|Implemented in this survey?|
As the number of the war veterans is decreasing, a concern over the diminishing demand of the institutional rehabilitation services and weakening financial positions of the service providers has emerged. Consequently, the Ministry of Social Affairs and Health appointed two experts to review the state and future prospects of the rehabilitation institutions in Finland. Based on their review the experts made proposals to develop the institutional rehabilitation service system.
The rehabilitation service system in Finland is divided into out-patient rehabilitation services and institutional rehabilitation services. This report focuses on the latter. The Finnish rehabilitation system has its root in the early 19th century when spas and some institutions for e.g. disabled and tubercular patients started to provide services that resembled rehabilitation services. The main developments of the service system have, however, taken place during the 20th century and especially during the post-war period, as the rehabilitation of war veterans has had a major influence on the developments of the rehabilitation service system. Presently there are some 100 institutes in Finland that provide different kinds of institutional rehabilitation services. These institutes (e.g. rehabilitation institutes, conference centres, spas and nursing homes) are mainly owned and run by third sector organizations, foundations or by private firms. The service users have, in general, got a referral from the public sector and the services are mainly financed by public sources. The main public financiers are the Social Insurance Institution of Finland (KELA) and the State Treasury. KELA finances mainly vocational rehabilitation, medical rehabilitation for seriously disabled and discretionary rehabilitation. The State Treasury finances mainly the rehabilitation of war veterans. Also municipals and Finland's Slot Machine Association (RAY) may be counted as sources of public finance.
The war veterans have been one of the largest groups that use rehabilitation services in Finland. As the number of war veterans is decreasing, a concern over the diminishing demand of the services and weakening financial positions of the rehabilitation service providers was aroused. Consequently, the Ministry of Social Affairs and Health appointed in February 2009 two experts to review the state and future prospects of the existing rehabilitation institutions in Finland. The review focused especially on institutional rehabilitation which is financed by social insurance, other statutory insurance schemes and by local governments (i.e. publicly financed institutional rehabilitation). The review was based on a survey directed to the service providers (85 institutions answered) and on hearings of the financiers, providers and experts of the field.
In general the review showed that the capacity of the institutions has continued to grow even though the demand of the services does not show a similar trend. Thus, the supply and the demand of the services are not in balance. In addition, the financial position of institutions seems to be challenging, partly due to the overcapacity of the institutions. Furthermore, there seems to be a need to enhance the coordination of the rehabilitation processes as well as to clarify the responsibilities of different stakeholders (i.e. providers, financiers, municipalities). Also better integration of rehabilitation with other parts of the health and social service system was found crucial.
Based on their review the experts proposed e.g. that:
The main objective of the review was to gain an overall idea of the clientele at the rehabilitation institutions, the financial capacity of the institutions as well as of their competence and opportunities to respond to rehabilitation needs as a part of the social and health service system. The primary tasks of the experts were:
The main incentive behind the review was a need to form a general picture of the contemporary rehabilitation service system for future purposes.
Service providers, Financiers, Citizens
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The report of the review enables to assume that no major controversies are occurring as to the opinions of the current state of the institutional rehabilitation. However, the views on how the current problems should be solved appeared to be rather controversial. Hence, as the proposals are based partly on the survey and hearings, there are chances to successful implementation, but controversies on the details of the possible reforms are likely to occur.
The propositions do not include any major innovations. Rather, the proposals concern mainly reorganizing the current system and the systemic impact seems, presently, rather marginal. However, the institutions potentially need to redefine their service packages and the number of financiers and institutions is likely to diminish. If the integration with the health and social services is progressing, fundamental institutional changes are likely to occur. All in all, currently the systemic impact is, however, difficult to anticipate.
Due to the fact that the Finnish rehabilitation institutions have to a large extent focused and been financially dependent on the rehabilitation of the diminishing group of the war veterans, the Advisory Board for Rehabilitation (appointed by the Council of State) together with the Ministry of Social Affairs and Health have drawn a conclusion that the current state of the rehabilitation service system needs to be reviewed. In addition, in 2009 the Government stated that a reform of the rehabilitation system should be included when the reform of the health and social service system is considered.
|Implemented in this survey?|
Since the 1970s the institutional rehabilitation has been reviewed several times. The present review can be seen a part of this series but it also reflects that decision makers, experts and other stakeholders in the field strongly realize that a reform of the Finnish institutional rehabilitation system is needed in the near future.
