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Public health services in Scandinavia
PUBLIC HEALTH SERVICES IN SCANDINAVIA By J. S. C O O K S O N ,
M.D., D.P.H.
County Medical Officer of Health, Herefordshire "I-'HEobject of this article is to give a brief account of the public health services in Scandinavia, the way the public health work fits in with the general medical scheme of things and the relationship of medical officers of health to other doctors. In March and April, 1961, I visited Denmark, Finland, Iceland, Norway and Sweden in order to study their Health Services. My itinerary was drawn up by the European Regional Office of the World Health Organization and by the medical administrators of the countries concerned. The statements made and the opinions expressed are not necessarily those of the World Health Organization. ADMINISTRATION
Before dealing with the public health services it is necessary to give an outline of the administration of the health services as a whole. Fortunately for the sake of brevity of description they all fit one common pattern. The health services of countries are determined by history, tradition, social and economic circumstances. This is true for the countries of Scandinavia which are also influenced by geographical considerations. Each has a relatively small population dispersed over a wide rural area, with a high proportion of the total population living in several large towns. With the exception of Iceland, the central government departments have delegated many of their powers to a central non-governmental body. This body is known as the National Health Service in Denmark, the State Medical Board in Finland, the Health Directorate in Norway and the Royal Medical Board in Sweden. It advises all central government departments on health matters; this must go a long way towards co-ordinating the work of the various central government departments. There is a provincial health officer who is centrally appointed, and is, in fact, an instrument of the central non-governmental body for supervision of the services provided locally. The third tier is the local board of health which is responsible for environmental public health nlatt~rS.
ENVIRONMENTAL PUBLIC HEALTH SERVICES A general oversight is given of the environmental public health services by the central non-govermnental body. The services themselves are provided in the larger cities by the city councils and in the communes by the local boards of health. In remote rural areas there is difficulty in providing water supplies and sewage disposal schemes. However, all countries still look upon these as basic 353
354
PUBLIC
HEALTtt
VOL.
LXXVI
NO.
6
public health requirements; not least in Finland where, during 1960, somc 1,000 cases of enteric fever occurred, of which quite a proportion wele c o n sidered to be water borne in origin. In Iceland there is a remarkable arrangement whereby most of the houses in Reykjavik have central heating and constant running hot water for domestic use, obtained from the naturally occurring volcanic hot springs. This water at a temperature of 85 ° C is pumped from sources near the Reykjalundur rehabilitation centre in pipes to the outskirts of the city to be held in hot water reservoirs. Due to good lagging with peat there is a heat loss of only 5 ° C on the way. The advantages of warmth to a household, and the better chances of personal hygiene, are of inestimable benefit. The Icelanders have even sv-prised themselves by its various potential uses, for example, in some cases they have changed the use of their buildings accordingly. It had been planned that the basement of the National Theatre should be used as a cold store, but because of the ready way in which it could be adapted for central heating it is now used as a fashionable restaurant. In Norway the same environmental problems are met and dealt with on modern lines. In Sweden I saw an up-to-date water purification plant at J6nk6ping and a reactivated sludge sewage disposal works at Tranos. In Demnark ! saw something of the environmental health problems created by unauthorized shack dwelling oll the outskirts of Copenhagen in the area of Tarnby. These buildings were inhabited by a high proportion of problem families. PERSONAL
PUBLIC
HEALTH
SERVICES
These were similar to the English pattern. The central non-governmental body supervises them. The actual services are provided by the appropriate local authorities. Almost all confinements in towns take place in hospital and up to 90 per cent of those in the rural areas. The object of the antenatal clinics, as elsewhere, is to give an opportunity for noting any departures from the normal and then to arrange adequate treatment for the patient. Most countries use a midwifery record card which is held by the patient, taken by her regularly to the antenatal clinic and then eventually on to hospital. The aim of the infant welfare centres is to deal with the healthy baby and to refer those who are not well, for treatment. Routine tuberculosis control work is undertaken at most clinics and venereal disease at some clinics. Mental hygiene is being developed at a few clinics. PUBLIC
HEALTH
WORK
MEDICAL
AND
THE
GENERAL
SERVICE
In Iceland, the whole country with the exception of Reykjavik is divided into medical districts, covered by governmental district medical officers. These
Pt,! B I . I C
t-I f A
I.Ttl
S[.RVICI
S
I N
SCAN
I) I N A V I \
355
