After Denmark (See ELAN SOCIAL No 31), this article covers Sweden and a welfare system hailed over the years thanks to a training sponsored by CNESSS.

Compared to the French system, the Swedish welfare system is first of all coherent. The Swedish social welfare funds mainly cover old age, family expenses, and refund sickness benefits in cash only. It is an 'organised care system' rather than a 'social welfare system' as far as other services are concerned.

Main differences between both countries – The Bismarck-inspired French system is supposed to run against the Beveridge-inspired Swedish system. On the one hand, we have management with social democracy and financing via contributions indexed to income, while on the other hand, we have elected management and financing via taxes.

This is the historical confrontation of two systems that are nevertheless sharing a number of common properties – They both are evolved and costly social welfare systems constantly being questioned – What are their differences and futures?

As in Denmark, the Swedish care system is managed by 'general' or city councils equivalent to counties or regions in France since the population of Sweden or Denmark is roughly equivalent to that of a French region.

In Sweden, the state makes laws, the general councils manage hospitals and the city councils manage the local care centres and social welfare. The social security funds are paying pensions, family allowances and sickness benefits in cash.

In Denmark, physicians have liberal practices in the cities. Their fees are paid 80% by capitation and 20% by individual codes by the general councils. They are attending general practitioners selected by insurance payers in a 10 km radius around their place of residence.

In Sweden, physicians are working for city care centres and their fees are apparently paid by the general councils. The selection may initially be free but it is our understanding that the patients are contractually allocated to attending physicians afterwards, and some witnesses have indicated that changing doctors is not an easy thing to do. However, children can be treated in exactly the same conditions by referring paediatricians in the cities.

The approach regarding direct access to specialists is not the same in Denmark or Sweden as it is in France – There are no, or very few, ambulatory medicine specialists. They are paid by and give their consultations in hospitals and have no private practices.

Some physicians have liberal practices in Sweden. In Denmark, selecting 'Sector 2' allows free access to any physician provided staggered refunds are accepted (1% of the population made this choice).

Swedish patients have to pay deterrent charges up to 900,00 FF for medical consultations and 1500,00 FF for prescriptions. They make the initial payments, children excepted since paediatric medicine is free. Payments are taken over by the social welfare funds once those sums are exceeded. The system is attempting to discourage giving abusive care to active individuals who are in good health while taking charge of really sick patients.

The Danish system is slightly different; deterrent charges are paid for prescriptions only but pharmacists are obliged to provide substitute drugs at a lower cost.

In Sweden and Denmark, hospitals are managed and financed with taxes by the local governments. Taxes are much more painful to pay than contributions (especially when they pretend to be "employer" or "employee" related contributions); the local governments consequently restructured hospitals in both countries a long time ago to avoid increasing taxes, whereas in France the hospital's situation is akin to that of the metallurgical industry and impossible to restructure without major social and political damage.

In Sweden, the general councils' administrative services are tough negotiators as far as hospital allotments are concerned and staff has been drastically reduced over the last few years. It is considered that every productivity gain that could be made has been made by optimising organisations. The social welfare funds will be subjected to additional rigors in the "2005" plan proposed by the guardian authority.

Once the project had been decided, the policy and the means were implemented with a stubborn coherence that is completely bewildering for French men and women who are use to piling up care services in a very disorderly fashion. The Swedish system is logic, well structured and coherent.

Leave is granted to parents of both sexes in a flexible enough manner as to be evenly distributed in time. In reality, most Swedish couples decide to let the mother take the first year off since this can only be beneficial to the baby. Beyond this stage, a highly elaborate nursery network is available and working hours are flexible enough to avoid leaving children for hours in a collective setting.

The equality of sexes already well established in Sweden was emphasized again. Vaginocratic services were provided to encourage the fathers to stay at home and look after their children, and those irresponsible enough to leave their home and family are sued for alimony payments and also strongly encouraged to give some of their time to their progeny.

Old age is the highest expenditure in the Swedish social welfare budget. Further to a traditional, highly democratic and local search for consensus, the government recently decided to add a funding stage to the existing system.

To give an example, the director of a sickness insurance fund is supposed to 'manage' a system where his/her sole duty is to refund expenses endlessly to preserve the patients' right to consult any physician they care to choose since this is a privilege bitterly defended by the unions, and to that must be added the physicians' right to write prescriptions non-stop as recommended in the tables of Ordinal Law. He/she is advised by a medical staff supervised by the national director. He/she is working with a relatively free accountant and a board including employer and employee trade unionists, which is supposed to be his/her boss, but is not really. He/she is suspiciously watched by an administration not for his/her results, quick payments and quality of service to whom a good many people are quite indifferent, but mainly to ascertain that he/she strictly complies with the many and diverse regulations applicable yesterday, today and tomorrow.

Sickness insurance funds are to take charge of insecurity without the necessary welfare services to do so since those are tied to regional funds that have no relation whatsoever with health care but are dealing with pensions and also, more or less (less than more), hospitals and care centres.

