A new healthcare act in process in Finland

A proposal for a new Health Care Act was published in Finland in June 2008 [1]. A working group was set by the Ministry of Social Affairs and Health in June 2007, with the mission of merging current legislation on primary healthcare and specialized care, which have been separate so far. The proposal consists of a thorough introductory chapter and the draft law itself. Wide circulation of the proposal for comments continued over the summer and ended in October. Finishing of the enactment is in process at the moment.

Reformation of the healthcare legislation is part of a fundamental restructuring of the municipal service provision [2]. It was preceded by an interim law in 2007 ordering municipalities either to merge or to create cooperation areas so that a basic population for organizing primary healthcare services would be at least 20 000 inhabitants. This law was expected to halve the number of municipalities and create a solid basis for future remodeling of healthcare structures.

One of the main goals of the new Health Care Act is to lower boundaries between primary and secondary care. In order to carry this out, the draft law offers two models, both of which maintain the responsibility for health service provision in the municipalities as it has been under the current legislation. The more radical version, called the healthcare district model, would bring provision of primary healthcare and a major part of specialized care into the same organization. In the more conservative hospital district model, primary and secondary care would remain in separate organizations as so far, but mutual planning and collaboration would be ensured with new administrative arrangements. The responsibility for organizing emergency care is proposed to be on the district organization level. Highly specialized medical care would be centralized at the national level.

Strengthening of primary healthcare is another major goal that is declared in the second paragraph of the draft law. This is the most welcome principle given that public health centres have faced multiple problems such as a shortage of physicians [3] and suboptimal continuity of care [4] during past years. However, here the content of the law proposal was disappointing. The draft law does not give any outlines for the structures of primary healthcare. This is probably because the hands of the working group were tied right at the beginning of its work regarding one of the major challenges in Finnish healthcare: fitting together municipal funding and funding from the Social Insurance Institution of Finland (SII). This issue was excluded from the tasks of the working group. The Finnish healthcare system comprises, besides the public primary and secondary care, a third “semi-private” party, which is partly supported by government money from the SII. Provision and use of health services by this third party are, however, not similarly under public control like the true public sector, and currently it tends to grow and absorb both economic and human resources. As long as this problem of multi-channel funding is not solved, structures of primary care remain undefined and true development of primary healthcare is difficult. As the Health Care Act proposal does not tackle this major challenge at all, it has been criticized for already being outdated at birth [5].

As long as future structures of primary healthcare are not defined, many other important goals written into the Health Care Act proposal are in danger of remaining only empty words. Reducing socioeconomic health inequalities has been one of the main strategies of Finnish health policy during the last decades. There has not been very much progress with that; on the contrary the inequalities have tended to increase [6], [7]. Moreover, the principles of strengthening health promotion and prevention as well as increasing patients’ freedom to choose their service providers remain in the air, even if these are fine and widely accepted ideas.

From the viewpoint of academic general practice, the draft law includes some important proposals on education and training in primary healthcare. In the introduction to the draft law the working group states that strengthening of GP specialist training in health centres is crucial, but unfortunately the enactments themselves do not provide much support for that. The draft law proposes the founding of specific “teaching health centres” which would provide all kind of education and training needed by healthcare professionals in relation to primary healthcare. In addition, a new national centre for developing primary healthcare is proposed to be founded to coordinate these “teaching health centres”. These proposals have raised a lot of questions and criticism, because they neglect all regional activities that have already been under way for some years. Regional units for developing education and training in general practice have been spontaneously founded in all five university hospital districts, in collaboration with hospital district organizations, university departments of general practice, and regional health centres. They have started to develop GPs’ education and training at all levels, both in undergraduate and specialist education as well as in CME. The regional units also provide support to research and development activities in the field.

The Finnish Association for General Practice (FAGP) has given its comments on the draft law, with the main focus on the proposals for GP training and research. FAGP criticized the model of one national centre with selected “teaching health centres”, but emphasized the strengthening of the already existing regional units. Besides, FAGP states that all health centres meeting the criteria of supervision and other facilities should be supported in tasks related to education and training as well as research and development activities. Many other important actors in the field of general practice have given comments with the same content, and there is hope that these unanimous opinions will be taken into account during the final revision of the draft law.

The Health Care Act is expected to be ready in spring 2009 and come into force on 1 January 2010. Even if the process is not yet finished, it is obvious that the new law does not in itself provide solutions to our healthcare problems – a large amount of work also remains to be done in the future.