Aiming for better services Social and Health- care Services POLICY BRIEFPOLICY in Finland Expert evaluation - Autumn 2018 Pekka Rissanen (ed.) 5/2019 REHEARSAL Healthcare and Social Services in Finland REHEARSAL Contents Introduction 3 Expert evaluation 4 Key findings 5 1. Population and the operating environment 6 2. Social and healthcare services funding and costs 11 3. Promoting health and well-being 13 4. Specialised medical care 16 5. Primary healthcare 21 6. Oral healthcare 24 7. Services for children, young people and families 26 8. Mental health and substance abuse services 29 9. Social services for working-age people 33 10. Services for disabled people 35 11. Services for the elderly 37 References 40 Professor Pekka Rissanen, Director of Assessment, is responsible for national monitoring and evaluation and has conducted the expert evaluation. The evaluation work has been coordinated by Project Manager Kimmo Parhiala. Research assistant Tuuli Suomela has participated in the compilation and processing of the data. Evaluation managers Tiina Hetemaa, Raimo Kekkonen, Nina Knape, Hannele Ridanpää, Eija Rintala and Jukka Kärkkäinen, as well as experts from various task forces have participated in the evaluation. ISBN 978-952-343-360-1 http://urn.fi/URN:ISBN:978-952-343-360-1 ISSN 1799-3946 (net publication) THL - Policy brief 5/2019 2 REHEARSAL Healthcare and Social Services in Finland REHEARSAL Introduction In the spring and autumn of 2018, the Ministry of Some of the indicator data have been updated Social Affairs and Health (STM) and the National since the regional evaluations in the autumn of Institute for Health and Welfare (THL) rehearsed 2018. Additionally, recent trends in key indicators the assessment and guidance activities related to have been included in the evaluation. The devel- the organisation of regional social and healthcare opment of conditions in Finland has also been services (HE 15/2017, § 30 and 31). compared, where appropriate, with international data, mainly from other European countries. To complement this, THL has now for the first time, in accordance with the Draft Law of the Act There have been challenges accessing the infor- on Organising Health and Social Services, com- mation needed for the evaluation. For example, piled this national expert evaluation. The eval- there is a lack of standardised information gath- uation is designed to help national and regional ered from across the country on several aspects level office-holders and decision-makers in their of social welfare. In the future, it is necessary to steering activities and decision making. pay attention to how up-to-date the available information is. The coverage of information that The evaluation focused on the activities of 2017 is produced needs to be improved and processes and used the regional division according to gov- accelerated in organisations which produce and ernment proposal (HE) 15/2017. THL compiled collect information. the SOTE (social welfare and healthcare reform) knowledge base for the exercise and made an When interpreting the results, it must be taken expert assessment of how the regions organise into account that regional organisation can only SOTE services. be evaluated once the responsibility for organis- ing services has been transferred to the regions. Results of THL's expert evaluations of regional This evaluation has been carried out by combin- SOTE services have been used in the national ing the activities of municipalities and hospital evaluation. They were based on national com- districts based on the proposed regional division parable indicator data and reports prepared by the government. Occupational healthcare and by the national supervisory authorities, and other privately funded SOTE services are therefore were produced in close cooperation with the excluded. regions. Most of the indicators used in the eval- uation have been taken from the Cost-effec - The social and healthcare system is changing, and tiveness Indicators in Social Welfare and Health as a result, so is the evaluation and control of the Care that is being prepared for the SOTE reform. system. In the future, guidance and evaluation The indicator data are publicly available at will increasingly be based on data. For its part, this http://proto.thl.fi/tietoikkuna evaluation report serves these new ideas. Helsinki 27/02/2019 Markku Tervahauta Pekka Rissanen Director General Director of Assessment National Institute for Health and Welfare (THL) THL - Policy brief 5/2019 3 REHEARSAL Expert evaluation REHEARSAL Equal access to services is inadequate Although the availability of several SOTE ser- For example, in South Karelia, Eksote is the vices has improved there are inadequacies in only organisation that provides services, and regional availability. There are, however, vari- has also been able to integrate service oper- ations in different services. ations. Regional SOTE expenses have risen For example, maternity and paediatric ser- moderately, and it can be estimated that vices and vaccination programmes are carried carefully implemented organisational service out almost equally across the country. integration has eased cost pressures. There are however considerable regional It is clear that the integration of services differences in access to primary healthcare. in different ways and at different levels can The differences are partly due to the deci- be greatly enhanced throughout the country. sions of municipal service providers and how Particularly important is the successful inte- they have structured the services. In part, the gration of services for the elderly so that local problems in equal access to primary health- services support different appropriate hous- care stem from the regional differences in ing and care services as well as possible. the availability of medical practitioners. The number of doctors per 10,000 residents var- The productivity of specialised ies from 4.4 to 8 in proportion to the regional medical care could be improved requirements. Shortages of medical prac- The costs of SOTE services vary a lot between titioners in primary healthcare are likely to regions. Variations in the net expenditure increase the use and costs of hospital ser- per resident are largely explained by the vices. differences in the needs of the population. There are also problems with equal access However, the need-adjusted expenditures in a number of social services, such as child also vary a lot. The differences are largely protection services. Regional differences can explained by reasons relating to service pro- be caused by a lack of qualified social workers vision. or other professionals, such as therapists. Regarding the productivity of SOTE ser- There are considerable differences in how vices, comparable information on specialised the regions have structured care services for somatic medical care is available. Differences the elderly, and whilst the need for institu- in productivity between hospitals and regions tional care is decreasing, the proportion of are considerable. Specialised medical care outpatient services in the service offering accounts for nearly 40% of the total SOTE varies considerably between regions. expenditure, so these productivity gaps are The nationally-targeted structure of care significant in terms of ensuring adequate services has not been achieved in many areas funding. The productivity of specialised med- in the country. Almost everywhere, there are ical care could be improved and more hospital problems with the availability of home-based services could be produced without the need services, especially for elderly people whose to increase the number of resources. This service needs are not considered critical. would slow down the rate of increase in SOTE expenditure without reducing the volume of There are considerable regional service provision. differences in administrative integration Pekka Rissanen In some regions, there is only one organisa- Director of Assessment tion that provides services, but in others there are over twenty. This naturally has an impact National Institute for Health and Welfare (THL) on the development of service integration. THL - Policy brief 5/2019 4 REHEARSAL Key findings REHEARSAL The increase in social and healthcare spend- The focus of both somatic and psychiatric spe- 1ing per resident appears to have stagnated 5cialist care is shifting from in-patient care in in recent years. However, there are differences in hospitals to outpatient care. On the other hand, the changes of expenditure between SOTE ser- jointly run emergency services have transferred vices. Expenditure on specialist medical care has some services from primary healthcare to special- increased slightly, but expenditure on primary ised medical care. healthcare has decreased correspondingly. Costs for round-the-clock elderly care have increased. The use of substance abuse services has SOTE expenditures vary widely by region. (In 6decreased due to the decline in sales of alco- 2017, the costs were EUR 2,850 per resident at holic drinks. Rates of homelessness have also their lowest, and EUR 4,010 per resident at their decreased. highest). This was mainly due to fluctuations in ser- vice needs, age structure and population changes In line with the current governmental policies, (birth rate, mortality, internal country migration / 7services for the elderly have shifted from insti- immigration). tutional services to home-based services. Institu- The impact of occupational health and tional care for the