The history of health care in Mittenälvsborg – then, now and afterwards

The site presents a history about how “Open Care” grew from the beginning of the 1800s till 2000 in Mittenälvsborg in western Sweden. Mittenälvsborg is a part of the region of Västra Götaland including the rural districts Lerum, Alingsås, Vårgårda och Herrljunga. Västra Götaland was established in 1999 by a union of the county councils of Skaraborg, Älvsborg , Bohuslän and the city of Gothenburg. In the first part we describe earlier historical times from the 17th century to 1969. It gives the background to the future – the time of Primary Health Care – that began in 1969. This is described in part 2, which is the main part. In part 3 we try to discover how the future will turn out.

Here we describe the project and the authors.
A summary for extract, pdf-fil

The project

This is the story of how open care has been developed in Mittenälvsborg, focusing on Lerum. We have wanted to emphasize various aspects. The first historical part up to 1969 gives a background to the the future primary care that started in 1970. We call it “the time of district medical doctors'”(“provinsialläkartiden”).Then, we want to focus on how the primary care built up from 1970s to the 1980s including the growth of the so called “Lerum model”.

The historical description treats the organizational development of health care from the 1700s until 1960. The historical process of medicine is viewed in a socio-economic context. It seems logical to look at the connections between factors such as demography, the residential environment, life habits, working conditions and the standard of living, and the occurrence of epidemic diseases, preventive health care and average lifespan. The influence of time and the causes and treatment of diseases are addressed too.

The historical study discusses changes at national, regional and local levels with different examples from parishes being included in current Lerum's municipality.

In view of the peculiar shape of the County Council of Älvsborg (Älvsborgslandstinget) as an hourglass and with three hospital areas, it was divided administratively into northern, southern and central districts one of them being Mittenälvsborg (the middle of Älvsborg). The area of responsibility of Alingsås's hospital corresponds to Mittenälvsborg with the current municipalities Lerum, Alingsås, Vårgårda and Herrljunga. Apart from the district medical doctor, consideration is also given to the other key health care workers such as hospital doctors, private practising doctors, midwives and nurses. As a group the midwives have a long professional tradition while the nurses in open care first appeared in the 1900s. The pharmacies, as an important part of the health care, get their own chapter.

In Part I of The history of health care in Mittenälvsborg, then, now and afterwards we note that the plans of Axel Höjer, chief of National Board of Health and Welfare during the 1940s, on an expanded open care in the 1940s met strong obstruction from the establishment. Open care was developed in the hospitals under the county councils' direction. The State, that had handled open care outside the hospitals – the system of district medical officers (provinsialläkarväsendet) – mismanaged its responsibility to the point of disaster. During 1950s and 1960s, however, the immediate future of open care was investigated. The county councils inherited the responsibility in 1963 and begun to restore the activity, but at slow-speed. The new National Board of Health and Welfare came out with a programme for open care in 1969, which opposed an expansion of Health Care Centres staffed by several doctors. Concurrently came several new laws and regulations that positively influenced open care. Sweden's flourishing economy and belief in the future also had a positive influence. The year was 1970 and Primary Health Care (Primärvården) was born.

Part II is about the time of primary health care (Primärvårdstiden). We describe how the county council took over the responsibility for the district doctors with one radical change of open care outside the hospitals. The surgeries with one doctor were replaced by well equipped surgeries with several doctors (three to ten). The doctors were helped by qualified personnel during office hours. The “out-of-hours” activity was reorganized so that the doctors got regular hours of work. Plans were made for more doctors – one doctor per 3.500 inhabitants. The district care (midwives and nurses) were housed together with the doctors surgeries in what we referred to as Health Care Centres.
During the build-up time of primary care, the focus became clearer on Lerum and the Lerum model. Lerum's primary care reflected much of what happened throughout the country during this time but was also a pioneer in many respects especially in Älvsborgslandstinget (the County Council of Älvsborg). This second part constitutes the real core of the study.
The story is completed in a third part with an analysis of the stagnation and the increasing problems that appeared during the 1990s and with reflections and speculations around developments after the turn of the century in 2000.

We call the future scenario “Local Care'” (Närvården). We collect impressions and opinions about how primary care might be developed into something new. Primary care never grew as it was intended to be. The goals were good but the resources were not enough to reach them. Perhaps people gave up, perhaps the research into diseases became framed differently and the demands from patients for time and quality became too big.
Above all we hope for the success of future open care in Mittenälvsborg!

