29Switzerland

Country and population

Switzerland is a country of 7.79 million inhabitants in a territory of 41 300 km² (OFS, 2010) and 60% of the territory is mountainous. This means that population density is 188.8 inhabitants/km² (Eurostat, 2010). It is divided into 26 “cantons” and four different languages are spoken: German by 63.7% of the population, located in the northern and central parts of the country, French by 20.4%, in the west, Italian by 6.5% and Romansh by 0.5% in the south-east. It is worth noting that 8.9% of the population has a mother tongue other than those four national languages (OFS, 2010). The 2009 population growth was 1.43%, due to strong immigration, with 21.7% of inhabitants being of a foreign nationality. The total fertility rate is 1.48 children per woman, 21.2% of the inhabitants are aged under 20 years and 16.6% are over 65 years (50.8% are women). Population density varies greatly between cantons, from 26.2 in Graubünden to 5046 hab./km² in Basel-stadt (Eurostat, 2010).

Development and economy

Switzerland is a federal parliamentary democratic republic, with three levels of political decisions: the Federal Council, the cantons, which have their own constitution and delegate some of their power to the federal state, and the municipalities. The country has two specificities: international neutrality, which has been internationally recognized since 1815; and direct democracy, in which every citizen who manages to gather enough signatures can modify the Constitution, vote or change a law. This is called “popular initiatives”.

Switzerland is the 36th largest world economy in 2007, based mainly on services, especially the banking and insurance sector. GDP per capita is 9th in the world in 2007, with a value of PPP$ 41 618 (IMF, 2010). Switzerland ranked 9th in the Human Development Index with 0.960 (UNDP, 2010). Unemployment is low: 3.7% of active population in 2009, more prevalent in the foreign population (7.2% vs. 2.7%) (OFS, 2009b).

Concerning education, 86.8% of the population has finished the secondary level of education (Eurostat, 2010).

Population’s health

Life expectancy at birth in Switzerland is one of the highest in Europe: 84.6 years for women, 79.8 years for men in 2008 (Eurostat, 2010) and healthy life expectancy at 65 respectively is 13.5 and 13 years in 2007 (OFS, 2009a). Infant mortality was 3.9 deaths for 1000 living births in 2007. Causes of death are quite similar in order between men and women: cardiovascular diseases are the main cause (39.6% for women, 34.2% for men), followed by cancer (22.8% and 29.9% respectively). External causes are then more preeminent for men (7.8% vs. 4.7% for women) and mental disorders for women (6.6% vs. 3.5% for men) (Eurostat, 2010).

Characteristics of the health care system

The Swiss health care system is mostly organized at two levels: federal and cantonal. The main responsibilities of the federal state for health are insurance provision, quality of environment (food, transmissible diseases), certification of professionals and disposals (including drugs), statistics provision and some actions in health promotion. The cantons are responsible for health care provision, both in the hospital and ambulatory sectors, and prevention. This distribution of levels of decision is not without drawbacks. In 2006 the OECD report recommended the elimination of redundant and excessive health provision between cantons and the promotion of national health prevention by creating a pluri-cantonal level of decision (OECD & WHO, 2006). Every Swiss resident has to subscribe to a mandatory health insurance in his or her canton. Swiss residents can choose from several providers, in a competitive market, but all insurers should follow these rules: a purpose of non-profit, a minimal health goods basket, obligation of insurance without restrictions and uniform fees whatever the risks or the income. Cantons and Confederation provide financial help to get this insurance for those with the lowest incomes (Confédération Suisse, 1994).

Total health care expenditure in Switzerland is above the EU average, as is the number of physicians per 100 000 population. Average length of stay in hospitals is slightly longer compared to the EU average, whereas the number of admissions per 100 000 population is comparable with the EU average in 2009 (see Table A29.1).