district medical officers have at least a dual responsibility, being in charge of all public health work in their areas, engaging in general practice and no: infrequently in hospital work. In fact, the district medical officer is nearly always the only doctor in the area. However, in the more urbanized areas where there are other doctors, the district medical officer deals with preventive work leaving general practice and hospital work lZ~r the others. In Finland, most of the country, with the exception of Helsinki, is covered in much the same way with district medical officers undertaking various duties. In Helsinki, the medical officer of health and his staff are responsible for the environmental and personal health services. However, the greater part of the country consists of dispersed small towns or communes. Roughly speaking, there is a communal physician to every 4,000 to 10,000 persons. The appointment is made by the communes subject to approval by the State Medical Board. The communal physician is responsible for public health, general practice and hospital work in his area. The patients pay him privately for general medical care although in cases of extreme hardship the fee is met by the communes. There are provincial health officers who, on behalf of the State Medical Board, supervise the work of the communal physicians. The provincial health officers each have a stall" including a provincial nursing officer and sometimes a provincial public health inspector to deal with these branches of the work. To return to the position in Helsinki, the public health staff carried out their duties quite independently of general practitioners. At an infant welfare centre, when the question arose of the reference of a case of congenital heart disease direct to hospital, there was no suggestion that the child should first be referred to a general practitioner. I pressed this point, and it seemed that a mother herself can take the child direct to a specialist at the hospital if she is so minded, or the infant welfare centre medical officer may send tile child direct. The general practitioner does not receive a report on such a patient. General practitioners do not have direct access to the laboratory at the Aurora Hospital for Communicable Disease. Specimens are referred either through the City Health Department or through a specialist on the staff of the Hospital. In Helsinki the position is further complicated since a district medical service for the provision of medical and nursing care has been superimposed on the above organization. Originally this service was to be for "poor people" but in recent years it has also been used extensively by the middle classes and, perhaps for some kind of case, is becoming a recognized method of gaining admission to hospital. In the scheme there are 14 medical officers, 72 home nurses and 4 physiotherapists, all on the staff of ttle City Health Department. The district medical officer receives a salary of about £600 a year and then is paid what are virtually half price fees of £1 per visit and 10/- per consultation. For the "poor people", and a quarter of the patients under the scheme are so categorized, the Social Board pays the fees of the district medical officers.
356
PUBLIC
ItliALTIt
VOL.
LXXV1
NO.
6
In the cities and larger towns in Sweden the service once more falls into the two distinct types. The public health staff of the City of Stockholm work independently of the general practitioners and the hospital staffs. Here again, where a member of the public health medical staff refers a child to a specialist in a hospital, it is considered to be quite unnecessary for this to be done through a general practitioner. It is clear that no person could really be looked upon as the family doctor. Outside the towns the appointments of district medical officers are made by the Royal Medical Board and the salary paid covers duties both in preventive and curative medicine. In addition, the district medical officers receive a fee of 10/- per consultation, of which 75 per cent. is recovered from insurance. This means that in most parts of the country the same doctor is dealing both with curative and preventive medicine. The district medical officer advises the local public health committee on public health matters. In Norway, on rnuch the same pattern, the public health staff of the larger towns, for example Oslo and Bergen, were full-time appointments; and here again there was no integration of work between the public health department and general medical practice. However, in the remote rural areas, where one doctor was working, he was appointed as public health doctor and then in addition undertook curative general medical care. In Denmark the arrangements are remarkably different from those in other Scandinavian countries. In Copenhagen the Board of Health is responsible for public health matters. It is made up of five members, the Commissioner of the Police (Chairman), the Mayor, the Commissioner of Health, and two members appointed by the City Council. The Board of Health employs three medical officers and two assistant medical officers. An interesting point in such appointments is that only the Commissioner for Health holds a whole-time appointment, the others also practise in other branches of medicine, e.g. general practice. It is said that in this way the medical officers keep in touch with modern medical problems. The Board of Health runs the Central Tuberculosis Dispensary, two clinics for venereal diseases, and 33 centres for the care of children up to 7 years of age. Most of the population belong to an insurance scheme and are on a doctor's list. The general medical practitioner here comes nearer to the conception of a family doctor than anywhere else in the Scandinavian countries. He is paid a capitation ~ze and also for certain items of service, which include the examination of children at defined intervals. These prophylactic medical examinations are made three times during the first year of life and once a year from the ages of 1 to 7 years, i.e. until the child goes to school. The doctor at such examinations gives general guidance in nutrition and child care. Much is made of the close connection between the family and a single general practitioner. The family may choose another doctor if they want or, for that matter, individual members of the family may each have different doctors. The connection between the patient and his general
