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Physician manpower politics in Sweden
HeaM
Policy, 15 (1990) 105-118
Elsevier
105
Chapter 4
Physician manpower
politics in Sweden
Johan Calltorp
The health care system Swedish health care is predominantly public. Roughly 90% of the health services are delivered within publicly owned and operated facilities. Twenty-six local county councils are by law responsible for providing and planning the health care for the inhabitants of the area. Local county council taxation finances around 2/3 of the total cost for health care. The major part of the remaining l/3 comes from central government subsidies, since 1983 distributed according to a per-capita-formula. The structure of the health care system is remarkably similar all over the country - the result of a long tradition within Swedish society for a centralized authority. Also extensive national health care planning during the expansion era of the 1960s and 1970s had an important impact on organization within the county councils. Sweden has a high ratio of hospital beds per population, but a remarkably low number of out-patient and primary-care visits per inhabitant. Earlier in this century, primary care was relatively well developed, but during the expansion period, especially in the 1960s. specialized hospital services got priority. During the 197Os, general health policy has favoured primary care as well as long-term care and psychiatry, but this policy has not been fully implemented. In the 1980s when expansion finally slowed down and resources became stable (Table 1) the dilemma of a considerable number of hospitals and a still poorly developed primary care system has become even more evident. Table 1 Health care costs as a Percentage Year % of GNP
of Gross National Product (Sweden)
1963
1970
1975
1980
1982
1985
1986
5.4
7.2
8.0
9.5
9.7
9.4
9.1
In the 1960s a system of regionalized planning for the more specialized services was introduced. The law requires cooperation between three to five neighbouring county councils in order to finance highly specialized service at a tertiary care center (mostly the regional or teaching hospital - one or two in each region). 0168-8510/90/$03.50@1990 Elsevier Science Publishers B.V. (Biomedical Division) [311
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Without a doubt this early regional system has helped to avoid unnecessary duplication of expensive equipment and facilities. Over the last ten years a system of nationwide ‘supra-regional planning’ has been introduced in order to plan for the most expensive types of care and those procedures that are in a stage between research and routine care (for example burn treatment centers, heart transplant activities, extracorporeal shock-wave lithotripsy etc.). In Sweden, private health care has traditionally been integrated with the public financing of care. For a long time the country has had between 600 and 800 full-time private practitioners working mainly as primary-care physicians. Most of them have contracts with the same National health insurance scheme that covers all citizens and is financed through employer contributions. Since 1983 insurance-affiliation and entry into the system for new practitioners is restricted through a mechanism that gives the county councils power to decide both the volume of this type of private care and which practitioners will be accepted. This new regulation was part of a government action to get control over the growth of the health care system and also distribute resources and physicians more evenly around the country. This last objective will be dealt with later in this paper. As for the growth of private medicine, the result has been a somewhat mixed picture. Some county-councils try to enhance private practice within the public finance system and as part of the county council-planned activities. Different kinds of contracts for private delivery of specialized services are increasingly seen in sectors which could not produce enough services within public care (for example implantation of intraocular lenses, hip-replacement, coronary-bypass surgery). To an increasing extent private health care is also produced without public financing or subsidies. Private health care insurance has been offered since 1984 a completely new element within the Swedish model. The volume is still tiny, not more than 15000 policies sold. Different kinds of initiatives can also be seen from single physicians or physician groups to offer services in new forms and outside the public sector (ambulatorys and walk-in clinics modelled after North America). An estimation made by Rosenthal (1986) suggests that in 1985 between 18 and 27% of Swedish doctors were engaged in some form of private practice. The ‘Swedish model’ is thus at present in a period of change or at least open to new and stronger pressures. Resource constraints, difficulties in adapting big public organizations to new technologies and increased consumer demands are factors responsible for some of the external pressures. There are also interesting tensions within the public system between the county councils and the central government. Successive health care reforms during the last 20 years have shifted more and more responsibility from central government to the individual county councils. Earlier, parts of the delivery system were owned and run by the state (mental hospitals and primary care, also two of the teaching hospitals). These have all been transferred to county councils. But also, the earlier laws and regulations which were important steering-mechanisms for the government have been modified into so called ‘frame-laws’ that give the county councils almost complete freedom to arrange health services according to their own decisions. This ‘decentralization’ WI
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is now also further performed within each county council. Resources have until now been controlled by quite detailed budgeting. Now, the trend within the county councils is to make frame-budgets with greater freedom for clinics to use their resources in alternative ways.
Physician manpower policy - an overview Since the early 195Os, physician manpower policy has been an important and integrated part of general health policy. A government proposal in 1953 (proposition 1953: 212) marks the beginning of a ‘planning ideology’ within health care. In this document physicians are regarded as the key personnel group. This group and their training is vital for the development of the health care system. Physician training is also viewed as a life-long process. Different phases can be used for different steering purposes. Public steering can be both quantitative and qualitative. This document is thus an ideological base for much of the further activities in physician manpower policy and educational reforms for the following 30 years. In the 1953 reform the basic medical curriculum was shortened and modernized. All physicians passed through a basic training that was quite similar as a basis for further specialization. During the late 1950s and 1960s increasing the number of physicians became the most important policy goal (Tables 2 and 3). The number of new students (entry posts) increased from 300 to 1026 (Table 4); and medical schools were added. Table 2 Total number of active physicians, percentage inhabitants per physician 1950-1995 (Sweden)
females and number of
Year
Total number of physicians
Percentage
1950 1960 1970 1975 1980 1985 1990 1995
4900 7100 10600 14000 18000 21600 24 900 27 900
9 13
Table 3 Number of inhabitants
per active physlcian
females
Inhabitants/Physician 1440 1060 770 590 460 390 340 300
::, 25 31 ;:
in the five Nordic countries
1985
Denmark
Finland
Iceland
Norway
Sweden
Total
350
470
350
450
390
410
[331
108 Table 4 Number of new students
per year in Sweden 1945-1987
Year
Students admitted
1945 1950 1955 1960 1965 1970 1973 1980 1985 1987
185 :E! 43.1 652 956 1026 1026 936 845
The next important reform regarding the structure of medical training was not made until 1969 when postgraduate training became modernized. That reform created a uniform internship (21 months) and compulsory residency training (3-5 years). Those two ‘modules’ were an important instrument for achieving the extensive national planning program that dominated the 1970s. The aim now became to allocate doctors both geographically and to different specialties according to a national plan. At the end of the 1970s and early 1980s the scenery changed and discussions on whether Sweden faced a physician-surplus or not started. A reduction of the number of entry posts (from 1026 to 845) at the medical schools was decided by parliament in 1984. The comprehensive national planning also became more and more questioned and general decentralization made it more difficult to carry out. Slowly the power of this system has eroded although national plans are still made. As has been mentioned earlier different government reforms have tried to more effectively address the problem of distribution of physicians to remote areas. Selective lack of physicians in some specialties and rural areas are still very much the focus of the physician manpower discussion. After this overview, a closer look at the different phases of the ‘physician manpower politics’ in Sweden is useful. Focus will be on planning activities, actors and their attitudes as well as the degree of cooperation or conflict. The expansion era during the 1960s is the first phase, then follows the 1970s with marked detailed planning and close cooperation between the major actors. The 1980s can be seen as a new era of tension and conflict as discussions about a surplus of manpower have become sharper.
