Policy responses for Finland - HSRM


Policy responses for Finland

3.3 Maintaining essential services

Municipalities are responsible for organising health care and social welfare services for their residents and this has not been changed by the epidemic. MSAH has issued a guidance note to all municipalities stating that necessary healthcare and medical treatment, livelihood and care of municipal residents must be ensured even under emergency conditions. MSAH has also stated that in a difficult epidemic situation, the priority of urgent care for patients should be emphasised, but that non-urgent treatment must always be provided if deemed necessary for patient’s health status.(1) Under the Emergency Powers Act and a Government Decree it is allowed for municipalities and hospital districts to deviate from the time limits for non-urgent healthcare, except for the assessment of the need for care. The assessment of the need for care must still be carried out within three weeks.(2) Some hospital districts have reduced their capacity on elective surgeries and non-acute ambulatory care appointments to prepare for treating COVID19 patients.

The ban of mass gatherings and closure of NGOs as of March 18th affects several services such as mental health and social welfare services. Where possible, e.g. mental health consultations and therapy is given online. Similarly, NGOs such as Alcoholics Anonymous have moved to online support groups, but as noted above have been given special dispensation to organise face to face meetings if deemed necessary. Furthermore, THL has given guidance on how to take care of individual wellbeing during the epidemic and how adults can support children to adapt to the situation.(3) Several NGOs also have similar guidance on their website. They also include links to different mental health support providers. In the symptom assessment services people can also find guidance on how to take care of their mental health during the epidemic. On April 8 2020 the MSAH urged municipalities to develop alternative ways of carrying out rehabilitative work in because group activities arranged in the same physical space are not possible. During the outbreak the alternately organized rehabilitative work may include, for example, online coaching, remote tasks, and individual guidance. (5)

MSAH has given guidance on responsibilities of local governments on services provided to over 70 year-old and other vulnerable people in their homes. Municipalities need to give instructions for family caregivers and persons who receive personal care aid and employers who provide personal care aid. Special attention needs to be paid for situations where family caregiver or personal care aide may fall sick. As an example of regional action South Savo Social and Health care Authority (Essote) started check-up calls for elderly people, first over 80 years old, later on over 70 year old to ensure they have enough food and medicine, and also to inform them about COVID-19.(4) In relation to the protection of at-risk groups, MSAH has instructed municipalities that during the coronavirus epidemic, those working in home care must use a mouth-nose mask to protect the client against any disease carried by the staff.

On April 20 2020 the MSAH issued guidance on what needs to be done in the healthcare and social welfare sector to increase operational capability before the work obligation of the Emergency Powers Act can be applied. The obligation to work should be the last measure to safeguard the services. Primary measures suggested by the MSAH include: reorganising work activities, acquiring services from private service providers and third-sector operators, and recruiting backup employees. The aim is to ensure that the operational capability of health and social services and a sufficient number of staff can be secured during the coronavirus outbreak and in the event of overload in the service system. (7)

It has been reported (8) that the number of primary care appointments (municipalities and occupational health care) has decreased substantially, raising concerns about the increase in unmet care needs. On April 24 2020, THL published a rapid impact assessment on the effects of COVID-19 epidemic on the population's service needs, the service system and the economy. According to the assessment, the range of services has been narrowed and the service forms have been altered to emphasise remote services. For this reason - and also because of customers’ fears - many necessary services requiring contact have not been realised, such as follow-up visits for people with long-term illnesses. It is feared that this will exacerbate the population’s disease load, prolong treatments, and increase treatment costs after the epidemic has come to an end. (9) The MSAH, hospitals and municipal health care providers have initiated outreach campaigns to remind people on the importance of treating existing chronic diseases and acute health problems. For instance Kirsi Varhila, Permanent Secretary of the Ministry of Social Affairs and Health stated on April 28 2020 that “what is more worrying than the adequacy of intensive care capacity at the moment is the ability of our healthcare and social welfare system to respond to service needs other than those associated with the coronavirus”. (10)

