Psychiatric care: Milton slams government

Following a number of murders, including that of foreign minister Anna Lindh, committed by mental health patients in 2003, Sweden's psychiatric care system leapt to the top of the political agenda.

In October of that year Anders Milton was appointed by the Swedish government to assess the state of psychiatric care in the country and propose improvements to the system. Now, halfway through his three-year project, Milton, who is resigning as President of the Swedish Red Cross in June, is coming to terms with the fact that the main obstacle to improvement is lack of political will to address the relevant issues.

Mental health care in Sweden is the responsibility of municipalities (local authorities) and county councils. Municipalities are responsible for social care while county councils are in charge of health care. One of Milton’s early criticisms of the current system concerned the lack of cooperation between these two levels of care.

“We are looking into how the resources are being used today, the cooperation between the local authorities and county councils, and of course the question of changes in the legal situation if necessary.”

At the height of the media frenzy in 2003 politicians were falling over themselves to express their desire to see better care for patients, and better protection for the public.

Upon Milton’s recommendations the government promised an additional 500 million kronor for 2005, although for 2006 there will only be 200 million kronor available. Milton suggested a system where the amount committed by central government would be matched by a commitment at the county council level.

“If you ask any politician working at the local or national level they would tell you that this is their highest priority,” says Milton.

“The reason that we wanted to do it this way was because we wanted more money to come both from the government and from their own budgets which would give these vulnerable people higher priority.”

But to Milton’s dismay, the government did not hold the county councils to their financial commitment.

“It makes me unhappy, to put it kindly. I’ve taken this up with many politicians and I tell them that they have to do better than they are doing. They have to act. If they cannot fulfil their responsibility they should walk down to parliament and say ‘we can’t do it’. I would like them to put their money where their mouth is.”

Knowing that there is ‘new money’ coming from government resources might tempt County councils into withdrawing money already pledged, and this seems to be exactly what happened once the big funds for this current year had been announced. A recent survey by Dagens Nyheter showed that despite the additional funds, one third of the country’s district councils are still planning to cut back their psychiatric services.

This, however, is just part of a decades-old trend. Forty years ago there were 35,000 beds in Swedish asylums. However, in the wake of the ‘care in the community’ reforms some 20,000 beds disappeared, leaving 15,000 care places – 5,000 in the health care sector and 8,000 community based places in small care centres.

“This means there are now some 20,000 people living in their own dwellings or with parents or with friends,” Milton points out.

“I believe the change towards community based care was a step in the right direction, but that the municipalities probably need to do more to find local care facilities. There is also the question of jobs. People with mental handicaps also need to have jobs, because it’s important for their rehabilitation that they have somewhere to go and earn a salary. They need to feel that they are part of the social community, otherwise many of them tend to just sit at home and smoke. They lead a pretty boring life and have too few friends.”

Milton feels that the county councils are defensive when it comes to allowing more private practitioners into the system.

“In other European Union countries there is greater choice and an easier access to health care. But in Sweden, for ideological reasons, we are very much tied to public provision.”

That’s something Milton would like to see changed, but he acknowledges that “the Swedish model” is deeply ingrained. While private healthcare exists in Sweden, there is little free market influence: the cost of going to a private GP, psychologist, or specialist is the same as visiting the state system.

“It’s the taxpayer who pays for both systems,” says Milton.

“If you want to establish yourself as a private practitioner you need permission from the county council if you want to be refunded. That means they control whether or not they want competition, and generally they don’t. Of course it’s all about ideology, and I’m not for it. I think we should use more private practice and allow people to be entrepreneurs.”

Milton points to Lysekil and Malmö where the county councils have outsourced increasing amounts of psychiatric care work to private practitioners and companies. He says that the systems there seem to be working well.

“I think we will see the change coming more and more,” he adds.

But it’s not just a question of treatment. The main concern for many Swedes, weary of hearing about murders committed by mentally ill people – and of murderers getting reduced sentences on the grounds of mental illness – is security.

“Preferably you want to use as little involuntary treatment as possible,” says Milton.

“On the other hand, you also have to realise that in some instances you need it. You have to be good hearted but not naïve. Some people will need to be locked up, maybe for a short time, because they are dangerous to themselves or to others.”

Nevertheless, he believes that it is important to try to allow people to live their lives within the community and not in institutions.

“Some will then need a lot of support, and medication. And they will need to refrain from abuse, from the illicit use of alcohol and drugs, which means you need to have a pretty tight network of people helping them.”

As usual, though, it comes down to resources. While the number of Swedes seeking psychological care after being caught up in the tsunami in Asia has not been as high as expected, it highlighted the fact that the current system is seriously stretched.

Although it is outside of his remit, Milton is not averse to the introduction of a mid level of psychological care and extending it to practitioners currently working outside the system.

But he emphasises that only evidence-based methods, with measurable results, would be acceptable.

“I don’t think that Swedish society, the taxpayers, will start paying for therapy that is not evidence-based.”

With eighteen months to go on the job, Milton is clear about his remaining objectives:

“More of a life for these patients – a life with more dignity, a life with more social contacts, a tighter social network and where the care from the different authorities is closer to each other, leaving no one behind.”

“If I hadn’t thought that we could achieve something of that then I wouldn’t have accepted this job.”