ing size, and each of the three big cities, Stockholm, Göteborg, and Malmö, constitutes a county. All these counties exercise functions concerned with the delivery of medical care. The county council has a right to levy a tax on the inhabitants of the county. This tax, a proportional income tax, - the "county" tax, is added to the state income tax mentioned earlier. Between 80 and 90 per cent of the county tax is spent on medical care, the balance going to other local affairs.

At first the county council was only responsible for regular hospitals, but during the last two decades it has also taken or been given by parliament the responsibility for all hospitals for mental illness. It is now also organizing outpatient care through district physicians, who were previously employed by the central state government and directed from Stockholm by the Board of Health and Welfare.

These changes have made possible a more rational organization of the medical-care system. It has also meant that greater expenditure for medical care has had to be assumed by the county councils leading to higher county taxes. The State Insurance Board reimburses the counties for part of the costs of medical care, but only to a small extent. For hospitalized patients reimbursement is based on the number of hospital days for each patient. The total cost per bed per day in most counties varies from about $15, U.S. currency (in chronic-disease hospitals or wards), to more than $100 (in neurosurgery, plastic surgery, acute coronary care, renal dialysis). Of this the patient pays nothing, and the State Insurance Board, $2, regardless of what kind of service the patient gets.

Under the new law in force since January 1, 1970, the patient pays $1.50 (U.S. currency) to the hospital for each outpatient visit. The RFV pays a flat sum of about $6 to the hospital for each such visit. The hospital administration or rather the county thus gets about $7.50 for each visit regardless of what is done, and irrespective of the laboratory and x-ray investigations made in conjunction with the visit.

For the patient needing a fairly thorough diagnostic work-up, the cost has thus decreased considerably since January 1, because he previously had to pay 25 per cent of the total cost, which might have been as much as $20 to $40 if extensive laboratory and x-ray examinations had been performed. For the patient with frequent visits of a routine nature under bishydroxycoumarin treatment or with diabetes, for example the cost remains roughly the same. All patients obtained two major benefits under the new law: they were no longer exposed to the possibility of having to make a large payment; and they no longer had to go to the trouble of getting some of it back. These changes were made mainly to decrease the pressure on hospital care which was and is free and to make outpatient

ORGANIZATION OF MEDICAL CARE

Each county employs a series of district physicians, partly to handle work in preventive medicine, but mostly occupied in ordinary general practice of medicine. They are responsible for health and medical care in a geographically defined district with 3000 to 5000 inhabitants. These physicians are sup ported by medium-sized hospitals staffed by a separate group of physicians with internal medicine and surgery as specialties and usually equipped to perform roentgenologic and laboratory investigations. An anesthesiologist is also on duty. Centrally located in the county usually in the largest town, where the county administration is also located - is a large, fairly well specialized hospital with a medical staff of 100 to 200 physicians, whose work is confined to the hospital. In some large or densely populated counties two such hospitals may exist (Fig. 2).

Only a few of these central hospitals, however, are large enough to allow higher degrees of specialization. To facilitate central planning for the creation and support of increasing specialization of hospital care a Royal Committee was appointed in 1957. In 1960 parliament acted on its recommendations, dividing the country into seven regions, each with a large specialty hospital (Fig. 3-5). Most of these are also teaching hospitals associated with medical schools.

The decision of parliament, however, was only advisory, for the economic responsibility for the maintenance of these specialty hospitals, as well as all health services, rests with the local county councils. They acted rapidly, however, in accordance with the recommendation of parliament and signed organizational and economic agreements to establish special rules governing the transfer between the counties of patients in need of special treatment. This was necessary because each patient only has free access to the hospitals of the county where he is living and where he is paying his county income

Figure 2. Facilities of a Central Hospital (Reproduced, with Permission of the Publisher, from Engel A: Perspectives in