Expansion at medical schools (1960-I 972) The number of posts for new medical students has always been fixed (numerus claurur). Decisions have traditionally been taken by parliament after proposals from expert offices within the administration (University Chancellors Office, Ministry of Health and the National Board of Health and Social Welfare). The right number of
[341
entry posts, however, has always been a big important policy issue debated in wide circles. This was true in the 1950s before the rapid expansion was decided upon and it is equally true in 1988 when an increased number of medical students in the northernmost university (Urn&) is proposed as an effort to increase the number of physicians working in this part of the country. In the 1950s when the intake to the medical schools was around 300 students per year, there was a sharp debate between the Swedish Medical Association (SMA) and the authorities, especially the National Board of Health. To oppose an increased production of physicians was in fact the main issue for the SMA. The association seemed to have a wide support within the profession. The situation in the 1930s and 1940s when there was, in fact, unemployment among physicians in Sweden was a strong motivating factor. The doctors did not seem to believe that a radical expansion of the health care system really could occur. Much of the professional opposition was linked - especially in the later part of the 1950s - to the chairman of more than 10 years, Dag Knutson. When his leadership concluded around 1960 a new generation of members of the board of the Association started to exercise a new manpower policy. That policy - more favourable towards increase - was parallel to a more modern and open attitude towards the public interest in health care as a whole. A leading young professor of medicine - Lars WerkU - was elected chairman of SMA and towards the middle of the 6Os, the tone within the Association was quite different. The formal beginning of the increase that took place during the 60s was a public inquiry published in 1961 (1960 tis htkarprognosutredning). In this document, a prognosis for the development of medical manpower to 1980 was made. Estimations were made regarding both the likely expansion of the health care sector and the need for physicians. An increase of the number of students ‘as big as possible without endangering the quality of the education* was recommended. This general policy document became politically accepted quite rapidly - in part because the previous loud opposition from the SMA was no longer heard. It also seems that the general climate at that time - early 1960s - indicated that rapid expansion of the health care system really was possible. A general lack of physicians was evident and it affected health services expansion. A number of more technical reports were developed during the following years in order to fulfil the expansion at the medical schools. The whole process was centrally directed from the national level. There was an increase of volume at existing schools (bigger classes and more hospitals transformed to teaching units). New schools were also started - Gothenburg, Umea and Linkoping - an addition to the existing old schools in Stockholm, Uppsala and Lund. Through successive decisions the number of new students increased from 450 to 1026 in twelve years. The central government provided the money needed since basic university training is financed through the state budget in Sweden. of course, the ‘marginal cost’ for some of the new training posts was much less than the cost for existing posts. But money was provided also for research combined with the teaching costs (a basic principle in the Swedish system). This made it a lot easier for medical faculties to accept the expanded classes. Negotiations with the
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county councils were performed regarding the extra costs for clinical teaching in the facilities operated by county councils. There was a self-interest involved for the county councils to accommodate more students - especially where new medical schools were built. A medical school meant prestige and promised future supply of manpower. In summary it can be said, in retrospect, about this dramatic expansion era that it was performed quite smoothly. Many interests could be combined around the work to expand the teaching capacity.
Extensive manpower planning (1972-l 980) The structure of the post-graduate medical training was reformed in 1969, providing the tools for the comprehensive planning system that was built during the 1970s. This decade became somewhat of a ‘golden age’for cooperation between the major actors on the physician manpower scene - authorities, hospital owners and doctors. The idea, launched by government in a 1969 proposal to parliament, was to develop the whole medical training system as a vehicle for exercising health policy. The basic medical training produced the needed number of doctors. Through the post-graduate training system, they could be distributed to different specialties and geographically according to a national plan. A system for this gradually evolved during the first years of the 1970.3,The National Board of Health and Social Welfare took the lead in this work - headed by the dynamic director general Bror Rexed, assisted by the head of the Planning Department Gunnar Wennstrtlm. There was strong continuity in this - because both Rexed and Wennstr(im had been the key persons since the late 1950s in work related to manpower expansion. The Board invited the other interest groups to a system of formal cooperation in the national manpower planning. Without much hesitation the Swedish Medical Association, the Federation of County Councils and the University Chancellors Office agreed to participate. A more or less permanent project organization was organized for the purpose. The author of this paper participated as leader of the SMA-delegation during the years 19744980. The main lines in this work were the following: a so called ‘planning horizon’ about ten years ahead in time was constructed which described the desired distribution of qualified specialists over the spectrum of medical specialties. The base for this was general health policy documents which described the planned development of the health care system. Local plans within the county councils - which were very popular, and quite long-ranging during the 1970s - also formed part of the background. From this, ‘planning horizon’ backwards calculations were made in order to assess how many training posts should be arranged in each specialty. For each year a detailed delivery plan was made describing for each county council and specialty how many training posts should be arranged, both for residency training and for internship. Thus a combined effort was made to achieve both a suitable specialty mix and a geographic distribution of doctors according to the goal of ‘as equal distribution as [361
possible’ among the county councils (certain quotas and higher density in counties with a regional hospital). An important base for executing this elaborate procedure was administrative regulations that gave the National Board of Health the power to decide the actual number of posts - both for training and for qualified specialists - in each county council. These regulations were typical of the highly centralized power structure all over the public sector in Sweden until the beginning of the 1980s. The effect of the extensive planning and some of the dynamics of this quite close cooperation between the actors will be discussed later in this paper. It was in many aspects a typical product of the ‘consensus society’ and a society with a public sector, still in rapid growth during the 1970s. All actors could find arguments for participating - and found this the best way to achieve their goals, rather than to object and stay ‘out in the cold’.
