1 A description on the health and social services reform in Finland

Jenni Repo, Tampere University

1.1 Introduction

Finland is often described as being a Nordic or a social democratic welfare state. Family-service orientation and universal services are characteristic of the Finnish welfare system, and special services, such as child welfare, are used when the universal services are not sufficient in assuring a child’s wellbeing.1 Höjer and Pösö¹ describe the families and children, who receive welfare services, as having complex needs that cannot be met in other services. Despite the extensivity of the welfare state and services provided for the families and children, there is a relatively high rate of out-of-home placements and families and children receiving child protection services in Finland.2

Currently, there are 195 municipalities and coalitions of municipalities that organize health and social services, including child welfare services, in Finland.3 The funding comes from different channels, such as the state, the municipalities, and employers. The municipalities and coalitions of municipalities have a strong self-government based on local democracy and decision-making and the right to levy taxes, and the municipalities’ function is based on national legislation. In practice, the budget aimed at, for example, child welfare services between different years and different municipalities.^1, 4

To guide the child welfare work and to support its organization, the Ministry of Social Affairs and Health, and Association of Finnish Local and Regional Authorities released a Quality Recommendation for Child Welfare. The recommendations concern participation, child welfare as part of the service system, the professionals and work community, assessment, and quality criteria for substitute care and its monitoring. The five ethical principles that are included in the recommendations are:

1. Human dignity and basic rights

2. Child’s best interest

3. Interaction

4. The quality of the work

5. Responsible decisions and working culture5

The current health and social services system is facing challenges, such as unequal access to services and the ageing of the Finnish population. To better the equality and quality of the services and to reduce health and wellbeing inequalities, the organization of public healthcare and social welfare will be restructured. In practice, the health and social services reform means that the responsibility to organize health, social and rescue services will be transferred from municipalities (1956) to the new wellbeing service counties (227). Some services will remain as municipalities’ responsibility, but most public and social services, including child welfare services, will be organized by the wellbeing service counties.³

This report is based on different ministries’ papers and websites in which the reform is argued and explained. Research papers, reports made by other actors and different contributions on the background and possible tensions of the reform are excluded. The first part of the report describes child welfare services and its challenges in Finland and the second part concerns the reform.

1.2 Child welfare services in Finland

In addition to the Constitution of Finland8 and the Convention on the Rights of the Child, the Child Welfare Act9 and the Social Welfare Act10 are the most focal laws when it comes to families’ and children’s wellbeing in Finland. Children and parents enter the system as a result of an assessment and will be directed either into services provided by the Social Welfare Act or by the Child Welfare Act.

The main objective of the Social Welfare Act is to promote social safety and wellbeing by providing social services for everyone. According to the Social Welfare Act, a child is considered needing special support when their growth or health is endangered/not assured, or they have difficulties in claiming or receiving services. In the Government’s proposal concerning the Social Welfare Act, it is stated that the act enables families and children to receive services and support without becoming a client in child welfare services. Ideally, the pressure from the child welfare services would be transferred to the general services provided by the Social Welfare Act which would, in turn, lower the threshold in getting services and support.11

However, the difference between the services provided by the Social Welfare Act and the Child Welfare Act is often unclear. For example, there is no clear distinction on the criteria concerning the children in need of services, and municipalities have organized the assessment, practices, and application of the laws in a variety of ways.

In child welfare services, the services can be divided into in-home services, emergency placements, voluntary and involuntary care orders and after care. Another way to view child welfare services is to divide them to ‘open care’ and ‘alternative care’ (out-of-home care or substitute care).12

In-home services or open care is voluntary, and it considers services such as family work. The objective is to support families and children in their own living environment. A placement out-of-home can also be a part of open care if it is short-term and voluntary (consent from a child over 12 years old and the parents). Open care placements can be used when a child or the entire family needs support outside of their home. In open care placements different restrictive measures (such as bodily search, restraining a child physically or restricting of contact) cannot be used. Restrictive measures can only be used under a care order in institutions providing substitute care. Open care placement needs to be discontinued if a parent withdraws their consent on the placement. A child cannot be placed under open care continuously or if it is likely that they need to be placed long-term, the necessity of a care order needs to be assessed. In open care placements the rights of the guardian remain unlike in care order.¹²

As for alternative care, a child can be taken into care and placed out of home voluntarily and involuntarily. If a child over 12 years old and the parents agree on a voluntary placement, the decision is made by a leading social work authority in the municipality. If it is an involuntary care order, the decision is made in court. Emergency placement can also take place if a child is in immediate danger.¹²

Statistics

Below is a table presenting some statistics on child welfare from year 2020. The numbers describe how many children/families received such services and the number in brackets is the percentage when comparing to all children under 18/all families with at least one child under 18. It should be noticed that a child can be compiled in the statistic receiving both ‘open care’ and ‘alternative care’ services and a child can also be placed in several ways during a year (for example, first as an open placement and later, as a care order).

