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Combining out of hours acute care services

Partner Institute: 
National Institute for Health and Welfare (THL), Helsinki
Survey no: 
(14) 2009
Liina-Kaisa Tynkkynen
Health Policy Issues: 
System Organisation/ Integration, Access
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no yes


Customarily, municipal primary and secondary care organisations have had acute care services run separately. One form to restructure these acute care services is combining primary and secondary care services into a single unit. The main aim in combining the emergency services has been to rationalize the use of the emergency services and to reduce the cost of care.

Purpose of health policy or idea

Finnish municipal health care is divided into primary care provided by health centres and secondary health care provided by hospital districts. Traditionally, this division has concerned emergency care services as well. Both levels of the system have had emergency units of their own; in order to have access to secondary care emergency units a referral from a primary care ermergency unit is needed.

However, in many regions emergency services have recently been restructured. This is done both horizontally (i.e. municipalities organize emergency care collectively within their region) and vertically (i.e. combining primary care and secondary care emergency services into a single unit).

As in other countries, the basic task of emergency care services - offering treatment for patients in need of urgent care - has become blurred in Finland. As health centers have not been able to treat all patients during office hours, patients have crowded acute care services in the evenings, even when they are not in a need of urgent care. Moreover, the out-of-hours acute care services are usually easy to use, despite sometimes long waiting times. This has further increased the "unnecessary" use of emergency services (i.e. by patients that could be treated as regular patients in health centers during office hours).

Municipalities have had difficulties to recruit personnel, especially physicians, to do the out-of-hours shifts in acute primary health care. This has concerned especially smaller municipalities and rural areas in Finland. It has been thought that centralization (i.e. combining primary care and secondary care emergency services) might work as a solution to the recruiting challenges. In addition, the restructuring could enable the use of more advanced technology in primary care and the possibilities for a primary care physician to consult a specialist would potentially be enhanced. These changes could make it possible to treat more patients at the primary care level, which has been one of the main purposes behind the restructuring. In addition, when the primary and secondary care units are combined into a single unit, it may be possible to reduce overlapping functions. The central idea is that by rationalizing the use of services as well as the processes and operations it is possible to gain cost reductions. By and large, the very reason behind the restructuring has been centralising primary care emergency services, as the larger units are likely to result in enhanced efficiency as well as better service quality.

Primary care and secondary care emergency services have been combined in several regions in Finland during the last decade and it has been forecasted that the number of combined acute care services will further increase. At the moment, nine out of the ten largest city regions in Finland have introduced or are planning to introduce the combined units. Basically, combining the primary and secondary care emergency services means that both, urgent primary healthcare patients and those who are in the need of immediate specialized medical care are treated in the same premises and partly by the same personnel.

Usually the combined emergency care unit is located in a secondary care unit, i.e. in a central hospital or in a university hospital. In the units a triage system is often used to assess the urgency of patients' needs. The assessment is usually done by a nurse and it can be also done by phone. Many municipalities have out-sourced out-of-hours acute health care services to private companies (HPM 9/2007) and private providers are also used in the combined units to some extend.

Main points

Main objectives

The main objective behind the restructuring has been rationalizing the provision of out-of-hours acute care services. Through centralization of acute care services it is possible to enhance the quality and effectiveness of the services.

Type of incentives

Difficulties to recruit personnel to primary care emergency service units have worked as an incentive to seek new ways to organize emergency services. The municipalities have found combining primary and secondary level emergency care to be a sensible solution. Also the national Project to Restructure Municipalities and Services (HPM 11/2008 & HPM 7/2006) endorses the co-operation between municipalities.

Groups affected

Health centres/hospital districts, healthcare personnel, patients

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent system-dependent system-neutral

In the Finnish system the organization of out-of-hours acute healthcare services is rather unique. Thus, the reform is rather system dependent. In the Finnish context, the nature of the reform is rather innovative as the separation of primary and secondary health care has traditionally been quite strict.

Political and economic background

The reform has not included any state level steering. However, combining primary care and secondary care emergency services into a single unit may be seen as part of a larger trend towards the integration of primary and secondary healthcare services (HPM 9/2007). This has been one of the main objectives of the legislative process through which the Primary Health Care Act (enacted in 1972) and the Act on Specialized Medical Care (enacted in 1989) are going to be merged into a single Health Care Act (HPM 12/2008). Also the Project to Restructure Municipalities and Services (HPM 11/2008 & HPM 7/2006) has potentially affected the restructuring of the emergency care services, as one of the main objectives of the project is to organize the municipal services into larger units.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no yes

Origins of health policy idea

The trend of combining primary care and secondary care emergency services was started in the turn of the century as a local initiative (Oulu region). After that it has spread to other regions.