Decline of lanning, reductions at medical schools (19804988 P. Discussion over an eventual surplus Towards the end of the 1970s tensions around the basic principles for the planning system became visible. These tensions mainly dealt with the question of a total oversupply of physicians, a fear once again strongly voiced by the SMA. Another important factor behind the gradual erosion of the system was the evolving decentralization of governance of the health care system. This was parallel to a general policy regarding decentralization within all public sectors. It was aiming at, among other things, improved efficiency in administration of services and increased involvement of the users of public services etc. The new health care act of 1982 took most of the regulation power away from central authorities, especially the National Board of Health. From then on County councils could arrange posts for physicians - both specialist - and training posts - without any permission from the National Board. In a formal sense the national planning continued and it still exists today - but it has now more the character of giving advice and declaring goals. The number of people involved and the volume of work is now tiny compared to the 1970 organization. These changes occurred gradually over a number of years and other factors besides the general decentralization of power also played an important role. Signs of saturation of the physician manpower market - at least in the university settings - began to be more evident around 1980. Changing national economic conditions were another important factor in the beginning of the 1980s when focus in government policy shifted from a wish to promote expansion of the health sector to a need to decrease and control growth. The Swedish Medical Association (SMA) gave voice to a concern about whether the basic production of graduates from the medical faculties was too high, with increasing intensity from 1978 and onwards. The representatives of SMA argued that the national manpower planning activities should also involve assessments of the need for manpower with prognoses based more on demand variables (government 1371
112
and county councils strategic economic documents) rather than the supply issues (health policy documents). The SMA did not succeed in convincing the other partners in the cooperation to put these aspects in focus. Both the government side and the hospital owners emphasized still visible defects in the supply. The SMA went its own way in these questions and started making manpower projections within the organization and by its own staff. ‘limoreports were published in 1980 and in 1981 that made projections for both supply and demand of physicians to the year 2020. SMA estimated an oversupply already in 1985 and a reduction at medical schools was recommended; 30% of the yearly entry posts should be closed. These proposals evoked strong opposition - especially from the employer/hospital owner side (The Confederation of County Councils). Constant high vacancy numbers and undersupplied areas were pointed at. Also the National Board rejected the proposals for decrease. Once again - as in the 1950s - this became a very sensitive public question, although the polarization was not as intense. Arguments and ‘civilized’ discussions were held both in public and private meetings. In the spring of 1984 the parliament decided to reduce the number of entry posts from 1026 to 845 - a reduction of about half the size SMA had lobbied for. The County Council federation was still in opposition to this decision, but the position of the National Board was more neutral. But this time more long-ranging projections made by the Board had estimated a market in balance in the 1990s. This proposal from the government was part of a bigger program for reduced spending (or more accurately less increase in growth of public spending) from the Social Democratic party that took office in 1982 (after a six-year right-wing government interval from 1976). Reduced spending within the university sector was one stated motive. Perhaps at this time a more hidden motive was a feeling within government that the number of physicians could be a key factor in regulating health care costs. This has never been officially stated by the government, but it is obvious that during recent years, different argument lines could be seen within the government discussions around this question. The County Council Federation has continued to lobby for an increased number of doctors pointing to the still high vacancy numbers (around 9% of the total of specialists’ post are vacant). Suggestions have been made to increase the number of students in Umd - the most northern university in order to achieve a better supply of physicians in the north. This year (1988) government has made a statement to parliament pointing to the intention not to let the county councils increase their expenditures more than 1% per year. If the growth will decrease to this figure (down from 2-3% that has been the actual figure during most of the 1980s) the government states that there will be a physician surplus in the 1990s. If the growth will be more than 1% during the next years the market will still be underbalanced, according to government. Obviously the actual growth of health care is the key factor both when looking back and forward at different projections and their reliability. The SMA today has to admit that the estimation of a surplus in 1985 did not prove to be correct. The main explanation is that the growth of the health care system became much bigger than estimated in 1980 (and actually according to what was declared as a policy goal from the finance minister at that time). Reduction of working hours and
113
better compensation in time off for on call hours have also ‘helped’ the market to swallow more physicians than estimated. In summary it can be said regarding all future projections of the need for physician manpower in Sweden - since the 1950s and onwards - that they have underestimated the demand. The projections have also somewhat overestimated the supply. But this conclusion does not mean that the ‘rational’ approach to these problems in Sweden, including the extensive planning - needs to be a failure. Ambitions have perhaps been too high and a more realistic approach, taking more of the ‘dynamics’ into consideration, could perhaps have been useful. What then can be learned from the quite unique Swedish effort to plan and control the physician labour market?
Discussion The Swedish model
Overall physician manpower policy forms an important part of health care politics in Sweden. Health care can, in many aspects, also be seen as the heart of the ‘welfare politics’ that has been a dominating idea in Swedish society over the last 50 years. ‘ILvoimportant goals in health policy pointed out in the 1950s were expansion of supply according to need and an equitable distribution of resources. The extensive physician manpower planning evolved gradually as a method to exercise this general policy. Judged as a component of an economy - and especially a health care system -that has been to a large extent planned and regulatedpublicly, it is a very natural development. It is not surprising that new circumstances and ideas in society around 1980 marked a beginning decline for centralized manpower planning. Economic restraints and new ideas about decentralized governing of the public sector are important factors. Planning was very much constructed for a system in growth - and it has not explicitly been declared to serve well when other problems became evident (need for restraints, reallocation etc.) The system was shaped based on societal needs in 1950s and it had great difficulty adapting in the 1980s when the problems in health care were different. Cooperation and ‘consensus politics’ are typical in Swedish society. The tradition that actors and interest groups meet around a table and negotiate as a first effort to solve problems goes far back. In modem times it has especially been associated with the general labour market which from 1938 (the so-called ‘Saltsjobads-treaty) has been more peaceful than in many other countries because of an extensive negotiating machinery. Also in the public sector it is a ‘reflex’action for addressing problems - to start a committee or a public inquiry. It could be a way of promoting progress - but also an effective way to put problems ‘under the table’. It is a cultural habit of ‘solving’ problems.
1391
114
The actors A simplified pattern of the dynamics between the main actors - government and hospital owners on one side, and physicians on the other - is one of the strong conflicts (195Os), then cooperation (1970s) and once again increased tensions (1980s). National Board of Health: The Board has been the key actor on the public or government side all the time. The Board - and important individuals for a long time connected to the Board - both developed policy and implemented it. The Ministry of Health, for several reasons, has had less impact on policy - at least until the end of 1970s (lack of personal continuity, lack of resources to perform large-scale investigations etc.) To be correct it should be said that several of the important government policy documents have been worked out by persons within the National Board - this is natural since traditionally the Board has been the executive body with much larger resources than the Ministry. In this history, parliament has a weak role; it serves as formal decision machinery. But important pressures could be visible here and the lack of physicians has often been debated in parliament. Federation of County Councils: The power of the Federation, which is a national organization for cooperation among independent county councils, has grown steadily since the 1950s. In particular, the recent decentralization of responsibility has increased the power of the Federation. All through the different phases of manpower planning the National Board has been more active than the Federation. The quite stable policy position of the Federation has been that physician supply always has been too small and that lack of physicians endangers development and maintenance of the present level of services. The Federation lobbies for increased capacity. As a politically governed organization, the Federation has to handle internal conflicts and tensions, as does the SMA. There are for example considerable differences of opinion between county councils in rural parts of the country and those representing more urban areas. These have to be handled at first hand within the Federation. To a growing extent during the 198Os, physician manpower questions have become negotiable between the two labour-market organizations. The government has officially pointed to this as a desired development for the future. Negotiations will also include more quality aspects and regulation of training. University Chancellors ofice: On the ‘public’ side this national authority for governing the universities (including medical schools) has also been an actor not always directly supporting the Board of Health and Social Welfare. The University Chancellor has focused on research resources and educational quality. Technical proposals to reduce student intake came from this office - but it is difficult to state to what extent policy originated from there. Swedish MedicalAssociation (SMA): The SMA has been an important actor since 1950s. The Association has always represented more than 90% of physicians and has often been regarded as the most powerful trade union on the academic side 1401
115
within Sweden. The SMA has not opposed increased capacity at medical schools all the time, although the Association got that image because of the very strong opposition during the 1950s. Already in 1961 the SMA declared that the physician pool needed a large increase. But during the late 1970s when discussions about a possible future surplus started, SMA in many ways got in the same ‘comer’ as in the 50s. The big difference was that SMA now worked with its own extensive forecast activity that became a basis for public discussions and lobbying. A balanced market is the stated goal from the SMA. What has been achieved?
