4.2 Human resources
4.2.1 Health workforce trends
The number of health care staff per inhabitant decreased during the early and mid 1990s but has increased since then. The main reason for the reduction during the 1990s was the structural change over this period, which led to a reduction in hospital beds as well as in the ALOS at hospitals. As the responsibility of care for older people was shifted from the county councils to the municipalities, there was a general reduction in the number of primarily unlicensed medical staff and a large number of unlicensed medical staff was transferred from the county council to the municipal sector.
Health care staff in the county council sector are predominantly licensed staff, such as physicians and nurses, whereas staff in the municipal sector are predominantly unlicensed medical staff, such as assistant nurses. In 2010, about 170 000 and 195 000 people, respectively, were employed by the county councils and the municipalities in the area of health, medical care and long-term care. Among the county council staff, about 17% were physicians, 42% nurses and 30% assistant nurses. Among the municipal staff, about 7% were nurses, whereas 83% were assistant nurses and other unlicensed staff (SALAR statistics www.skl.se). Since the late 1990s, there has been an increase in the number of licensed health care staff per inhabitant, that is, an increased number of physicians and nurses in the county council sector (Table4.1).
In 2008, there were about 35 000 registered physicians (non-retired) and 115 000 registered nurses (non-retired) in Sweden working in the county council, municipal and private sectors (National Board of Health and Welfare, 2010d). According to the Swedish Medical Association, which represents about 90% of Sweden’s doctors, about two-thirds of its members worked in the hospital setting and 17% in the primary care setting in 2009. About 8% worked in the private health care sector and about 8% worked outside the health care sector, for example, in a pharmaceutical company (Swedish Medical Association, 2010).
The number of physicians per inhabitant is higher than in Denmark but lower than in Norway (Fig4.4). Since the mid 1990s the number of physicians per inhabitant has continuously increased from 289 to 372 per 100 000 population between 1995 and 2008 (Table4.1). This corresponds to an increase of nearly 30%. The number of physicians per inhabitant was in line with the EU average until the late 1990s and thereafter it has been increasingly higher in Sweden.
About 70% of all physicians have a specialist degree. Almost one-quarter of all specialist physicians are specialists in general medicine. The terms “general practitioner”, “family physician” and “district physician” vary depending on the prevailing local political and organizational decisions, but all refer to specialists in general medicine within primary care.
The proportion of female physicians is continuously increasing in Sweden and was about 43% in 2008 compared to 38% in 2004 (National Board of Health and Welfare, 2010d). Although the most common specialist physicians are specialists in general medicine, there is a shortage of physicians in primary care. This has led to solutions with private companies offering so-called “physicians for hire” (hyrläkare) to primary care providers, which in turn has led to problems with the continuity of care in relation to patients. There is also a shortage of specialists in geriatric care and this shortage is expected to worsen as the proportion of older people continues to grow (National Board of Health and Welfare, 2011a).
The number of nurses per inhabitant has increased slightly since the mid 1990s and was almost 1100 per 100 000 inhabitants in 2008 (Table4.1). It is, however, lower than both Denmark and Norway although higher than the EU average and the United Kingdom (Fig4.5 and Fig4.6). Almost 90% of all nurses are women (National Board of Health and Welfare, 2010d). The increase in the number of nurses per inhabitant between 1995 and 2008 was about 14% for all nurses whereas it was about 7% for district nurses. District nurses play a central role in Swedish health care, as many first contacts with the health care system are their responsibility. District nurses work both in the county council sector within the primary care setting and in the municipal sector. The salary for district nurses is higher in the municipal sector than in the county council sector since the municipalities compared to the county councils experience difficulties in attracting staff in general and licensed staff in particular (see section 5.8).
The number of dentists per inhabitant has been stable during the period 1995–2008 in Sweden and is higher than the EU average, in line with Denmark and slightly lower than Norway (Fig4.7). About half of all dentists are women in Sweden. There has been an increase in the number of dental hygienists from 3500 to 4000 per 100 000 inhabitants between the years 2004 and 2008. About 98% of all dental hygienists are women (National Board of Health and Welfare, 2010d).
The number of pharmacists per inhabitant is higher in Sweden than in the other Nordic countries and compared to the EU average (Fig4.8). During the last five years the number of pharmacists has shown an upward trend (Table4.1).
In the 2015 Budget Bill, the government has proposed to provide SEK 1 billion (about €107 million) annually from 2015 to enable health care staff to make better use of their professional specialties and spend less time on unnecessary administrative tasks. This is supposed to be achieved by improving administrative procedures and systems, and by better matching of tasks with skills and competences among health care personnel. The shortage of hospital beds and the problem of overcrowding in hospitals will also be addressed. For more information in Swedish: http://www.regeringen.se/sb/d/14830/a/248273
In November 2013, a Government Committee Directive appointed a national coordinator, with the task to analyze how health care personnel resources can be better utilized in Sweden (Ministry of Health and Social Affairs, 2013). The coordinator’s aim is to carry out an investigation revealing efficiency problems and areas in need for improvement, as well as to suggest measures for improvement at local, regional and national level, ensuring that health care professionals’ competences, time and engagement are used in an efficient and effective manner. The main goal is to improve quality and cost efficiency in health care. Three basic questions are guiding the investigation: how to improve the value for patients, how administrative work can be less burdensome, and how health care can be performed more cost-effective. The results are to be presented by 31 December 2015.
This government’s initiative will take on challenges recently identified in a report by the Swedish Agency for Health and Care Services Analysis (Swedish Agency for Health and Care Services Analysis, 2013). The report identified and analyzed challenges and suggested improvements on how doctors’ skills and time on duty could be better used. The report found potential for more efficient use of doctor resources, and provided recommendations for improvement in four main areas: 1) to create a prioritization among administrative requirements, 2) to improve IT-support, 3) to develop and optimize the division of labor between health care staff, and 4) to plan and organize staffing based on patient needs.
