Context

Swedish health care, like many other health care systems, is in a constant development mode to meet never-ending demands for improved efficiency and quality. Competitive and integrative policies are for example concurrently introduced in Swedish primary care; citizens‘ choice of primary care is launched while primary care is expected to integrate its activities with other providers for the creation of =local health care‘. Competition has though a tendency fragment the provision of services. The aim of this study is therefore to explore whether or not these two strategies are compatible in practice.

Methods

Group interviews were conducted at four locations in Sweden. The groups included persons aged between 20 and 45 years, 46 and 64 years and 65 years or over. The interviewees were living either in a big town or in a small community. Altogether, 21 randomly selected individuals participated in the group interviews. A deductive approach was chosen: six question topics were formulated with guidance from a theoretical framework about choice of care. The group interviews were thus semistructured without any predetermined codes. Each group interview took between 1 and 1.5 h to complete. Moreover, the conversations were recorded and transcribed as verbatim reports. As a consequence of the deductive approach, directed content analysis was chosen for the analysis of the group conversations.

Results

Choice of care is executed from the perspectives of being a prospective or current patient, which, in practice, imply choices are performed passive and active respectively. If the later group perceive interpersonal continuity, accessibility and demeanour of health professionals as favourable, they remain faithful to their actively chosen provider. The only condition that seems to trigger this group of patients to reconsider their choices is if they been the subject of bad manners. Those executing passive choices are less faithful to their original choice. When these former prospective patients, often younger persons, are in need of primary care they often disregard their choice if waiting times are shorter at other providers. This group generally prefer accessible service and seldom consider where it is provided. The group of passive choices also include citizens accepting suggestions presented by the authorities, founded on the conviction that ―they know what is best for me.

Discussion

Many patients that have made active choices are thus faithful to their choices. This is rare in a consumer-market, which is characterized by high degree of exchangeability of providers; a condition which by and large corresponds with the attitude of those making passive choices. Nevertheless, a majority of patients stay with their choice of provider, often selected among a limited number of options. Moreover, health care providers and patients have long-term relationships, which is typical of a producer-market. In other words, if politicians strive for a competition-exposed primary care, the competition concept ought not to be founded on the theories of a consumer-market. The principles of a producer-market seem instead to be more applicable, which imply that providers will be competitive if they are able to build stable relations with their patients, which, in turn, facilitate for integrative arrangements among health care providers.