Primary care in Sweden is being opened up to private competition. We interview Professor Anders Anell, at the University of Lund, and Anders Olsson, who runs the project for Stockholm County Council, about the changes, and about Anell's fears that, in the long run, Sweden might end up with 4-5 big chains of primary carers.

At the moment, just three of the 21 Swedish counties - Stockholm, Västernorrland and Halland - have moved to the new model, but Anell says a further 5-6 have stated that they will do so shortly, and that a new Health Act, likely to be passed by January 2009, will force everyone to move by January 2010.

The new approach appears to be working; Anders Olsson, head of the project in Stockholm, says that it has led to 12% more visits, 20 extra practices and 9% more people visiting primary doctors, with the 2008 budget increasing by just 3%. In the new model the money follows the patient, giving the patient far more power and influence.

Anell's concern is that the changes could lead to "a situation where there are a few big chains dominating local markets - an oligopoly."  Others are less worried. Olsson says that today in Stockholm private companies make up 51% of the market, and are growing fast, but says that 2-3 big groups together have only 25% of the market.

First, Anell points out that the main driver for the change is not to privatise, but to provide a better primary care service, with more choice and greater accessibility. Anell himself has done research showing that Swedish primary care quality lags behind other Nordic countries. The aim, he says, is partly to produce bigger and more sophisticated practices, not just with family doctors but also employing other specialist doctors and nurses, such as paediatricians or physiotherapists. To do this, he thinks (and the government thinks) that more competition is necessary.

Anell says that the new system is unlikely to lead to the situation in the UK, where far more money is being spent for a similar level of service. "The amount spent is fixed," he says.

Anell admits that generating more competition may be difficult.  There is talk of extending the complex set of league tables used to measure secondary care to include primary care, but Anell is doubtful as to whether this will actually lead to more competition: "We already pay privately for most dentistry, but we know that most Swedes never change practice." 

Initial feedback from Halland county, the first to move to the new model, suggests it has worked well in the first two years, but Anell repeats that his real concern is an oligopoly developing: "I keep saying this to the county councils, but I am not sure they hear me."

Our Analysis: One issue here is competition. Olsson admits that there may not be much competition in reality. His take is that "most of us never see the doctor, apart from the old, who want someone close to them." So it is unclear just how much competition there will really be in the new model.