What results within the health services can be seen from the manpower planning activities, especially the major effort of the 197Os? The aim was to distribute physicians according to both specialty and geographical goals. The ambitions in details were high. A superficial summary could be that actual distribution of specialists in the ‘horizon year’ 1985 has not much deviation from the desired plan. But the same specialties that were in great need in the 70s were also in relative shortage 1985, particularly general practice, psychiatry and some laboratory specialities (Table 5). Table 5 Distribution of specialists. Real distribution over the medical specialty groups 1982, planning ‘horizon’ per 1995 as decided upon 1973 and real distribution 1985
Specialty (group)
Real distribution 1972
Planning ‘horizon’ for 1985
Real distribution 1985
N
%
N
%
N
%
Primary care Long term care/rehabilitation
870 116
16
2500 650
18 5
2569 501
19 4
Internal medicine (group) Pediatrics Dermatology Neurology oncology Surgery (group) Othorhinolaryngology Gynecology Ophthalmology Anesthesiology Clinical laboratory Radiology Psychiatry Other areas
277 964 97
18 3 2
5’; 847 225 312 144 214 301 420 501 23
: 16 4 :
1600 1000 210 100 100 1870 530 880 460 625 675 850 1200 900
11 7 1 1 1 13 4 :
1598 805 219 163 114 1941 471 935 471 704 634 669 1058 885
162 2 1 1 14 3 7 3 5 4 5 8 6
5425
100
Total
Z : 0
14150
4 : 8 6 100
13675
100
However, geographical distribution deviates more from the goals. There are significant differences in population/physician ratio among the county councils. The situation that has gotten particular attention is the number of vacant posts, which is still around 10% of the total. The number of vacant posts actually increased between 1411
116
1985 and 1987. The situation is illustrated in Table 6. Some areas, especially the most remote, and some specialties, suffer from this situation. University hospitals are well saturated with physicians, perhaps overstaffed. There is, however, no clear relationship between the ratio of population per active, existing physician and the number of vacant posts. The structure and the number of arranged physician posts differ among county councils - therefore the vacancy rate can mean quite different things in different areas. There is still a maldistribution problem, but it is difficult to judge how big it is. It can be concluded that the planning did not solve the geographical distribution problem - but is the situation better or worse compared with countries that are more marketoriented? Table 6 Geographic distribution. Total number of active physicians (specialists and non-specialists) in selected county council areas, and inhabitants per physician Number of vacant posts and percentage of total 1666 and 1967 Area
1985
Physicians
1985.
1987
Inhabitants per physician
Number of vacant posts
(%I
Number of vacant posts
(%J,)
CounIy councils with regional hospital Stockholm Uppsala Link&ping Mahnij Lund Gothenburg UmeH
5015 1005 1009 822 1585 1614 743
315 251 390 280 328 263 330
128
4.9
zz 7
::22
4; 70
:.: 3:2 15.4
3; 42 65
5.3 3.5 8.1 1.6 3.5 4.0 13.4
18.4 2.9 16.7
109 11 70
20.8 5.3 15.9
111 45 23
18.9 13.5 7.8
1374
9.9
149 562
Regular county councils - highest ratio of physicians thebro Blekinge Gavleborg
672 351 638
402 430 453
787 446 458
543 534 524
t;: 6
13.0 11.9 2.3
387
1204
9.4
79 6:
Regular county councils - lowest ratio of physiciam Alvsborg Kalmar Halland Total Sweden Sources for statistics: Bureau of Statistics.
21589
National Board of Health, Swedish Medical Association
1421
and Central
117
Double book-keeping
In reality a factor that can explain why the planning machinery did not technically achieve what it ‘promised’ is the existence of both formal, official posts and physicians hired more or less permanently to fill the posts when the ordinary physician is on leave (mainly free time after on-call duty). During the 1970s this became a common practice - although to different extents - all over the country. This practice meant that popular specialties, like surgery, could train 20 to 30% more doctors than specialties in shortage. This practice also affected the geographical distribution. This can be described as a ‘hidden dynamic’ in the manpower play, actually the most important one. This mechanism helped the central actors (especially the SMA and the County Council Federation) to sit both at the negotiating table making quite strong plans - and then meet their local members having other expectations and wishes. At several times, official recommendations were made to ban these unofficial posts, but locally at hospital level, physicians, politicians and administrators supported each other in a common desire to have full staffing. It also illustrates the fact that the working capacity of a trained physician has always been used, until now at least, in a system like the Swedish where public money finances health care. The public’s demand for health care is without limits and a pressure emerges to use all available medical manpower. Another factor that explains why the system has been able to accommodate so many new physicians is the decreased number of working hours per physician. In 1970 the average doctor’s daytime working week was 48 hours. In 1985 the comparable time could be estimated to 28-30 hours (reductions for on-call compensating time etc.). But many doctors want to work more - and the expansion of the private sector - both within the insurance scheme and the totally private has a clear connection to this fact. The concept ‘lack’ of physicians
The main problem in the 1950s when the health care system was ready for strong expansion, was a lack of physicians. The medical profession opposed increase and the public officials worked for it. These quite simple roles and dynamics have stayed - and perhaps blocked more rational policy discussion. Especially has the concept ‘lack of physicians’ stayed and is still very powerful in public debate and in media. There are clear problems in some parts of the country, but not a general one. One could sometimes get a feeling that maintaining a focus on this concept also serves the purpose of drawing the attention away from other serious problems that are present in today’s health care system. The lack of financial resources to operate a health care system being able to match increasing demands for care is an underlying problem. A system that is administratively very inflexible is another. Organizational reforms, restructuring of services, another speciality mix, increased use of nurse personnel and effective assessment of technology - these are examples of alternative ways to tackle some of today’s problems. [431
118
If it is true that the concept ‘luck ofphysicians’ in this way is masking other problems then it is an interesting example of how the past, and the way problems then were formulated, really is influencing the way problems are handled today and tomorrow.
References 1 Anderson, O.W., Health Care, Can There Be Equity? Sweden, Britain and the United States. John Wiley & Sons, New York, 1972. 2 Anderson, O.W., privatization, Competition and Health Maintenance Organization - Implications for Sweden. Paper delivered at a Conference on privatization at SPRI, August 27, 1986. 3 Borgenhammar. E., Health Services in Sweden. In: Raffel, M.W., ed. Comparative Health Systems. University Park and London: The Pennsylvania State University Press, 1984, 470-87. 4 Calltorp, J., Consensus Conferences in Sweden - Effects on Health Policy and Administration. Intern. J. Technol. Assess. Health Care, 4 (1988) 75-88. 5 Ginzberg, E.. L&arna m&ste ta ansvar fdr kosmadskontmlli (Swe). (Physicians must take responsibility for cost control). Key note adress at a seminar on ‘Planning and Competition - What proportions in Swedish Health Care?’ in Uppsala, September 26, 1984. LZkartidningen 81 (1984) 4336-4138. 6 Ham, C., Steering the Oil Tanker: Power and Policy Making in the Swedish Health Service. King’s Fund Institute, London, 1987. 7 Heidenheimer, A.J. and Elvander, N.J. (eds.). The Making of the Swedish Health Care System Croom Helm, London, 1980. 8 Rosenthal, M., Beyond Equity? Swedish Health Policy and the private Sector. The Milbank Quarterly 64 (1986) 592-621. 9 Saltman, R.B. and von Otter, C., Revitalising Public Health Care Systems: A proposal for Public Competition in Sweden. Health Policy 7 (1987) 21-40. 10 Wennstrom, G. and Hultin, J., Central planering av l&kart%rdelning behtivs - men forutsatter ijkad regional lyhijrdhetf (Swe) (Central planning of manpower is needed - but requires cooperation from regions). Lakartidningen 84 (1987) 2016-2018.