2.1. Primary care governance

There are currently several policy documents published by Swiss public institutions (ASSM) or non-governmental organizations (e.g. Federatio Medico Helveticorum, Swiss Society of General Practice, Swiss Society of Internal Medicine, see section 2.3). However, none of them has been formally endorsed by the Swiss government. These documents reflect diverse visions on present and future primary care. They have a common denominator: the importance of promoting primary care through several means such as political promotion of primary care by encouraging young physicians to get involved in family medicine, providing adequate training facilities and operational settings. A citizen’s initiative called “Oui à la médecine de famille” (“Yes to the family physician”) has currently gathered enough signatures to be put on the agenda for debate at the federal level and eventually accepted by the Swiss population through voting afterwards. This initiative wants to modify the Constitution and includes three principles: access to family medicine for all, ensure a high-quality of care in family medicine and to promote family medicine among young physicians (Confédération Suisse, 2010).

Currently, governance in primary care consists mostly of licensing physicians, which is a federal-level decision. But authorization of primary care practices to operate depends on cantonal health authorities, cantonal/local medical associations and health insurance companies. They provide a concordat number to physicians, which allow them to be reimbursed by insurance. Stakeholders contributing to the primary care policy development are the FMH (Swiss Medical Association), the Conference of Regional Health Directors and cantonal or regional primary care professionals’ associations. Some local authorities provide facilities to be rented by health professionals in order to promote primary care but there are not yet any pro-equality measures, although some shortages in certain regions have been described. There is no policy on cooperation of primary care services. No laws have been implemented concerning patients’ rights, but access to their own medical files and the confidential use of medical records are laid down in the health professionals law (Confédération Suisse, 2006).

For Swiss physicians, there is an obligation of 80 hours in-service training per year and regular meetings are organized by regional and national primary care medical associations. But evidence-based guidelines have not been produced yet for specific use by GPs (FMH, SIWF & ISFM, 2009).

2.2. Economic conditions of primary care

The primary care budget in Switzerland is not specifically identified, but an estimation of it, made by calculating it from primary care expenses, including all ambulatory drugs prescribed, including those by specialists, is around 25.6% (€11.6 billion) of total expenditures on health (Santésuisse, 2010).

Due to the obligation for every person living in Switzerland to be insured, 99.2% of the population is fully covered or insured for primary care costs, including general practice services and prescribed medicines. The remaining 0.8% corresponds to people who do not contract insurance, such as illegal migrants, people outside the social network and foreigners with international insurance. As mandatory insurance is contracted directly by the patient (and not taken at the source of its income, for example), 30% of the population benefits from social aid funding for care either totally or partially. But, in fact, almost 66% of the costs of primary care physicians are “out-of-pocket” expenditures, because patients have a deductible of CHF 300–2500 (€225–1875), depending on the insurance contract, and 10% of the physician’s fee up to CHF 700 (€525) a year after this limit is reached (Confédération Suisse, 1994; Santésuisse, 2009). The exact cost of health care is unknown, because many patients have a high deductible and do not send their invoices to health insurance companies.

Primary care physicians, including GPs, paediatricians and internal medicine physicians, are, for the great majority, self-employed with a contract to the health insurer. Health insurers have the obligation to reimburse all physicians with a concordat number (this topic is currently under debate in Switzerland as health insurers would like to have the right to choose which physician can be reimbursed). They are paid on an exclusive fee-for-service basis, regulated by the law. A number of points are allocated to each activity uniformly in Switzerland, but the value of one point varies from one region to another, depending on the local regional income. It is also worth noting that, rarely, some physicians create small companies and are employed by those independent companies.

The mean gross annual income for self-employed GPs in Switzerland in 2005 was €126 006, after accounting for practice costs but before tax (Hasler & Reichert, 2010) (see Fig. A29.1).

