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Case studies

II.Case studies

In Finland, public health work has a long tradition. One of the best-known health policy and public health initiatives in Finland has been the maternity allowance and the related development of counseling. In the 1940s, attention began to be paid to safeguarding the health of schoolchildren by introducing school meals and establishing school doctors and dentists. However, the prolonged focus on population policy missed the prevalence of chronic diseases. In the early 1960s, at the initiative of individual specialized organizations such as the Cancer Society, the Diabetes and Heart Disease Association, and the Rheumatism Association, chronic diseases gradually became the main targets of health policy.

In 1972, the Public Health Act aimed to improve the health of the population in Finland through primary healthcare, preventive healthcare, and public health work. In practice, municipalities set up health centers and provided dental care to everyone under 17 years of age. In addition, investment in health education began in the 1970s, and this was also reflected in preventive dental care. Teaching children how to brush teeth properly began in schools and the use of fluoride tablets and fluoride paste became more common. The results were gradually seen with a reduction in cavities.

The focus of health policy has varied over the years as views on health, health problems, and ways to achieve health have changed. However, thanks to long-term work, people in Finland now have more healthy life years than ever before. Changes in the age structure of the population and growing pressures on public finances are also affecting social and health policies. Despite the reform of structures and focus, the basic idea remains: a socially sustainable Finland that supports wellbeing, health, increases inclusion, and provides the necessary services and security for people.

Case: Finland’s maternity benefit and maternity healthcare

Finland’s maternity benefit is an excellent example of preventive measures aimed at the wellbeing of the family after the birth of a child. In Finland, the law on maternity benefit was enacted in 1937. At that time, the purpose of the maternal benefit was to support low-income mothers and promote the health of their children.

When introduced, child mortality was high, birth rates were low, and poverty was common – the maternity benefit aimed to turn this around. In addition to a low standard of living, there was poor general hygiene, tuberculosis, and various communicable diseases.

For the first eleven years, the maternity benefit was distributed only to low-income mothers. In 1949, the right to the maternity benefit was extended to all mothers living in Finland. The maternity benefit was also more closely linked to healthcare. In order to receive the maternity benefit, the expectant mother had to visit a doctor, midwife, or maternity clinic before the end of the fourth month of pregnancy. In this way, expectant mothers entered the healthcare system and child mortality was effectively reduced.

How it works

All mothers living permanently in Finland who have been pregnant for 154 days and have undergone a health check-up no later than 18 weeks into their pregnancy are still entitled to the maternity allowance. Parents of adopted children (under 18 years) are entitled to the same benefits. The parent can choose the grant either as a maternity package or as a tax-free amount of money, which is currently 170 euros (in 2020).

The maternity package or “baby box” is a package containing more than 60 items which a newborn needs the most, for example a snowsuit, sleeping bag, outdoor and indoor clothing, personal care items, and also condoms for the parents. The maternity package is offered by Finnish social security (Kela). The box itself can be converted into a practical crib where the newborn can sleep during its first months of life – having the baby sleeping on their back in the same room with the parents but not in the same bed reduces the risk of sudden infant death syndrome, which is very rare in Finland.

Outcomes

The effects of the maternity benefits on Finnish society have been significant. From the point of view of the health effects of the maternity package, it has been essential to integrate the maternity benefit into healthcare, including health check-ups. Regular health examinations help prevent illnesses and identify possible risks at an early stage.  Although direct research evidence is not available on the effects of maternity benefits on, for example, neonatal mortality, many experts agree that the maternity benefit – together with other significant factors such as maternity health clinics and child health clinic services – has contributed to reducing child mortality in Finland and also improving public health.

At present, infant and maternal mortality rates in Finland are one of the lowest in the world. In the late 1930s, nearly one in ten children died when they were less than one year old. Today in Finland, only a few children per thousand will die under the age of one. Mortality among children aged 1–14 has also fallen radically: the deaths of children of this age have fallen by more than half between 1989 and 2010.

Case: The North Karelia project

Coronary heart disease mortality associated with cardiovascular disease was particularly high in Finland, especially eastern Finland, based on the results of a study covering seven countries that began in the 1950s. These results led to the creation of the North Karelia project, a widely known Finnish community-level health program that helped reduce the risk factor level of the population, reduce heart disease and total mortality among working-age people, and improve the health status of the population.

Studies show that smoking, high serum cholesterol, and high blood pressure are major risk factors for cardiovascular disease. Being overweight, low physical activity, diabetes, and low socioeconomic status also increase the risk of coronary heart disease. From 1978–1998, the North Karelia project investigated the occurrence and change of factors affecting the health of North Karelians aged 15–64. The means by which health behavior was influenced included behavior modification,  communication, diffusion of innovation, community organization, and social marketing.

