Developments in Finnish general practice
After several decades of rather disciplined and incremental development in the 1970s to 1990s, Finnish primary healthcare is now going through times of turmoil and anticipation of changes. Since 2002 a national development action project Citation[1] for the whole public service system has been in progress. In short, the essence of the somewhat complex project is a deal between the government and the field of healthcare. The healthcare field, where the local municipalities are the ultimate actors, is expected to introduce a series of structural measures to improve productivity and the often too difficult access to services. The government will, in turn, raise the levels of funding of health services through both general increases in the state subsidies to the municipalities and also through earmarked project-type funding.
New standards of access
Among the many action proposals of the national project, proposals to rule by law national standards of access to health services have been in effect since April 2005. The primary healthcare centers must, first of all (it may sound amazing that this should be the subject of a national legal stipulation), answer the phone during working hours! They must provide assessment by a health professional of the need for care even in non-urgent cases within three working days. For specialist services maximum waiting times for an outpatient visit and for elective diagnostic or therapeutic procedures have been set to 2 weeks and 3–6 months respectively Citation[2].
Reform of the entire municipal structure?
As the measures stemming from the project are being implemented, a new wave of reforms is rocking the whole structure of municipalities in Finland, and this could possibly result in significant changes in the structure of health centers. There are currently 432 local municipalities. The mean size is about 12 000 inhabitants and the median only slightly above 6000. A large number of rural municipalities are losing inhabitants at an accelerating rate, and also losing out in the collection of local income tax revenues. The whole income basis is shaky and unstable, even for the traditionally better-off urban cities.
The main direction in the future will most certainly be towards organizing health center services for larger catchment populations than today.
Shortage of medical manpower in health centers
The Finnish health centers were still adequately manned by physicians, dentists, and other health professionals in the mid-1990s. Since then, there have been growing difficulties to recruit or retain general practitioners and dentists. Recently, similar problems have expanded to psychologists, speech therapists, and some types of auxiliary technical staff. The remote rural centers have been at highest risk. However, the services to challenging multi-problem populations of large cities have been similarly affected. The shortage amounts to about 8–10% of all vacancies in the health centers.
Young medical graduates have favored working for medical staffing agencies, which have for years provided out-of-hours or locum doctors. During the past couple of years, the same firms have taken up contractual management of selected individual health center units, or “health stations” in some cities. The entry of these firms into the field has aroused mixed reactions and debates. Established and experienced general practitioners, most of whom have received the formal specialty training of about 6 years, have not necessarily welcomed the young doctors, some even not yet through with their basic medical training, whose earnings may exceed the level of the existing GPs. The young doctors argue that they deserve the rate of pay since they often work unsocial hours or drive long distances to remote places. Many municipal health centers have no alternatives for providing medical services locally.
New task profiles for primary care staff
Nurses have had a strong position in Finnish primary healthcare services as independent providers of preventive services and already for some time also of chronic care. The shortage of medical manpower has spurred expansion of the nurses’ tasks in outpatient care. In many small municipalities the local community health nurses or nurses with other training have been the only sources of help for much of the time in the working week. Undertaking new tasks has led to the following developments at various sites in Finland:
Nurses play a more independent role in seeing chronic patients for planned control visits. They monitor care according to guidelines and may adjust the medication for common chronic conditions.
Nurses take comprehensive responsibility in assessing the status and needs of patients presenting with acute or new problems or minor injuries.
Certain of the physicians’ tasks have been transferred to nurses, who have received extensive special training for the purpose. These may include stitching of wounds, or performing other diagnostic or therapeutic procedures, or issuing of certificates that used to be “doctor's certificates”. Discussions on the possibility of opening up the right to limited prescribing have begun.
Nordic developments in integration of GP societies are followed with interest
The largest professional society in general practice, Kunnallislääkärit ry. – Kommunalläkarna r.f., changed its name in 2005 to Suomen yleislääkärit – Allmänläkare i Finland – General Practitioners in Finland ry. /r.f. This society of 2200 members has traditionally represented the interests of the general practitioners working in municipal health centers. The new name steps outside the realm of municipal employment, which reflects the anticipated direction of development in how services of general practitioners may be provided in the future.
The Finnish Association of General Practice, which in the connotation of its name in Finnish carries a reference to the academic side of general practice, is the sister organization of about 1000 members. The majority of members belong to both societies. In addition to the two mentioned above, the Finnish Medical Association has its own subdivision of general practice.
All three organizations have their own development histories and their own central foci of interest. They have worked in good cooperation, for example in organizing the Nordic Congresses of General Practice. Now talks are being held about organizing joint national training days and other events for the whole body of Finnish general practitioners. The atmosphere of the discussions may lead to consideration of the possibilities for more advanced integration, which seems to be happening in other Nordic countries. Simo Kokko Chairman, Finnish Association for General Practice Helsinki, Finland [email protected]