2.3. Primary care workforce development

The core of the primary care workforce in Switzerland mainly relies on GPs and ambulatory specialists of internal medicine. Both types of doctors are doing a similar job at least in urban areas, with a concordat number recognized and delivered by health insurers. Both will be referred to as family physicians in this report. A project has been approved by the Swiss GPs association and internal medicine association to give up their own certified-board title and replace it by one single title of family physician. Paediatricians work alongside GPs in the primary care workforce and are responsible for the care of those under the age of 16. Gynaecologists are also part of primary care for some clinical situations, such as Pap smear tests and oral contraception, but more often they are seen on referral.

The other medicine specialties work mostly through referral. However, patients are free to seek specialized care, even without a referral. No gatekeeping exists in Switzerland, unless patients subscribe to one of the few HMO-based (health maintenance organization) insurance contracts. However, home care nurses are not directly accessible without a referral and there is limited access to specialized nurses are rare. Currently there are no primary care nurses in Switzerland. Visits to rehabilitation professionals are only refunded if prescribed. Dentists are covered by insurance only if the patient contracted a special private insurance: few people are covered for that aspect of care (Confédération Suisse, 1994).

The average GP is 52.6 years old and 75% of them are aged over 45. The mean workload for a self-employed GP is around 44 hours: 8.8 half-days every week, 1 half-day being 4–6 hours (Kraft, 2010). These data reflect the average working hours of both full-time and part-time physicians, and may underestimate the real workload of full-time self-employed GPs.

General practice is a subject in the undergraduate medical curriculum and the postgraduate family medicine programme lasts a minimum of five years, with at least one year in an ambulatory setting or in a primary care service. Primary care pre-graduate training (in an ambulatory setting) is the responsibility of the five Swiss medical schools (Basel, Bern, Geneva, Lausanne and Zurich). Teaching is provided by primary care university departments and the five family medicine academic institutes. Postgraduate training is provided by hospitals, outpatient clinics and some private practitioners, all accredited by the FMH. The FMH at the federal level is responsible for the validation of the postgraduate training. Around 45% of all medical graduates choose a primary care discipline: between 9.7% in German medical schools and 21.4% in canton de Vaud in general practice, around 8% in internal medicine and around 15% in paediatrics (Buddeberg-Fischer et al., 2006; Jeannin, Meystre-Agustoni & Paccaud, 2007). Currently, the ratio of GPs to total number of specialists is 0.78 in 2004 (Observatoire suisse de la santé, 2007). By 2030, a deficit in family physicians is expected, which might lead to up to 40% of primary care consultations not being able to be carried out. This projection is based on the increased rate of primary consultations between 2001 and 2006 (Seematter-Bagnoud et al., 2008). Network and community orientation are currently existing specializations for self-employed nurses: a Certificate of Advanced Studies (25 days in one year) is available under the title “Liaison and orientation in the health care network” and a Diploma of Advanced Studies (> 1050 hours of lectures over two years) called the “Diploma in community action and health promotion”.

Four different medical associations exist: the College of Primary Care Medicine, to coordinate activities in primary care settings and promote quality, training and research; the Swiss Society of Internal Medicine; the Swiss Society of General Practice; and the Association of Family and Childhood Physicians. The aim of the latter is to represent the political interests of primary care physicians in Switzerland and has been created recently. Nurses have the Swiss Association of Nurses. There is a main journal edited in Switzerland on family medicine, called Primary Care, but it is not usually a platform for scientific publications. Praxis is also a journal dedicated to ambulatory care, in the German language.

3.1. Access to primary care services

Accessibility of primary care is not currently a major concern in Switzerland, with the exception of shortages in some rural regions, but it may become one in the coming years. The availability of GPs is very different between cantons, with densities varying from 706 GPs per 100 000 population in Schwytz to 167 in Basel-Stadt (FMH, 2009). Average density of GPs is 78 per 100 000 inhabitants in rural areas, compared to 127 in the five major cities of Switzerland (Basel, Bern, Geneva, Lausanne and Zurich). These numbers have to be interpreted cautiously as difficulties remain in Switzerland with regard to the calculating the exact number of physicians. Indeed, the FMH keeps records of all physicians with a title of specialist (including GPs), independently of their real activity as physicians, that is, whether they work part time or have retired.