PUBLIC
HEALTH
SERVICES
1N
SCANDINAVIA
357
practitioner is firm and personal. In the rural areas local health officers are appointed for public health and general medical practice. These doctors have done a special post-graduate course. COMMENT
As has been pointed c~ut (Frandsen, 1952) health services have a common purpose ; the treatmem. ~,f the sick, the prevention of disease, and the promotion of health. But their administration differs from country to country for it depends on the social structure and economic strength of each community. Like other legislation, health legislation leaves its own national stamp and has its own historic background. So far as the administration is concerned (Evang, 1958) it is noted that the dualism is preserved by which curative medicine is separated from public health and that they are administered through different channels. l found considerable emphasis laid on the value of the central government delegating to a central non-governmental body. It is said that the administration is both centralized and non-centralized (Friedberg, 1959). No ministry deals exclusively with health matters; the various government departments themselves attend to such health matters as fall within their fields. These efforts are co-ordinated by the central non-governmental body headed by the directorgeneral. It has been felt in some quarters (McParland, 1960) that such an arrangement makes it easier for the medical profession to get its views accepted. The decentralized part of the health administration is vested in the county and municipal authorities. This decentralized work is carried out in close contact with the central non-governmental body, by means of representative provincial medical officers throughout the country. Looked at on its own, it would seem to be a bold and original line to take. However, other comparable social services have also been so delegated and make a whole series of central non-governmental bodies dealing with various aspects of social work. Does this, in fact, in any way affect the functioning of the public health services? Does it really alter the way the public health services fit in with the general medical scheme of things? Surely all that has happened is that the health services have followed the patterns of the other social services. In the day to day running of the services there does not seem to be a great deal of difference in control by the central non-governmental body from control exercised directly by a ministry. The administration of the environmental health services rests mainly with the local authorities, who also bear their proportion of the cost. The local councils elect health committees. The medical officer of health is a member, and these committees supervise sanitation within their area (Henningsen, E. J., 1947), deal with drinking water, sewerage, foodstuffs, dwellings, etc. The public health nurse service and the school health service are in the hands of the local bodies and the State shares the cost.
358
PUBLIC
HEALTH
VOI_.
LXXVI
NO.
6
As has been pointed out (Fry, 1961), there is no one special system of preventive services for the Scandinavian countries. So it cannot be argued that good health of their peoples depends on any one system; differing methods arc used in the various countries. In Sweden all infimts are seen at the clinics described as of varying grades. Grade I is a clinic staffed by a pmdiatrician, grade II is a clinic staffed by a district doctor with a public health nurse, and grade III is run by a district doctor without a public health nurse. The public health nurse is given much greater responsibility than in England. She deals with routine preventive care, visits mothers and infants and personally carries out inoculations, etc. In Denmark (Backer, 1958) the general practitioner undertakes the prophylactic attention of children prior to school age and of pregnant women. With the exception of Copenhagen, prophylactic consultations are carried out by the general practitioner. Where this is the case, the natural connectidn between prophylaxis and therapy is not impaired. The prophylactic consultations are remunerated by a fee per consultation. Such fee is met by public authorities through the State and the local authorities. The relation of public health work and the general medical service must affect to a great extent the relation of the medical officers of health to other medical practitioners. As has been stated (Franks, 1959) the position of the medical officers corresponds much more closely to that of consultants in a specialized medical field than to that of their colleagues in England. Theirs is the field which covers specifically all the problems of the community, or of the groups within it, to which medical knowledge can be carefully applied. In this context they speak, to local government authorities and all other bodies alike, with the status and authority of physicians of local high standing, who have been selected by the central advisory body. The medical officers of health cover a much wider field than the local authority services. They are truly consultants to the local authorities and are independent of them as regards their appointments, policies and relations with other bodies. The local authorities, on the other hand, are bound to consult them on specific matters connected with their statutory public health functions, and are dependent to some extent on their approval for the continuance of subsidies from the central government. In all the Scandinavian countries, with the noteworthy exception of Denmark, there is no such person as the family doctor, so the problem of reference of cases to a particular doctor in general practice does not arise. In Denmark there is a general medical practitioner who is paid both on a capitation basis and for services r e n d e r e d ~ h e may well be described as a family doctor.