The project's implementation

The project's first part – the time of district medical doctors (Provinsialläkartiden) – was a collaboration between Jan Kuuse and Bengt Dahlin with the aid of archivists, library personnel and managers of museums – all of whom showed a most helpful attitude to our project. Ella Carlsson, Stenkullen helped us in the interviews.
In a seminar on December 2 2004 organized by the department of General Medicine of Gothenburg University we received many valuable ideas from those present, including all the help the department's management obtained for us.
Primary Care management in Borås with Kerstin von Sydow as manager has also supported the project, as have many staff from Mittenälvsborg. Without their help, we would probably have run out of energy before the end. Many people were involved in building up primary care in Mittenälvsborg. They still remember what has happened during the development of primary care from 1970 to 1990. Jan Kuuse and Bengt Dahlin continued to type, collect, and sort out the material that was in the archives. But several key persons have helped us with materials. We want to acknowledge those who have participated and shared their thoughts and opinions.
Here are some of them: Kerstin von Sydow, Lennart Hallerbäck, Solweig Kärrman, Gunnar Hedelin, Bengt-Ivar Nöjd, Hans Lundgren, Björn Nilsson, Olof Wik, Christer Forsell, Ingegerd Emrén, Ella Carlsson, Solweig Kärrman, Ulla Sandvall, Ulla Wessman, Ulla Blomberg, Birgitta Nilsson, Barbro Hallengren, Ann-Marie Gustavsson, Margareta Brantdahl, Birgitta Klintberg, Ronny Gunnarsson, Henric Hultin, Leif Bäckman, Lars Egedius and others.
At a seminar in the R & D unit in Borås on March 2006 the document was tested. Valuable views were expressed. Moreover, Part III, which presents development trends in the material we have collected, was discussed.

Publication is a problem. In order to make the material available to many at reasonable cost, the material has been published on the internet at the address We also hope to produce it as an electronic book and on CDs. We have not the resources to print the material and we still cannot find sponsors. We would have to consider editing the material in order to make it more compact

The region West Götaland

West Götaland (Västra Götalandsregionen) is a political and democratically governed organization. The Region has 149 delegates. who are responsible for the care, interests and needs of the inhabitants. A regional board prepares the proposals for decisions by delegates. The regional board has 17 members – full-time politicians. The board also has to ensure that the decisions are implemented.
The West Götalands region has 1.5 million inhabitants, is 300 km long and 250 km broad. It is Scandinavia's biggest transport region and port – a node for roads and railways with four airports. The region has a strong position within vehicle industry, also in chemistry, medicines, foodstuffs, electronics, tourism, culture and the communication media. Within the region there are two universities, a technical college and four other colleges with 75 000 students.

The authors

Jan Kuuse

Associate professor in economic history at the University of Gothenburg since 1971. He has specially investigated different aspects of the modernization of Swedish society and published books on following subjects:
. _ The mechanization of Swedish agriculture
. _ The development of the Swedish welfare state
. _ The Swedish labour market in the 20th century
. _ The Swedish shipbuilding industry
. _ The trading houses in Gothenburg
. _ The Telephone Company L. M. Ericsson
. _ The Swedish Sugar Company
. _ Felix – a Swedish food industry
. _Billingsfors papermill
. _Scandia – an insurance company
. _and other companies in western Sweden.

Books in English published by Jan Kuuse:
∑ Interaction between Agriculture and Industry. Case studies of farm mechanisation and industrialisation in Sweden and the United States 1830-1930. (1974)
∑ L. M. Ericsson 100 years. Pioneer period - Struggle for concessions -Crisis 1876-1932 (1976) /together with two colleagues/
∑ The Swedish Sugar Company - Cardo 1907-1982. Swedish Sugar in an International Perspective. (1983)
∑ Beside these books he has also published about a dozen books in Swedish - the latest published in 2003.

In particular, he has investigated the growing Swedish community, the mechanization of agriculture when Sweden became a industrialized country, the development of the Swedish welfare society, the labour market at the beginning of the 20th century, the shipbuilding industry and trading houses in Gothenburg, Other industries he has written about include L.M. Ericson, The Swedish sugar company, Felix - a Swedish food industry, Billingsfors papermill, Scandia - an insurance company and several other companies in western Sweden.

Bengt Dahlin

Fully qualified doctor (Examination in Gothenburg and certified 1957), General Practitioner (Specialist in general Practice, Allmänmedicin), District medical officer (past) in Korpilombolo 1959 - 1962 and in Gråbo and Lerum 1962 - 1995. Chief Physician Primary Health Care in different periods and levels. Doctor honoris causa 2000 (The university of Gothenburg). The University Orator made this short presentation, marking the achievements of the honorand: "He has been clinically active from Korpilombolo to Gråbo and Lerum and he has worked admirably and assiduously to make general practice a valid academic subject. He was involved in the early thesis in general medicine (allmänmedicin). Early he took the initiative in training doctors. That made general medicine into a pioneer in the education of doctors and in the guidance of them in their studies. It also made general medicine to a pioneer in the education of specialists in medicine. Furthermore, he was one of the initiators and builders of research and development (R&D) in primary health care. He has personally and actively developed medical informatics as an aid to the classification of diagnosis, and of information processing, specially for health care records. Above all, the Faculty of Medicine will thank him for a considerable work on the improvement of quality in undergraduate studies in medicine. He was organizer and promotor in development of a new Consultation curriculum at the faculty. It became the start of a dynamic restructuring of undergraduate education of physicians in Gothenburg.

All his publications are in Swedish. Please refer to the Swedish language version.

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