5.3. Primary / ambulatory care

Primary care is provided through three overlapping health systems, i.e. the public municipal health centre-based system, occupational health care and private for-profit care. Also, the FSHS, a not-for-profit organization, provides primary health care services, including mental and oral health care services, for students of universities and other institutions of higher education (Hetemaa et al., 2018).

Box5.3 discusses the key strengths and weaknesses of primary care in Finland.

Box5.3

Municipal health centres

The ground-breaking Primary Health Care Act of 1972 (77/1972) outlined the current system of delivering municipal primary health services through health centres, which provide primary curative, preventive and public health services to its population. The health centre is an administrative body and its activities can be organized at several locations, i.e. at health stations or clinics and increasingly at patients’ place of domicile. Municipal health centres or stations usually denote GP group practices which employ nurses, public health nurses, and other professionals depending on the size and needs of the population. Furthermore, remote services are developing, and digitalization plays an increasing role in health care.

Municipalities (of which there are 311 in 2019) can organize primary care services on their own (about 60%), form a joint authority with other municipalities (about 20%), or transfer the responsibility to a host municipality (also about 20%).

During recent years, smaller municipalities typically have either not been able to organize these services due to, for example, a workforce shortage, or have anticipated increased productivity with cost savings and therefore outsourced the provision of all or some of the services to for-profit companies (Junnila & Fredriksson 2012; Junnila et al., 2012). The latest analysis of this trend showed that 13 of the 151 organizing bodies had outsourced all of their primary care functions, and 14 some functions, to private companies (Parhiala & Hetemaa, 2017). Some 6.8% of the population and 50 health stations were thus in 2017 covered by private provision, with half of these stations having only private providers. Two large for-profit companies had 62% of the overall market and three, 96%. Private staffing companies started to lease physician workforce to health centres at the end of the 1990s. Currently, approximately one in 10 health centre physicians are employed by these companies and other salaried employees (Finnish Medical Association, 2016).

Legislation does not stipulate in detail how services should be provided, and in most cases this is left to the discretion of municipalities. For some services, such as maternity and child health clinics, as well as school health care, there are national guidelines. Typically, health centres provide the following services: 1) ambulatory curative care, both for acute and chronic patients; 2) preventive services, including maternity and child clinics; 3) home nursing for older people or for selected groups of patients with chronic conditions; 4) dental health services; 5) rehabilitation in various forms; and 6) mental health services and substance abuse services (Hetemaa et al., 2018). Health centres typically have a stock of medications for their own use. Other services, such as physiotherapy, psychotherapy, speech and language therapy, occupational therapy and medical specialist consultations may be available, depending on the municipality. Larger health centres are usually well equipped with staff and medical technologies. They have routine access to other specialties; for example, for interpreting radiological examinations. In addition to consultation rooms, larger centres may provide radiological facilities, laboratories for taking samples (analysis is typically outsourced to larger entities owned by hospital districts), other diagnostic equipment (such as for undertaking electrocardiogram and ultrasound examinations), and even facilities for minor surgery and endoscopic examinations. The array of services provided in these facilities is in most cases wider than that seen in GP practices in other countries.

The personnel of larger health centres consist of a wide range of health professionals: GPs, nurses, public health nurses, midwives, social workers, dentists, physiotherapists, psychologists, nutritionists, speech and language therapists, occupational therapists and administrative personnel. The number of inhabitants per health centre physician varies and is not officially defined. GPs and nurses play a key role in coordinating services, particularly for patients with chronic conditions.

A team model of care of complex patients is more and more prevalent, and a nurse may function as a case manager. Nurses in primary care have adopted increasingly advanced roles, particularly in the care of chronic conditions, and retain the responsibility for many parts of acute care; since 2010, nurses have had limited rights to prescribe medications (Pasternack et al., 2018; Keskimäki et al., 2019). Smaller remote health stations may have a nurse or a physician intermittently present, as there has been a chronic shortage of physicians in more remote rural areas. A recent Finnish study showed that approximately 50% of acute cases can be handled by a nurse without the physician’s intervention (Parhiala et al., 2016). In addition, nurses provide telephone consultations and they also coordinate care of patients with chronic or multiple illnesses. The number of patient contacts using electronic consultations is on the rise (Hetemaa et al., 2018) and such consultations are typically handled by a nurse, with physician backup.