Many social and health services have become digital remote services. Digital remote service models will likely become more common permanently, which can be considered a positive change. On the other hand, their use requires well-functioning network connections, IT skills and the possibility to identify oneself in a service using, for example, online banking ID codes - if these conditions are not met, the risk of exclusion increases. In the report it is assessed that vulnerable population groups will be the most adversely affected by the epidemic. (9)

In terms of COVID-19 services for vulnerable groups, free health service is available to all through the infectious disease law. The homeless are deemed especially vulnerable to the COVID19 virus. Because of this, their services have remained open, with services previously shared with other vulnerable groups provided only to the homeless. Cities and municipalities are responsible for services for the homeless. No special health services have been arranged for COVID-19 care for the homeless or migrants. With the closure of Global Clinic, there are e.g. counselling directed at migrants but no healthcare for COVID. Prisons went into lockdown early (see section 6 below).

In terms of old age care, on April 15 the MSAH issued guidance on home care protection and practices during the epidemic. The guidance was given to employers in the social and healthcare field, responsible for implementing it across the country. Change in carers for high risk clients in homecare should be reduced where possible. Home care personnel are instructed to wear PPE during visits with ill clients, single use or fabric nose and mouth covers with healthy clients. This instruction has sparked controversy in terms of the availability of PPE for home care personnel. (11) On 13th May the MSAH issued a decision which makes wearing PPE compulsory for those working in close contact with clients and to wear a mask in social welfare units providing 24-hour care and in home care services. (12)

On 14th May THL published news that during the spring a significantly lower number of children and adolescents have participated in national vaccination programme for children and adolescents in the areas of some hospital districts. The numbers of vaccinated have decreased at least in Pneumococcal conjugate (PCV), rotavirus, and 5-in-1 vaccine (DTaP-IPV-Hib). The decrease is estimated to be due to non-adherence by the families but also because municipalities have downscaled their preventive and primary care services. (13)

Waiting-times to non-urgent specialised care increased substantially during the spring in all hospital districts. This is probably explained by the combination of people refraining to seek care, patients cancelling their appointments and hospitals scaling back their capacity in order to increase the ICU capacity (15). Visits to child health and maternity care clinics decreased 10-40 % and in school health care the visits decreased by 60-80 % compared to the previous year. (15)

Hospital districts have limited elective activities cautiously according to the epidemic situation in their area and are prepared to implement more extensive actions if needed. Some hospital districts, such as the Helsinki-Uusimaa, Northern Ostrobothnia and Päijät-Häme (6), are now considering expanding elective activities again. Hesitation of seeking care and arriving to the appointments have been noticed widely across the country. Hospital districts emphasize that precautions are made to enable safe access to hospitals and health centres, and it is important to take care of chronic illnesses and seek help when noticing acute symptoms.

Municipalities are responsible for organising rehabilitation services which should have continued throughout the epidemic, unless specifically ordered by the authorities under the Communicable Diseases Act. However, many municipalities closed their rehabilitation facilities when the Government banned gatherings of more than ten persons on 16 March 2020, although these rules did not apply to rehabilitation and social welfare services. In response and to reassure municipalities, the MSAH issued guidelines on 26 May 2020 on how to implement rehabilitative services between 1 June and 31 July 2020. Rehabilitative care implemented as group activity may be resumed starting from 1 June, subject to hygiene and physical distancing measures. Alternative provision may be continued until at least the end of July. (14)

On 17th June Government further relaxed the rules for visitors to health care facilities. Units providing 24-hour care and treatment must provide their older clients and others belonging to risk groups with the opportunity to meet their visitors safely, for example by ensuring adequate protection in an outdoor location or by arranging separate, protected meeting facilities. However, the Government recommends that access to the premises of units providing 24-hour care remain limited to the staff of the unit.
There have been concerns on the systems resilience and ability to absorb a potential second wave of coronavirus epidemic in a situation in with potentially substantial number of unmet care needs.

