Frequently asked questions about freedom of choice
It means clients’ right to choose a suitable service provider, service entity and professional to provide them with health and social services. These rights to choose are to be expanded as of 1 January 2020. The draft bill for the Act on Clients’ Freedom of Choice in Healthcare and Social Welfare (Freedom of Choice Act) proposes that publicly funded health and social services could in future be provided by public, private and third-sector operators, such as organisations and foundations. Client charges will be the same for the same service, irrespective of service provider. Clients would have more freedom to choose the service providers that best suit them.
- This would mean that clients can sign up with the health and social services centre and dental clinic (oral health services unit) of their choice. The service provider would have to be approved by the county and the national licensing and supervisory authority.
- Clients could even get health and social services vouchers or a personal budget to get the health and social services defined in their client care plan.
- When using services provided by the county, clients could also choose which unincorporated county enterprise and which of its service entities to use. The service entity could be a social services clinic or a hospital, for example. Services provided by counties include social services and specialised medical care and some other health services.
- Clients can choose the professional they wish to see if it is possible and appropriate.
- Clients can seek medical care in another EU or EEA country already under existing provisions.
A service provider offers healthcare and social welfare services to people. The service provider can be public or private operator or entrepreneur. For example, health and social services centres’ service providers can be unincorporated county enterprises or county-owned companies, private companies, cooperatives or third-sector operators.
Clients may choose an unincorporated county enterprise and its service entities from their own county or a neighbouring county. Unincorporated county enterprise means an administrative entity Unincorporated county enterprises will offer, for example, specialised medical care, social services, maternity and child health clinic services, rehabilitation, as well as school and student healthcare services. Unincorporated county enterprises are also economic entities. Unincorporated county enterprises must keep accounts separate from the county’s other activities.
A service entity of an unincorporated county enterprise means an administrative entity for the provision of a package of services. Service entities can offer several services or just one service. A social services clinic or a hospital, for example, can be service entities of an unincorporated county enterprise. Unincorporated county enterprises’ service entities can be different in different counties.
Unincorporated county enterprises’ service entities can have one or more service units for the provision of services. This means, for example, that a social services clinic (service entity) has one unit that offers child welfare services and another unit offering services for people with disabilities. The service units of a service entity do not need to be located in the same place. Services may also be arranged in such a way that all units of the service entity offer all services available at the service entity.
Health and social services centres and oral health services units (dental clinics) will be offering direct-choice services. Direct-choice services mean that county residents can sign up with the health and social services centre and dental clinic of their choice directly without prior assessment of their service needs by a professional, which is a condition for many other health and social services.
Direct-choice services mainly include primary healthcare services and certain types of consultations with medical specialists as well as guidance and advice on social services. Basic-level services given by dental clinics are also direct-choice services. The Freedom of Choice Act will lay down provisions on this.
Health and social services centres offer their clients primary health services and guidance and advice on social services. Health and social services centres offer for example:
- health counselling
- health checks
- appointments with general practitioners
- assessments of functional capacity and work ability
- guidance and advice given by social welfare professionals (see social services), and
- appointments with selected specialists.
The aim is to improve the availability and quality of services and to encourage counties and service providers to work in the most efficient and effective way. This ensures that clients will get help for their matter or problem faster than today. Clients will have faster access to a nurse, physician, social worker or to other services. Clients will also have more freedom to choose where to get services and which services to use. The goal is that clients have better opportunities to have a say in decisions that concern them and their care and treatment. It is believed that the quality and cost-effectiveness of health and social services will improve when there is competition for clients among service providers.
Yes, they can. Patients can, for example, choose their health centre. They can also use private health services and receive reimbursement for the costs from Kela, the Social Insurance Institution of Finland. Patients can also choose a specialised medical care unit located in Finland. They can even seek medical care abroad. In social services, however, the clients do not yet have the same freedom of choice based on legislation, although they can choose some services using the current service voucher.
More information on choosing a care facility at present:
The Act is scheduled to enter into force at the beginning of 2020 when the counties start to organise health and social services. Clients can receive services from public or private health and social services centres as from the beginning of 2021. As of 2022, clients can receive dental care services from public or private dental clinics (oral health services units). Personal budgets and health and social services vouchers would be available by 1 July 2020. The draft bill contains several transition periods.