There is a legal obligation for after-hours care services, but the systems vary between the cantons. They are mainly based on after-hours primary care centres and practice-based services. The affordability of general practice seems quite good in the country, but there is no national survey regarding the satisfaction of Swiss people with primary care.

Telephone consultations are common in Switzerland and most practices have an appointment system in place. E-mail consultations are rare (see Fig. A29.3).

3.2. Continuity of primary care services

GPs do not currently have a patient list system and there is no data about how the management of such lists might work in practice. It is not encouraged at all by the structure of primary care in Switzerland, but 87.9% of the adult population declare having the intention to see their GP for common health problems (OFS, 2008a).

Around 90% of GPs report keeping clinical records of their patients routinely, but these records are not used to obtain epidemiological information about the community. Communication with secondary care and the out-of-hours services is bidirectional and works well.

3.3. Coordination of primary care services

No compulsory gatekeeping occurs in Switzerland, unless the patients subscribe to HMO-like insurances, in order to pay lower premiums. Patients are free to seek advice directly from a specialist or from multiple physicians for the same condition.

Around 63% of primary care practices are single-handed and cooperation within primary care is generally rare. Face-to-face meetings occur with other GPs and nurses but rarely with other professionals, including specialists. Phone contacts are more frequent, especially with internists, surgeons, neurologists and dermatologists, for example. Joint consultations or replaced care do not occur. Ambulatory health education structures are very uncommon too. In the medico-social field, it is worth noticing that social workers have both the responsibility for social care and community mental health care duties.

3.4. Comprehensiveness of primary care services

GPs in Switzerland offer a large range of services, including diagnosis and follow-up for chronic conditions (see Table A29.2). They are maybe less used and less inclined to provide services for gynaecological problems or minor surgery, but it depends on the medical environment. Wedge resections, for example, are more usual in rural regions.

They are formally responsible for one act of prevention and health promotion: vaccinations. Other health promotion and prevention interventions depend on the physician’s own interests.

Almost all (99%) of medical contacts with a GP are handed solely by the professional.

4.1. Quality of primary care

Using only 6 DDD of antibiotics per 1000 inhabitants per day, ambulatory physicians in Switzerland are among the lowest prescribers of those drugs in Europe.

Among the population known to have diabetes, in 2007:

• 40% were overweight, 25% obese
• 54% had a blood pressure above 140/90 mmHg
• 42% had a LDL-cholesterol serum level above 5 mM (OFS, 2008b).

No data have been collected about the HbA1C level or eye fundus inspection. In the same way, no national data are available about the follow-up of asthma or COPD.

The vaccination coverage of infants is high: 95% for diphtheria, 96% for tetanus, 94% for pertussis, 87% for measles, 86% for mumps and rubella at the age of 2 (Office Fédéral de la Santé Publique, 2008). Of the population aged 60+, 41% are vaccinated against flu (OFS, 2008b).

In 2007, 52% of women aged 52–69 had at least one mammogram in the past three years in 2007 and 71% of women aged 21–64 had at least one Pap test (cervical cytology test) in the same timeframe (OFS, 2008b). Fig. A29.4 shows the number of hospital admission for cases with a primary care sensitive diagnosis.

4.2. Efficiency of primary care

Of all contacts between GPs and patients, 3.2% are made at the home of the patient, expressed in total time of consultation charged to the health insurance. Of those contacts 5.8% are made by telephone. GPs can charge patients and insurers for this form of care. The average consultation length for GPs was 17 minutes in 2009 (Napierela, 2010).

There is a mean of 2.8 general practice consultations per capita per year (Seematter-Bagnoud et al., 2008), which may be low when compared to other systems. However, this may be explained by the absence of the gatekeeping system and the heavy presence of specialists in ambulatory care. New referrals from GPs to medical specialists per 1000 listed patients per year are estimated at between 50 and 100.