Sweden has a long tradition in geriatrics and gerontology. During the 1970s and 1980s, geriatric medicine in Sweden had a leading international role because of its developing hospital care, nursing home care, day care/night care, home health care, health monitoring, and prevention. Professor Alvar Svanborg (1921–2009) in Göteborg was the architect and international pioneer for this development. He initiated, and for many years headed, the well-known longitudinal population study of aging called H70 (Health for 70 year olds), by including cohorts of 70-year-old people from the Göteborg area and following them prospectively in 5-year intervals. This pioneering work laid the foundation for the approach to geriatrics in Sweden today.
In December 2011, the Swedish total population was 9,482,855, of which 18.8% was age 65 years and older. According to Statistics Sweden, this part of the population will increase by 50% between the years 2011 and 2040, while the age group 90 years and older is estimated to increase by 125%.
Organization of Health Care for the Elderly
In Sweden, health care is socialized and financed by taxes derived principally from 21 county councils and 290 municipalities, and, to a smaller extent, from the state. The public health care system is complemented by a small private sector with a few private hospitals and a small and declining number of private physician clinics.
Two pieces of legislation regulate care of the elderly in Sweden: the Health and Medical Services Act (Hälso-och sjukvårdslagen) of 1982 and the Social Service Act (Socialtjänstlagen) of 2001. Health care for elderly people is divided by these 2 laws into 2 financial and organizational systems: medical health care through the county councils and social and nursing health care through the municipalities. In 1992, a major political reform (“ÄDEL reform”) transferred about 40,000 beds and 55,000 staff, including the formal responsibility for long-term care patients, from the county councils to the municipalities. Physicians could also no longer be employed by the municipalities, but would be contracted on commission by the county councils instead. As a result, physicians have no formal role in the organization, team-building work, or staff education in the municipalities, which are responsible for long-term, social, and nursing health care needs of many older Swedes.
Since 1992, more than 95% of all geriatric hospital beds in Sweden have been closed and geriatric medicine is now only present in hospitals in larger cities, particularly in the Stockholm area, with a strong focus on acute geriatric medicine. There is also a small number of geriatric rehabilitation centers.
A study of the organization, staffing, and care production in geriatric medicine in Sweden showed, on average, 1 geriatric bed for every 799 individuals age 65 years and older, with a 10-fold variation between the counties. There were 41 independent Departments of Geriatric Medicine with 85 beds per clinic on average, again with a 10-fold variation between the counties. The report concluded that “there is no overall structural plan for the role of geriatric medicine in Swedish health care, with the desired close connection between content and dimensioning of geriatric specialist training and the practical organization of the activities.” Since then, the closing of geriatric units has continued, but no current detailed national data on the number of geriatric beds are available. This closing process has been driven by the independent county councils without any strategic national planning or broader discussion about the role of geriatric medicine in Sweden.
This development should be viewed against the fact that 75% of all hospitals open in 1980 in Sweden have since been closed. According to the OECD, Sweden had 2.8 hospital beds per 1000 population in 2009 (compared to the U.S. rate of 3.1 and the OECD average of 4.9), which was the lowest number of hospital beds in Europe. As a consequence, the average inpatient length of stay has been cut in half and many older patients are discharged too early to home care or municipality care.
A previous version of the Health and Medical Services Act stated that physicians serving as “stable physician contacts” in primary care must be specialists in general medicine. In the last revision of 2009, this rule was changed to allow patients to choose any specialist working in primary care as their stable physician contact. However, a number of county councils still require that all physicians serving in primary care must be specialists in general medicine. There are only occasional geriatric medicine units in primary care in Sweden, and these focus on “elderly care,” not geriatric medicine.
The medical specialty in long-term care medicine was instituted in 1969 and renamed geriatric medicine in 1992. In 2006, the Swedish government made geriatric medicine a “basal medical specialty”; that is, it is possible for physicians to specialize only in geriatric medicine. The medical specialties in Sweden were reorganized in 2012. Geriatric medicine in Sweden has no formal subspecialties, but geropsychiatry became an “additional specialty” to both geriatric medicine and psychiatry. However, on the other side of the age spectrum, there are 3 pediatric basal specialties: pediatric surgery, pediatric psychiatry, and pediatric medicine, and the latter has 5 defined additional specialties: allergology, cardiology, neonatology, neurology/habilitation, and oncology.