INCOME OF DOCTORS IN THE MEDICAL-CARE

SYSTEM

in some

cases even

Until the end of 1969 all Swedish physicians employed by the government had terms that gave them considerable freedom regarding both work and income. They all had a basal salary, ranging from about $6,000 a year for residents in hospitals and district physicians to $12,000 to $15,000 for the chief physicians in a hospital. This salary usually provided about half their income less. All physicians had a right to charge patients seen on an outpatient basis, usually in accordance with the official rate of fees. Because the size of outpatient work varied widely in different hospitals, different specialties and with different motivation of the individual doctor, the income obtained directly from patients varied considerably. Many residents could have a total income of around $20,000 (range of $12,000 to $30,000) and some heads of hospital services had incomes of $40,000 or more. Those working in the hospitals in Stockholm or in the university hospitals were free to charge ambulatory patients whatever they wanted, and their income was sometimes larger or collected with a smaller outpatient load. Although the heads of the different services in university hospitals thus usually had a higher income than most chiefs of county hospitals, the reverse was true for the residents, because the amount of outpatient work was much less for residents in university hospitals than for those in county hospitals. It should be pointed out that since 1957, no patient occupying a bed in a hospital has been allowed to pay anything to his doctor. All income from patients has thus depended on outpatient work.

NEGOTIATIONS FOR SALARY INSTEAD OF FEES
FROM PATIENTS

Extensive changes in this system came about through a new law originally suggested to simplify the work of RFV and enacted on January 1, 1970. All physicians employed by the government are now on a total salary. They are supposed to work a fixed work-hour week, now 45 to 55 hours (in some places even 60 hours) but by the late 1970's, it is hoped, not more than 40 to 42 hours, night duty excluded.

The new law prohibits all doctors employed by the government from receiving any fees from patients whether they are hospitalized or seen on an outpatient basis in the hospital during the specified hours when the physician is working for the state. This new law, passed by parliament in late December, 1969, forced the Medical Association to negoti ate with the employers of the doctors the State, the three big cities and the counties to guarantee that the physician's income should not suddenly drop to 50 per cent or less of what it had been. This was a difficult negotiation since it involved

more difficult, the employers wanted at the same time to fix the working hours for each category of doctor and to decide on a full-time salary to be determined in relation to the time spent at work, but otherwise the same for each category employed, regardless of the place of work.

During these negotiations, the doctors were divided into several camps, the younger quite eager to have the daily working hours fixed, but those more senior opposed to this concept, which would deprofessionalize medical practice and make it more like common work. Different working conditions in the university hospitals in comparison to others, and in the hospitals run by the City of Stockholm as compared to the county hospitals all over the country, also made the different categories of physicians view the problems from varying standpoints. Doctors in Sweden do not enjoy the status of select members of a profession, and the present trend in society has been to reduce the position of the members of the medical profession further to make them just another type of health worker

among many.

During recent decades, the Swedish medical-care system has favored the use of hospital care to an increasing extent. For both doctors and patients the government-operated hospitals have provided the best facilities for the patients inexpensive access to skilled specialists in well equipped surroundings, and for the doctors high income, usually good working conditions, and the possibility of using all new scientific advances in their wish to serve the patient best regardless of the cost.

Rapidly increasing costs that the community incurred for both hospital inpatient and outpatient services, however, led to a new emphasis on ambulatory care outside the hospital. This, coupled with a more veiled political wish to reduce the income of doctors, led early in 1969 to an agreement among the several responsible governmental agencies to advocate a new law prohibiting all economic transactions between patients and doctors employed by the community about 2/3 of all Swedish doctors. This agreement was reached before a single physi cian or the Swedish Medical Association had been consulted.

Indeed, the agreement was made public, and negotiations were started before the text of the new law was presented to parliament. It was soon evident that the employers wanted not only to regulate the physician's income but also to change many of the conditions of his work, with strictly defined working hours, and with decision by the employer about the type of work a doctor should do.

a

These developments were completely unacceptable to the medical profession. Especially those working in university hospitals demanded definition of how much time should be spent in care of the sick, how much for teaching, and how

ment on a working week defined in hours. After three months of negotiations with most of the time spent on this point, the final agreement which includes a defined working week for all doctors in hospitals, even in university hospitals, except for those of professional rank only states that there will be no difference under the new scheme regarding the proportion of time to be devoted to medical care, teaching and research as compared to the rules during 1969 - when there really were no rules! Since the university hospitals have had a rapidly increasing load of specialized care and teaching during the last years the medical students have more than doubled with little increase in teaching staff this noncommittal statement has been received with dire forebodings by most university teachers.