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Policy, 15 (1990) 105-118
Elsevier
105
Chapter 4
Physician manpower
politics in Sweden
Johan Calltorp
The health care system Swedish health care is predominantly public. Roughly 90% of the health services are delivered within publicly owned and operated facilities. Twenty-six local county councils are by law responsible for providing and planning the health care for the inhabitants of the area. Local county council taxation finances around 2/3 of the total cost for health care. The major part of the remaining l/3 comes from central government subsidies, since 1983 distributed according to a per-capita-formula. The structure of the health care system is remarkably similar all over the country - the result of a long tradition within Swedish society for a centralized authority. Also extensive national health care planning during the expansion era of the 1960s and 1970s had an important impact on organization within the county councils. Sweden has a high ratio of hospital beds per population, but a remarkably low number of out-patient and primary-care visits per inhabitant. Earlier in this century, primary care was relatively well developed, but during the expansion period, especially in the 1960s. specialized hospital services got priority. During the 197Os, general health policy has favoured primary care as well as long-term care and psychiatry, but this policy has not been fully implemented. In the 1980s when expansion finally slowed down and resources became stable (Table 1) the dilemma of a considerable number of hospitals and a still poorly developed primary care system has become even more evident. Table 1 Health care costs as a Percentage Year % of GNP
of Gross National Product (Sweden)
1963
1970
1975
1980
1982
1985
1986
5.4
7.2
8.0
9.5
9.7
9.4
9.1
In the 1960s a system of regionalized planning for the more specialized services was introduced. The law requires cooperation between three to five neighbouring county councils in order to finance highly specialized service at a tertiary care center (mostly the regional or teaching hospital - one or two in each region). 0168-8510/90/$03.50@1990 Elsevier Science Publishers B.V. (Biomedical Division) [311
106
Without a doubt this early regional system has helped to avoid unnecessary duplication of expensive equipment and facilities. Over the last ten years a system of nationwide ‘supra-regional planning’ has been introduced in order to plan for the most expensive types of care and those procedures that are in a stage between research and routine care (for example burn treatment centers, heart transplant activities, extracorporeal shock-wave lithotripsy etc.). In Sweden, private health care has traditionally been integrated with the public financing of care. For a long time the country has had between 600 and 800 full-time private practitioners working mainly as primary-care physicians. Most of them have contracts with the same National health insurance scheme that covers all citizens and is financed through employer contributions. Since 1983 insurance-affiliation and entry into the system for new practitioners is restricted through a mechanism that gives the county councils power to decide both the volume of this type of private care and which practitioners will be accepted. This new regulation was part of a government action to get control over the growth of the health care system and also distribute resources and physicians more evenly around the country. This last objective will be dealt with later in this paper. As for the growth of private medicine, the result has been a somewhat mixed picture. Some county-councils try to enhance private practice within the public finance system and as part of the county council-planned activities. Different kinds of contracts for private delivery of specialized services are increasingly seen in sectors which could not produce enough services within public care (for example implantation of intraocular lenses, hip-replacement, coronary-bypass surgery). To an increasing extent private health care is also produced without public financing or subsidies. Private health care insurance has been offered since 1984 a completely new element within the Swedish model. The volume is still tiny, not more than 15000 policies sold. Different kinds of initiatives can also be seen from single physicians or physician groups to offer services in new forms and outside the public sector (ambulatorys and walk-in clinics modelled after North America). An estimation made by Rosenthal (1986) suggests that in 1985 between 18 and 27% of Swedish doctors were engaged in some form of private practice. The ‘Swedish model’ is thus at present in a period of change or at least open to new and stronger pressures. Resource constraints, difficulties in adapting big public organizations to new technologies and increased consumer demands are factors responsible for some of the external pressures. There are also interesting tensions within the public system between the county councils and the central government. Successive health care reforms during the last 20 years have shifted more and more responsibility from central government to the individual county councils. Earlier, parts of the delivery system were owned and run by the state (mental hospitals and primary care, also two of the teaching hospitals). These have all been transferred to county councils. But also, the earlier laws and regulations which were important steering-mechanisms for the government have been modified into so called ‘frame-laws’ that give the county councils almost complete freedom to arrange health services according to their own decisions. This ‘decentralization’ WI
107
is now also further performed within each county council. Resources have until now been controlled by quite detailed budgeting. Now, the trend within the county councils is to make frame-budgets with greater freedom for clinics to use their resources in alternative ways.
Physician manpower policy - an overview Since the early 195Os, physician manpower policy has been an important and integrated part of general health policy. A government proposal in 1953 (proposition 1953: 212) marks the beginning of a ‘planning ideology’ within health care. In this document physicians are regarded as the key personnel group. This group and their training is vital for the development of the health care system. Physician training is also viewed as a life-long process. Different phases can be used for different steering purposes. Public steering can be both quantitative and qualitative. This document is thus an ideological base for much of the further activities in physician manpower policy and educational reforms for the following 30 years. In the 1953 reform the basic medical curriculum was shortened and modernized. All physicians passed through a basic training that was quite similar as a basis for further specialization. During the late 1950s and 1960s increasing the number of physicians became the most important policy goal (Tables 2 and 3). The number of new students (entry posts) increased from 300 to 1026 (Table 4); and medical schools were added. Table 2 Total number of active physicians, percentage inhabitants per physician 1950-1995 (Sweden)
females and number of
Year
Total number of physicians
Percentage
1950 1960 1970 1975 1980 1985 1990 1995
4900 7100 10600 14000 18000 21600 24 900 27 900
9 13
Table 3 Number of inhabitants
per active physlcian
females
Inhabitants/Physician 1440 1060 770 590 460 390 340 300
::, 25 31 ;:
in the five Nordic countries
1985
Denmark
Finland
Iceland
Norway
Sweden
Total
350
470
350
450
390
410
[331
108 Table 4 Number of new students
per year in Sweden 1945-1987
Year
Students admitted
1945 1950 1955 1960 1965 1970 1973 1980 1985 1987
185 :E! 43.1 652 956 1026 1026 936 845
The next important reform regarding the structure of medical training was not made until 1969 when postgraduate training became modernized. That reform created a uniform internship (21 months) and compulsory residency training (3-5 years). Those two ‘modules’ were an important instrument for achieving the extensive national planning program that dominated the 1970s. The aim now became to allocate doctors both geographically and to different specialties according to a national plan. At the end of the 1970s and early 1980s the scenery changed and discussions on whether Sweden faced a physician-surplus or not started. A reduction of the number of entry posts (from 1026 to 845) at the medical schools was decided by parliament in 1984. The comprehensive national planning also became more and more questioned and general decentralization made it more difficult to carry out. Slowly the power of this system has eroded although national plans are still made. As has been mentioned earlier different government reforms have tried to more effectively address the problem of distribution of physicians to remote areas. Selective lack of physicians in some specialties and rural areas are still very much the focus of the physician manpower discussion. After this overview, a closer look at the different phases of the ‘physician manpower politics’ in Sweden is useful. Focus will be on planning activities, actors and their attitudes as well as the degree of cooperation or conflict. The expansion era during the 1960s is the first phase, then follows the 1970s with marked detailed planning and close cooperation between the major actors. The 1980s can be seen as a new era of tension and conflict as discussions about a surplus of manpower have become sharper.