Physicians’ choice of medical specialty is controlled by the local county councils in how they advertise “specialty training positions,” and is not regulated by the Swedish National Board of Health and Welfare (Socialstyrelsen). This lack of national planning has led to a longstanding lack of geriatricians, general physicians, and psychiatrists, and a disproportional increase in, for example, cardiologists. According to statistics from the Swedish Medical Association, in October 2012, there were only 628 (63% female) active specialists in geriatric medicine in Sweden, many of whom have other medical specialties as well, and who frequently work part-time in their role as geriatricians (Table 75–3).
Table 75–3.The number of active working medical specialists in 10 medical specialties in Sweden in October 2012. ||Download (.pdf) Table 75–3. The number of active working medical specialists in 10 medical specialties in Sweden in October 2012.
|Medical Specialty ||Total Number ||Relation to All 22,179 Medical Specialists ||Female |
|Geriatric medicine ||628 ||3% ||63% |
|General medicine ||5467 ||25% ||46% |
|Internal medicine ||3000 ||14% ||37% |
|Cardiology ||742 ||3% ||25% |
|Neurology ||400 ||2% ||38% |
|Obstetrics/gynecology ||1213 ||5% ||67% |
|Oncology ||406 ||2% ||54% |
|Pediatric medicine (including the 5 “additional specialities”) ||1809 ||8% ||54% |
|Psychiatry ||1595 ||7% ||53% |
|Surgery ||1537 ||7% ||21% |
Very few geriatricians serve in primary care in Sweden and there are very few care units designated for older adult care in the primary care setting. Thus, geriatricians in Sweden serve almost entirely in hospitals, mostly in acute geriatric medicine wards or in units specializing in certain “geriatric giants,” usually falls/fractures/osteoporosis, stroke, and dementia.
During the 5.5 years of medical school, medical students get 1–2 weeks of formal education and training in geriatric medicine; that is, less than 1% of the total time in medical school. Different aspects of diagnostics, treatment/care, and evaluation of older adults are taught during many other courses, but not presented as a coherent geriatric theme or curriculum during medical school.
Regarding specialist training, only physicians specializing in geriatric medicine are required to train and serve in geriatric medicine. For all other specialists, including primary care specialists (general physicians) and internists, such education is optional and based on individual interest.
For all other health/nursing care staff groups, there is very limited education and training in geriatric medicine during basal educational programs, and what exists is usually not called geriatric medicine, but rather “care of the elderly.” A small number of nurses and physiotherapists have 1 year of formal training in geriatrics/gerontology or “care for the elderly.” A recent investigation from the Swedish National Board of Health and Welfare found that only 1.6 % of all 12,316 nurses employed in municipality elderly care in Sweden have formal education in “care for the elderly.”
In several medical faculties, there are a limited number of shorter courses in geriatric medicine for different health care staff groups, but there are small incentives for employers to allow members of the staff to attend such courses during working hours.
Patients in the Health/Nursing Care System
In Sweden, older patients (age 65+ years), who often have multiple morbidities requiring multiple treatment methods, dominate in all parts of the health care system. In primary care, these patients represent approximately 50% of physician working time. In hospital departments such as internal medicine and its subspecialties, they account for 60% to 70% of all inpatients. In municipality care dedicated to older adults, 100% of all resources is given to older residents. Thus, there is a significant mismatch between the number of older patients with multimorbidities and the competence in geriatric medicine among physicians and health/nursing care staff across all groups.
All medical faculties have university professors in geriatric medicine and there are units for geriatric medicine in all 7 Swedish medical faculties, except for Örebro. The professors in 3 of the faculties are focused on dementia (Stockholm, Uppsala, Linköping) and 1 is focused on osteoporosis (Göteborg). There are about 10 other professors in geriatric medicine in these faculties with different research focuses. Only a few are devoted to the study of multimorbidity in older adults, with a focus on clinical management in primary care/municipality care.