Ministry of Health and Social Affairs (2013). Kommittédirektiv 2013:104 En nationell samordnare för effektivare resursutnyttjande inom hälso- och sjukvården [Committee Directive 2013:104 A national coordinator for the efficient utilization of resources within the health care]. Available at: http://www.regeringen.se/sb/d/16823/a/228906, accessed 14th January 2014
Swedish Agency for Health and Care Services Analysis (2013). Ur led är tiden – Fyra utvecklingsområden för en mer effektiv användning av läkares tid och kompetens [The time is out of joint – four development areas for a more efficient use of doctor time and skills]. Available at: http://www.vardanalys.se/Rapporter/2013/Ur-led-ar-tiden---Fyra-utvecklingsomraden-for-en-mer-effektiv-anvandning-av-lakares-tid-och-kompetens/, accessed 14th January 2014
4.2.2 Professional mobility of health workers
In 2009, approximately 2000 physicians were granted a licence to practise medicine in Sweden, of whom half had been educated in Sweden and half abroad (Swedish Medical Association, 2010). During the period 2000–2008, between 1.6% and 2.1% of all physicians stopped practising medicine and started working in other areas each year. The corresponding figures for nurses were between 1.8% and 2.1% (National Board of Health and Welfare, 2010c).
Between 2000 and 2008, about 5% of all licences for nurses were granted to people educated in other countries, corresponding to 170 nurses on average each year. During the same period, about 400 nurses emigrated to another country and about 250 previously emigrated nurses returned to work in Sweden each year (National Board of Health and Welfare, 2010c).
4.2.3 Training of health workers
Universities and colleges are directly accountable to the central government in Sweden. The National Agency for Higher Education (Högskoleverket) is the authority responsible for providing the government with information on which to base decisions regarding the planning of education at the universities. The Agency’s responsibilities include assessing current and future demand for different staff categories. There are 52 institutions offering higher education in various forms in Sweden. The majority of universities and university colleges are public authorities, subject to the same legislation and regulations as other public authorities in Sweden, in addition to the particular statutes, ordinances and regulations relevant to the higher education sector (National Agency for Higher Education, 2011).
In Sweden, medical education is entirely financed by the state. The training of physicians, nurses, dentists and other medical staff is linked to the university hospitals and other relevant parts of the medical services. The National Board of Health and Welfare is the licensing authority for health care staff. After completing study and training programmes, physicians, nurses, dentists, pharmacists and other licensed health service staff can apply for a licence to practise their professions at the National Board of Health and Welfare. The licences are not granted for a specific period of time, that is, health care personnel do not have to re-apply in order to keep their licence.
There are seven universities authorized to educate physicians in Sweden: in Lund, Gothenburg, Linkoping, Stockholm (Karolinska Institute), Uppsala, Umeå and Örebro. Approximately 1600 students were admitted to medical school in 2011 (National Agency for Higher Education, 2011). For admission to a university medical school, graduation from secondary school with subjects that include natural science is required. To become a registered physician, a student must successfully complete a study programme of five and a half years, and after that, a 21-month training period in general medical care, followed by a written examination. Most physicians choose to specialize within any of the approximately 60 recognized specialist fields, which requires another five years of studying and training in the relevant area.
Nurses are educated at approximately 30 universities, university colleges and independent programme providers located throughout the country. Approximately 5000 students are admitted to the nursing programme every year (National Board of Health and Welfare, 2010c). To become a registered nurse, a student must complete a study programme of three years, including one or two periods of training. After having worked for a period of at least one year, nurses can continue with specialist training which lasts for 40–60 weeks. Nurses can choose among 10 recognized specialist areas, for example, midwifery, intensive care and anaesthesiology.
Dentists are trained at the universities of Gothenburg, Stockholm (Karolinska Institute), Umeå and Malmö. As for medical school, admission to a university dental school requires graduation from secondary school with subjects that include natural science. The study programme lasts for five years and includes both theoretical and practical training. About 275 students are admitted to the study programme each year.
4.2.4 Career paths for physicians and other health workers
Broadly speaking, physicians and other health care staff can undertake a clinical career, an academic career or a combination of both. Most physicians and about half of all nurses choose to continue their studies in order to qualify as specialists after receiving their licence to practise their profession. Physicians and nurses working in hospitals and the primary care setting can then choose to continue with an academic career, that is, entering a PhD-programme, or a clinical career with or without more managerial responsibility.
The responsibility for continuing professional education for all employed medical staff rests with the employer. For physicians, an academic career is often combined with work in clinical practice. Physicians pursuing academic merits often base their research on their clinical practice and most often combine their work with patients with teaching and conducting research at universities. For other health care professionals, such as nurses, an academic career is more difficult to combine with continued work in clinical practice.
In the past, physicians holding managerial posts were commonly appointed based on their academic careers and/or academic positions, for example, as a professor at a university. Moreover, until the late 1990s only physicians were allowed to become clinical directors. In 1997, a new regulation (Clinical Directors in Health Care) was adopted making it possible for health care workers other than physicians to become clinical directors. Since then, an increasing proportion of health care workers holding managerial posts have another professional background than as a physician, most often a nursing background. Approximately one-third of all clinical directors were non-physicians in Swedish public hospitals in 2005 (Granestrand, 2005). The most prominent change, however, has taken place within the primary care setting, where about half of all clinical directors were nurses in 2008 (Kennedy, 2008). It has also become less important to have an academic or research background in order to become a clinical director at a hospital. Physicians and nurses who move into managerial posts often stop working in clinical practice instead of combining their managerial responsibility with clinical work and academic research.