In Sweden, the phrase “Go to the ER” has become a common refrain for patients unable to access timely primary care — a symptom, critics argue, of deeper systemic inefficiencies. Fanny Nilsson, a Swedish physician, has published a provocative comparative study examining the country’s healthcare model alongside those of Spain, the Netherlands and the UK. Her book, ‘Go to the ER’, serves as a stark wake-up call for policymakers and practitioners alike.
As Europe’s population ages and medical innovation expands the scope of treatable conditions — often at considerable financial and human cost — Nilsson raises pressing questions: Can universal healthcare systems continue to deliver both equitable and high-quality care? And how can societies reconcile rising expectations with the principle of equal access?
Nilsson’s analysis invites a broader debate on the sustainability of public health systems across the continent.
Nilsson, a medical doctor training to be an internal medicine specialist, sat down with Euractiv in Stockholm. As a columnist and debater in Sweden’s largest daily newspaper, Aftonbladet, she has frequently highlighted healthcare-related issues.
Pushing the dialogue
Her book has sparked a heated debate in Swedish healthcare, with numerous regional health politicians requesting meetings with her.
Swedish healthcare is described as excellent in terms of treatment, but it is often criticised for its poor waiting times and limited accessibility, particularly outside regular working hours.
To gain a better understanding of today’s situation in Europe, Nilsson travelled by train to Spain, the Netherlands, and the UK last year.
She spoke to general practitioners, medical specialists, healthcare experts and patients. In her exposé, she describes the historical context, discusses the roles of politicians, doctors, and public and private contractors, as well as the relatively vague notion of healthcare efficiency.
The Spanish and Dutch examples
Spain has a regional and national model based on a strong primary care system, centrally planned and tax-financed, with private entities as contractors, and a small sector of voluntary private health insurance and private caregivers. It has the longest life expectancy but half the healthcare costs of Germany.
The same model is used in the Swedish example, except that Swedish primary care is much weaker and has a higher cost of healthcare per capita.
“The most spectacular difference where Sweden stands out, I would say, is the low percentage of regular contact with a family doctor,“ Fanny Nilsson told Euractiv.
Only 32 per cent have a regular family doctor, which means that seven million Swedes see a different doctor each time they need an appointment. Meanwhile, in the Netherlands, nearly everyone has a regular family doctor.
Moreover, the Dutch system – which the author calls a darling in the healthcare world – is basically financed through compulsory social health insurance, which is funded by a combination of individual monthly premiums, income-based contributions and government taxes.
Regulation is strong. Private insurers and elderly care facilities are not allowed to make a profit, and no patient can bypass the queue by paying extra for healthcare, unlike in other countries.
The first line is described as very important, as primary care doctors also work at the hospital’s ER, doing triage.
“A Dutch person could not see an emergency doctor without a referral from a primary doctor, unless there is a very urgent case, like a heart attack”, Nilsson noted.
While COVID-19 impacted all countries, and the new resources promised have not materialised in the four countries studied, staff shortages are commonplace, especially the lack of general practitioners and specialised nurses.
On the flip side
“In Sweden, we have very few hospital beds, the lowest number in the EU. We also have the lowest number of intensive care beds in the EU, and even fewer now than before the last pandemic. And these are very negative parameters,” Nilsson said.
At the same time, in the UK, the NHS is in an even worse state. The National Health Service (NHS) is financed primarily through general taxation and National Insurance contributions. However, austerity measures over the past decade, combined with the COVID-19 pandemic and Brexit, have led to a grave crisis.
“At least in Sweden, we don’t yet have what they have in the UK with 18-hour waiting times for the ambulances when you have fallen to the ground and can’t stand up. That you can’t even leave the patient at the ER because the emergency department itself is too full. They have reached effects in their system that we haven’t seen here yet, and are said to be near collapse.”
Where to focus
The question then is, which healthcare system is the best for Sweden to emulate?
“I don’t think you can say which one is the best system. It depends on the population and what it expects. Do you want high availability, high quality or low cost? You cannot maximise all three at the same time.”
At the same time, she cherishes a strong primary care, with generalist doctors working smoothly together with hospital specialists.
“A Norwegian study shows 25-30 per cent less mortality and 25-30 per cent less risk to end up in the emergency room, if patients had had a regular family doctor for 15 years, compared to those who only had had it for one year.”
Sweden, she concludes in her book, needs a huge primary care reform and politicians must take more control over the situation with a heavy hospital dominance and freedom of establishment for private care givers.
Nilsson is also inspired by the trend Choosing wisely, as overdiagnosis and overtreatment with new, expensive methods and “drugs of questionable effectiveness” are constantly being used against better judgment, especially when it comes to older people, she writes, and urges doctors to clear out medicines that are ineffective.
“We want as much health as possible for as little money as possible. That, I think, is the overall task of healthcare policy. Today, we are lost. Politicians should ask themselves how they would like to invest in the best way.”
(VA, BM)