The North Karelia project has reduced the level of risk factors for key chronic diseases in the population. As a result, overall mortality, cardiovascular mortality, and cancer mortality have decreased in the working-age population in North Karelia. Overall, the health behavior of North Karelians has moved in a positive direction. In particular, eating habits have improved and smoking among men has been reduced.

Case: Developing acute ischaemic stroke treatment path in Kanta-Häme Central Hospital

Example messaging designed to encourage emergency department staff.

Source: Heikkilä et al. 2016

Acute ischaemic stroke (AIS*) patients are the largest neurological group in need of first aid. In Finland, AIS affects about 14,000 people every year. The Kanta-Häme Central Hospital (KHCH), which is a secondary-care hospital in Hämeenlinna, Southern Finland, has implemented a new treatment protocol for AIS. There was a need to reorganize the protocol – previously only internists or neurologists could be responsible for stroke patient care, which caused problems as specialists’ availability varied depending on the day of the week and the time of day. This caused uncertainty over who is responsible and how to reach that person, which caused delays in starting treatment. Speed is of the essence in treating a stroke patient, which is why the change was needed.

The biggest change in the treatment path was the transfer of responsibility for the care of a stroke patient when no neurologist is available – from neurologists or internists to emergency physicians (EP). The transition phase included education and practical training for nurses and physicians and motivation for the clinical staff.

The study results show that the new protocol does not compromise patient safety. On the contrary, after the reorganization door-to-needle time and onset-to-treatment time has decreased. The number of stroke patients per year who were treated with tPA has also increased compared to previous years. Because the median NIHSS score of the patients decreased and no stroke mimics were treated, the stroke protocol improved the treatment of patients with acute ischemic stroke. It’s noteworthy that the results were achieved in the first year the protocol was put into practice.

This AIS pathway model developed at Kanta-Häme Central Hospital is the first to give emergency physicians the main responsibility for treating AIS patients, thus accelerating the start of treatment. The reform did not require additional resources and resulted in a shortening of total and in-hospital treatment delays. The opinion of the research team is that this model is applicable elsewhere, both in Finland and internationally.

AIS care pathway in Kanta-Häme Central Hospital

Source: Suomen Lääkärilehti

Flow chart of the new in-hospital treatment path for patients with suspected AIS. it is based on scrutinized teamwork led by an EP for most of the time.

Source: Heikkilä et al. 2016

Key Terminology

  • AIS is acute ischaemic stroke, which according to international guidelines should be treated with recombinant tissue plasminogen activator (tPA) within 4.5 hours after the onset of symptoms and within 60 minutes after patient arrival at an Emergency Department to get the maximum benefit from the treatment.
  • Ischaemic stroke occurs when the blood supply to brain tissue is blocked by a blood clot
  • tPA is given to patients through an IV and it works by dissolving blood clots that block blood flow to the brain.
  • NIHSS = NIH Stroke Scale = Neurological status


Case: Tesoma Welfare Service Alliance

In Finland, the Tesoma Alliance is a completely new entity that provides a wide range of services for people, which is produced in cooperation between the public sector, the private sector and the third sector. The Tesoma Alliance unites the residents of the region, regardless of their different socioeconomic backgrounds, provides health, wellbeing and social services in the same compact facilities and invests in improving the wellbeing of the residents in many ways. The concrete example of this is the Tesoma Wellbeing Centre´s community café that aims to promote mixing between different generations and socioeconomic groups.

Alliance contracting offers a different approach to cooperation between clients and contractors compared with traditional forms of contracts. Alliances are a form of collaborative contracts that detail a delivery framework for multiple stakeholders, such as a municipality, private healthcare provider and third sector organizations.

The development of the Tesoma Welfare Service Alliance is linked to the renewal of the service model of the City of Tampere and the city government’s policies on wellness and local markets. The goals of the alliance are to increase the wellbeing of the residents of the Tesoma area.

How it works

The implementation of services takes place using an alliance model of public, private and third sector actors. The service concept has been created in open cooperation with service users, the city’s own production, companies and the associations. Procurement has been implemented with an innovative approach which combines result based, development partnership and various funding and reward models.

The main principles of the alliance are the sharing of risks and benefits together, common goals, a common revenue model and organization, innovation and continuous improvement and building of trust/confidence.

Outcomes

The benefits of the alliance model are the development of cost-effective and high-quality services, integrating development into the operating culture of the city, and the development of market and partnership-based practices.

Wellbeing is achieved by increasing services, strengthening self-care opportunities and increasing the digitalization of wellbeing services. The operation of the partnership network enables open and active cooperation with actors outside the alliance. Involving customers in the development and production of services ensures that the services are customer oriented.

In the planning of welfare services, there has been a desire to understand Tesoma’s residents and the area, and therefore the residents have been involved in the development work in many ways.