13^, 14

In comparison, in year 2010 there were 14 199 (1,2%) children placed outside of their homes and 70 212 (6,5%) children received ‘open care’ services15. The reason for the decreased number in children receiving open care services between 2010 and 2020 is the introduction of the Social Welfare Act in 2014 and children and families receiving services under that law. Respectively, the number of out-of-home placements has increased since the 1990’s.

There are big differences in numbers of clients between municipalities and there are many possible reasons for that. First, the decision whether a child receives services under the Social Welfare Act or becomes a client in child welfare services depends on the assessments made by organizations and social workers.16 Second, people may differ in when and where they seek services and how the support from school and other institutions functions. The general service system and regional culture also affects the numbers.

Challenges

According to Government’s proposal¹¹ concerning the Social Welfare Act, there are many challenges in child welfare services. There have been attempts to move the pressure from the child welfare services to early support and preventive services because of the growing need for child welfare services. Despite the attempts, the need for ‘remedial’ child welfare services has increased, as well as the rate of out-of-home placements. It is stated in the government’s proposal, that children and families are not receiving services they need, but there are also challenges concerning the working situation of the social workers. Some of these challenges include low salaries, heavy workloads, a general lack of appreciation of the work, and employees transferring away from the municipalities (turnover and recruitment difficulties). These factors all affect the work that is done with the clients and puts a strain on the strength of the system.

In addition, the Government’s proposal states that there is a growing need for intersectional cooperation so that people would get services on time. It is also stated that child welfare services are used to patch up deficiencies in other services, such as child and youth psychiatry services.

1.3 The health and social services reform

As stated before, the organization of health, social and rescue services will be restructured. The obligation to organize health and social services will be transferred from municipalities to wellbeing service counties from the beginning of year 2023. Municipalities will still be organizing services such as daycare, education, and culture but other services, like child welfare, will be organized by the wellbeing service counties.³

General challenges and objectives

The main challenges behind the reform are the long wait for access to care and services, unequal access to health and social services, the ageing of the Finnish population and therefore the increased need of care, and the fall of the birth rate. In practice, there will be less working age population in the future and therefore the tax revenue will likely also decrease.

The main objectives of the reform are:

• “Reducing inequalities in health and wellbeing

• Safeguarding equal and quality health, social and rescue services for all

• Improving the availability and accessibility of services, especially primary services

• Ensuring the availability of skilled labor

• Responding to the challenges of changes in society

• Curbing the growth of costs

• Improving security”³

As a part of the health and social services reform, the services for children and families will also be developed (this will be covered later in the report).

The structure of the reform

Currently, “municipal social welfare and health care services, implemented with government support, form the basis of the social welfare and health care system”.3 In addition, private companies and other social welfare and health care organizations provide services. In other words, municipalities and coalitions of municipalities organize the health and social services. They can also provide services themselves or purchase them from other municipalities, organizations, or private service providers. When it comes to health care, and especially specialized medical care, hospital districts oversee them. The most demanding medical operations are centralized to the university hospitals.17

In the new model, the wellbeing service counties will organize health and social services. The reform will significantly affect the functioning and economy of the municipalities. The main changes will, for example, include municipalities’ duties and their funding, municipalities’ right to levy taxes and the staff employed by the municipalities. In addition to health and social services, the organization of the rescue services will also be the wellbeing service counties’ responsibility. It is stated on the website concerning the reform, that according to research, a larger actor organizing health and social services will have a better opportunity to safeguard equality on service provision and the efficacy of action.³

The wellbeing service counties will be self-governing areas that will in early stages get funding from the state. The right to levy taxes will be solved later. The responsibilities will be as follows:

• State: guidance and direction, funding

• 22 wellbeing service counties: organizing health and social services, and rescue services

• 5 collaborative areas: division of responsibilities in specialized services³

Wellbeing services

Public services, such as basic and specialized health care, mental health and substance abuse services, and child welfare services, that are organized by the wellbeing service counties, will be developed as part of the Future Health and Social Services Centres Programme. The aim of the programme is to establish health and social services centres and to provide services that will meet people’s individual needs. It is also stated that the programme “is also aimed at improving people’s trust in health and social services”. In addition, digital and mobile services, weekend and evening service times and low-threshold service points are developed.³

Child welfare services will be developed as part of the reform especially through The Programme to Address Child and Family Services. The object of the programme is to develop family centres and early support for children, youth and families, low-threshold mental and substance abuse services for children and youth, and multi-disciplinarity in child welfare. The latter will include safeguarding multi-sectoral services for children in need and developing new services that will combine child welfare services and psychiatry. Cooperation between child welfare services and mental health and substance abuse services, and education will also be developed. Additionally, the implementation of the systematic welfare (based on the Hackney model) will be supported.18

As part of the Programme to Address Child and Family Services, it has been suggested, that the structure of child and family services would be reorganized. The structure is an outline for practice, and it guides the services that will be provided for children and families (the structure supports practice and does not base on, for example, legislation). The services would be divided as follows:

• Low-threshold services (family centre model, services such as early childhood education, divorce services, student welfare services)

• Specialized services (such as child welfare and specialized healthcare)

• Demanding services (such as demanding specialized services in child welfare)19

Most of the child welfare services are specialized services, including out-of-home placements and care orders. OT-centres (covered later in this report) support the handling of the most demanding cases in child welfare, thus the OT-centres and the support (and for example the Barnahus-model) the centres provide are part of the demanding services.

