By Klas Winell, the Finnish Association of General Practice, klas.winell@conmedic.fi
The Economical Situation and the Health Care
The world wide economical recession and the growing number of unemployment also in Finland have strongly influenced the tax flow to the municipalities, which are responsible for organising health care to the inhabitants. The situation has lead to diminished budgets of health centres. Some health centres don’t have resources for CME of GPs.
Several governmental programmes promote development in health care to a direction that politicians want. The government continues to force small health centres to unite. Each health centre should serve a population of at least 20 000 inhabitants. This has caused turbulence in small health centres. GPs have left for this reason many well functioning centres that are too small to qualify for the new legislation.
7 % of the GP positions are now vacant in health centres. Many young physicians work in private companies, where they can dictate their own working conditions. The companies then hire physicians to health centres. The young physicians stay often a very short time in each centre, which results in bad continuity of care.
Nurses get all the time more prominent roles in primary care. Special competencies like diabetes nurse, asthma nurse and others are started. Many health centres with shortage of GPs transfer tasks from GPs to nurses. The government has decided that nurses can start to write recipes on certain medicines. A new proposal came up recently that nurses would take over a case manager role in chronic diseases.
Patient Security and Harm Reduction
The ministry of health and welfare started a new programme in 2009 on patient security and harm reduction. The programme is very much quality based. It has a strong support from the specialised care, which now seems to find its aspect in QI – adverse event reduction. Most of the cases concern mistakes in ordering and delivering medicines. Nurses have been very active in this new programme. Time will show if the doctors use the possibilities of harm reduction in larger scale.
So far the programme has very limited connections to ambulatory care and there is a concern that this programme can overlook the positive development in chronic disease management and quality development in primary care. A new Society of Patients Security was started recently.
Current Care Guidelines and Evidence Based Handbook
94 national evidence based guidelines are available by Duodecim. An English summary of 73 of them can be read on www.kaypahoito.fi. Many of the guidelines have already been rewritten with the new evidence included. Maximum time before rewriting is three years. Implementation of the guidelines is the tough part of development. There is no organised way of doing that so far. Some research is done on implementation, mainly on guidelines of hypertension. The Finnish Quality Network (FQN) is doing that so some part and Rohto to some part.
The evidence based hand book that is used in electronic form by most physicians in Finland is now been translated in several other countries like Germany, Switzerland and Portugal. All health centres have in electronic version of the hand book available. This is important when thriving for evidence based medicine. Duodecim produces also electronic programmes for testing medicine interactions and use of medicines during pregnancy or nursing.
Rohto
Rohto, which is a governmental programme that started by promoting rational use of medicines is moving more to helping process development in primary care. Rohto uses the working method of workshops. In 2009 Rohto has started a break through project (IHI method) with 15 health centres in developing the updating of medicine lists in patient records.
Rohto programme involves now about one fourth of GPs in the country. With this programme regions have got GPs who are responsible to develop CME for PC personnel in the region.
The Finnish Quality Networks
There are four quality networks in function: the Quality Network of Prevention of Cardiovascular Diseases, the Quality Network of Reducing Risk Use of Alcohol, the Quality Network of Osteoporosis and Fracture Prevention Network and the Quality Network of Memory Dysfunction. Conmedic is running the networks. The networks have in total about 60 health centres joining. These cover about 60 % of all GPs in Finland.
The activities of networks are yearly measurement of quality and intermediate outcomes, network meetings and campaigns for good care. Local quality meetings in health centres are organised 1-3 times a year. In these meetings the results are analysed, processes developed and quality thinking is taught. Health centres get the bench marking results from Conmedic in power point presentations which are easy to use in local quality meetings. The GPs at the health centres have also the possibility to get help from the quality facilitators, if they so wish. More information is available on www.conmedic.fi.
The networks are developing material that is available for all members from the data ware house. The data ware house on the web site of Conmedic possess bench marked models of good clinical care, examples of good instructions for different working models and patient leaflets. Examples of quality indicators and bench marking analysis are easily available.
Conmedic has developed a web audit instrument for quality measurement. It is easy and fast to use and secures high quality of data collection in quality measurements.
Indicator development
Several bodies have shown their interest to develop indicators. The Guideline office intends to develop indicators to follow up how the guidelines are implemented. At the same time there is a goal to get indicators to support process development on health centre and hospital level.
Rohto people have also started indicator development. Their first intention is to get indicators for good ordering praxis for prescriptions and maintenance of medicine lists for chronically ill.
THL has also shown interest for indicator development. Instead of having only national indicators for performance there is now a goal to get indicators for hospitals and health centres.
The Finnish Quality Networks have developed indicators mainly for primary care, but to some extend also to specialised care. The latest development work has been on indicators for dementia care and care of chronic respiratory disease.
DEHKO, the national development programme for prevention and care of diabetes is inspecting its old indicators and making new recommendations in 2010.