The Tesoma Wellbeing Centre

The Tesoma Wellbeing Centre is the product of the Tesoma alliance. Key performance areas emphasize Triple Aim thinking and include:

• the wellbeing of children, young people and families

• the wellbeing and work capacity of the adult population

• the wellbeing and ability of older people

• reduced use of services

• stakeholder satisfaction with the Wellbeing Centre’s work

How it works

The Tesoma Wellbeing Centre consists of two complementary parts: social and health services and services that strengthen the community and activate residents. It serves all residents of the area and includes social and welfare counselling, service guidance and other low-threshold services.

Many centralized services of the city of Tampere, such as an employment and social services expert, have also entered the Wellbeing Centre. In this way, services are brought closer to the customer. The Centre serves as a base for home care and family work in the area. Services that meet the needs of the Wellbeing Centre’s customers and health and wellbeing promotion services are produced using a multi-producer model.

The concept has been created in open cooperation with service users, the city, companies and associations. The Wellbeing Centre has a health kiosk where a nurse or other healthcare professional provides low-threshold health counseling and other light health services, such as vaccination campaigns and oral health counseling.

Preliminary outcomes

After the first year of operating, third sector activities, low-threshold services, community support and cooperation between the services have increased local wellbeing significantly. Bringing services and their management close to the end customer also seems to work. Based on this experience, the alliance model is recommended as a model for welfare services.

The economic figures have not yet been officially released as the Tesoma Alliance will not have a definitive review until 2021 when the first commercially binding contract period has ended. However The Finnish broadcasting company, YLE, has announced that in 2019 the target cost of EUR 12.7 million would in fact be approximately EUR 1 million lower. In 2018, the costs were also clearly lower than expected, with a target maximum of EUR 9.7 million and an actual result of EUR 8.8 million.

Performance-based procurement and cooperation between the public sector and market players are seen as accelerators of the digitalization of services, the adoption of an experimental culture and the market entry of growth companies. By duplicating Tesoma’s best experiments, the aim is to improve the effectiveness of the services.

Case: Children’s wellbeing program financed with a social impact bond (SIB)

The program Lapset SIB focuses on the welfare of children, youth, and families. The program finances preventive child welfare measures. The aim is to lower the costs of child welfare and social exclusion for municipalities through early interventions with a proven impact that reduce the need for child protective services.

The program was commissioned by five Finnish municipalities: Helsinki, Hämeenlinna, Kemiönsaari, Lohja, and Vantaa. In each municipality the service offering is tailored to a specific target group of children and their families with the aim of preventing the need for child welfare actions. A separate target group will be selected for each participating municipality with the selection made on the basis of data analysis. For the selected target group, a service package is tailored that is planned, appropriate, timely, and based on the child's needs while taking the whole family into account.

An example of Lapset SIB’s activity is the start of a new “family partner activity” (Perhekumppani-toiminta) in the city of Vantaa, which supports families in the target group and works in close cooperation with Vantaa’s social and educational professionals, together with the NGO SOS Children’s Village.

How it works

The length of the program varies by municipality from six to 12 years. Preventive social services provided to children and their families are produced by several actors, which are mainly third-sector organizations such as SOS Children’s Villages and Icehearts.

The municipality or city usually saves on costs when the welfare objectives set out in the SIB agreement are achieved. Part of these savings will be returned to the SIB fund. The public sector will therefore only pay for the results achieved.

The program is administered by FIM Vaikuttavuussijoitukset Oy (formerly Epiqus Oy) in cooperation with the Central Union for Child Welfare. The program was launched in 2019.  Investors include the City of Espoo and Tradeka.

Case: Intensive care consortium for quality assessment

In Finland, an intensive care consortium for quality assessment was established in 1994 by anesthesiologists and intensive care physicians. With the increase in intensive care in the 1960s and 1970s, interest in the outcomes of a new and expensive form of treatment arose. Initially, the intensive care units treated a large number of patients whose prognosis was hopeless, making mortality high. Therefore, there was a desire to study and publish treatment outcomes. The early days of intensive care consortium research were challenging, but much research has been done in recent years. Currently, the task of the intensive care consortium is to coordinate the peer review of intensive care units and guide intensive care quality control and benchmarking.

How it works

The intensive care consortium includes all Finnish general ICUs in central and university hospitals. Core data for each treatment period, such as disease severity, treatment given, and outcomes, are stored in a national quality database.

Outcomes

The cooperation between departments in the intensive care consortium has already produced several extensive prospective cohort studies, conducted as multi-center studies (FINNICU).

One example of these cohort studies is the FINNSEPSIS study, which increased awareness of sepsis treatment and made it more effective. The study showed even severe sepsis is very cost effective to treat. The FINNSEPSIS study was the first cohort study and showed that the Finnish intensive care community is capable of high-quality research collaboration covering the entire country. After FINNSEPSIS there have been several new cohort studies.

