, and the operational managers report to a great extent in open text a concern that the demands on primary care centers have increased, while there is a skills shortage, especially of licensed doctors and district nurses, but even psychologists.
Above all, there is a higher sick prescription rate for specialist doctors, but other professional groups are also affected.
Regarding various efforts that could have helped the general managers fulfil the requirements of the Good and Near Care initiative, 85% answered increased financial resources, as well as increased staffing at 83%. 33% cite listing caps per health center, as a solution. The business managers share the target image of Good and Close care, but believe that it is difficult to realise in the current structure.
The data also shows that the share of resources for primary care has increased by just over one percentage point since 2017. Within many regions there is also a large variation in the net cost of primary care per resident, and also an increase or decrease in the cost share of primary care.
As many as 33% of general managers, state that the coordination with the specialised care works poorly, and even for student health and social services, that figure is as high as 28%. Municipal home health care or special accommodation works best in terms of coordination. In free text, the co-ordination between psychiatry and primary health centers, is often mentioned as a particular problem.
In terms of reasons, 58% report the main reason being role ambiguity. In open text, often mentioned reasons are also a need for common systems, and outdated technical solutions.
A new task for primary care is preventive work. Large differences exist from 27% to over 80% in terms of the opportunity to work preventively. Again, the main reason identified by the business managers is financial resources. In plain text, they mean that it is simply a question of priorities.
When one can't event treat what's urgent, prevention is not that interesting.
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