Dr Phillip Palmer, October 2004 - Having just returned from a trip to Sweden for 3-4 weeks, and been put up in a house with a Swedish dentist, I thought it may be worthwhile sharing some of the information I found out about Dentistry in Sweden.

Firstly, some facts about Sweden. Sweden has a population of about 9 million, spread out throughout the country, but mainly settled in the south of the country. There are lots of towns of 30-100,000 people, with 3 larger cities—Malmo, Gothenburg, and Stockholm, with populations of 250,000 to 1.2 million people. Sweden is divided up into 24 counties, each with their own local government, and a centralised government, based in the capital Stockholm. A Social Democratic party has governed the country centrally for about 70 years, apart from a 3-year period in the ‘80s.

This has led to a country that is extremely heavily taxed (makes Canberra look like they’re in kindergarten in learning how to tax), but has a social welfare system that is second to none in the world. My host explained that 32% of his net is paid as social welfare (compared to our 1.5% Medicare levy). Of the remainder paid out as salary there is a progressive taxation. Approximately 50 % of his salary goes to taxes. Say that there is $120,000 Net after running expenses. Then 32% goes to social welfare, leaving $80,000 for his salary. For this he pays 50% leaving $40,000 in his pocket. On everything he buys there is VAT of 25%. However there was a true cradle-to-grave welfare system. Maternity leave, paternity leave, sick leave, care for the handicapped and disadvantaged, free schools up and thru university, and digital TVs in every house, were just some of the wonderful benefits available.

Dentally speaking, there are about 9,000 dentists registered in Sweden of which 7,600 are working (about 1: 1,000 population vs. 1:2,200 in Australia). Swedish dentists have also been leaving to work overseas in ever-increasing numbers. It has been estimated that there are 900 Swedish-trained dentists in the United Kingdom alone and 300 in other countries.

Of the 7,600 dentists, about 3,300 are in private practice with the rest, 4,300, employed by Folktandvarden (FTV roughly translated as ‘peoples teeth care’), through local dental governing councils. FTV charges each patient for dental care, but the government sets the rate, and FTV is heavily subsidised by the central government. Since 1999 (see later) dentists are leaving the FTV as it is regarded as a dead-end-street career-wise, and going to private care.

Of the private dentists, about one third of them have employed one company PTJ (1500) (Praktikertjanst) to be their service company. PTJ as a concept was set up in the 1960s as a private company, has very strict rules, and the dentists who use it are the only shareholders. Each dentist sells their practice to PTJ using an agreed formula, and can buy out of PTJ at any time, using the same formula. Basically, what happens for most dentists is that when they want to buy a practice, they approach PTJ to buy it on their behalf. The dentist contracts to pay back PTJ, much as they would any other lending institution.

PTJ then employs staff for the dentist (and gives all the HR advice needed), orders their supplies (at a considerable discount), administers their practices, does their accountancy, and organizes their pension funding (quite a complex system, as it was explained to me). For this they charge the dentist about $10-15,000 per year. PTJ also has general practice medical practitioners and dental labs as members. It has 14,000 employees, and has become one of the top 100 companies in Sweden.

Dentistry has changed much in the way it is delivered since it was de-regulated in January 1999. Up till then, prices were set by the government, as they were subsidising each patient through the social welfare system, and there were restrictions on setting up private practice - you could only buy an existing one, but not set up a new one. FTV existed side-by-side with the private practices. Then four years ago, much of the state subsidy of dentistry was removed, and all dental fees, both private and for FTV lifted immediately, by 10-30%.

However there is a very complicated and bureaucracy-heavy system still in place. Hardly anyone seems to understand it fully, and the different reforms take up 90% of all paperwork that the dentists do. The community pays for the poor people to have cheap dentistry. There are special rates for people who have had radiation treatment for facial cancers. There is a special rate for patients with Xerostomia induced by medication. There is a special rate for Sjogren’s syndrome patients. There is a special system (free treatment) for the young from 3 to 19 years of age. There is a normal system for the 20 to 64 year olds.

Then two years ago, some politician decided that he didn’t want to pay for his mother’s new dentures. As a result, a government decision was made to heavily subsidise dentistry for the over 65s. They thought up a scheme whereby the maximum any senior can pay for prosthetic dentistry would be about $1,500 plus lab fees. It was amazing how much demand for full mouth implants that was unleashed by this subsidy. Wealthy members of the community, who until that point were very happy with their full dentures, suddenly decided they desperately needed implant-supported bridgework.

The politicians were shocked. They thought that this “dentistry for the seniors” would be of minimal cost to the government, and were stunned that it actually came with considerable cost. They are attempting now to work out how to change the rules to decrease their exposure.

What they are now realising in Sweden is that any subsidy in any area corrupts a system. There are unlimited demands in healthcare that get unleashed by subsidies. I wonder if Australian politicians will have to learn this lesson over again.

[Published in Australasian Dental Practice, October 2004]