Leena Forma, Laurea University of Applied Sciences and Tampere University

Emilia Leinonen, University of Jyväskylä

The long-term care system in Finland is characterised by a universal public LTC system. Thus, access to publicly organised services is needs-tested. However, the role of families has increased in recent decades[1]. LTC in mainly funded publicly, but the out-of-pocket payments are relatively high.

[1] Szebehely M, Meagher G 2017: Nordic eldercare – Weak universalism becoming weaker? Journal of European Social Policy 28, 294–308. https://doi.org/10.1177/0958928717735062

In Finland legislative responsibility for LTC at national level is with the Ministry of Social Affairs and Health (MSAH). The responsibility for organising health and social services for all citizens, including older people, is with the wellbeing services counties (n=21). These counties were established in the beginning of 2023. Until that reform, the responsibility for organising services for older people was with the municipalities (n=309). Health and social services are integrated both at legislative and organising level, but at the practical level there may be silos and e.g., difficulties in change of information.

LTC is financed by taxes (about 84%) and user fees/out-of-pocket payments (about 16%)[1]. Services are financed by national taxes, and wellbeing services counties do not have a right to levy taxes. The public system coverage is universal for all citizens of Finland. However, many older people complement the public services by purchasing private services. Private LTC insurance is not available in Finland, but private health insurance has a role in financing of private health care. Out-of-pocket payments are mainly dependent on income, but there are also co-payments that are the same for all, such those for support services. Family members who provide care  for older people may have a contract and support from wellbeing services counties but that is not always the case. Family carers with a contract with the wellbeing services county receive both financial support and some services.

[1] Official Statistics of Finland 2023: Terveydenhuollon menot ja rahoitus 2020. [Health care expenditure and financing in 2020]. Statistical report 18/2023. Helsinki, Finnish Institute for Health and Welfare.

The Finnish public LTC system is oriented towards community-based care, and residential-based care is offered only for those with the highest needs.

In the first instance older people living at home are offered support services such as security services, meals on wheels and cleaning services. Home care is integrated service that includes home help (social care) and home nursing (health care). Day centre care is typically offered once a week, to support living at home, maintain social contacts or to provide leave to family and other unpaid carers. Reablement services are not offered regularly but have been piloted in multiple areas. Support for family carers includes services for the care receiver, care allowance, leave  and support services for the care giver. Remote home care has been developed in recent years.

Home care is mostly provided by public actors, but about 11% of services have been outsourced to private actors or municipalities. Individuals receive vouchers fthat can be used to purchasing private home care[1]. In addition, older people may purchase services directly from private providers[2]. Home care is mainly funded by taxes, but care users pay a client fee, funding about 18% of the total costs in 2020[3]. The client fees may be high for those with low income and prohibit the use of services that are needed.

In addition to informal care and home care, there is a small but growing type of home-like care called adult foster care that is meant for those older people who have care needs but no need for 24-hour assistance (see below in the new models of care section).

[1] Sotkanet 2023: Statistical information on welfare and health, home help visits in households with older people (group id 126). Finnish Institute for Health and Welfare. https://sotkanet.fi/sotkanet/en/index  Accessed on 20th June 2023.

[2] Puhenparambil JM, Kröger T, van Aerschot L 2015: Users of home care services in a Nordic welfare state under marketisation: the rich, the poor and the sick. Health and Social Care in the Community 25, 54-64. https://onlinelibrary.wiley.com/doi/10.1111/hsc.12245

[3] Official Statistics of Finland 2023: Terveydenhuollon menot ja rahoitus 2020. Tilastoraportti 18/2023. Helsinki, Finnish Institute for Health and Welfare.

[4] Leinonen, E. (2020) Caring in space: The boundaries between public and private spaces in Finnish adult foster care homes. Ageing and Society, 1-18. DOI: https://doi.org/10.1017/S0144686X19001831

Institutional care in nursing homes and health centres (LTC in primary care hospitals) has decreased remarkably in recent decades. Residential care is mainly provided in sheltered housing with 24-hour assistance. Ordinary sheltered housing (without 24-hour assistance) is relatively rare. A half of sheltered housing is provided publicly, and a half by private providers, outsourced by wellbeing services counties. Private providers are mainly large multinational chains, that have purchased smaller providers, but there are still also small providers, such as non-profit organisations.

The development of digital services in LTC has been a central policy goal in recent governmental programmes. The aim has been to increase the use of electronic patient recording (EPR) systems, robots, Artificial Intelligence and different digital services such as remote surveillance services in both home care and sheltered housing to improve care providers’ operational efficiency and support care recipients’ independent living and lower the need for physical visits in home care[1] . In 2018, 50% of the public home care and ordinary service housing units were using different kinds of assistive technology (including videoconferencing, alarm/safety bracelets, and robots). Out of all public home care units, 40 % were using remote/virtual care in 2018.[2][3]

[1] Rantala, E., Taipale, S., Oinas, T., and Karhinen, J. (2022) Digital skills and application use among Finnish home care workers in the eldercare sector. In: Hirvonen, H., Tammelin, M., Riitta Hänninen and Wouters, E. J.M. (eds.) Digital Transformations in Care for Older People: Critical Perspectives. Routledge