SUMMARY
The public health services of the Scandinavian countries are similar to each other but different from those of the United Kingdom.
PUBLIC
itlLALTtt
SERVICES
IN
SCANDINAVIA
359
The public health service, like other social services, has been built up on the history, traditions, social and economic circumstances, and with special consideration for the exceptional geographical characteristics of each of these countries. There is a marked similarity in the way the public health work fits in with the general medical scheme of things. In the cities, the services are run separately but in the remote rural areas the one doctor does the two or more kinds of work. Such relationship between the public health work and the general medical scheme of things necessarily affects the relationship of medical officers of health to o!her doctors. With the exception of Denmark there is no family doctor as the term is understood in England. I am grateful to the Ministry of Health for nominating me for the Travelling Fellowship, and to the European Regional Office of the World Health Organisation for the excellent arrangements made with the administrators of the countries concerned and to the many people whom I met for their great kindness and generous hospitality. R E FE R E N CE S B A C K E R, K . H . (1958). Dan. Med. Bull., 5, 184. E v a N O, K . (1958). Lancet, 2, 1003. I-" n A N D S E N, T. (1952). Ibid., 1, 352. F n a N K S, H . (1959). Publ. Hlth., 73, 336. F R I E D ~ E R G, R. (1959). Brit. J. ¢lin. Prac., 13, 209. F n v, J. (1961). Brit. reed. Y., 1, 350. H ENNINGSEN, E. J. (1947). Ibid., 2, 121. M CPARLAND, M. (1960). Irish Y. reed. Sci., 6, 310.
M.D., D.P.H.
County Medical Officer of Health, Herefordshire "I-'HEobject of this article is to give a brief account of the public health services in Scandinavia, the way the public health work fits in with the general medical scheme of things and the relationship of medical officers of health to other doctors. In March and April, 1961, I visited Denmark, Finland, Iceland, Norway and Sweden in order to study their Health Services. My itinerary was drawn up by the European Regional Office of the World Health Organization and by the medical administrators of the countries concerned. The statements made and the opinions expressed are not necessarily those of the World Health Organization. ADMINISTRATION
Before dealing with the public health services it is necessary to give an outline of the administration of the health services as a whole. Fortunately for the sake of brevity of description they all fit one common pattern. The health services of countries are determined by history, tradition, social and economic circumstances. This is true for the countries of Scandinavia which are also influenced by geographical considerations. Each has a relatively small population dispersed over a wide rural area, with a high proportion of the total population living in several large towns. With the exception of Iceland, the central government departments have delegated many of their powers to a central non-governmental body. This body is known as the National Health Service in Denmark, the State Medical Board in Finland, the Health Directorate in Norway and the Royal Medical Board in Sweden. It advises all central government departments on health matters; this must go a long way towards co-ordinating the work of the various central government departments. There is a provincial health officer who is centrally appointed, and is, in fact, an instrument of the central non-governmental body for supervision of the services provided locally. The third tier is the local board of health which is responsible for environmental public health nlatt~rS.
ENVIRONMENTAL PUBLIC HEALTH SERVICES A general oversight is given of the environmental public health services by the central non-govermnental body. The services themselves are provided in the larger cities by the city councils and in the communes by the local boards of health. In remote rural areas there is difficulty in providing water supplies and sewage disposal schemes. However, all countries still look upon these as basic 353
354
PUBLIC
HEALTtt
VOL.
LXXVI
NO.
