|Implemented in this survey?|
In order to prepare new legislation on health and social care administration, the Finnish Government set up a project on regional health and social care area pilots in autumn 2010. The objectives of the pilot project focus on administrative and operational integration, such as enhancing the integration of health and social care administration, and on improving the integration of specialized services with primary level services.
Reforming the administrative structure of health and social care is high on the political agenda in Finland at present, and a new act on the administrative structure of health and social care is in preparation. Related to the ongoing administrative reforms, the Government set up a project on regional health and social care area pilots in autumn 2010. The aims of the project are (1) to explore, how the health and social care system should be developed and (2) to gather information on changes needed in legislation on the administration of health and social care. The project will enable participating areas to organise their health care and social services in a new way. The municipalities willing to take part in the pilot are supposed to send their applications to the Ministry of Social Affairs and Health by the end of October 2010. The applicants can either be single municipalities or municipal co-operation areas.
The Ministry will decide on the eligibility of the municipalities to join the pilot by the end of the year 2010. In the plans there should be clear evidence of the applicant's willingness to promote the set of objectives for the pilot areas. In addition, the eligibility of the applicants is based on several criteria such as:
The main objectives of the project on health and social care area pilots are:
Expert support as well as some financial support is announced for the municipalities participating in the pilot. One of the aims of the pilot project is to offer support for the preparation of the new act on the administrative structure of health and social care. Hence, the participation in the pilot also offers the municipalities a possibility to influence national policy making.
Municipalities, Hospital Districts, Citizens
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Degree of Innovation: If the pilots are to influence national policy making they can be seen as a rather innovative way to prepare new policies. However, it is not clear whether the actual aim is to prepare policy decisions in a new way, that is, based on evidence. If the pilot project is more considered to be a political compromise, then the innovativeness is more like a side effect of this compromise. The structural reform as such may be regarded as rather innovative, even though some municipalities have been introducing models with integrated health and social care as well as primary and secondary care since the 1970s. However, the main trend has been that the health and social services as well as primary and secondary level services are administratively separated.
Degree of Controversy: The policy process of the structural reforms of the health and social care system as a whole has been rather controversial. However, a consensus on this particular project exists between the main Government parties and between other stakeholders.
Structural or Systemic Impact: The pilots probably will have fundamental impact on the structures of health and social care in the participating areas.
Public Visibility: The issue has not been discussed very widely in the media.
Transferability: This reform may be regarded as rather system dependent, as it takes place in a context of one particular health and social care system. However, the ideas and concepts implemented in the reforms (e.g. the integration of health and social care and the integration of primary and secondary level services) are somewhat universal and may, thus, be transformed to other contexts.
Originally the new Health Care Act was supposed to be accompanied by a bill on a new administrative structure for health and social services (HPM 15/2010). This ball was introduced in Parliament in summer 2010. However, the main government parties (the National Coalition Party and the Finnish Centre Party) could not agree on the content of the Act. In the end, the controversies resulted in a political compromise: the project on regional health and social care area pilots.
|Implemented in this survey?|
In August 2009, the Minister of Health and Social Services (representing the National Coalition Party) introduced the proposal for the new administrative structure of the health and social services. The Minister suggested to divide the country into 40-60 health and social service areas that are responsible for primary health care and social services, as well as for most of specialized medical care. The population base, as well as the economic position of these health care areas, should be strong enough to secure the operational preconditions for these services. The most demanding tasks of specialized medical care and some special social services would become more centralized and belong to the responsibility of five responsibility areas. These areas would probably be formed on the basis of the already existing tertiary care regions.
The proposal of the Minister was, however, not accepted by the other major Government party (the Finnish Centre Party). Consequently, the preparation process of the Act was postponed. However, in February 2010, the Government announced that even though the proposal of health and social service areas would not be executed as such, the municipalities and municipal co-operation districts would be given a possibility to organize their services based on a special pilot legislation that would be in accordance with the health and social service area proposal.
Participation in the pilots is voluntary. Thus, it may be assumed that the participating municipalities have a very supportive position towards this initiative. However, in theory it is possible that if the pilot is implemented as a joint initiative by several municipalities, some municipalities may be more supportive than others. However, according to the Ministry of Social Affairs and Health (MSAH) a consensus on the participation in the pilot exists in the areas applying for the pilot. Hence, at least a nominal acceptance is needed from all the participants in each pilot.
The municipals have a strong influence on the content of the reforms introduced in the pilot areas, as the MSAH has only provided general guidelines concerning the content of the pilots. However, some basic requirements, such as a realistic model to integrate health and social services as well as primary and specialized level services, need to be fulfilled.
The plans submitted to the Ministry of Social Affairs and Health need to be discussed and accepted by the hospital district of the participating area. Hence, it is plausible to assume that the hospital districts in general have a supportive position towards the pilots.
