CEditoriasl

V. J. Ylanko Finland's National Health Service Revisited: A Personal View Dr. Ylanko, a certificant of the the table' system that kept everyone As a member of the executive of the College, practices family medicine happy. Patients on welfare had their Association of Community Physicians in the Department of Family medical needs covered by the local in Finland, I was able to observe how Practice, Women's College government, and physicians, as true events progressed, leading to the es- Hospital, Toronto, and is an members of the community, knew pa- tablishment of the new Community assistant professor of family tients well enough to adjust fees ac- Health Care Act. This had been pre- medicine at the University of cordingly. It didn't matter where pa- ceded in 1956 by the Hospitals' Act, Toronto. Reprint requests to: tients lived; many physicians had large which transferred the ownership of Women's College Hospital, 76 practices extending well beyond the regional hospitals from central govern- Grenville St., Toronto, ON. borders of their home communities. ment to federations of local author- M5S 1B2. I inherited my parents' practice, ities, and in 1964, by the establish- house, and position in the community ment of the Sickness Benefits Act, and, with two other physicians, pro- which provided an income subsidy for vided complete medical care to the those stricken by illness and accident. TN MID-JUNE 1972, my family and town's 16,000 inhabitants and to many These changes made the transition not 1I boarded a Finnair flight to Mon- patients in the surrounding areas. only politically necessary, but rela- treal; we were emigrating to Canada. I Naturally, the standard of living and tively easy to implement. I was 43, my children were entering job satisfaction of physicians during university, and I had had a flourishing those halcyon years were high. In my The Community Health Act practice in Lapua, a small, agricultural case, these were enhanced because of town in western Finland. What events Locally, the 1972 Community the town's new hospital with full Health Act meant creating a new net- led to this decision, and what has hap- operating facilities and an active ma- pened in Finland since my departure? work of community health centres ternity ward. The concept of admitting with clearly defined areas, and a man- privileges did not exist, because com- date to provide all community medical munity physicians were expected to services, including antenatal care, well The History Of look after their patients in the hospital. baby care, industrial medicine, and Health Care in Finland Also, I had my own private laboratory preventive medicine. Based on the principle of local self- with staff and fairly sophisticated Physicians for these centres were government, established in Finland in equipment. readily available from the well estab- 1865, local authorities were obliged to lished group of community physicians, provide primary care to the commu- who simply became employees in the nity. A network of community physi- Difficulties new health centres. cians was hired by the local health In Remote Areas In most cases, the change was no- councils, and although their salaries However, there were problems in minal at first, but in my case, it was were modest, free, often quite luxuri- Finland. In remote areas, patients had quite drastic. Three quarters of my ous, houses and staffed offices made great difficulty in obtaining medical practice had come from outside the the positions very attractive. I know, services, especially those of special- new health centre's area, and I was no because I grew up in one of those ists. Advances in medical technology longer allowed to see those patients. houses; both my parents were physi- created an ever-increasing need for The hospital provided an on-site of- cians. doctors, and the rising costs of the ser- fice, meaning I could not use my own Physicians' income was based vices made a change in the system po- home office. Because the hospital had mainly on a fee for service, 'cash on litically very attractive. a laboratory, I was not expected to use

CAN. FAM. PHYSICIAN Vol. 30: JANUARY 1984 my own-at least not during office had their work cut out for them. A one (Finnish Medical Journal).5 In the edi- hours. My free time was still my own, percent increase in the number of phy- torial page, the editor in chief dis- so I could have continued private prac- sicians for 1,000 people automatically cussed these results. tice after 4 p.m. and on weekends. increases the number of visits by The members were asked: how did Doctors' income was quite good at 0.2%, according to May.2 they perceive their position in society; first; there was still the incentive of fee The organizational power of the what was the personal esteem they felt for service but with some limitations, profession was reduced because the they had among the people they and overtime was not frowned on. Finnish Medical Association was served? However, in negotiations with the represented to the government by an Of the respondents, 49% stated that government, the feelings were made umbrella organization for all govern- the loss of esteem was very great, and quite clear, and the government stated ment employees. 