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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Learning from other health care systems in reform – Finland

Filed Under (Finland, Health Policy, Public Health) by Paul on 13-01-2011

This week I have spent 3 days in Finland talking to clinicians, civil servants and managers about reforming their health services. I was invited to talk to two very different gatherings about some of the lessons from my experience of the last decade of reform in England. Of course the really interesting issues that come out of explaining your own nation’s experience is how much you have to learn about another one. Every time you make a point about some aspect of reform in England – for that point to stick – you have to make the idea work in a very different set of circumstances and ones that you need to carefully relate to your own.

So if you want to communicate anything at all about English reform, you need to get to learn some things about Finland.

There were three different audiences. First, the equivalent of the Finnish BMA. Second, given they have elections coming up in the spring, one of the sessions that I was involved in was for me to run a panel – and ask questions of – the political parties. Third a smaller group of people who, if they were to undertake a programme of reform in the spring post election, would be involved in making that reform work.

The first issue about Finland is obvious and material when you spend any time there. Finland is a very large country (Seventh largest in Europe) with very few people – 5.5 million. Apart from the cities, many Finns live in large areas with very sparse numbers. This not only dominates some alternatives for health care policy – choice in primary care let alone secondary care is a problem – but it has also created a culture of municipally based health services.

In such a sparsely populated country, the government of a locality has always represented an important cultural, as well as political, organisation. Municipalities matter organically, not just politically. When the winter comes and your local village or town is cut off for a weekend, your neighbours work with you to ensure everyone is all right. Within living memory it was the municipalities that helped to organise the collective production of agriculture and machinery, and out of this came a very local set of health and education services.

So as their public health services developed there was no talk of nationalising local endeavour – the development from organic municipalities was vital.

There are 336 municipalities, some of which are very small but have the responsibility to organise local health services. Some of them organise for 6000 people.

Over the last few years there has been much talk in England about how some PCTs with only 200,000 populations are much too small to be able to purchase health care. A municipality of 6000 would appear to be impossible.

And those Finns interested in reform would agree – for all the reasons that we have rehearsed in England. They are much too small to either provide the sorts of health centre primary care services that are normal in Finland or to have the skills to buy health care at a post primary level.

On top of this universal municipal system an occupational health system has developed, paid for by employers, employees and the state. This provides health care at an initial primary care level and means (see the English system) that you don’t have to take a day off work to go to see your GP. You can then go on to secondary care through this referral. It also provides a much better incentive structure within employment to limit the impact of sickness on the staff and employer. It incentivises the employer to keep the employee well.

And it provides better, quicker care than the municipal scheme. But because it’s only open to those who are employed this creates an inequality that worries the Finns. As they put it, it is the healthier people (those in work) that get the better care that should be going to the older people – who get municipal care.

Then there is some very specific private insurance which parents take out for babies and children which provides instant access to the very best services.

Given the nation has an important morality about equality this overlapping set of systems causes some disquiet but also feels, to some Finns, a mess.

They are also facing a growth in their elderly population that is proportionally greater than any country in Europe and as with England recognise that there will be a growth in demand for health care from long term conditions. They know that if this new demand is met with the existing form of supply the system will be stretched to breaking point.

There are 8 important political parties none of which exactly relate to our Parties but the expectation is that there will be some form of coalition after the spring election. We had a panel of politicians from each of these parties to talk through the major questions about reform. Several things emerged from this.

First, all had interesting things to say about the health service and reform that were not a million miles apart. They were not all the same, but they did not have ideological arguments about words or phrases, but discussed their similarities and differences. Most of them were medical staff or had been involved in health policy in some way.

Second it was not possible to predict what they would say from their political label. The “far left” party spoke the most about the need to increase health service staff productivity, and the green party was the most vehement in saying that small municipalities are much, much too small and health care procurement needed them to be bigger. So whilst there were differences, it was not possible for me to see how these were driven by the sort of political ideologies that spring to my mind.

There was a growing recognition that there was an urgent need for reform, but their electorate, the Finnish people, did not see the health service as being in crisis. Indeed in 2011 there is no crisis today, but by the end of this Parliament it may start – as demand outstrips resource.

Politics at the local municipality level is about the health service. But the drive for reform will come from a national politics not from the local. The expectation is that health care reform will not be what the election is about, but immediately afterwards government and opposition need to get some momentum around reform and change and see it through over the next decade.

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One Response to “Learning from other health care systems in reform – Finland”


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