6
public health requirements; not least in Finland where, during 1960, somc 1,000 cases of enteric fever occurred, of which quite a proportion wele c o n sidered to be water borne in origin. In Iceland there is a remarkable arrangement whereby most of the houses in Reykjavik have central heating and constant running hot water for domestic use, obtained from the naturally occurring volcanic hot springs. This water at a temperature of 85 ° C is pumped from sources near the Reykjalundur rehabilitation centre in pipes to the outskirts of the city to be held in hot water reservoirs. Due to good lagging with peat there is a heat loss of only 5 ° C on the way. The advantages of warmth to a household, and the better chances of personal hygiene, are of inestimable benefit. The Icelanders have even sv-prised themselves by its various potential uses, for example, in some cases they have changed the use of their buildings accordingly. It had been planned that the basement of the National Theatre should be used as a cold store, but because of the ready way in which it could be adapted for central heating it is now used as a fashionable restaurant. In Norway the same environmental problems are met and dealt with on modern lines. In Sweden I saw an up-to-date water purification plant at J6nk6ping and a reactivated sludge sewage disposal works at Tranos. In Demnark ! saw something of the environmental health problems created by unauthorized shack dwelling oll the outskirts of Copenhagen in the area of Tarnby. These buildings were inhabited by a high proportion of problem families. PERSONAL
PUBLIC
HEALTH
SERVICES
These were similar to the English pattern. The central non-governmental body supervises them. The actual services are provided by the appropriate local authorities. Almost all confinements in towns take place in hospital and up to 90 per cent of those in the rural areas. The object of the antenatal clinics, as elsewhere, is to give an opportunity for noting any departures from the normal and then to arrange adequate treatment for the patient. Most countries use a midwifery record card which is held by the patient, taken by her regularly to the antenatal clinic and then eventually on to hospital. The aim of the infant welfare centres is to deal with the healthy baby and to refer those who are not well, for treatment. Routine tuberculosis control work is undertaken at most clinics and venereal disease at some clinics. Mental hygiene is being developed at a few clinics. PUBLIC
HEALTH
WORK
MEDICAL
AND
THE
GENERAL
SERVICE
In Iceland, the whole country with the exception of Reykjavik is divided into medical districts, covered by governmental district medical officers. These
Pt,! B I . I C
t-I f A
I.Ttl
S[.RVICI
S
I N
SCAN
I) I N A V I \
355
district medical officers have at least a dual responsibility, being in charge of all public health work in their areas, engaging in general practice and no: infrequently in hospital work. In fact, the district medical officer is nearly always the only doctor in the area. However, in the more urbanized areas where there are other doctors, the district medical officer deals with preventive work leaving general practice and hospital work lZ~r the others. In Finland, most of the country, with the exception of Helsinki, is covered in much the same way with district medical officers undertaking various duties. In Helsinki, the medical officer of health and his staff are responsible for the environmental and personal health services. However, the greater part of the country consists of dispersed small towns or communes. Roughly speaking, there is a communal physician to every 4,000 to 10,000 persons. The appointment is made by the communes subject to approval by the State Medical Board. The communal physician is responsible for public health, general practice and hospital work in his area. The patients pay him privately for general medical care although in cases of extreme hardship the fee is met by the communes. There are provincial health officers who, on behalf of the State Medical Board, supervise the work of the communal physicians. The provincial health officers each have a stall" including a provincial nursing officer and sometimes a provincial public health inspector to deal with these branches of the work. To return to the position in Helsinki, the public health staff carried out their duties quite independently of general practitioners. At an infant welfare centre, when the question arose of the reference of a case of congenital heart disease direct to hospital, there was no suggestion that the child should first be referred to a general practitioner. I pressed this point, and it seemed that a mother herself can take the child direct to a specialist at the hospital if she is so minded, or the infant welfare centre medical officer may send tile child direct. The general practitioner does not receive a report on such a patient. General practitioners do not have direct access to the laboratory at the Aurora Hospital for Communicable Disease. Specimens are referred either through the City Health Department or through a specialist on the staff of the Hospital. In Helsinki the position is further complicated since a district medical service for the provision of medical and nursing care has been superimposed on the above organization. Originally this service was to be for "poor people" but in recent years it has also been used extensively by the middle classes and, perhaps for some kind of case, is becoming a recognized method of gaining admission to hospital. In the scheme there are 14 medical officers, 72 home nurses and 4 physiotherapists, all on the staff of ttle City Health Department. The district medical officer receives a salary of about £600 a year and then is paid what are virtually half price fees of £1 per visit and 10/- per consultation. For the "poor people", and a quarter of the patients under the scheme are so categorized, the Social Board pays the fees of the district medical officers.