THL and specialists have evaluated the effects of COVID-19 epidemic in Finland on the population’s service needs, the service system and the economy twice. The first rapid impact assessment was carried out in early spring (9). A more thorough evaluation was carried out in the autumn of 2020. The epidemic and containment measures affected the service system extensively. In specialized care, non-acute care was decreased substantially due to preparedness measures during spring 2020 and the recovery has varied. Service provision in acute care functions mainly recovered well whereas in non-acute care it varied. Service and care delays increased especially in certain specialities and among older people. In primary care the main concerns are providers’ financial difficulties and the adequacy and wellbeing of the personnel. During spring 2020 the visits to health centres dropped and changes were made to deliver services via remote consultations. However, provision of services declined, e.g. in oral health care when their staff was redeployed to COVID-related tasks. In addition, the remote services are not adequately reaching many vulnerable groups. (16)

When compared to 2018-2019, the number of referrals to non-urgent hospital care decreased by 6% in 2020. (19) However, the waiting lists to non-urgent hospital care have remained at record high, despite the hospitals attempts to shorten them in autumn. In December 2019 waiting lists comprised 115,700 individuals of which 2% (2,400) had waited over 6 months. (20) In August 2020 the respective numbers were 137,000 and 13% (17,700); and in December 2020 they were 141,000 and 5% (7,600). (21,22)

In December 2020, THL restarted monitoring the availability of services and sufficiency of workforce in social and health care. Information is gathered from social and health care administrators through electronic questionnaires. The results are reported every second week. (17)

In January 2021, the Helsinki University Hospital reported that the Covid-19 pandemic had affected only little on the number of organ transplants in 2020 (18). The Helsinki University Hospital performs all organ transplants in Finland – and has been able to secure intensive care of organ donors even amid the pandemic.

In light of the issues with availability of blood plasma, which is need for manufacturing of treatments containing immunoglobulin, on 29th January MSAH decided that reserves can be used for certain medicinal products (e.g. those containing immunoglobulin) from 1st February if necessary (26), under the Act on Mandatory Reserve Supplies (979/2008) and the Government Decree on Mandatory Reserve Supplies of Medicines (1114/2008) (27).

On 26th January both MSAH and Ministry of Education and Culture expressed concern for provision of adequate services in child health clinics and school health care. (23) Though the need for these statutory services has increased, part of their workforce has been redeployed to support COVID-19 response. The ministries emphasize that the provision of children’s and youth services should not be even temporarily impaired during the COVID-19 vaccine roll out – but rather strengthened.

In February 2021, the Finnish Cancer Registry reported that COVID-19 has affected the cancer screening and diagnostics. When compared to respective time period in 2019, the participation rate in cervical cancer screening decreased by 9 percentage-points in Jan to Oct 2020. (24) The number of cancer biopsies decreased by 12% in Mar to Jun 2020, compared to 2018-2019. (25)

The number of COVID-19 patients has increased in the Helsinki University Hospital during February 2021. Three COVID-19 patients from the ICU were transferred to other hospitals’ ICUs to ensure the capacity to treat non-COVID patients as in normal circumstances. Nevertheless, some operations have been cancelled and minor procedures postponed. (28)

Despite the Covid-19 epidemic the queues to non-urgent hospital care in region of Southwest Finland shortened in 2020 by little less than 10%. (29) However, the number of those who had waited over six months slightly increased. This occurred mainly due to challenges in providing care in some medical specialties with increased risk of Covid-19 transmission – such as in Ear, Nose and Throat specialty care.

Referrals to adolescent psychiatry inpatient care have doubled in hospital district of Southwest Finland between July and December 2020 and increased significantly in the hospital district of Pirkanmaa, exceeding capacity in both areas. In the hospital district of Pirkanmaa, a new ward is planned to be opened to ease the situation. (28,29) In addition, according to the municipal survey conducted by THL, the pandemic has increased the need support for child welfare and aggravated the mental health problems. There have been deficiencies in childcare services before the pandemic, which exacerbated the situation further. (31)

Due to the impact of COVID-19 epidemic, physical visits to health centers decreased in 2020 17.5 % compared to 2019. Physicians remote consultations on the other hand increased by 20.8 % compared to 2019. (32) Remote services counted for 30% of all the social and health services used in year 2020 and the use of remote services increased by 8 percentage points compared to year 2019. Nevertheless, the usage of remote services has increased yearly ever since the follow-up began in 2013. Whether the increase in the usage of remote services in early year 2020 was due to new service delivery, additional resourcing of existing remote services or altered procedures of operations, remains unclear. (32)