Expansion at medical schools (1960-I 972) The number of posts for new medical students has always been fixed (numerus claurur). Decisions have traditionally been taken by parliament after proposals from expert offices within the administration (University Chancellors Office, Ministry of Health and the National Board of Health and Social Welfare). The right number of
[341
entry posts, however, has always been a big important policy issue debated in wide circles. This was true in the 1950s before the rapid expansion was decided upon and it is equally true in 1988 when an increased number of medical students in the northernmost university (Urn&) is proposed as an effort to increase the number of physicians working in this part of the country. In the 1950s when the intake to the medical schools was around 300 students per year, there was a sharp debate between the Swedish Medical Association (SMA) and the authorities, especially the National Board of Health. To oppose an increased production of physicians was in fact the main issue for the SMA. The association seemed to have a wide support within the profession. The situation in the 1930s and 1940s when there was, in fact, unemployment among physicians in Sweden was a strong motivating factor. The doctors did not seem to believe that a radical expansion of the health care system really could occur. Much of the professional opposition was linked - especially in the later part of the 1950s - to the chairman of more than 10 years, Dag Knutson. When his leadership concluded around 1960 a new generation of members of the board of the Association started to exercise a new manpower policy. That policy - more favourable towards increase - was parallel to a more modern and open attitude towards the public interest in health care as a whole. A leading young professor of medicine - Lars WerkU - was elected chairman of SMA and towards the middle of the 6Os, the tone within the Association was quite different. The formal beginning of the increase that took place during the 60s was a public inquiry published in 1961 (1960 tis htkarprognosutredning). In this document, a prognosis for the development of medical manpower to 1980 was made. Estimations were made regarding both the likely expansion of the health care sector and the need for physicians. An increase of the number of students ‘as big as possible without endangering the quality of the education* was recommended. This general policy document became politically accepted quite rapidly - in part because the previous loud opposition from the SMA was no longer heard. It also seems that the general climate at that time - early 1960s - indicated that rapid expansion of the health care system really was possible. A general lack of physicians was evident and it affected health services expansion. A number of more technical reports were developed during the following years in order to fulfil the expansion at the medical schools. The whole process was centrally directed from the national level. There was an increase of volume at existing schools (bigger classes and more hospitals transformed to teaching units). New schools were also started - Gothenburg, Umea and Linkoping - an addition to the existing old schools in Stockholm, Uppsala and Lund. Through successive decisions the number of new students increased from 450 to 1026 in twelve years. The central government provided the money needed since basic university training is financed through the state budget in Sweden. of course, the ‘marginal cost’ for some of the new training posts was much less than the cost for existing posts. But money was provided also for research combined with the teaching costs (a basic principle in the Swedish system). This made it a lot easier for medical faculties to accept the expanded classes. Negotiations with the
110
county councils were performed regarding the extra costs for clinical teaching in the facilities operated by county councils. There was a self-interest involved for the county councils to accommodate more students - especially where new medical schools were built. A medical school meant prestige and promised future supply of manpower. In summary it can be said, in retrospect, about this dramatic expansion era that it was performed quite smoothly. Many interests could be combined around the work to expand the teaching capacity.
Extensive manpower planning (1972-l 980) The structure of the post-graduate medical training was reformed in 1969, providing the tools for the comprehensive planning system that was built during the 1970s. This decade became somewhat of a ‘golden age’for cooperation between the major actors on the physician manpower scene - authorities, hospital owners and doctors. The idea, launched by government in a 1969 proposal to parliament, was to develop the whole medical training system as a vehicle for exercising health policy. The basic medical training produced the needed number of doctors. Through the post-graduate training system, they could be distributed to different specialties and geographically according to a national plan. A system for this gradually evolved during the first years of the 1970.3,The National Board of Health and Social Welfare took the lead in this work - headed by the dynamic director general Bror Rexed, assisted by the head of the Planning Department Gunnar Wennstrtlm. There was strong continuity in this - because both Rexed and Wennstr(im had been the key persons since the late 1950s in work related to manpower expansion. The Board invited the other interest groups to a system of formal cooperation in the national manpower planning. Without much hesitation the Swedish Medical Association, the Federation of County Councils and the University Chancellors Office agreed to participate. A more or less permanent project organization was organized for the purpose. The author of this paper participated as leader of the SMA-delegation during the years 19744980. The main lines in this work were the following: a so called ‘planning horizon’ about ten years ahead in time was constructed which described the desired distribution of qualified specialists over the spectrum of medical specialties. The base for this was general health policy documents which described the planned development of the health care system. Local plans within the county councils - which were very popular, and quite long-ranging during the 1970s - also formed part of the background. From this, ‘planning horizon’ backwards calculations were made in order to assess how many training posts should be arranged in each specialty. For each year a detailed delivery plan was made describing for each county council and specialty how many training posts should be arranged, both for residency training and for internship. Thus a combined effort was made to achieve both a suitable specialty mix and a geographic distribution of doctors according to the goal of ‘as equal distribution as [361
possible’ among the county councils (certain quotas and higher density in counties with a regional hospital). An important base for executing this elaborate procedure was administrative regulations that gave the National Board of Health the power to decide the actual number of posts - both for training and for qualified specialists - in each county council. These regulations were typical of the highly centralized power structure all over the public sector in Sweden until the beginning of the 1980s. The effect of the extensive planning and some of the dynamics of this quite close cooperation between the actors will be discussed later in this paper. It was in many aspects a typical product of the ‘consensus society’ and a society with a public sector, still in rapid growth during the 1970s. All actors could find arguments for participating - and found this the best way to achieve their goals, rather than to object and stay ‘out in the cold’.