It depends on when their county starts organising the services. The Freedom of Choice Act gives counties the option of a transition period, which means that different counties may introduce freedom of choice at different times.
People can sign up as clients with health and social services centres in all counties as of 2020, if not earlier. Earlier signing-up will be available to the residents in the counties taking part in the freedom of choice pilot projects. The counties will determine the timetable. People can sign up as clients with the oral health services unit of their choice as of October 2021, if not earlier.
Those who have not chosen their health and social services centre will be first registered as clients of the health and social services centre of the unincorporated county enterprise in their county. They will be notified of the health and social services centre where they have been registered as clients. The decision is based on their place of residence. They will also be informed that they have the right to change their health and social services centre straight away.
Once clients have chosen a health and social services centre, they have to wait at least six months before they can change the centre to another.
Those clients who have not chosen a health and social services centre by the end of 2022 will be assigned a health and social services centre by the county. The county must choose the (public or private) health and social services centre in the county which is most accessible to the client.
Oral health services units (dental clinics) will start operating in all counties on 1 January 2022. Data on all county residents who have not chosen a dental clinic will be entered into a database of the unincorporated county enterprise. However, this process does not sign them up as clients with any dental clinic. If residents do not themselves choose a dental clinic by 1 January 2024, after that date they will receive the services from the dental clinic assigned to them by the county. The county must choose the public or private clinic that is most accessible to the client. Once clients have chosen a dental clinic, they have to wait at least six months before they can change the clinic to another.
Today’s freedom of choice will be extended further: clients will have more freedom to choose a health and social services centre where they can visit nurses and GPs and get advice and guidance on social services. In addition, clients can choose a dental clinic. Clients can even see a specialist in their health and social services centre.
Clients may choose between the unincorporated county enterprises and their service entities. Unincorporated county enterprises will offer services at health and social services centres and dental clinics but they will also provide all those services that are not available in centres and clinics, including maternity and child health clinics, hospitals, child protection services, home care, and services for people with disabilities.
This means that clients make three choices: an unincorporated county enterprise, a health and social services centre and a dental clinic.
Clients can also choose their service provider when they get a health and social services voucher from the unincorporated county enterprise. They can receive a voucher for getting physiotherapy or home care services. A personal budget can be granted to older clients and clients with disabilities who need many different kinds of services. Clients can use the personal budget to get housing services, for example. Clients can choose a service provider from anywhere in the country. Client charges will be the same for the same service, irrespective of service provider. They will be collected by the county, not the service provider.
If the unincorporated county enterprise offers a services voucher, the client can still choose to receive the service from the unincorporated county enterprise.
Once a client has chosen a service entity, he or she can then ask for a particular professional.
Some clients need more health and social services than others. In such cases, a service entity of the unincorporated county enterprise (for example social services clinic, hospital or unit offering services for persons with disabilities) will assess the client’s need for services and draw up a client care plan. The client can then get the services defined in his or her care plan directly from the service entity of his or her choice. Alternatively, the client can receive a health and social services voucher or a personal budget which he or she can use to get the services included in the client care plan. In that case the client can get the services from private or third-sector operators.
No, they don’t. A referral from a GP working at a health and social services centre can be processed electronically at the unincorporated county enterprise, and the need for specialised-level services can be confirmed in the same connection. The client will then be referred to the kind of treatment his or her needs require.
The county must make social welfare experts available at health and social services centres as needed. These experts can be social welfare workers or geriatric nurses. In such cases, the client’s life situation is assessed by a social welfare professional or a group of professionals together with professionals working in the health and social services centre. A client care plan will be drawn up for the client, recording the services the client needs, and the client is referred to the kinds of social services he or she needs.
Health and social services centres offer guidance and advice on social services. Some staff from the county’s social services will also be working at health and social services centres. Counties must have one or several groups working at health and social services centres, including a social worker, other social welfare professionals and even healthcare professionals, when necessary. In this way county staff would offer social services and make needs assessments at health and social services centres, and clients would not need to visit a service entity of their unincorporated county enterprise.
Clients who need social services will be referred to an unincorporated county enterprise. The client may also be referred to receive peer support from a third-sector operator if there is no need for health and social services.