The review was based on a survey directed to the service providers and their influence on the proposals made in the review might be seen very strong. However, also hearings of the financiers, municipalities and experts of the field were used and their influence must be seen at least strong. Taking these considerations into account, it might be assumed that the financiers, providers and municipalities positions towards at least most of the proposals are supportive.
In the review it is suggested that "the public procurement procedures for rehabilitation services are relieved within the confines of the Public Procurement Act or by revising the Public Procurement Act". If the proposal progresses, it may have implications on legislation. According to the review, especially the uniformity of the interpretations of the Public Procurement Act was required. In addition, the experts proposed that "the Ministry of Social Affairs and Health launches, in collaboration with the organizers and financiers of rehabilitation services, a state-financed project on the common policy definitions for rehabilitation services and the division of responsibilities between different actors". If this comes to fruition, the review will evidently affect the policy making. As a whole the institutional rehabilitation system is likely to face major reforms and the proposals made in the review are most probably taken into account as the new rehabilitation policies are planned and implemented.
The implementation of the proposals has not yet been initiated.
As the proposals have not been implemented yet, no evaluation or monitoring has been initiated.
The contemporary rehabilitation system in Finland is rather fragmented and lacking an overall coordination. Neither has the integration with other health and social services been sufficient. The system can also be found rather inequitable as citizens living in different areas as well as different patient groups have dissimilar possibilities to receive rehabilitation. In addition, the rehabilitation institutions serve, to a large extent, for the purposes of the war veterans' rehabilitation leaving several other groups underserved. In other words, the system is facing challenges.
The institutional rehabilitation services are mainly provided by private service providers and financed from public sources. In a situation of decreasing demand, the competition between providers is likely to increase. It is probable that providers need to diversify their services as well as find new market niches in order to survive. This relates also to the productising of services as it may help service providers to modify their service profiles more accurately. If productising is becoming a common national procedure, also the monitoring of the effectiveness and quality of services might improve. This, in turn, could result in improvements in purchasing processes as well as in increased cost-effectiveness of services. Overall, it might be assumed that the increased productising of services serves especially for the interests of service providers as they are competing on contracts of public financiers.
The integration with health and social services could improve a comprehensive care of patients as well as clarify the responsibilities between different quarters of the service system. However, integrating two very different systems with strong professions and differing organizational cultures is challenging. Also the fragmented health service system puts challenges on the integration. It may be that in a current situation with financing coming from several sources and service providers being multiple, the integration is a too difficult task to accomplish.
If the released resources are reallocated for the elderly care and the rehabilitation of informal care givers, it may have positive implications on municipals possibilities to organize these services. It would also be beneficial for other prone patient groups (e.g. alcohol and drug abusers) if resources were directed to their rehabilitation. At worst, the reallocation does not, however happen as the public economy is struggling with increasing debt and deficit. Hence, instead of reallocation there is possibility of service cuts.
All in all the proposals are based on the survey and hearings on the financiers, providers, municipal representatives as well as experts. Thus, it may be assumed that the suggestions are adequate and try to encompass the main problems presently occurring in the field. Different stakeholders were rather unanimous in their views of the current problems occurring in the field of institutional rehabilitation. However, the policy solutions brought up by stakeholders differed, which may put obstacles on the implementation. Finally, it remains to be seen, how the forthcoming proposal for the new Health Care Act and other reforms taking place in the service system affect the further development of the institutional rehabilitation service system.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
If institutions succeed in productizing their services it might have positive impacts on service quality. In addition, if the integration with the health and social care is enhanced, the quality of overall service system might improve (e.g. quality in care chains and continuity of care).
Presently, the rehabilitation system as a whole (i.e. including out-patient and institutional services) is not as equitable as it should be. However , through, for instance, productizing the service packages the system might, become more transparent and the allocation of services might, thus, become more adequate (i.e. more based on need). If new groups (e.g. informal care givers) are given a possibility to receive rehabilitation services, it would also be something to improve equity.
One of the proposals made in the review emphasized the need to enhance efficiency of the institutional rehabilitation services. Reducing the overcapacity, for instance, might improve the cost-efficiency. In the case of rehabilitation the cost-efficiency is not always easy to measure. This, might be improved if productizing the services in a nationally uniform manner is progressing.
Ihalainen & Rissanen. 2009. Review on rehabilitation institutions in 2009. The state of rehabilitation institutions and the rapporteurs' proposals for developing the rehabilitation institution activities. Ministry of Social Affairs and Health, Finland. (English summary available at: http://www.stm.fi/c/document_library/get_file?folderId=39503&name=DLFE-10772.pdf)
Jutta Pulkki (University of Tampere) has made valuable comments on this survey.