Initiators of idea/main actors

  • Government
  • Providers
  • Civil Society

Actors and positions

Description of actors and their positions
Governmentvery supportiveneutral strongly opposed
Municipalitiesvery supportivesupportive strongly opposed
Hospital districtsvery supportivevery supportive strongly opposed
Civil Society
Citizensvery supportiveneutral strongly opposed

Actors and influence

Description of actors and their influence

Governmentvery strongweak none
Municipalitiesvery strongvery strong none
Hospital districtsvery strongstrong none
Civil Society
Citizensvery strongweak none
Hospital districtsMunicipalitiesGovernment, Citizens

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The first combined emergency service unit was introduced in Oulu in the early 2000s. After that several regions have introduced the model. A major drawback reported concerning the implementation is caused by the data systems as the primary and secondary care units use different programs in their patient administration. However, despite some technical problems, it is likely that through combined units, the information exchange between primary and secondary care will be improved compared to the old set up as the primary and secondary care services are situated in a single organization.

Monitoring and evaluation

The monitoring of the units and their outcomes has been a responsibility of the collaborating municipalities and hospital districts. Not any systematic or official monitoring is usually done.

Results of evaluation

Experiences from the combined units have mainly been positive. It has been reported that through the reforms it has been possible to gain cost savings and to reduce the number of emergency care visits. Not many studies have been conducted regarding patients' opinions. However, it seems that in some cases the patients have not even been aware of the new service structure. In some units the need for personnel has been underestimated and additional personnel had to be recruited.

Expected outcome

Several large city regions have been interested in introducing the combined emergency care units and also in further developing the emergency care services. The experiences have mainly been good. However, the emergency care service can not be developed without taking the overall service structure into account. It may be assumed that even while the number of the emergency service visits decreases, overall demand has remained constant. In other words, tightening the provision of the emergency services possibly increases the burden on the primary care health centres already struggling with the excessive demand. In the end, the well functioning primary health care, run by the health centres in the Finnish system, is probably the most effective tool in reducing the number of the emergency care visits. Thus, the primary health care services must be developed in parallel with the emergency care services.

When it comes to the patients, with the new single units patients do not have to seek care from several places. Moreover, referrals to further care are controlled by medically trained staff. As a consequence, it may be assumed that patient coordination becomes more effective and thus, treatment may become more adherent to patient pathways. On the other hand, since the combined emergency units are meant to reduce unnecessary visits to emergency care, patients that are not in a need of urgent treatment may find the new situation annoying. Showing up in an emergency unit with a non-urgent indication, they would be referred to their own health centre. There, non-urgent patients are treated during the office hours by appointment with a waiting time of possibly several days.

In addition, when emergency care services are centralized as a result of the combining, the distance to services for patients is likely to grow. This especially has a negative effect on citizens living in areas where the services have been run down and moved to larger cities. On the other hand, the growth in distances may reduce the number of visits to emergency care as the access to care is not as easy as if the services were offered in the local unit. This reform may lower the costs of emergency care, but on aggregate, healthcare costs will not necessarily be reduced. This is mainly due to the possible increase in transport costs to health services paid by the National Health Insurance. It is, therefore, worth asking whether the centralizing would also appear financially beneficial to municipalities if they were to pay for transportation costs.

As a result of centralizing, primary care organizations are able to use more advanced technology. Moreover, laboratory and imaging services are available around the clock also at the primary care level. The possibilities for a primary care physician to consult with a specialist would also be potentially enhanced. All this is likely to result in enhanced service quality. In addition, municipal costs are likely to be reduced, as in combined units it is possible to treat more patients in primary care settings. However, the centralization might have a negative effect on some citizens as the distances to services may grow and the access to emergency services is likely to be reduced. On the system, level the division between primary and secondary care may become clearer.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable two system more equitable
Cost Efficiency very low high very high

The impact on the quality of the services is likely to be positive as the possibilities to consult specialists and e.g. use imaging and laboratory services are improved. If the acute care services are relocated in large cities, the impact on the equity might be negative when citizens living in small municipalities are concerned. Through rationalizing and centralizing it is probable that cost-efficiency is improved.


Author/s and/or contributors to this survey

Liina-Kaisa Tynkkynen

Suggested citation for this online article

Tynkkynen, Liina-Kaisa. "Combining out of hours acute care services". Health Policy Monitor, October 2009. Available at