The final decision on working hours and the salary based on them gave many physicians a boost in income, especially at university hospitals. At the same time their incomes decreased in many of the county hospitals. The strict definition of working hours to be spent at the hospital varying from 44 to 60 hours a week, with night duty not included seemed, however, to place a heavy burden on a profession in which now almost 15 per cent are women. Many physicians now aim at a 52-day working week since a five-day week seems out of the question. This means that the average working day will last from 8 in the morning to 7 at night, plus extra work in the hospital, either one evening a week to 11 p.m., or every Saturday. A new law recently passed states that after January 1, 1971, the working week for the public at large will decrease from 42 to 40 hours between 1971 and 1973. This obviously will not apply to physicians.

FUTURE DEVELOPMENTS

The details in the complicated working schedule have not yet been determined in all hospitals or districts, but the general feeling of belonging to a free profession, free to decide at least in principle how to organize its work has been lost. Many hospital-based physicians regard their work now with an apathy previously unknown. Whether this attitude will change nobody knows, but the way the new rules are going to be implemented will certainly be of importance. It has already been demonstrated that some local representatives of government treat their doctors with more regard to their wishes than others do, no doubt to prevent "their" doctors from moving to another place, or from resigning and entering private practice, which still offers a reasonable living at least in the largest cities.

One of the many details in the final agreement was that both the governmental employers and the employed physicians agreed to keep the part of the "production of medical care" that the physicians could influence unchanged. The sudden change from fee for service to salary for time might other

wise diminish the doctor's motivation to accept more patients at the end of a long working day. The definition of "production of medical care" has not been agreed upon. Still, this term was used in the final agreement, although both parties knew how impossible it is to define, measure and control it.

The agreement has now been in effect for several months. Several difficulties have appeared, not unexpectedly, in the interpretation of the new regula tions, but have usually been met with good cooperation between employer and employed. The great administrative changes that the new order required were, surprisingly enough, unexpected by many employers, and in many counties, the new routines for the admission of patients to outpatient depart ments, decisions about exact working times for doctors and similar problems have not yet been solved.

ROLE OF PRIVATE PRACTICE

With the fairly well organized system of em ployed physicians all over the county, private practice has a minor role for the delivery of medical care. It has been calculated that in the past about half of all outpatient visits were to a private practi tioner. Many of these, however, were employed by industry, or had part-time work in schools or insur ance companies. It is only in the largest cities that private practice really thrives, and about 10 per cent of all doctors are private practitioners. A grand plan for the establishment of group practices was put forward eight years ago by the Swedish Medical Association, and private group practices operate now in the eight to 10 largest cities. The idea of group practice has also appealed to the county councils, which have created several and are planning more practices of this type in different parts of the country.

With the increasing costs for rent and for delivery. of medical care younger physicians are reluctant to start private enterprise, even in the form of group practice. The mean age of our private practitioners is therefore high. Many believe that the new law offering medical care cheaply or free to anybody will eventually kill private practice. So far, it has not had this effect. The queues for hospital outpa tient care increase, and private physicians have more work than ever. The long-term prognosis is uncertain and depends on how the government will organize medical care in the future, especially if it can make all newly graduated physicians government employees when the shortage of doctors ceases.

There are only two private hospitals in all Sweden, in Stockholm and Goteborg, and these are small. Patients treated there have to cover all the costs themselves, except part of the physician's fee This restricts the use of private hospitals to a very small part of the population, and their future is

uncertain.

In principle, a free choice of physician still exists. A patient is thus free to go to any general practi