|Implemented in this survey?|
The Government has proposed that the nurses working in public health centres are given a limited right to prescribe medication to patients in their care. The aim is to rationalize the work in health centres as the more autonomous work of nurses would allow the physicians to use their time to the duties requiring advanced medical expertise. Presently, the bill is under committee reading.
According to the Government bill, the nurses working in public health centres would be given a right to prescribe certain pre-defined drugs and vaccines. In addition, the Government proposed that opticians and self-employed dental hygienists are given a right to acquire the medication that they need in their practice (i.e. topical anaesthetics).
According to the proposal, a nurse could prescribe certain pre-defined drugs and vaccines with long post marketing experience. A nurse could also re-prescribe medication for certain chronic medical conditions (e.g. type 2 diabetes, hypertension, and asthma). In these cases the medical condition should be diagnosed and medication prescribed originally by a physician. Furthermore, there should be a statement in a patient's care plan that the medication will continue and that the patient's condition and medication are stable at the given moment. In addition, nurses would get a right to prescribe hormonal contraceptives for women under the age of 35 and, in emergency situations, certain pre-determined medication on common conditions (e.g. urinary tract infection, inflammation of the eye). In the cases of wide epidemics or pandemic, a Government decree can be issued to give nurses a right to prescribe drugs for prevention and treatment of the infectious disease in question. In practice the list of medicines to be prescribed by an individual nurse would depend on her/his job description. Hence, the general list of medication the nurses are given a right to prescribe would be substantially wider than the one for an individual nurse.
The requirements for the limited prescription right would be employment with a public health centre and authorization of a physician in charge. The physician in charge would define the list of the medicines an individual nurse could prescribe for the patients treated in their clinics. Getting the limited right would also provide further training (45 ects, which equal some 1200 hours of studying). The content of the training would be defined by the Ministry of Social Affairs and Health together with universities and polytechnics. The National Supervisory Authority of Welfare and Health (Valvira) would record the nurses' limited prescribing rights in the national register for health care professionals. It is also the duty of Valvira, together with the health centres, to control that the criteria for the limited prescribing right are met.
The main objective of the reform is to improve the possibilities to reorganise the distribution of work in the health centres in order to make the functions more rational.
The efficiency of health centres is believed to improve.
Primary health care services are believed to become more accessible.
Because of the redefined distribution of work the possibilities of the health centres to attract personnel are believed to improve.
The costs of care are believed to be decreased as a substantial amount of patients are already requiring only a nurse's consultation.
Nurses, Physicians, Patients
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
This is a new tool to improve the distribution of work between health care professionals in Finland. It also reshapes the traditional professional boundaries and it weakens, at least apparently, the prominent position of medical profession. Consequently, the physicians oppose the reform in general whereas the politicians and the nurse profession support it. All in all, the changes are likely to enable true alterations in the distribution of work and thus, its systemic impact may be found rather fundamental. The reform is not very system dependent and similar reforms have been executed for instance in Sweden, Ireland and the UK.
Several policy programmes (e.g. National Development Programme for Social Welfare and Health Care (Kaste) and An Effective Health Centre) as well as a new Health Care Act to be passed in 2010 aim at restructuring the health care system in Finland. It has been proposed that the division of work and responsibilities between nurses and doctors should be used as a tool to reform current service structures. The nurses' limited right to prescribe medication is related to these developments as well as to the proposals of OECD (2005).
|Implemented in this survey?|
Due to several demographic changes (e.g. population ageing, immigration, migration) and medical and technological innovations, to name but a few, health care services need to be restructured. Consequently, also the distribution of work calls for revision. According to the bill proposal, also developments in the educational system (e.g. establishing polytechnics in the early 2000s) have made it possible to expand the role of nurses.
Government: The reform is in line with the Government's aims to restructure the service system. The Government is a key actor when changes in legislation are drafted.