[2] EPTA report (2019) Technologies in Care for Older People. Available at: https://eptanetwork.org/images/documents/minutes/EPTA_report_2019.pdf

[3] THL (2018) Kotihoidon ja ympärivuorokautisen hoidon toimintatavat 2018. Vanhuspalvelujen tila 2018-tutkimusaineisto. Helsinki: Terveyden ja hyvinvoinnin laitos. Available at: https://www.slideshare.net/THLfi/kotihoidon-ja-ymprivuorokautisen-hoidon-toimintatavat-2018-118997643

In care for older people, practical nurses (lähihoitaja) are the most common professionals. They have vocational education lasting 2 to3 years. Registered nurses (sairaanhoitaja) also work in care for older people, they are educated in universities on applied sciences, and their studies last for 3.5 years. Care assistants (hoiva-avustaja) are a new professional group in Finnish care for older people, and they have a 3-month education.

Family carers are mostly spouses of older people and thus, they are also old and may have care needs themselves. Children and children-in-law also act as family carers and they may have difficulties in combining work life and care responsibilities.

There is a huge shortage of workforce due to large generations retiring and because this sector is not considered very attractive by younger people. Measures adopted to increase workforce include extending work careers of nurses approaching retirement age and increasing the hiring of nurses from other countries. There is also a programme to educate foreign nurses in Finland.

The Resident Assessment Instrument (RAI) has been used in many care services for a while, e.g., in home care, 40% of clients wereassessed using RAI in 2020. From the beginning of 2023 RAI assessments became mandatory in all care services, both in home care and residential care.

Information on care use is available in national registers maintained by the Finnish Institute for Health and Welfare (THL). The data is available for research purposes under tight data protection conditions. THL provides statistical reports on care on a yearly basis, mainly on care use, not on performance of the care servcies.

The THL also started to collect data on client satisfaction in 2022. There has been critique towards the methods of collecting the data. i.e., that professional carers are collecting data about themselves.

In 2023 a major reform of social welfare and health care was was adopted. The responsibility to organise health and social services was transferred from municipalities to wellbeing service counties. The financing system was not changed in that reform, but that may be the next set of reforms.

A new amendment to the Employment Contracts Act called Carer’s leave (Omaishoitovapaa) came into force on 1st August 2022. According to this new amendment, an employee has a right to have up to five days off during a calendar year if the employee’s immediate presence is needed because their relative or someone else close to them needs a considerable amount of support or assistance because of serious illness or injury.

An Act on client fees in health and social services came into force in 2021, which also regulated the fees for sheltered housing. Before that, there were extensive variations between regions and care providers in client fees.

The Act on care services for older people is under reform and at the moment, currently the required minimum number of nurses per client in 24-hour sheltered housing (staff/client ratio) is 0.65 (should be 0.7. in December 2023).[1]  The implementation of required minimum number of nurses has been postponed since there are not nurses enough available. Some care providers have stated that they would need to close their care homes, because they are not able to fulfil the requirement. Many are also afraid that the requirement in residential care causes a shortage of nurses in home care.

[1] Government proposes to gradually increase minimum staffing level in services for older people https://stm.fi/en/-/government-proposes-to-gradually-increase-minimum-staffing-level-in-services-for-older-people-

There is a new and growing type of service offering adult foster care, where people live in ordinary homes with foster carers who are not related to them and who provide care. These foster carers are not formally employed by the public sector but have a commission arrangement with the wellbeing services county[1]. In 2022, more than 2000 older persons were cared for in adult foster care, either short-term or long-term[2] . Adult foster care is similar to UK’s Shared Lives Scheme.

[1] Leinonen, E. (2020) Caring in space: The boundaries between public and private spaces in Finnish adult foster care homes. Ageing and Society, 1-18. DOI: https://doi.org/10.1017/S0144686X19001831

[2] Sotkanet 2023: Statistical information on welfare and health, home help visits in households with older people (group id 126). Finnish Institute for Health and Welfare. https://sotkanet.fi/sotkanet/en/index  Accessed on 20th June 2023.

Access to care is considered to be poor, and there are signs that older people with multiple care needs do not receive home care. Residential is specially hard to get.

The out-of-pocket payments in Finland are higher than in other Nordic countries, and some older people cannot afford all the care they need. In principle care organisers are obliged to moderate the payments, if the client is not able to pay them, but it is not known, how often this happens.

There is very scarce evidence on effectiveness of care. Only some small-scale studies have been conducted. There are hints that in many cases care is very fragmented, which may threaten effectiveness.

During the COVID-19 pandemic, care for older people is considered to have continued to work quite well. However, social isolation increased as visits were not allowed, and it has been suggested that the restrictions were too tight.

In 2019 there was a care crisis, as multiple quality problems came into daylight. These occurred mainly in private care homes, which were obliged to close or transferred to public providers. Following this, the monitoring of care homes was strengthened.

Forma, L. and Leinonen, E. (2023) Long-Term Care Sytem Profile: Finland. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/finland/

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