Beyond Appointments: The Lifelong Commitment to Health
This blog post reports on work-in-progress within the DfG course! The post is written by group 2C dealing with Kela’s and the Ministry of Social Affairs and Health’s brief on Exploring Continuity of Care as a new Kela reimbursement model. The group includes Robert Hartmann from Collaborative and Industrial Design program, Devayani Mohanraj and Sofia Pascolo from Creative Sustainability program (Design Track), and Heidi Mäkitalo from Computer, Communication and Information Sciences program (Human-Computer Interaction Major).
Written by: Heidi Mäkitalo
Our first steps
The beginning of our journey into understanding opportunities for continuity of care (CoC) within the Finnish healthcare system has consisted of two main moments: acclimation into the healthcare system and understanding the meaning and benefits of CoC. So far, all three groups have done their desktop research individually. However, we then shared our findings with each other, and from this basis we proceeded to conduct a roundtable discussion with our partners.
Policy as prioritisation
Policy – as I’ve come to understand it – is always a compromise between different priorities. CoC was a priority of the Finnish healthcare system in the 80s, and by the 90s, personal doctor models were widespread throughout the country. However, as the recession hit, cost-cutting measures by the municipalities resulted in a workload that was too big per doctor. If one doctor went on leave, their patients were left without a doctor, or the work was piled on a colleague, describes Tapani Hämäläinen, Medical Counsellor from the Ministry of Social Affairs and Health (Nuutinen-Kallio, 2023). This led to a lack of access to care. Thus, the priorities shifted to increasing the access to care in the 2000s, with CoC taking a back seat. Nowadays, we are starting to see the adverse effects of the lack of continuity, and so it goes. With the combination of Kela’s new reimbursement system and the reinstallation of (a new version of) the personal doctor model, a balance is sought between the two priorities: access and continuity. But what of the Finnish citizens, many of whom have grown up without much – if any – continuity in their healthcare? From the 5593 people who answered a poll on Yle’s website (Nuutinen-Kallio, 2023), most (46.6%) lack continuity in their healthcare and are annoyed by this. However, the second biggest group (27.6%) doesn’t have continuity and feels they visit the doctor so rarely that it doesn’t matter to them that their physician keeps changing. On a personal level, they don’t feel the need to have relational continuity – at least, they don’t feel it yet. Patients surveyed in the United States value continuity in their care relationship, but they appear to be unwilling to spend either more time or money to maintain continuity with an individual physician. The exception to this is patients with chronic diseases, who prioritise continuity even at a personal cost (Stokes et al., 2005). It only makes sense that once a person faces more severe health issues and especially once the web of their issues starts to grow larger and more difficult to go through, continuity starts to tip the scales. The short time allowed by one doctor’s visit is not enough to untangle the web.
Cruxes of continuity
What, then, is currently on the other side of the scale, and how can we start to tip the balance in favour of continuity already before the patient’s condition deteriorates? If we think of the factor of money, there could be a monetary incentive for maintaining contact with one’s physician. The time factor seems more complicated. In the 18th and 19th centuries, a district doctor could look after the patients in their area throughout their life (Eskola et al., 2022). Modern life, on the other hand, is more dynamic. If the patient or the doctor moves to the other side of the country, ending the care relationship seems like the only viable option. Here, the transference of information to the new physician taking over the patient is crucial. Potential pain points for continuity can be seen on this macro scale of the lifespan of a patient, but also on a micro scale within one series of hospital visits: for example, one key moment is when a patient is handed over from the primary physician to a specialist. How can this handover be made as smooth as possible, and with as little a loss of informational continuity as possible?
Different approaches
There are attempts to release pressure from the overworked public healthcare system into the private side. They are seen in both Kela’s new reimbursement model and the pilot in the welfare services county of Western Uusimaa. The idea of the pilot is to get entrepreneurial physicians on the private side to take responsibility for some of the citizens in the welfare services county, explained the county’s Chief Administrative Physician Veli-Pekka Puurunen in our roundtable discussion. Alternatively, another approach has been taken into use in Sodankylä. According to Tuula Saukkonen, Director of Disease Prevention and Treatment in the Lapland welfare services county (MOT, 2024), their model has solved much of the problem of access to care while also increasing continuity with the assignment of a personal doctor and nurse to each patient. The necessary savings are made by cutting back on contracts with high-cost private general practitioners. The success of this very different kind of model from the Western Uusimaa pilot has made me wonder, what are the main requirements for a model that is able to achieve CoC? The framework for healthcare is very different in Western Uusimaa compared to Lapland since the population is highly concentrated in the south. To what extent can a model which has been successful in one area of the country be generalised to the whole of Finland?
Moving forward
As we can see, continuity can be viewed from many angles, each of which raises a myriad of questions. Our focus as we move forward with our project is the patient side of the equation – how patients understand and value continuity, and how we can incentivize them to prioritise it. We’re also trying to gauge if there is an entry point into the lifespan of a patient which is especially fruitful for achieving CoC and supporting their health in the long run. We’re excited to continue into the next stage of our research, which includes interviews with relevant parties such as doctors, patients, and representatives from interest organisations for patients.
References
Eskola, P., Tuompo, W., Riekki, M., Timonen, M., Auvinen, J. (2022). Hoidon jatkuvuusmalli : Omalääkäri 2.0 -selvityksen loppuraportti. Sosiaali- ja terveysministeriö. https://julkaisut.valtioneuvosto.fi/handle/10024/164291
MOT. (2024). Diagnoosi puhelimessa [Film]. Yle. https://areena.yle.fi/1-66871385
Nuutinen-Kallio, T. (2023, October 20). Terveyskeskuksessa on huomattu, että toimiva hoito perustuu potilaan tuntemiseen – lääkäriltä toiselle pompottelu loppui. Yle. https://yle.fi/a/74-20056258
Stokes, T., Tarrant, C., Mainous, A. G., Schers, H., Freeman, G., & Baker, R. (2005). Continuity of care: is the personal doctor still important? A survey of general practitioners and family physicians in England and Wales, the United States, and The Netherlands. The Annals of Family Medicine, 3(4), 353-359.
The DfG course runs for 14 weeks each spring – the 2024 course has now started and runs from 26 Feb to 29 May. It’s an advanced studio course in which students work in multidisciplinary teams to address project briefs commissioned by governmental ministries in Finland. The course proceeds through the spring as a series of teaching modules in which various research and design methods are applied to address the project briefs. Blog posts are written by student groups, in which they share news, experiences and insights from within the course activities and their project development. More information here about the DfG 2024 project briefs. Hold the date for the public finale on Wednesday 29 May!