356
PUBLIC
ItliALTIt
VOL.
LXXV1
NO.
6
In the cities and larger towns in Sweden the service once more falls into the two distinct types. The public health staff of the City of Stockholm work independently of the general practitioners and the hospital staffs. Here again, where a member of the public health medical staff refers a child to a specialist in a hospital, it is considered to be quite unnecessary for this to be done through a general practitioner. It is clear that no person could really be looked upon as the family doctor. Outside the towns the appointments of district medical officers are made by the Royal Medical Board and the salary paid covers duties both in preventive and curative medicine. In addition, the district medical officers receive a fee of 10/- per consultation, of which 75 per cent. is recovered from insurance. This means that in most parts of the country the same doctor is dealing both with curative and preventive medicine. The district medical officer advises the local public health committee on public health matters. In Norway, on rnuch the same pattern, the public health staff of the larger towns, for example Oslo and Bergen, were full-time appointments; and here again there was no integration of work between the public health department and general medical practice. However, in the remote rural areas, where one doctor was working, he was appointed as public health doctor and then in addition undertook curative general medical care. In Denmark the arrangements are remarkably different from those in other Scandinavian countries. In Copenhagen the Board of Health is responsible for public health matters. It is made up of five members, the Commissioner of the Police (Chairman), the Mayor, the Commissioner of Health, and two members appointed by the City Council. The Board of Health employs three medical officers and two assistant medical officers. An interesting point in such appointments is that only the Commissioner for Health holds a whole-time appointment, the others also practise in other branches of medicine, e.g. general practice. It is said that in this way the medical officers keep in touch with modern medical problems. The Board of Health runs the Central Tuberculosis Dispensary, two clinics for venereal diseases, and 33 centres for the care of children up to 7 years of age. Most of the population belong to an insurance scheme and are on a doctor's list. The general medical practitioner here comes nearer to the conception of a family doctor than anywhere else in the Scandinavian countries. He is paid a capitation ~ze and also for certain items of service, which include the examination of children at defined intervals. These prophylactic medical examinations are made three times during the first year of life and once a year from the ages of 1 to 7 years, i.e. until the child goes to school. The doctor at such examinations gives general guidance in nutrition and child care. Much is made of the close connection between the family and a single general practitioner. The family may choose another doctor if they want or, for that matter, individual members of the family may each have different doctors. The connection between the patient and his general
PUBLIC
HEALTH
SERVICES
1N
SCANDINAVIA
357
practitioner is firm and personal. In the rural areas local health officers are appointed for public health and general medical practice. These doctors have done a special post-graduate course. COMMENT
As has been pointed c~ut (Frandsen, 1952) health services have a common purpose ; the treatmem. ~,f the sick, the prevention of disease, and the promotion of health. But their administration differs from country to country for it depends on the social structure and economic strength of each community. Like other legislation, health legislation leaves its own national stamp and has its own historic background. So far as the administration is concerned (Evang, 1958) it is noted that the dualism is preserved by which curative medicine is separated from public health and that they are administered through different channels. l found considerable emphasis laid on the value of the central government delegating to a central non-governmental body. It is said that the administration is both centralized and non-centralized (Friedberg, 1959). No ministry deals exclusively with health matters; the various government departments themselves attend to such health matters as fall within their fields. These efforts are co-ordinated by the central non-governmental body headed by the directorgeneral. It has been felt in some quarters (McParland, 1960) that such an arrangement makes it easier for the medical profession to get its views accepted. The decentralized part of the health administration is vested in the county and municipal authorities. This decentralized work is carried out in close contact with the central non-governmental body, by means of representative provincial medical officers throughout the country. Looked at on its own, it would seem to be a bold and original line to take. However, other comparable social services have also been so delegated and make a whole series of central non-governmental bodies dealing with various aspects of social work. Does this, in fact, in any way affect the functioning of the public health services? Does it really alter the way the public health services fit in with the general medical scheme of things? Surely all that has happened is that the health services have followed the patterns of the other social services. In the day to day running of the services there does not seem to be a great deal of difference in control by the central non-governmental body from control exercised directly by a ministry. The administration of the environmental health services rests mainly with the local authorities, who also bear their proportion of the cost. The local councils elect health committees. The medical officer of health is a member, and these committees supervise sanitation within their area (Henningsen, E. J., 1947), deal with drinking water, sewerage, foodstuffs, dwellings, etc. The public health nurse service and the school health service are in the hands of the local bodies and the State shares the cost.