Nurses: The reform would increase the nurse's professional autonomy and make the work more rewarding as the nurses would be more independent of physicians. The trade unions (e.g. the Union of Health and Social Care Professionals TEHY) have pronounced that the reform is required and welcome. The trade unions have traditionally been influential as to the reforms concerning the work of the nurse profession.
Physicians: The reform would, at least to some extent, challenge the prominent position of the medical profession. There is a fear that the responsibilities of different professions become ambiguous. The Finnish Medical Association opposes the reform and suggests other tools to reform the service system. The Finnish Ophthalmological Society and the Finnish Dental Association find it unnecessary to give opticians and dental hygienists a right to acquire the medication that they need in their practice.
The Finnish Medical Association and other associations representing the medical and dental profession have traditionally been very influential as to the reforms in health care in general. The physicians are also the key actors regarding the implementation as an authorization of a physician in charge is required for granting nurses' prescription right.
Municipalities: In the long term the reform could decrease the cost of care and improve the access to care. Hence, municipals are rather supportive towards the reforms. However, municipals are responsible for financing the further training that is provided in order to receive the limited prescription right. This might raise slight opposition if the financial position of a municipality is poor. If the bill is passed the municipalities are in charge of executing the reform.
Patients: The reform may improve the access to care and thus, it may be assumed that patients are supportive towards it. However, it has been proposed that a client fee should be charged also for the nurse consultations presently being free of charge. This may alter the patients' viewpoints to a slightly negative direction.
|Government||very supportive||strongly opposed|
|Municipalities||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|Nurses||very supportive||strongly opposed|
|Physicians||very supportive||strongly opposed|
The bill is under committee reading and will most probably be passed in spring 2010.
As the bill has not been passed yet, the reform is not implemented until now. However, in many health centres, the nurses already have their own consultation hours and the limited prescribing right would be consequential to these developments.
Individual health centres together with the National Supervisory Authority of Welfare and Health (Valvira) would be responsible for monitoring that the requirements to prescribe medication are met. The National Institute for Health and Welfare (THL), Finnish Medicines Agency (Fimea) and Social Insurance Institution of Finland (Kela) would be responsible for evaluating the reform together with the Ministry of Social Affairs and Health. According to the Government's proposal the first evaluation would be carried out after three years after the execution of the reform.
Not yet available
At its best the reform could improve the functioning of the health centres and decrease overlapping work of physicians and nurses. It may also cut the costs of care as the unit cost per nurse consultation is lower compared to the one by a physician. Moreover, in some health centres the physicians are already signing empty prescriptions to be used by the nurses at their own consultations to prescribe required medication. The reform would, thus, put already prevailing but presently informal and illegal practices into legal form.
The reform has a strong political support and public debate has indicated that also physicians are starting to adopt the idea. This is crucial, as the support from the side of medical profession is one of the key elements as to the successful implementation of the reform. In addition, adequate changes in the nurses' training are required. Further education and training should provide the nurses with sufficient skills in order to prescribe medicines. The nurses' limited right to prescribe medication would make it possible to expand the marketing of pharmaceuticals also to the nurse profession. This might require a revision of the work of the Finnish Medicines Agency as the scope of monitoring the pharmaceuticals marketing should potentially be expanded. In the field of education these aspects should be taken into account as well. Designing the content of the education requires a multiprofessional approach to the issue. Municipals, for their part, need to be willing to invest in the nurses' further education.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The reform might improve access to care, but the quality of care might suffer if the nurses are not adequately trained.
If the access to care improves the reform might increase equity. However, it has been proposed that due to the new tasks (i.e. limited prescription right) a client fee should be charged also for the nurse consultations presently being free of charge. This may have implications also to the equity of the system.
In the long run the reform may cut the costs of care as the unit cost per nurse consultation is lower compared to the one by a physician.
The Ministry of Social Affairs and Health: Press release 17/2010.
OECD. 2005. OECD Reviews of Health Systems: Finland. OECD Publishing.
The author is a PhD student in the University of Tampere.