It may be assumed that the hospital districts have some influence on the degree of integration of primary and specialized health care services. However, the pilots also include other structural reforms on which the hospital district might not have much influence. In addition, the basic requirements for the pilots are formulated by the Ministry of Social Affairs and Health. The means to comply with these requirements are, in turn, decided upon by the municipalities/regions participating in the pilots. Hence, hospital districts do not have that much a say in the content of the pilots.
As the project on the pilots results from a political compromise, it is assumed that the Government supports the initiative. The Government decided on the basic set of requirements for the areas to be eligible to apply for the project. The Government will also select the areas to be participating. However, the Government is likely to not have a substantial influence on the actual detailed content of the structures and reforms made in the pilot areas, since the Government's guidelines concerning the pilots are rather loose.
It may be assumed that the citizens are not very aware of the ongoing reforms regarding the administrative reforms. Thus, at present the position of the citizens is likely to be rather neutral. Towards which direction the citizens' position will turn depends on the reforms, and their effects on the content, availability and quality of the services.
Due to the Finnish political culture, as well to the practical reason of a tight decision making schedule, it is not likely that the citizens will have much influence on the reforms, even though one of the aims set by MSAH is to develop the services taking into account the citizens' point of view.
|Government parties||very supportive||strongly opposed|
|Municipalities||very supportive||strongly opposed|
|Hospital Districts||very supportive||strongly opposed|
|Citizens||very supportive||strongly opposed|
One of the ideas behind the pilot project is to influence the preparative process of the new Act on the administrative structure for health and social services. The preparation is made by a working group set up in September 2010. At the same time a special subgroup was set up to monitor and evaluate the pilots in order to influence policy making.
|Government parties||very strong||none|
|Hospital Districts||very strong||none|
The municipals are supposed to send their plans to the Ministry by the end of October. The implementation will start in 2011.
A subgroup of the working group preparing the act on the new administrative structure for health and social services will monitor and evaluate local structural reforms introduced in the pilot areas. On the one hand the subgroup will evaluate the administrative integration of health care and social services. On the other hand the subgroup will evaluate the degree of integration of primary and specialized services. Concerning the operational targets set for the pilot areas, some qualitative evaluation on the operations will be carried out.
Not relevant - the planned pilots have not yet implemented.
If the reforms implemented in the pilot areas succeed, the services may become more appropriately allocated. Moreover, the care of the patients has the potential to become more comprehensive, as the new organisation structure would comprise both the health and social care services. The reforms also have the potential to make it easier for a patient to move between primary and secondary level as the borders between these two levels of care are likely to be dimished. The aims set for the pilots are evidently in accordance with the national health policy goals. At this stage, however, it remains to be seen whether the pilots actually influence the national policymaking as well.
The reforms implemented in the pilot areas have the great potential to improve the quality, effectiveness and efficiency of the services. The implementation will, however, not succeed if the professionals do not engage in the reforms. If the reforms are implemented only on an organizational level, the positive impact of the reforms may not be realized. The mere administrative reforms are, thus, not enough and it should be carefully thought through, how the professionals coming from different sectors and representing different disciplines are made to work together. If the pilots are to influence also the national policy making, the evaluation of the pilots should be conducted thoroughly.
In the end, the pilot project may be considered as a result of a political compromise and not an actual aim in itself. In other words, considering the political process it looks like that at least partly the pilot project was introduced not because there was willingness to prepare structural reform in a new and innovative way, but as it was a decent way to solve the disagreements between the main Government parties. While the general election will take place in spring 2011 in Finland it may happen that the main direction of the structural reforms will be decided upon just after the election, regardless of the pilots. This depends, however, on the coalition that forms the Government after the election. If the parties currently in the Government will form the new Government as well, it may be that the pilots have a certain role considering the structural reforms. If there are major changes in the coalition, the significance of the pilots may diminish.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Quality of Health Care Services: It is likely that the integration of the health and social care on the one hand, and the primary and secondary level services on the other hand will have positive impact on service quality. This kind of reform has a potential to enable a more comprehensive approach to the care of the patients, as well as a potential to improve the professionals' competence to take care of patients requiring both health and social services (e.g. the elderly). The reform is also likely to improve the possibilities to take care of patients with chronic diseases at the primary level already.
Level of Equity: The aims set for the pilot areas are, among others, to improve the access, effectiveness, efficiency and quality of services. Thus, the reforms have the potential to improve equity as well. In addtion, through the integration of health and social care, the services may be allocated better. That is, those who need social services, but seek their way to the health centres may have better possibilities to be directed to the social sector, compared to the situation in which the health and social care operate under different organization.
Cost Efficiency: The reform is likely to reduce overlapping of services. The integration of primary and secondary level services is likely to enable to take care for more conditions on the primary level, which is less expensive compared to providing care on the specialized level. In addition, the services may be allocated better in a situation in which there is deeper integration of different sectors and different levels of care.
The Ministry of the Social Affairs and Health. (http://www.stm.fi/en)