Now, as regards the medical/union/city fortress, which is the French hospital system, it is supposed to be managed as in Sweden or Denmark by local government since the mayor is chairing the Board of Directors, but the comparison stops there because the payers are the social welfare funds instead of the managers. One would think they have a right to scrutinize the management, but this is the privilege of a third party i.e. the government via DDASS. Tom is managing, Dick is paying and Harry is watching. Who is responsible for what? The Minister ?

The French system was designed by Kafka and Alfred Jarry's Père Ubu after they had had a few drinks on a celebration night. But since it was far too simple, a few embellishments were added in the name of the old Archimedes' principle – "When an administration is immersed in a regional liquid, the buoyant management force is equal to the square of the surface of its budget" – These embellishments are identified with lovely acronyms e.g. ARH, URCAM, UGECAM and other regional sickness insurance funds. They also have nice operating budgets, exquisite statistics and responsibilities that are as confusing as the rest. However, a lack of regional organisation is much more prestigious than a local one, everyone tends to believe miracle solutions have been found and the ego of the regional elected representatives is boosted.

Sweden is much better organised even if the tenets of 'social democracy' are somewhat rigid or dogmatic for the French.

Health care democracy is opposed to social democracy. The care system is managed by elected representatives who, contrarily to what is happening in France, are sanctioned democratically. They had better watch out for the next elections if the level of care is poor, too expensive and taxes are increased as a consequence !

Social democracy is accountable to no one in France. Employers are doing their very best to limit expenses while the employee unions' logic is that they must be increased. Proper management is supposed to come from the balance or imbalance between those extremes, but there is no financial or democratic sanction – Contributions are less painful but also less clear than taxes and the government is blamed when they are increased - Furthermore, the public plan administrators have not been democratically elected for a long time now.

In Sweden, hospitals are managed by those paying for their upkeep. The payers accepted this challenge naturally and assumed difficult but necessary restructurations in time very much like their Danish counterparts. Meanwhile, the hospital system in France developed into a metallurgical industry conundrum, poorly distributed with very different occupancy rates and even a dangerously low level of care in some of the smaller facilities. After years of 'laissez faire', it is now very difficult to explain to the elected representatives and the unions that the time has come to painfully close 60 000 beds and save billions!

Yesterday's government and perhaps CNAMTS today seem to have a serious problem with that.

Still, the system is not perfect in Sweden and desperate in France. Some of us were shocked to learn that patients were turned down because the waiting lists were too long. One should understand and respect anxiety borne out of illness and patients should not be kept waiting, but is it the current situation that is so unfavourable in France or the future as it is now painted? In which country is the fear of the private big bad wolf most acutely felt?

The same is true as regards family policy. The coherence, strength and simplicity of the Swedish policy forces admiration even if one does not totally agree with its final outcome. The complexity of the French services offered without apparent purpose or logic and, consequently, no visible results is difficult to contemplate after this.

However, we are taking advantage of our drawbacks in this field with fine services suitable for complex social situations and a good management cost / service efficiency ratio.

Sweden is not without social problems. Our visit to a family centre in the suburbs of the capital gave us the opportunity to watch in a few hours an impressive collection of individuals of every nationality. There again the efficient and simple policy involves teaching Swedish to foreigners to facilitate their integration and ability to work; this immigration problem is not so acute in France.

Significant efforts are being made; a controlled social policy is in place but there are major problems in both Swedish and French suburbs.

The overall impression is that of a higher level of coherence in the Nordic countries than in France. Responsibilities are clearly defined and there is above all a political will. The Swedish system as the French one is encountering major difficulties, but the first seems better prepared to face the changes and competitions of the future.

A social welfare fund is a social welfare fund, even if it is called "Försäkringskassan i sollentuna" (Social welfare and family allowances fund). There is a main entrance hall, leaflets, counters, offices, meeting and working rooms. The offices are of the open plan type, well arranged with regular boxes and half partitions.

The sickness insurance manager, Mrs Ingrid Karlsson, gave her introduction in French since she has been studying in our country and trained in our funds. We were kindly greeted with a poster repeating the cover of the book...

- A hospital without managing staff

Visit to the University Hospital in Linköping

The management is explained to us with attrition figures lined up on the video projector. These are as in France employees retiring but not replaced; yet we were told in confidence that the youngest administrative staff members were fired.

This is a prestigious hospital. We visited an advanced cardiac surgery service and were given a brilliant exposé in French by the surgeon running the department.

We were told that that the managing staff had purely and simply been dismissed since the tough financial negotiators in the general councils preferred dealing directly with the heads of departments.

To some, those negotiators are pure technocrats without any understanding of medical problems; to others, they are difficult to come to terms with but they are also defending a respectable standpoint i.e. taxes imposed on the population at large.

The hospital superintendent acting as guide is married to a Frenchman and also speaks our language. She takes us to the social welfare office exceptionally located in the hospital. A whole range of medical literature is available with books, videotapes, CD-ROMS and other Internet services intended for the patients. The intention clearly is to help them obtain as much information as possible regarding their pathologies and avoid a one-to-one relationship with their physicians. This Swedish experiment, and it is an experiment, demonstrates how much ground we still need to cover regarding medical confidentiality in France !