Duodecim’s article from 2018 encourages intensive care, like other specialities, to take the following steps in quality control: “In connection with the healthcare reform, a healthcare quality registers coordinating center should be established in Finland with the resources to fund key registers and the right to store personal IDs and link data from different registers. A comprehensive and high-quality register data is an excellent opportunity to monitor the effectiveness of treatment and also to carry out high-quality research.”

Case: FINBB Biobank

The FINBB biobank includes all public biobanks in Finland and was established in 2017 by the Finnish Institute for Health and Welfare, Finnish universities, and Finnish university hospitals.

Biobanking enables professional collecting, storing, and releasing of human biological samples including blood samples and biopsies. FINBB helps to facilitate medical research for new drugs and therapies while ensuring that the rights and privacy of sample donors are protected. All samples are donated voluntarily and include a high level of privacy protection. These samples will be held in long-term storage for future medical studies which allows for decades of follow up in data sets.

The Biobanking and Biomolecular Resources Research Infrastructure (BBMRI-ERIC) is a European level biobanking initiative that Finland is part of. The goal is to facilitate high-quality research via biological samples. The Finnish agency Valvira (the National Supervisory Authority for Welfare and Health) is responsible for supervising the biobanks and has currently licensed 10 biobanks in Finland.

Source: BBMRI

Case: The Act on the Secondary Use of Health and Social Data

The secondary use of health and social data refers to the use of customer and register data collected during health and social service activities for a different purpose than the one for which they were originally stored.

In Finland, a separate law has been passed on the secondary use of health and social data (the Act on the Secondary Use of Health and Social Data). The law was enacted in May 2019 and enables the use of such data in a way that will benefit patients and healthcare.

The law is designed to ensure effective and secure processing and access to personal, social, and health information in order to facilitate guidance monitoring, research, statistics, and development in the health and social sector. The law guarantees an individual’s legitimate expectations for how this data is used and stored, as well as their rights and freedoms when processing data.

This law will help with the duplication of administration related to permit processing, streamline the processing of permits, and improve the sorting of information from different registers. The use of social and healthcare materials will also be facilitated, making research activities more efficient.

The secondary uses allowed by the law include scientific research, statistics, development and innovation activities, guidance and supervision by authorities, the planning and reporting obligations of public authorities, teaching, and knowledge management.

A practical example of where the benefits of the law will be seen is social security and healthcare reform, where both the promotion of information management by service providers and the expansion and timeliness of national monitoring data are key areas for development. The secondary law facilitates better use of data to support decision-making.

Source: The Ministry of Social Affairs and Health

Key Terminology

A reservation price is the upper limit (price) a buyer is willing to pay for a product or service or the lower limit a seller is willing to accept for a product or service.

Measuring hip and knee replacement treatment outcomes

Osteoarthritis (OA) is a degenerative joint disease associated with ageing. Osteoarthritis is one of the ten most disabling diseases in developed countries. According to the WHO, 80% of those who have osteoarthritis will have limitations in movement, and 25% cannot perform their daily activities. Hip and knee replacement surgeries can be effective treatments and can significantly improve a patient’s quality of life and associated functional capacity.

In Finland, about 10,500 hip and 11,500 knee artificial joints are operated annually. It’s important that the surgery is performed to a high standard in order to obtain all possible benefits for the patient. The artificial joint hospital Coxa serves as an example of a Finnish hospital that measures and publishes its patient-reported outcome measures (PROMs) annually.

Measuring outcomes is an important part of quality control, and publishing the results provides patients with the information they need to make a choice about who is treating them.

The effectiveness of artificial joint surgery on a patient’s life is measured with an Oxford score based on the patient’s own assessment. Patients answer 12 questions about their symptoms and these result in one figure. The best possible score is 48.

2019 Oxford Score examples from Coxa

Oxford score

Measuring the success of surgery is important for quality control. Surgery can be considered successful if the patient does not have to have another operation within two years of surgery. Monitoring the number of people returning to inpatient care also indicates the success of the surgery – patients return to the ward when there are surgical complications, which means the lower the percentage returned to inpatient care, the fewer patients have experienced a surgical complication or other problem.

Complication indicators

Source: Coxa

Infection is one of the most difficult complications after artificial joint surgery. Follow-up of infections is an important part of continuous quality control after surgery.

Infection percentage within one year from the operation

Source: Coxa

When using internationally recognized and valid PROM measures like the Oxford Score, even a broader comparison of treatment outcomes is possible. In its 2019 report, the OECD published the results of international artificial joint surgery.

Crude mean pre- and post-operative Oxford knee score, 2013-2016 (or nearest year)

Crude mean pre- and post-operative Oxford hip score, 2013-2016 (or nearest year)

Source: OECD

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