Decline of lanning, reductions at medical schools (19804988 P. Discussion over an eventual surplus Towards the end of the 1970s tensions around the basic principles for the planning system became visible. These tensions mainly dealt with the question of a total oversupply of physicians, a fear once again strongly voiced by the SMA. Another important factor behind the gradual erosion of the system was the evolving decentralization of governance of the health care system. This was parallel to a general policy regarding decentralization within all public sectors. It was aiming at, among other things, improved efficiency in administration of services and increased involvement of the users of public services etc. The new health care act of 1982 took most of the regulation power away from central authorities, especially the National Board of Health. From then on County councils could arrange posts for physicians - both specialist - and training posts - without any permission from the National Board. In a formal sense the national planning continued and it still exists today - but it has now more the character of giving advice and declaring goals. The number of people involved and the volume of work is now tiny compared to the 1970 organization. These changes occurred gradually over a number of years and other factors besides the general decentralization of power also played an important role. Signs of saturation of the physician manpower market - at least in the university settings - began to be more evident around 1980. Changing national economic conditions were another important factor in the beginning of the 1980s when focus in government policy shifted from a wish to promote expansion of the health sector to a need to decrease and control growth. The Swedish Medical Association (SMA) gave voice to a concern about whether the basic production of graduates from the medical faculties was too high, with increasing intensity from 1978 and onwards. The representatives of SMA argued that the national manpower planning activities should also involve assessments of the need for manpower with prognoses based more on demand variables (government 1371
112
and county councils strategic economic documents) rather than the supply issues (health policy documents). The SMA did not succeed in convincing the other partners in the cooperation to put these aspects in focus. Both the government side and the hospital owners emphasized still visible defects in the supply. The SMA went its own way in these questions and started making manpower projections within the organization and by its own staff. ‘limoreports were published in 1980 and in 1981 that made projections for both supply and demand of physicians to the year 2020. SMA estimated an oversupply already in 1985 and a reduction at medical schools was recommended; 30% of the yearly entry posts should be closed. These proposals evoked strong opposition - especially from the employer/hospital owner side (The Confederation of County Councils). Constant high vacancy numbers and undersupplied areas were pointed at. Also the National Board rejected the proposals for decrease. Once again - as in the 1950s - this became a very sensitive public question, although the polarization was not as intense. Arguments and ‘civilized’ discussions were held both in public and private meetings. In the spring of 1984 the parliament decided to reduce the number of entry posts from 1026 to 845 - a reduction of about half the size SMA had lobbied for. The County Council federation was still in opposition to this decision, but the position of the National Board was more neutral. But this time more long-ranging projections made by the Board had estimated a market in balance in the 1990s. This proposal from the government was part of a bigger program for reduced spending (or more accurately less increase in growth of public spending) from the Social Democratic party that took office in 1982 (after a six-year right-wing government interval from 1976). Reduced spending within the university sector was one stated motive. Perhaps at this time a more hidden motive was a feeling within government that the number of physicians could be a key factor in regulating health care costs. This has never been officially stated by the government, but it is obvious that during recent years, different argument lines could be seen within the government discussions around this question. The County Council Federation has continued to lobby for an increased number of doctors pointing to the still high vacancy numbers (around 9% of the total of specialists’ post are vacant). Suggestions have been made to increase the number of students in Umd - the most northern university in order to achieve a better supply of physicians in the north. This year (1988) government has made a statement to parliament pointing to the intention not to let the county councils increase their expenditures more than 1% per year. If the growth will decrease to this figure (down from 2-3% that has been the actual figure during most of the 1980s) the government states that there will be a physician surplus in the 1990s. If the growth will be more than 1% during the next years the market will still be underbalanced, according to government. Obviously the actual growth of health care is the key factor both when looking back and forward at different projections and their reliability. The SMA today has to admit that the estimation of a surplus in 1985 did not prove to be correct. The main explanation is that the growth of the health care system became much bigger than estimated in 1980 (and actually according to what was declared as a policy goal from the finance minister at that time). Reduction of working hours and
113
better compensation in time off for on call hours have also ‘helped’ the market to swallow more physicians than estimated. In summary it can be said regarding all future projections of the need for physician manpower in Sweden - since the 1950s and onwards - that they have underestimated the demand. The projections have also somewhat overestimated the supply. But this conclusion does not mean that the ‘rational’ approach to these problems in Sweden, including the extensive planning - needs to be a failure. Ambitions have perhaps been too high and a more realistic approach, taking more of the ‘dynamics’ into consideration, could perhaps have been useful. What then can be learned from the quite unique Swedish effort to plan and control the physician labour market?
Discussion The Swedish model
Overall physician manpower policy forms an important part of health care politics in Sweden. Health care can, in many aspects, also be seen as the heart of the ‘welfare politics’ that has been a dominating idea in Swedish society over the last 50 years. ‘ILvoimportant goals in health policy pointed out in the 1950s were expansion of supply according to need and an equitable distribution of resources. The extensive physician manpower planning evolved gradually as a method to exercise this general policy. Judged as a component of an economy - and especially a health care system -that has been to a large extent planned and regulatedpublicly, it is a very natural development. It is not surprising that new circumstances and ideas in society around 1980 marked a beginning decline for centralized manpower planning. Economic restraints and new ideas about decentralized governing of the public sector are important factors. Planning was very much constructed for a system in growth - and it has not explicitly been declared to serve well when other problems became evident (need for restraints, reallocation etc.) The system was shaped based on societal needs in 1950s and it had great difficulty adapting in the 1980s when the problems in health care were different. Cooperation and ‘consensus politics’ are typical in Swedish society. The tradition that actors and interest groups meet around a table and negotiate as a first effort to solve problems goes far back. In modem times it has especially been associated with the general labour market which from 1938 (the so-called ‘Saltsjobads-treaty) has been more peaceful than in many other countries because of an extensive negotiating machinery. Also in the public sector it is a ‘reflex’action for addressing problems - to start a committee or a public inquiry. It could be a way of promoting progress - but also an effective way to put problems ‘under the table’. It is a cultural habit of ‘solving’ problems.
1391
114
The actors A simplified pattern of the dynamics between the main actors - government and hospital owners on one side, and physicians on the other - is one of the strong conflicts (195Os), then cooperation (1970s) and once again increased tensions (1980s). National Board of Health: The Board has been the key actor on the public or government side all the time. The Board - and important individuals for a long time connected to the Board - both developed policy and implemented it. The Ministry of Health, for several reasons, has had less impact on policy - at least until the end of 1970s (lack of personal continuity, lack of resources to perform large-scale investigations etc.) To be correct it should be said that several of the important government policy documents have been worked out by persons within the National Board - this is natural since traditionally the Board has been the executive body with much larger resources than the Ministry. In this history, parliament has a weak role; it serves as formal decision machinery. But important pressures could be visible here and the lack of physicians has often been debated in parliament. Federation of County Councils: The power of the Federation, which is a national organization for cooperation among independent county councils, has grown steadily since the 1950s. In particular, the recent decentralization of responsibility has increased the power of the Federation. All through the different phases of manpower planning the National Board has been more active than the Federation. The quite stable policy position of the Federation has been that physician supply always has been too small and that lack of physicians endangers development and maintenance of the present level of services. The Federation lobbies for increased capacity. As a politically governed organization, the Federation has to handle internal conflicts and tensions, as does the SMA. There are for example considerable differences of opinion between county councils in rural parts of the country and those representing more urban areas. These have to be handled at first hand within the Federation. To a growing extent during the 198Os, physician manpower questions have become negotiable between the two labour-market organizations. The government has officially pointed to this as a desired development for the future. Negotiations will also include more quality aspects and regulation of training. University Chancellors ofice: On the ‘public’ side this national authority for governing the universities (including medical schools) has also been an actor not always directly supporting the Board of Health and Social Welfare. The University Chancellor has focused on research resources and educational quality. Technical proposals to reduce student intake came from this office - but it is difficult to state to what extent policy originated from there. Swedish MedicalAssociation (SMA): The SMA has been an important actor since 1950s. The Association has always represented more than 90% of physicians and has often been regarded as the most powerful trade union on the academic side 1401
115
within Sweden. The SMA has not opposed increased capacity at medical schools all the time, although the Association got that image because of the very strong opposition during the 1950s. Already in 1961 the SMA declared that the physician pool needed a large increase. But during the late 1970s when discussions about a possible future surplus started, SMA in many ways got in the same ‘comer’ as in the 50s. The big difference was that SMA now worked with its own extensive forecast activity that became a basis for public discussions and lobbying. A balanced market is the stated goal from the SMA. What has been achieved?