Counties must decide in which at least two fields health and social services centres will provide consultations and appointments with specialists. The fields can include internal medicine, paediatrics, geriatrics, ophthalmology, psychiatry, physiatry, orthopaedics and dermatology. The fields can also be other than those mentioned above.
The counties will be responsible for organising healthcare and dental care services for school students and students in general and vocational upper secondary education This will not affect the content of services. University students will receive their services from the Finnish Student Health Service as before.
School and student healthcare and associated dental care will be organised by the counties, and students have no freedom of choice in these services. Municipalities will continue to organise psychologists’ and school social workers’ services for students. Dental care for adults will fall within the scope of freedom of choice, which means that clients can choose their dental clinic themselves.
Home care for older people will be the responsibility of unincorporated county enterprises. Older people and people with disabilities can even get a health and social services voucher or a personal budget which they can use to get the services, such as home care, listed in their client care plan.
Mental health patients and clients with substance abuse issues may contact their own health and social services centre or even the relevant service entity of the unincorporated county enterprise. The health and social services centre will refer clients with a more demanding or long-term mental health or substance abuse problem or clients who need social welfare services to the unincorporated county enterprise’s unit for mental health and substance abuse services, for example.
Maternity and child health clinics are the responsibility of the unincorporated county enterprise. The county can decide that health and social services vouchers can be used to get even maternity and child health clinic services. This would mean that clinics could be operated by private service providers.
County residents can choose, as of 2022, a public or private dental clinic (oral health services unit). If a resident has not chosen a dental clinic before 1 January 2024, the county will refer him or her to the unit which is most accessible to the resident. Dental clinics will offer oral and dental care, as at present. Services for children and young people are the responsibility of the unincorporated county enterprise. Counties can decide to grant services vouchers for orthodontic treatment and dental prosthetic treatment.
Your county will keep an online record of service providers (incl. service entities of the unincorporated county enterprise, health and social services centres, dental clinics and other services). The record must also include information on the quality and availability of services. In addition, the Social Insurance Institution of Finland will maintain an information service that contains information on the health and social services centres’ and dental clinics’ service providers and on the service providers approved to deliver services against health and social services vouchers. Private service providers will enter, for example, their tax and salary details in the information service.
Health and social services centres and dental clinics will be obliged to provide online up-to-date information about their effective waiting times.
Clients will have the right to receive the information even orally or in writing if they ask for it.
No, they don’t. The county will decide which service provider will be used if clients do not decide themselves. Family members can participate in the decision-making, if necessary. Clients who have not chosen a service provider will be assigned a health and social services centre and/or a dental clinic by the county.
The service provider for a minor will be chosen by the person responsible for the child’s care and custody or his or her other legal representative. Young persons aged 15 may themselves choose their service providers.
When necessary, clients can get support to choose the service providers that suit them. All service providers are obliged to give advice and guidance to clients. There will be an online service with information that helps clients compare different service providers. In addition, clients can get assistance and support through a telephone helpline, from service coordinators or from their designated primary social worker. Clients who do not want to exercise their right to choose a service will be guided to suitable services by their county.
As a rule, all clients have freedom of choice. There are, however, some exceptions, such as school and student health care and child protection services. Similarly, as a rule, inpatients receive healthcare and social welfare services from the unit caring for them, such as a hospital.
The unincorporated county enterprises and their companies, too, can market their services. Moreover, the age and morbidity of clients will affect the amount of compensation the counties pay the service providers. As a result, it pays off to have many different kinds of clients.
Counties will determine beforehand the amount of compensation to be paid to health and social services centres and dental clinics. As a rule, the compensations are not based on performance: instead they are determined by the number of clients and their personal characteristics, such as age, gender and morbidity. Moreover, service providers cannot choose their clients. They must accept all those who sign up as clients with them.
The county determines beforehand the amount of compensation payable against health and social services vouchers granted by the county. The unincorporated county enterprise determines for each client the services included in the personal budget and the compensation payable for the services.
Service providers must be registered service providers and they must meet the conditions set out by the county. Health and social services centres and dental clinics must sign agreements with counties and assume responsibility for organising service packages defined by law and county decisions. This will safeguard the quality of services and transparency of operations.
The service providers must also publish all required information online, including waiting times for their services.