44% felt it was considerable. Thus, publicly: doctors' income was intoler- When I emigrated, I had some 93% of the membership felt that their ably high and the new system was in- thoughts on where 'progress' would position in the community had de- tended to control that. lead the medical profession; during my teriorated. At this point, I decided to emigrate. visits, I saw most of these thoughts The editorial mentions one re- During the past 11 years, I have confirmed. To outsiders, the system sponse, which stated, "To be a doctor visited Finland three times: twice for seems excellent, as was verified by a in Finland in 1983 is a crime." Only the national medical conventions in recent visit of a Canadian colleague to 39% of physicians still in private prac- 1980 and 1982, and once in the sum- Finland.3 The new regional hospitals tice perceived this loss of esteem, mer of 1983. During the conventions, are sterling examples of world-famous whereas 52% of those working in the I attended the meetings of my former Finnish architecture and medical tech- university hospitals, regional centres association. nology, and computer technology is a and local health centres reported the In 1980 I was delighted to see reason for delight-and some envy, no loss of esteem as very great. No doubt members actively debating important doubt. The problem of providing med- the private physicians were older, their issues-the sound old militancy was ical services to remote areas has been position in the community was well es- still there. The fact that the most im- solved: every vacant position has at tablished before the new system was portant issue was whether the 30-min- least five applicants now. implemented, and they were still mas- ute lunchbreak should be counted as If all is as good as it looks, why do I ters of their time and working environ- work or free time did not hamper the write this? Am I merely trying to de- ment. However, they were also the enthusiasm-perhaps my colleagues fend my emigration from the couintry majority of the Finnish Medical Asso- could pull it through after all! of my birth. ciation's membership when the new During the 1982 convention, the The health centre where I used to act was planned and implemented. tone was different: only a handful of work is different now: the maternity When income satisfaction was doctors participated, and although the ward is closed, and deliveries are done queried, 96% reported dissatisfaction, unresolved 30-minute lunchbreak was in the regional hospital 25 km away; and in this respect, there was no dif- still the issue for which the Associa- the operating room-where I used to ference between salaried physicians tion officially was willing to go on perform cesarean sections, appendec- and private practitioners. strike, the tone of the speeches was tomies, and even remove gallblad- The political attractiveness of the different and there was little opposi- ders-is closed. The wards are now medical system run by the local health tion to anything. used for longterm geriatric care-the councils is undoubtedly great, and In private talks with colleagues, the regional hospital provides active care even here in Canada, the trend appears remarkable change in tone was even in most cases. to favor this system. The rationale, more evident. The number of medical The continuity of care, formerly the reasoning and conclusions are almost graduates from the three new universi- hallmark of the community physician, exactly the same as those used in Fin- ties had soared: from 1965 to 1975, the is gone. In a recent study, my former land, Sweden, England and other Eu- number had virtually doubled-from chief Dr. P. Kekki showed that only ropean welfare states." Although the 3,693 to 6,701.1 Therefore, if you had 41% of patients were seen by the same system appears to be effective-it does a job, you were well advised to hang physician during an episode of ill- not create an environment conducive onto it, despite markedly decreased in- ness.4 There are no patients of physi- to personal patient care. This fact does come and other benefits. cians anymore, only customers of the not hinder plans and implementation The physician working in the health health centres; services are provided of similar systems elsewhere. centre I left behind was earning about by the most appropriate member of the 50% of what I did before I emigrated, health care team. It is ironic to note, Conclusion and this does not include the effects of that now one of the raison d'etres of I have practiced under all possible inflation. The policy of free housing the Association of Community Physi- systems: cash on the table, fee for for physicians had also been cians is establishing the concept of a service, partially subsidized, pri- abolished. family physician in the health centres. vately-oriented, fully controlled em- My colleagues were now employees What about the doctors' own opin- ployer-based, and lastly, under the ar- of the health centres, working 37½/2 ion of their work? The Finnish Medi- rangement in Ontario. To me the hours a week, plus time on call. Fee cal Association conducted a survey Ontario system is almost ideal; while for service was eliminated, and private among its membership recently, and eliminating the burden of excessive practice was discouraged. Despite the first reports on the results were pub- medical bills, it maintains the incen- increased number of doctors, they still lished in the Suomen