358
PUBLIC
HEALTH
VOI_.
LXXVI
NO.
6
As has been pointed out (Fry, 1961), there is no one special system of preventive services for the Scandinavian countries. So it cannot be argued that good health of their peoples depends on any one system; differing methods arc used in the various countries. In Sweden all infimts are seen at the clinics described as of varying grades. Grade I is a clinic staffed by a pmdiatrician, grade II is a clinic staffed by a district doctor with a public health nurse, and grade III is run by a district doctor without a public health nurse. The public health nurse is given much greater responsibility than in England. She deals with routine preventive care, visits mothers and infants and personally carries out inoculations, etc. In Denmark (Backer, 1958) the general practitioner undertakes the prophylactic attention of children prior to school age and of pregnant women. With the exception of Copenhagen, prophylactic consultations are carried out by the general practitioner. Where this is the case, the natural connectidn between prophylaxis and therapy is not impaired. The prophylactic consultations are remunerated by a fee per consultation. Such fee is met by public authorities through the State and the local authorities. The relation of public health work and the general medical service must affect to a great extent the relation of the medical officers of health to other medical practitioners. As has been stated (Franks, 1959) the position of the medical officers corresponds much more closely to that of consultants in a specialized medical field than to that of their colleagues in England. Theirs is the field which covers specifically all the problems of the community, or of the groups within it, to which medical knowledge can be carefully applied. In this context they speak, to local government authorities and all other bodies alike, with the status and authority of physicians of local high standing, who have been selected by the central advisory body. The medical officers of health cover a much wider field than the local authority services. They are truly consultants to the local authorities and are independent of them as regards their appointments, policies and relations with other bodies. The local authorities, on the other hand, are bound to consult them on specific matters connected with their statutory public health functions, and are dependent to some extent on their approval for the continuance of subsidies from the central government. In all the Scandinavian countries, with the noteworthy exception of Denmark, there is no such person as the family doctor, so the problem of reference of cases to a particular doctor in general practice does not arise. In Denmark there is a general medical practitioner who is paid both on a capitation basis and for services r e n d e r e d ~ h e may well be described as a family doctor.
SUMMARY
The public health services of the Scandinavian countries are similar to each other but different from those of the United Kingdom.
PUBLIC
itlLALTtt
SERVICES
IN
SCANDINAVIA
359
The public health service, like other social services, has been built up on the history, traditions, social and economic circumstances, and with special consideration for the exceptional geographical characteristics of each of these countries. There is a marked similarity in the way the public health work fits in with the general medical scheme of things. In the cities, the services are run separately but in the remote rural areas the one doctor does the two or more kinds of work. Such relationship between the public health work and the general medical scheme of things necessarily affects the relationship of medical officers of health to o!her doctors. With the exception of Denmark there is no family doctor as the term is understood in England. I am grateful to the Ministry of Health for nominating me for the Travelling Fellowship, and to the European Regional Office of the World Health Organisation for the excellent arrangements made with the administrators of the countries concerned and to the many people whom I met for their great kindness and generous hospitality. R E FE R E N CE S B A C K E R, K . H . (1958). Dan. Med. Bull., 5, 184. E v a N O, K . (1958). Lancet, 2, 1003. I-" n A N D S E N, T. (1952). Ibid., 1, 352. F n a N K S, H . (1959). Publ. Hlth., 73, 336. F R I E D ~ E R G, R. (1959). Brit. J. ¢lin. Prac., 13, 209. F n v, J. (1961). Brit. reed. Y., 1, 350. H ENNINGSEN, E. J. (1947). Ibid., 2, 121. M CPARLAND, M. (1960). Irish Y. reed. Sci., 6, 310.