Companies operating health and social services centres and dental clinics are free to decide where to establish their service entities. International experience indicate, however, that people tend to visit services located close to their home or workplace. In the Finnish model, the location of a service entity will not have any significant effect on profitability. This is because the compensations paid to service providers are based on factors that define the kind of services the clients need. Such factors include age and morbidity. Some of the funding can also be based on performance. For these reasons, a client who needs many different kinds of services can be as profitable for the service provider as a client who uses services only occasionally.
It is true that many health and social services centres will probably offer also services against a fee in addition to the services that are funded by the county. The important fact is that all clients are equal in the basic-level services funded by the county. According to the draft Freedom of Choice Act, health and social services centres would also provide consultations and appointments with specialists at least in the fields of internal medicine, paediatrics, geriatrics and ophthalmology. The reform would mean that all clients have better access to services of these specialists.
Services will be organised in packages so that the unincorporated county enterprise will be responsible for certain services, such as social services and specialised medical care. This will be taken into account in the funding. When a health and social services centre refers a client to the unincorporated county enterprise, the unincorporated county enterprise will assess the client’s need for care and services. If the service needs assessment and maybe even examinations reveal that the client does not need services for which the unincorporated county enterprise is responsible, the client will be referred back to the health and social services centre.
Small enterprises have good chances of delivering services against health and social services vouchers and personal budgets. Moreover, health and social services centres and unincorporated county enterprises could supplement their own service provision by purchasing services from small and micro enterprises. Small enterprises could provide services for health and social services centres by means of cooperation agreements or joint enterprises. Small enterprises could also offer various support services, such as cleaning and catering.
The clients can choose which unincorporated county enterprise and service entity they want to use. The unincorporated county enterprise grants the client a health and social services voucher or a personal budget if the service needs assessment shows that the client needs services which he or she could get against a services voucher or personal budget. The client can, then, get the services included in his or her client care plan from the service provider of his or her choice.
Access to urgent care remains unchanged. Clients will still have the right to seek urgent care regardless of their home municipality or place of residence. In emergencies people can call 112 or go to the nearest emergency care services.
Clients can be charged for using a service, as at present. The client charge will be the same for services provided by an unincorporated county enterprise, a company or a third-sector operator. The amount of the client charge will be defined by law. The act on client charges will be amended and the amendment work is already going on. Client charges will be clarified and harmonised. At the same time it will be ensured that the payment burden will not become too heavy for anyone. It will always be the county who collects the client fees, not the service provider.
Clients make a six-month commitment with the health and social services centre and dental clinic they choose. This means that once clients have chosen a service provider, they have to wait six months before they can change from one service provider to another. However, clients who move to another town or have some other well-founded reason can change their choice of a health and social services centre or dental clinic when it suits them. If, for reasons of work, studies or recreation, clients are temporarily residing in a municipality where their chosen service provider is not operating, they can get services from another service provider. They have to notify their county of the temporary change.
Clients can change from one service provider to another also in cases where they have received services against a health and social services voucher or a personal budget.
Unincorporated county enterprises can grant their clients health and social services vouchers. Clients can then choose a service provider and get the agreed service from that provider against the services voucher. A services voucher can be granted after the unincorporated county enterprise has assessed and verified which services the client needs. Clients can get services vouchers for buying home services, for example. In that case the client can choose a service provider that best suits him or her.
A services voucher is not money or a banknote given to the client. Health and social services voucher means that the county is committed to compensate the costs of the service given to a client, up to the amount recorded in the voucher. Service types and their maximum costs will be defined in the services voucher. Counties pay compensations directly to service providers. Clients only pay the client fee which is the same for the same service, irrespective of service provider. Clients can buy additional services at their own cost if they want.
With services vouchers clients can themselves choose a service provider approved by one of the counties. Unincorporated county enterprises must give their clients information on the service providers that deliver services against services vouchers.
A client may always refuse a services voucher offered to him or her. In that case the unincorporated county enterprise must arrange the services for the client in another way.
Unincorporated county enterprises must take into use health and social services vouchers for services defined by the Act on Clients' Freedom of Choice in Healthcare and Social Welfare. Services vouchers must be offered, for example, in the case of services for older people and people with disabilities and rehabilitation services.