Laakarilehti tive of private enterprise and provides 10 CAN. FAM. PHYSICIAN Vol. 30: JANUARY 1984 Ontario citizens with medical services on a par with the best in the world. Having seen the events leading to a totally controlled health care delivery system, and its longterm effects on the medical profession, I am worried. No doubt the problems of equal access and universality of services are real and difficult to solve, and I cannot suggest easy solutions. However, I maintain that a unified, dedicated medical pro- fession, facing the challenges squarely Alison Quaggin in their daily work is the best way to create a good health care system within the economic resources of the Les gens de la presse country. This is a task physicians should address in their contacts with friends and patients, with MPs and MPPs, and others in positions of LE "JOURNALISTE execrable" 6h00. 1Evidemment que le medecin power. est un personnage nord-americain voulait tenir les journalistes 'a l'ecart! A main reason that the medical pro- issu de la mythologie, tout comme Je ne me suiviens pas de la fin du fession in Finland and in many other Ichabod Crane ou Paul Bunyan; qui film, mais je me souviens avoir pense Scandinavian countries has de- de nous n'a pas cette image du jour- que meme si le film est tout 'a fait teriorated, was the lack of communica- naliste gueulard, vetu d'un habit bouf- vieillot (les journaliste ne portent plus tion between government and physi- fant, un flacon de scotch et un paquet leur laissez-passer 'a leur chapeau et la cians. We can't let that happen here. de cigarettes dans les poches de son plupart utilisent des enregistreuses et Physicians cannot afford the pleas- pantalon, un laissez-passer fixe 'a la non plus des calepins), certaines des ant isolation our predecessors used to bande de son chapeau-et, bien sfur, vieilles croyances concernant les am- enjoy as the top figures in their com- un calepin, un crayon et un appareil bitions et les motifs qui poussent les munities. photo equipe d'une lampe-eclair de journalistes existent toujours. Je taille a eclairer tout Carnegie Hall? m'expliquerai 'a partir d'une anecdote Le journaliste a une personnalite personnelle. taillee sur mesure pour s'adapter 'a ses Au debut de l'annee, j'ai assiste 'a References caracteristiques physiques: c'est-ia- une reunion provinciale d'une asso- 1. Kekki P: Analysis of Relationships be- dire fonceur, aimant le sensationna- ciation medicale oCu regnait une cer- tween Resources and Use of Health Ser- lisme et l'indiscretion. taine apprehension envers les journa- vices in Finland. A cross sectional study. listes. Par exemple, une session Publication J'ai vu recemment un film datant of the Social Insurance Institu- des annees 40 qui demontrait jusqu'a prealablement ouverte aux journalistes tion, Helsinki, 1979, pp 3-9, M:34/1979. a 2. May J: Utilization ofhealth services and quel point les journalistes incommo- 'te interdite 'a tous au dernier mo- availability of resources, in Andersen R, dants peuvent etre particulierement ment, sauf 'a ceux travaillant pour des Kravits J, Anderson DW (eds): Equity in nuisibles lorsqu'il s'agit de sujets revues medicales; un organisateur m'a Health Services: Empirical Analyses in So- mecdicaux. explique plus tard son inquietude 'a cial Policy. Cambridge, MA., Ballinger l'effet que les journalistes puissent Publishing Co., 1975, pp 131-149. Le heros du film est un pathologiste mal interpreter la session, laquelle 3. Morgan PP: Some observations on the americain qui dcecouvre qu'un voyou Finnish medical care system. Can Med s'adressait aux medecins desengages Assoc J 1983; 128:858-859. est porteur d'une maladie contagieuse du systeme provincial d'assurance- 4. Kekki P: The continuity and coordina- tres rare. Le medecin suggere aux au- sante. Lorsque les journalistes inter- tion of the care in the health centres. Suo- torites gouvernementales et policieres dits ont innocemment envahi la men Laakarilehti 1983; 20:1208-1212. de le suivre, et les previent que les reunion, ils en ont ete mysterieuse- 5. Vartiovaara I: The appreciation of the journalistes ne doivent pas en etre in- medical profession. Suomen Laakarilehti ment exclus; c'est le genre de situa- 1983; 20:1790. formes si on veut eviter que le voyou tion qui amene les journalistes 'a se 6. Mustard JF, et al: Final Report of the n'apprenne qu'il est poursuivi et qu'il questionner sur la nature de ce qui Task Force to Review the Primary Health ne quitte la ville, dissiminant ainsi leur est cache et 'a poser des questions Care. The Canadian Institutefor Advanced l'infection 'a travers le pays. Research. December 30, 1982. embarrassantes. C'est alors qu'ils de- Toutefois, un journaliste sent qu'il viennent execrables. se passe quelque chose. I1 talonne les I1 est important, dans la mesure du policiers jour et nuit, devient emcom- possible, que les associations et les brant et menace de faire echouer toute individus decident leur politique face l'investigation. aux reportages sur un sujet en particu- Froidement indiff6rent au fait que lier avant ladite reunion ou entrevue le monde entier puisse contracter la avec les journalistes. On sait alors maladie, tout ce qu'il veut c'est un quoi dire; si quelqu'un ne repond pas bon article pour son echeance de aux questions d'un journaliste, celui-

12 CAN. FAM. PHYSICIAN Vol. 30: JANUARY 1984