Frequent users of basic health care services

Conclusions of the National Audit Office

A small percentage of the Finnish population is responsible for most of the country’s health care costs. The aim in the audit was to determine whether the care provided for this group of frequent service users is organised in such a way that the potential for cost-effectiveness can be maximised. The audit covered the reception of customers in outpatient medical services provided as part of basic health care. In the collection of information for the audit, the focus was on whether the best customer- oriented practices that are in accordance with the chronic care model and the Health Care Act (1326/2010) are observed in outpatient reception services. It was also examined whether these practices help to keep costs under control and improve the health of the customers or slow down the deterioration of their health.

Information on adherence to best practices was obtained by interviewing nurses working in outpatient reception services in health centres and their customers, by carrying out a questionnaire among the management of health centres and by using the questionnaire material on the organisation of outpatient care collected by the National Institute for Health and Welfare (THL). Studies on the cost-effectiveness of the chronic care model and the distribution of services among different customer groups were also used.

In 2014, Finland spent a total of 19.5 billion euros on health care, and 52.2 billion euros on social welfare. In the same year, spending on basic health care services by central and local government totalled more than 2.8 billion euros. Substantial resources are allocated to the care of the customers using the services. According to a number of studies, ten per cent of the customers using the basic health care services or of the population covered by the services are responsible for between 70 and 80 per cent of the social welfare and health care costs incurred By municipalities. There is also the question of the appropriate allocation of economic resources. In other words, it has to be decided how municipalities (and in a few years’ time, the regions) will allocate resources to specialised medical care and basic health care services (that will be provided in SOTE centres). The type and range of the preventive services that will be available to frequent users of basic health care services will partially depend on these choices.

The issue is highly relevant to central government finances: If the health of the customers deteriorates, it may prompt them to use more extensive and costly social welfare and health care services or specialised medical care, which in turn will mean higher costs.

The auditors noted one clear inadequacy. There have not been any systematic nationwide surveys to determine the number of frequent users of basic health care services or the costs of the services that they use. The information is based on a small number of surveys and local social welfare and health care statistics, as well as on cost data. The number of such customers, the care chains suited for them and the operating models applied to them will, however, have a significant impact on health care costs and cost trends.

Frequent users of basic health care services are not yet identified and there is not yet any explicit definition for this customer group. Frequent service users (and not the medically diagnosed patients) are the key customer group from the perspective of central government finances. At the moment, the customer segmentation in health care is largely based on the classification of illnesses and diagnoses.

In 2016, only 20 of the 118 health centres responding to the questionnaire carried out as part of the audit had a segmentation model based on the chronic care model and written guidelines for frequent users of basic health care services. More than 2.6 million Finns live in the catchment areas of health centres that do not have any written guidelines on identifying such customers or that do not specifically identify them.

From the perspective of central government finances, identifying frequent users of basic health care services is also important under the present service system. It will, however, become even more important in the future social welfare and health care service system. This is because in the new model, frequent users of basic health care services must be identified in the SOTE centres and referred to the regional enterprises for assessing their service needs. According to the audit findings, health centres are not yet particularly well prepared to identify such customers.

In the view of the National Audit Office, the Ministry of Social Affairs and Health should in its steering emphasise the importance of systematically collecting information about the manner in which frequent users actually use basic health care services and the costs resulting from this. The ministry should also draw attention to the fact that the information should be effectively used in the management and development of the service system.

The nurses and multi-professional teams working in outpatient reception services play a central role in the care of frequent users of Basic health care services. The nurses and customers interviewed for the audit also commented on the practice in which a customer-specific service coordinator (a primary nurse or a person responsible for customer service) ensures that frequent service users receive appropriate care and that the care is monitored and coordinated. The interviewees were satisfied with the practice and felt that it works well. The practice helps to reduce the number of visits to doctors and unplanned, unnecessary and overlapping use of the services. In addition to personal appointments, telephone contacts with the nurses and up-to-date care plans can also be used as instruments for managing the services.

According to the audit interviews and the questionnaire directed at managerial staff at health centres, the existing legislation makes it difficult for health care professionals to share customer information. Under the current legislation, the information produced by a health centre may only be used for internal planning and management in the health centre in question. Sharing of customer information between parties such as hospitals and social welfare service providers must be in accordance with section 10 of the Act on the Electronic Processing of Social Welfare and Health Care Customer Information (159/2007). In practice, sharing of the information requires the consent of the customer.

The large number of parties administering patient information registers, the multitude of different systems in use and the incompatibility of the systems also make the sharing of information more difficult. Thus, it seems that the problems of information sharing are caused by inflexible legislation, information systems and operating practices. The Government is proposing major changes to the information systems in its proposal for amending the act on the electronic processing of social welfare and health care customer information. The changes proposed by the Government would provide a basis for the introduction of nationwide information systems in social welfare services and for flexible processing of customer information in social welfare and health care. The practices of consent and prohibitions would be harmonised and clarified.

Few health and care plans have been prepared and, as noted in the audit, this is a clear inadequacy. Under section 24 of the Health Care Act (1326/2010), which entered into force on 1 May 2011, care and service plans must be drawn up to provide rehabilitation and care, as necessary. THL prepared national criteria for the health and care plans and guidelines for structural care plans in 2011. However, according to the audit findings, the care plans have not yet become a well-established part of the outpatient reception practices. One reason is that the process of constructing and introducing the nationwide Kanta service was still underway at the time of the audit. The care plan should guide the care of the customer and the daily routines of the outpatient reception services. As stated above, it is laid down in the Health Care Act that the care plans should only be prepared as necessary. This provision has been given a wide interpretation in health centres.

It was concluded in the audit that health centres need guidelines on what is meant by the obligation laid down in the Health Care Act and the Patient Act under which care plans must be drawn up for the patients as necessary. In the guidelines, consideration should be given to ensuring that people living in different parts of Finland who, for various reasons, are frequent users of basic health care services should be in an equal position with regard to care plans.

Care plan objectives connected with the customers’ daily routines will make customers more motivated to take part in the care process. This will make it more likely that the care will produce better health impacts. From the perspective of cost-effectiveness, it is therefore essential that the needs and objectives included in the health and care plans are jointly determined by the customers and the care personnel. Digital tools have also been developed to support customers in selfcare, and to strengthen their own role in the process.

Recommendations of the National Audit Office

The Ministry of Social Affairs and Health should

1. ensure that the nationwide criteria for identifying frequent users of health care services are communicated to health centres and future health care operators and that they will start applying the criteria. The most important issue is to identify customers’ needs, monitor use of the services, and treat all customers equally.

2. review the obstacles preventing the sharing of information on frequent users of basic health care services (data protection issues, access rights of professionals and cooperation practices) and to promote the integration of patient information systems and the use of customer information in the identification of the customer group in question and in the planning of care chains. This could be done as part of the implementation of the Act on the Electronic Processing of Social Welfare and Health Care Customer Information.

3. ensure that customers are more closely involved in the definition of the objectives and instruments laid out in their own health and care plans and that this should be achieved by monitoring the number and content of the health and care plans.

4. ensure that social welfare and health care coordinators, together with the multi-professional teams, organise the planning, implementation and monitoring of the care tailored to the needs of frequent users of basic health care services in a coordinated manner. The main aim should be to allocate resources in accordance with the customers’ service needs in an efficient manner and to coordinate evidence-based and performance-oriented social welfare and health care services.