Inpatient departments in health centres are a specific feature in Finnish primary care. There were 226 of these inpatient hospital-type wards staffed with nurses and overseen by a permanent or visiting GP, or specialist in geriatrics in 2015 (Mikkola et al., 2015). These units account for about 20–25% of all acute admissions. A typical health centre inpatient facility has 30–60 beds, but, in bigger cities such as Helsinki, they are even larger and include medical specialists among the permanent staff. These wards have for a long time been used for the long-term treatment of older people with chronic diseases. During the last decade, due to the centralization of specialist care and changes in the care for older people (see section 5.8), these GP-run facilities have in some areas taken a more active role in rehabilitation and some parts of specialist care, such as cancer care. Currently these wards are often used in equal parts for acute and chronic care, with some beds reserved for patients suffering from dementia or otherwise needing intermittent care. This arrangement contributes to the high overall number of hospital beds in Finland (Mikkola et al., 2015).

All health centres offer acute emergency services during office hours, provided by either GPs or nurses. In exceptional circumstances, and with permission from the MSAH, municipalities can organize 24/7 emergency care, but since 2013 the responsibility for most out-of-hours services has been transferred to hospital clinics, where primary and specialist on-call services take place in the same premises, making specialist consultation more accessible.

Health centre-based home nursing is provided together with home help services, which originate from the social sector, forming a new entity called “home care”. Many health centres also provide other social services for their population and disseminate information on, for example, social welfare benefits.

In 2017, there were on average 4.6 visits for any type of public primary care service and 2.2 GP contacts per inhabitant (Sotkanet.fi). There were marked regional differences in the number of visits per population (Fig5.1).

Fig5.1

Routinely, citizens are registered with the health centre closest to their place of residence. According to the provision of the 2010 Health Care Act implemented in 2014, patients can choose their health centre once a year from all centres in the country. However, they cannot choose the treating physician and have to notify the health centre they wish to choose in advance of their plans to use its services. If they do not exercise this right to choose, they are listed to the health centre closest to their place of residence.

Occupational health care services

Employers organize mandatory preventive occupational health care for their employees (Occupational Health Care Act 1383/2001). To a varying extent, employers also organize curative services. Occupational care reimbursed by NHI covered 87.6% of the workforce in 2017 (Kela, 2018c). These clients received occupational care services from private for-profit companies (60%), from municipal health centres (22.8%) or from dedicated occupational care centres (15%). The total number of occupational care visits has been around 6 million annually, i.e. approximately three per person and year. These include visits to physicians, nurses, psychologists and physiotherapy for preventive check-ups and medical indications. Other services such as nutritionist and specialist consultations may be available, depending on the contract the employer has made with the service provider.

The occupational health care costs constitute approximately 20–30% of primary care costs but vary considerably by region (Hujanen & Mikkola, 2013). These costs are highest in the Helsinki-Uusimaa region (31%) and lowest in Eastern Savo (17%). There is an inverse correlation between total primary care costs and occupational care costs. This arrangement into two separate health care systems depending on employment status has been criticized for its overall inequity implications and for its potential attraction of physicians to shift away from municipal primary care services, but political support to retain the current arrangement is broad.

Private health care services

Altogether, in 2017, NHI reimbursed 707 000 visits to primary care level private providers and there were 12.8 visits per 100 inhabitants (Kela, 2018b). The reimbursement was on average 16% of the cost of the visit (Kela, 2018b). The patient fee can typically be determined by the practising physician and is often time-dependent, with costs of any diagnostic examinations and medical certificates billed separately.