Clients who receive a health and social services voucher or a personal budget do not get any money from the county. Instead, the service provider receives compensation from the unincorporated county enterprise for services delivered against services vouchers or personal budgets. There may be a client charge for the service which the client must pay. The client charge usually covers a small proportion of the actual costs of the service.
The health and social services voucher, granted by unincorporated county enterprises, will replace the current service voucher granted by municipalities. The counties must introduce health and social services vouchers at least in the services defined by law by 1 July 2020.
Once the Freedom of Choice Act enters into force, clients can use the service voucher granted to them earlier as long as it is valid. However, the voucher must be used within six months of the date on which the county introduces the health and social services voucher. Clients may also request that they will be allowed to use their service voucher for a maximum of two years. Counties must, where possible, ensure that the client will also continue to receive care and treatment from the same service provider after the service vouchers are no longer used.
Personal budget means a financial obligation which the client can use to get services defined in his or her client care plan. Before granting a personal budget, the unincorporated county enterprise must assess what services the client needs and draw up a client care plan for him or her. The services the client needs will determine the content and amount of the personal budget. A personal budget must be offered to older people and people with disabilities who need continuous and broad-based support.
Clients can themselves decide where to get the services defined in their client care plan, and they can also influence the content of their services. In this way clients will receive services that best meet their needs. The service providers receive compensation from the counties for services delivered against personal budgets. Clients do not get money from the county.
Yes, they can. Clients have the right to refuse a services voucher or personal budget offered to them. The unincorporated county enterprise must, then, organise the client’s health and social services in some other way, by either providing the service itself or by outsourcing it.
The personal budget is valid either for a fixed term or indefinitely. The county will monitor the adequacy of each personal budget at least once a year and make any necessary adjustments. The personal budget can be adjusted for example if there are substantial changes in the client’s life situation or need of assistance. The personal budget can also be adjusted in case of significant changes to the service costs.
One of the two counties where you live is your home county because everyone is registered as a resident of a municipality (within a county). However, the new Freedom of Choice Act is flexible and allows you to change your home county temporarily. If for reasons of work, studies or recreation you are temporarily residing in a municipality where your chosen service provider is not operating, you can visit some other service provider’s health and social services centre or dental clinic. However, you must notify your own county either via national online services or otherwise in writing that you are using another service provider on grounds of temporary residence.
You also have another alternative. You may originally choose a private health and social services centre or dental clinic that has local service units across the country. They would have a local service unit both in your home county and in the county where your summer cottage is located. You would then be able to use even other service units of the same service provider in Finland without submitting a notification.
If you receive a health and social services voucher from your county for some particular service (such as physiotherapy, home care, surgical operation), you may freely choose your service provider from all over Finland. The service provider must, however, be approved by one of the counties. In other words, the service provider must meet the conditions and requirements set by the county. Counties keep online records on services providers. You can also get further information from the county's advice service.
- Additional information on freedom of choice model from the clients' perspective (in Finnish)
The amount of the personal budget is based on the client care plan, and it will cover the necessary costs. In other words, the client will be able to get all the services recorded in his or her client care plan using the personal budget. However, clients who want to get services that are not recorded in their client care plan must pay for the services themselves. The personal budget cannot be used to pay for services not recorded in the client care plan.
The costs of transport services can be included in the personal budget, if it has been determined that the client needs transport services and wants to purchase them using his or her personal budget. If the client does not want to include transport services in his or her personal budget, the unincorporated county enterprise will produce these services for the client in another way.
A rush to public services is not likely. The current reimbursements under health insurance for specialists’ services are fairly small. In the future the employers will still arrange occupational healthcare for the majority of the working age population. The freedom of choice is likely to benefit the most people who need services often and in a variety of ways.
Service supply will not be as good in sparsely populated areas as it will be in towns and cities. Some areas in Finland may have one service provider only. Those areas, too, will have services because counties have a statutory obligation to safeguard services in sparsely populated areas. Some services can also be offered in new ways, for example as online or home-delivered services.
Not everybody can become a service provider. Service providers must be registered in a national register of providers of health and social services. Only service providers fulfilling the requirements laid down by legislation can be entered in the register.
