Emergency, Disaster, and Defense Medicine: The Swedish Model

Abstract

[Brismar B, Totten V, Persson BM: Emergency, disaster, and defense medicine: The Swedish model. Ann Emerg Med February 1996;27:250-253.] Sweden is a northern European country with a population of 8 million. The medical system is publicly owned and managed and single-payer financed. The private medical system is small and confined to a few specialists working in outpatient clinics. Acute or urgent medical care is provided mainly by hospitals. Minor urgent care (such as treatment of colds or minor injuries) is provided by general practitioners at neighborhood health centers. Sweden has three types of hospitals: university (or regional) county, and district, serving progressively smaller catchment areas. Until recently, all hospitals provided the same range of services, differing mainly in the numbers of patients treated. However, measures to reform the hospital system will soon change the distribution and character of hospitals. Some will become more specialized, mainly providing services such as elective surgery and same-day surgery. Others will specialize in rehabilitation or geriatric care. Primary care is provided by general practitioners working in neighborhood primary care centers that serve between 2,000 and 2,500 inhabitants each. Neighborhood clinic access is mostly by appointment; these clinics also offer walk-in hours for semiurgent or new problems. Urgent and emergency care is supplied by prehospital providers and hospital-based "acute wards." At the government level, the focus of "emergency medicine" is on military preparedness and disaster medicine. Prehospital services, hospitals, and primary care clinics are all integrated into this system. Changes are planned for the way in which emergency care is delivered in Sweden. The first change springs from the decision to include, as part of the function of an "emergency department," 24-hour care offered by experienced specialist physicians. There is also debate on the need to stratify EDs by the levels and types of services available. The highest level of care would include 24-hour in-house anesthesia and specialty surgery services. The lowest level would be allowed to receive only the simplest ambulance cases such as acute urine retention or routine ambulette transfers. Criteria for the intermediate level emergency departments are the focus of debate. Previously, Swedes "belonged" to neighborhood hospitals and were expected to go to these with all health problems. As medical care has advanced and specialization has come to demand ever-greater abilities and facilities, not every hospital can offer the full range of services. This inability has made the neighborhood hospital concept less practical. Swedes are now admitted to the most appropriate hospital for a particular problem. As the emerging paradigm, many neighborhood hospitals have become specialized in one area. However, patients well known to a specific neighborhood hospital, with an exacerbation of a previously known problem, will continue to be received by the acute ward of that hospital, even if the hospital does not meet the highest criteria for an ED. Patients with new problems will go to hospitals with fully developed EDs.