- UCANSS also known as FNOSS, UNCAF and other central agencies

Visit to the Swedish UCANSS i.e. the agency federating the local funds' Board of Directors. The Swedish word for UCANSS is "Förskaringskasserförbundet" i.e. "Social welfare funds association". Once the necessary explanations had been requested, and recognized experts such as our friend Jean-Pierre Rey had been consulted, this would appear to be the Swedish version of the now defunct National Federation of Social Welfare Agencies (Fédération Nationale des Organismes de Sécurité Sociale) allied to the no less defunct National Union for Family Allowances Funds (Union Nationale des Caisses d'Allocations Familiales).

We were most graciously welcomed by the administrative manager, Mr Leif Torpefält, and his colleagues with a buffet served in the building's cellar going back to the 17th century.

This Association is managed by a board representing the local funds councils. The members are general councillors defending the funds' interests, which are sometimes opposed to the financial savings requested by the elected representatives. The Swedes also have some historical contradictions to overcome. Social democracy is not managing social welfare, but employer and employee trade unionists are sitting on local commissions devoted to service allocation rather than management.

Our group also visited a number of national agencies that are sometimes difficult to define. An animated discussion did not allow finding out whether "Riksförsäkringsveket" i.e. the "National Office for Social Welfare" was some sort of National Fund or a Ministry A1 Office representing the government in the funds.

However, the Federation of General Councils was clearly identifiable as was its Danish counterpart. This Federation's head office is in a superb building designed as an inverted ship's hull, with offices and balconies facing inner patios topped by a huge glass canopy.

This Federation has undertaken to review the quality of medical care and the outlines of this project were explained to us.

A second witness told us he had to wait several hours in the emergency department with his daughter for a fractured clavicle and was not allowed x-rays (the Swedes apparently do not like 'rays') or a plaster.

A third explained that he was refused when he arrived in the country those drugs essential to treat his allergy, and this even when he offered to have them imported from France.

As one looks deeper into these cases, one realises that since there was no dehydration, it was perhaps best in the first case to wait for the virus to subside with an appropriate regimen; it must be noted in the second case that plasters are not necessarily used for clavicles in any case, and we were also explained that if there are long waiting times in the emergency departments, urgent cases are not kept waiting. Finally, the allergic patient was suddenly cured since he had been living in Sweden.

This situation is quite normal for Swedes. The French, on the other hand, are so used to imposing their requirements on physicians, they are surprised when they realise the physician is the decision maker because he/she is not accountable in the exercise of his/her profession to the insurance payer or the care unit manager, but to the patient instead who then becomes a customer. The French 'liberal' physicians are fighting the wrong fight.

Swedish physicians are content to cure the patient or follow up this cure. French physicians relieve symptoms, and accessorily the patients or mainly the parents' anxieties. While France is suffering from over-prescription, the main concern in Sweden is the refusal to assume pain and suffering.

Out of the conversations we have had with different individuals came the impression that both the Swedish and the French system, which are totally opposed, are perhaps too dogmatic when considered individually. How can one choose between Swedish medicine, which is efficient, but somewhat Spartan and French medicine, which is warm and watchful but generates exorbitant expenses and unacceptable situations?

Part of the answer to this question is perhaps found in the joint approach of both countries i.e. the search for evaluation and quality. This is perhaps less difficult in Sweden, the land of painful but effective consensus, whereas this is the subject of a hot debate in France, the land of confrontation between medical know-how and the legitimacy of social welfare bodies, but efforts are made to evaluate and appreciate care on both sides.

Add some URCAM directors interspersed with insurance fund managers and you have a very lively group.

There they are together to discover the Swedish welfare system and visit Stockholm.

They are very enthusiastic, have no language problems (Interpreters were available at all times) and are not put off by the grey Scandinavian Autumn.

Stockholm is a beautiful city built on the water and known to some as the Venice of the North. I would like to remarks at this stage that if Venice, Italy is unique, the Venice of the North title is claimed by several cities e.g. Bruges in Belgium, Amsterdam in The Netherlands, Saint Petersburg in Russia etc. It suffices to say that Stockholm is built on a group of islands divided between lakes and the Baltic Sea. This is why walks around the city were unanimously appreciated at the end of the day and gave the opportunity to some, who were not always believed by their colleagues, to watch salmons being caught in the centre of the city.

The Swedish social welfare system seems extremely rich and complex, with many participants and services. Without going back into the operating details that were already clearly explained, let us simply state here that the Swedish system into which the government, local governments and companies are playing a part at different levels is faced with the same problems described in those developed countries that have a 'luxurious' but economically heavy (pensions, health expenses, dependency, social integration etc.) social welfare system.

Although our Swedish partners were patient, clear and welcoming, one week was not enough to grasp the social reality of this country. All in all, it was a total success, even if some pretended not to have understood everything and insisted that our faultless mentors organise a second trip next year.