Service providers who fulfil the requirements laid down in the Freedom of Choice Act can express their interest to operate as health and social services centres or oral health services units. Counties will approve the service providers on the basis of their expression of interest and conclude contracts with them. Counties will also approve service providers who deliver services against health and social services vouchers.
A national licensing and supervisory authority will monitor the service providers’ activities. In addition, counties will have a responsibility to monitor health and social services centres, dental clinics and other providers of freedom of choice services. Clients who feel that there are deficiencies in the service provider’s services, access to these services or the treatment they receive will have the right to have the matter investigated by the county.
Counties will be responsible for ensuring that all residents get the services they need and that services by all service providers form a well-functioning system that runs smoothly and efficiently. Counties can set out conditions for service providers to ensure well-functioning service chains and packages.
The unincorporated county enterprise will be responsible for each client’s services as a whole, even when it grants services vouchers which clients can use to buy the service from another provider. Similarly, health and social services centres will be responsible for their service package for the client, even when the centre purchases some of the services from another service provider.
Client care plans are used to integrate the different kinds of services the clients need. Each client will have one client care plan, drawn up when necessary. It will contain a plan on all health and social services for the client, irrespective of service provider. Drawing up client care plans is the responsibility of the unincorporated country enterprise or the health and social services centre together with other service providers. All service providers would have to follow the client care plan.
The Freedom of Choice Act will lay down provisions on openness and corporate social responsibility which will apply to providers of direct-choice services in healthcare and social welfare and to providers delivering services against services vouchers. Those provisions would not, however, apply to the healthcare and social welfare sector in general. According to the Freedom of Choice Act, health and social services centres’ and dental clinics’ private service providers would be obligated to issue annual reports on revenue, taxes paid and place of taxation, profit and loss, management salaries and bonuses as well as on corporate social responsibility. The same would apply to private service providers delivering services against health and social services vouchers. In large companies this regulation would also apply to information regarding the whole company group. All information must be available in data systems related to the freedom of choice, which makes it easier to find the information. This will safeguard openness and give opportunities to assess companies’ activities.
People will be encouraged to get involved in the improving of health and social services. County residents can, for example, participate in developing health and social services by attending client panels or councils for older people or people with disabilities. Voting in county elections will also be an important way to contribute. Clients can influence, for example, by choosing the provider of their health and social services. Clients will have the right to change their service provider.
Clients have the right to seek non-urgent care abroad in an EU or EEA country and to receive compensation. The Social Insurance Institution of Finland will afterwards pay reimbursement for the costs of medical care acquired in another EU or EEA county or Switzerland. The reimbursement grounds are the same as for treatment by private healthcare providers in Finland. A prerequisite for the reimbursement is that the treatment received must be part of the service selection of the Finnish healthcare system and reimbursable under the Finnish Health Insurance Act.
- How to seek care abroad (www.choosehealthcare.fi)
Persons seeking care in another EU country would get health services on the same reimbursement grounds as in Finland. In the case of direct-choice services referred to in the Freedom of Choice Act, the person would not need any prior authorisation or notification. Reimbursement for other health services would be subject to a prior assessment of need for care or referral.
Persons seeking care in another EU country would still be obliged to pay for their care and travel costs first themselves. Costs would be reimbursed retroactively up to an amount corresponding with the costs of organising the same care in the health services of the county where the person is a resident. Persons seeking care in another EU country would still have to pay themselves for the client fee charged from patients receiving the same or corresponding care in Finland.
- Costs of seeking care in another EU country will decrease (Press release, 1 June 2017)
There are several provisions that aim to ensure comparability:
- As a rule both private and public operators have the same tasks (section 18).
- The conditions are the same and they are based on administrative decisions. The conditions must be harmonised (section 42), fair and in accordance with the principle of proportionality (section 44).
- Grounds for compensations are the same (chapter 10).
- The pricing of the services an unincorporated county enterprise sells internally to a health and social services centre or the services sold by the service centres must be market-based (section 61).
- Both private and public operators must comply with general administrative legislation (section 3).
- The accounts for direct-choice services must be kept separate from other accounts (sections 56–57) or one or more separate public utilities must be established for the purpose (section 16).
- Private and public operators have the same obligations when they provide direct-choice services (section 54).
- Private and public operators have the same criminal liability and liability for damages (section 75).