What results within the health services can be seen from the manpower planning activities, especially the major effort of the 197Os? The aim was to distribute physicians according to both specialty and geographical goals. The ambitions in details were high. A superficial summary could be that actual distribution of specialists in the ‘horizon year’ 1985 has not much deviation from the desired plan. But the same specialties that were in great need in the 70s were also in relative shortage 1985, particularly general practice, psychiatry and some laboratory specialities (Table 5). Table 5 Distribution of specialists. Real distribution over the medical specialty groups 1982, planning ‘horizon’ per 1995 as decided upon 1973 and real distribution 1985
Specialty (group)
Real distribution 1972
Planning ‘horizon’ for 1985
Real distribution 1985
N
%
N
%
N
%
Primary care Long term care/rehabilitation
870 116
16
2500 650
18 5
2569 501
19 4
Internal medicine (group) Pediatrics Dermatology Neurology oncology Surgery (group) Othorhinolaryngology Gynecology Ophthalmology Anesthesiology Clinical laboratory Radiology Psychiatry Other areas
277 964 97
18 3 2
5’; 847 225 312 144 214 301 420 501 23
: 16 4 :
1600 1000 210 100 100 1870 530 880 460 625 675 850 1200 900
11 7 1 1 1 13 4 :
1598 805 219 163 114 1941 471 935 471 704 634 669 1058 885
162 2 1 1 14 3 7 3 5 4 5 8 6
5425
100
Total
Z : 0
14150
4 : 8 6 100
13675
100
However, geographical distribution deviates more from the goals. There are significant differences in population/physician ratio among the county councils. The situation that has gotten particular attention is the number of vacant posts, which is still around 10% of the total. The number of vacant posts actually increased between 1411
116
1985 and 1987. The situation is illustrated in Table 6. Some areas, especially the most remote, and some specialties, suffer from this situation. University hospitals are well saturated with physicians, perhaps overstaffed. There is, however, no clear relationship between the ratio of population per active, existing physician and the number of vacant posts. The structure and the number of arranged physician posts differ among county councils - therefore the vacancy rate can mean quite different things in different areas. There is still a maldistribution problem, but it is difficult to judge how big it is. It can be concluded that the planning did not solve the geographical distribution problem - but is the situation better or worse compared with countries that are more marketoriented? Table 6 Geographic distribution. Total number of active physicians (specialists and non-specialists) in selected county council areas, and inhabitants per physician Number of vacant posts and percentage of total 1666 and 1967 Area
1985
Physicians
1985.
1987
Inhabitants per physician
Number of vacant posts
(%I
Number of vacant posts
(%J,)
CounIy councils with regional hospital Stockholm Uppsala Link&ping Mahnij Lund Gothenburg UmeH
5015 1005 1009 822 1585 1614 743
315 251 390 280 328 263 330
128
4.9
zz 7
::22
4; 70
:.: 3:2 15.4
3; 42 65
5.3 3.5 8.1 1.6 3.5 4.0 13.4
18.4 2.9 16.7
109 11 70
20.8 5.3 15.9
111 45 23
18.9 13.5 7.8
1374
9.9
149 562
Regular county councils - highest ratio of physicians thebro Blekinge Gavleborg
672 351 638
402 430 453
787 446 458
543 534 524
t;: 6
13.0 11.9 2.3
387
1204
9.4
79 6:
Regular county councils - lowest ratio of physiciam Alvsborg Kalmar Halland Total Sweden Sources for statistics: Bureau of Statistics.
21589
National Board of Health, Swedish Medical Association
1421
and Central
117
Double book-keeping
In reality a factor that can explain why the planning machinery did not technically achieve what it ‘promised’ is the existence of both formal, official posts and physicians hired more or less permanently to fill the posts when the ordinary physician is on leave (mainly free time after on-call duty). During the 1970s this became a common practice - although to different extents - all over the country. This practice meant that popular specialties, like surgery, could train 20 to 30% more doctors than specialties in shortage. This practice also affected the geographical distribution. This can be described as a ‘hidden dynamic’ in the manpower play, actually the most important one. This mechanism helped the central actors (especially the SMA and the County Council Federation) to sit both at the negotiating table making quite strong plans - and then meet their local members having other expectations and wishes. At several times, official recommendations were made to ban these unofficial posts, but locally at hospital level, physicians, politicians and administrators supported each other in a common desire to have full staffing. It also illustrates the fact that the working capacity of a trained physician has always been used, until now at least, in a system like the Swedish where public money finances health care. The public’s demand for health care is without limits and a pressure emerges to use all available medical manpower. Another factor that explains why the system has been able to accommodate so many new physicians is the decreased number of working hours per physician. In 1970 the average doctor’s daytime working week was 48 hours. In 1985 the comparable time could be estimated to 28-30 hours (reductions for on-call compensating time etc.). But many doctors want to work more - and the expansion of the private sector - both within the insurance scheme and the totally private has a clear connection to this fact. The concept ‘lack’ of physicians
The main problem in the 1950s when the health care system was ready for strong expansion, was a lack of physicians. The medical profession opposed increase and the public officials worked for it. These quite simple roles and dynamics have stayed - and perhaps blocked more rational policy discussion. Especially has the concept ‘lack of physicians’ stayed and is still very powerful in public debate and in media. There are clear problems in some parts of the country, but not a general one. One could sometimes get a feeling that maintaining a focus on this concept also serves the purpose of drawing the attention away from other serious problems that are present in today’s health care system. The lack of financial resources to operate a health care system being able to match increasing demands for care is an underlying problem. A system that is administratively very inflexible is another. Organizational reforms, restructuring of services, another speciality mix, increased use of nurse personnel and effective assessment of technology - these are examples of alternative ways to tackle some of today’s problems. [431
118
If it is true that the concept ‘luck ofphysicians’ in this way is masking other problems then it is an interesting example of how the past, and the way problems then were formulated, really is influencing the way problems are handled today and tomorrow.
References 1 Anderson, O.W., Health Care, Can There Be Equity? Sweden, Britain and the United States. John Wiley & Sons, New York, 1972. 2 Anderson, O.W., privatization, Competition and Health Maintenance Organization - Implications for Sweden. Paper delivered at a Conference on privatization at SPRI, August 27, 1986. 3 Borgenhammar. E., Health Services in Sweden. In: Raffel, M.W., ed. Comparative Health Systems. University Park and London: The Pennsylvania State University Press, 1984, 470-87. 4 Calltorp, J., Consensus Conferences in Sweden - Effects on Health Policy and Administration. Intern. J. Technol. Assess. Health Care, 4 (1988) 75-88. 5 Ginzberg, E.. L&arna m&ste ta ansvar fdr kosmadskontmlli (Swe). (Physicians must take responsibility for cost control). Key note adress at a seminar on ‘Planning and Competition - What proportions in Swedish Health Care?’ in Uppsala, September 26, 1984. LZkartidningen 81 (1984) 4336-4138. 6 Ham, C., Steering the Oil Tanker: Power and Policy Making in the Swedish Health Service. King’s Fund Institute, London, 1987. 7 Heidenheimer, A.J. and Elvander, N.J. (eds.). The Making of the Swedish Health Care System Croom Helm, London, 1980. 8 Rosenthal, M., Beyond Equity? Swedish Health Policy and the private Sector. The Milbank Quarterly 64 (1986) 592-621. 9 Saltman, R.B. and von Otter, C., Revitalising Public Health Care Systems: A proposal for Public Competition in Sweden. Health Policy 7 (1987) 21-40. 10 Wennstrom, G. and Hultin, J., Central planering av l&kart%rdelning behtivs - men forutsatter ijkad regional lyhijrdhetf (Swe) (Central planning of manpower is needed - but requires cooperation from regions). Lakartidningen 84 (1987) 2016-2018.
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