According to a ‘roadmap’ for the transition from municipal child welfare services to county-based operations, the objective is to strengthen the basic services provided for the children and families so that the focus would be in preventive and early support. In a long run, this will lower the pressure in child welfare services. To strengthen the basic services the low-threshold services should be developed, family centres should be established and the cooperation with education and early childhood education should be strengthened. In turn, to develop child welfare services, multi-disciplinarity and systemic welfare model should be developed alongside with developing and monitoring substitute care.

Furthermore, according to the ‘roadmap’, the challenge with the reform will be the transformation of the staff from the municipalities to wellbeing service counties. Placing the staff in specialized and demanding child welfare services will be challenging and to support the reform, education, testing new methods and experimenting is needed.20

Staff and resources

The Act on Social Welfare Professionals21 regulates the education needed to have a right to practice such professions as social work. All registered social welfare professionals can be found in a central register called Suosikki. The object of the act is to safeguard the safety of the clients and their right to good quality social welfare and fair treatment. The objects will be reached by ensuring the education, capabilities and qualifications of the professionals working in social welfare, by promoting cooperation between different social welfare workers in a way that the needs of the clients will be met, and by organizing the monitoring of the social welfare workers. Valvira (National Supervisory Authority for Welfare and Health) grants social welfare professionals the right to 1) act as a licensed social welfare professional, 2) use a protected professional title and 3) grants a restricted license to practice a profession.^21, 22 For instance, the Child Welfare Act specifies that the social workers who are responsible for the child’s affairs in child welfare need to meet the criteria of a social welfare professional as stated in the act mentioned above.

From the staff’s point of view, the reform means that “the healthcare and social welfare personnel and rescue services personnel employed by municipalities and joint municipal authorities will be transferred along with their duties to the wellbeing services counties and joint county authorities for wellbeing services.” The personnel will also retain their rights and obligations after the transfer.³

The government has also proposed that from the beginning of year 2022, a social worker who is responsible for the child’s affairs can only have 35 children as clients. From the beginning of the year, the number of clients needs to be reduced to 30.23

Collaborative areas and OT-centres

To safeguard the regional cooperation and appropriate service system, five collaborative areas will be established. The wellbeing service counties that are part of a collaborative area will conclude a collaboration agreement four times a year to secure the division of labor, collaboration, and coordination so that the health and social services will be carried out efficiently and economically.

The five university hospitals will be located in the five collaborative areas.24

Since it is not feasible or effective for the wellbeing service counties to organize the most demanding services that require multi-sectoral and integrated support and special expertise, a new service structure is developed. The object is, that the OT-centres will serve as a nationwide network of providers of special expertise, and it will be aimed primarily to different professionals. The mains tasks of the OT-centres will be to support young people and families in need through supporting the work carried out in individual regions in complex and new situations, disseminate and develop evidence-based methods and train such methods, maintain expertise, and support research and development work. In practice, the OT-centres mainly support professionals so that children and families can get multiprofessional support in the most demanding and challenging situations. The basis of the work done in OT-centres will be in networking and coordination. The OT-centres will cooperate closely with higher education institutions and centres of expertise.^3, 25

The most demanding health care services have been centralized into university hospitals for a long time, but it has not been the case with social services. The needs of children, young people and families that are the most demanding and complicated must be addressed by the most efficient and economical way possible. The OT-centres will do that by bringing together a variety of different sectors and professionals.¹⁹

The Barnahus-project is a part of developing the OT-centres. The object of the project is to develop “practices compliant with the Barnahus standards in investigation processes of suspected cases of violence against children as well as in support and treatment provided for children who have encountered violence”. The project will be implemented regionally in university hospitals, as well as nationally, by using the models for interprofessional cooperation and information sharing between authorities. The key actors in the university hospitals are the forensic psychology/psychiatry units. 26 The project is funded by the state in 2020–2023 but the goal is to make it a permanent operation model.

1.4 Conclusion

This report gathered information about the health and social services reform in Finland. It needs to be noted, that the process, drafting of the laws and practical application of the reform is ongoing. It is still unclear how the reform affects, for example, the child welfare services in practice and the health and social services reform is not the only process which will change the organization, produce and practices of child welfare services. As stated in the beginning of this report, the sources referenced consist mostly of preparatory papers and statements, and websites describing the reform. The effects the reform will have on different sectors cannot yet be proven and the outcomes have to be evaluated later when the application of the reform is completed