During a recent visit to Finland, Pamela Mason examined the practice of community pharmacy and its role in the Finnish health care system
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Finland (Suomi) is the fifth largest country in Europe, but with a population of 5.2 million, it is one of the most sparsely populated. Geographically, it is usually thought of as a Scandinavian country, but to some extent this denies Finland's unique heritage. True, the country has shared almost 700 years of history with Sweden, and the road signs in both Finnish and Swedish reflect the presence of the 350,000 or so Swedish-speaking Finns, most of whom live in the west and along the coastal areas. However, despite the fact that Finland has been free from Russian domination since 1917, the Russian tradition has also been a strong influence, particularly in the east of the country. |
A customer receives advice on her asthma therapy in a Finnish pharmacy. On the dispensary counter are copies of Terveydeksi, the customer magazine produced by the Association of Finnish Pharmacists |
Finland has a strong welfare system and to support it, according to some statistics, the highest tax rate in the world. The provision of health care services has been a public responsibility for over 450 years, and in principle, the Finnish health care system is, like the United Kingdom's, a national health service financed through taxation and run by salaried staff. Total health care expenditure amounts to around 7.5 per cent of gross domestic product.
The system is now largely decentralised, and the 452 municipalities into which the country is divided not only deliver health care but are also major funders of health services with the power to allocate health care resources. Central government supports this system through legislation and grants to the municipalities, and also allocates funds from the national health insurance system to cover the costs of drugs.
However, during the 1990s, budgetary control at a national level limited the money given by central government to the municipalities, and increasing responsibility for raising funds has therefore fallen on the municipalities.1 As a result, there is concern related to inequities between geographical areas, particularly in the context of higher costs in sparsely populated, rural or other areas that are poor or contain a lot of elderly people, or both. The municipalities have the power to raise tax, but the money collected is a reflection of the taxable population, so increasing the possibility of inequity between areas.
In addition, patients have to make co-payments for various health care services, such as visiting a general practitioner, diagnostic services and prescriptions. The proportion of drug costs that patients have to pay has increased considerably during the past 10 years. Moreover, the drug reimbursement system in Finland is complicated, and there is growing pressure to change it, not least from the community pharmacists, who spend a considerable amount of time managing the system for the social insurance institution.
Every patient has to pay something for a prescription. There are no exemptions for the young, the old or those suffering from specific diseases. How much the patient has to pay depends on the drug category, of which there are four — 100 per cent reimbursement, 75 per cent, 50 per cent, and no reimbursement. Even for a medicine that is 100 per cent reimbursable, the patient still has to pay 25 Markka (about £2.55). Provided the patient shows his or her sickness insurance card, the pharmacist recovers the remaining cost from the social insurance institution and, as in the UK, this is achieved by sending all the prescriptions off for pricing each month. If a prescription contains multiple items, the first thing pharmacists have to do is add up the costs of all the medicines in each reimbursement category and then calculate the reimbursements.
With the high cost of many new drugs, an increasing number of medicines fall into the non-reimbursable category, a situation which was affected by Finland joining the European Economic Area in 1994, prior to joining the European Union in 1995. Before 1994, pharmaceutical manufacturers had to quote a price for a new drug before marketing it. Now, however, they can do this after the drug has been marketed, and if the board for drug reimbursement considers the price of a drug too high, no reimbursement is paid under the sickness insurance scheme.
The first Finnish community pharmacies were established in 1689, and today there are nearly 800 community pharmacy outlets. The population per pharmacy of around 6,500 is higher than in the UK (4,500), but throughout the Nordic countries pharmacies tend to be large and the pharmacy network less dense than it is in middle and southern European countries. In fact, Finland has the densest pharmacy network of all the Scandinavian countries.
In principle, medicines are sold and supplied only in pharmacies under the supervision of a pharmacist, although in sparsely populated areas some of the commonest medicines are available in post offices and grocers. Patients in these areas can also have repeat prescriptions delivered to these outlets, but they have to go to a pharmacy if any of their medication is changed. These outlets have to keep medicines in a locked cupboard and if customers want advice they have to telephone a pharmacy. Because the provision of advice in pharmacies is now valued so highly by the Finnish authorities, this system, even though an exception, is not thought to be ideal, and the number of outlets supplying medicines in this way is decreasing.
Most Finnish pharmacies are privately owned, and no pharmacist can own more than one pharmacy. However, with the permission of the national agency of medicines, a pharmacist can also own up to three "subsidiaries "in the neighbourhood. The only "chain "is the Helsinki University Pharmacy chain, owned by the University of Helsinki, which consists of one main pharmacy at the university plus 15 subsidiaries.
The number of pharmacies in Finland is carefully regulated by the national agency for medicines. To buy a pharmacy usually means waiting until a current pharmacy owner retires, receives a licence for a new pharmacy or dies, when the licence for that pharmacy will be declared open. In addition, the national agency of medicines can, at its discretion, establish community pharmacies in areas with growing populations that it considers to be deficient in pharmacy services.
Pharmacists can then put in an application for the licence, and the agency makes a selection from the applicants, of whom there might be five or six in a rural area and up to 20 in a more densely populated region. Selection criteria are not published, but applicants know that success depends mainly on their level of experience and education. Moreover, an explanation is given to unsuccessful applicants and, although seldom used, a complaints procedure exists, so ensuring some transparency in the system. Pharmacists tend not to own their first pharmacy until the age of about 40, starting with a small pharmacy, then progressing to a larger pharmacy as finances and family commitments allow. The price paid for a pharmacy is basically the value of the stock — there is no charge for goodwill.
Average pharmacy turnover is around £1.2m a year, of which nearly 80 per cent is generated by prescription medicines, about 15 per cent by non-prescription medicines and 5 per cent by other items. The average number of prescriptions per pharmacy is 54,000 a year.
In contrast to other "businesses”, which have to pay all the usual Finnish taxes (eg, value added tax, income tax, municipal tax, church tax), community pharmacies have to pay a separate "pharmacy fee "based on total turnover. The idea of the pharmacy fee is to even out differences in financial profitability between pharmacies of different sizes and hence to ensure the maintenance of pharmacies in remote areas. Small community pharmacies pay only small fees, and the smallest pharmacies pay no fees at all, but for the biggest pharmacies, the fee may be over 10 per cent of turnover. The University of Helsinki chain is exempt from this fee, which, given that its turnover amounts to 10 per cent of the total turnover of Finnish pharmacies, is something of a contentious issue.
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As in Norway and Sweden, there are two pharmaceutical qualifications in Finland, a situation that often appears confusing to pharmacists from non-Nordic countries. One qualification is the master of pharmacy degree, which takes five to six years to complete, including six months' practical training in a pharmacy, and can be obtained from either Helsinki or Kuopio university.
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 The provision of advice in pharmacies is valued highly by the Finnish authorities |
In Finland, as in other European countries, people are being encouraged to manage their own ailments and conditions, and during the past 20 years Finnish pharmacies have started to bring some of their non-prescription products from behind the pharmacy counter to place them in the customer area.
However, the Association of Finnish Pharmacies (AFP) is keen to ensure that medicines are not seen by consumers as ordinary items of commerce, and it has made a recommendation that a pharmacy should not resemble a supermarket or any other self service outlet. The association's guidance also suggests that newly registered over-the-counter medicines, those switched from prescription status to OTC and other powerful medicines such as analgesics and those with the potential for abuse should be kept in a location where there is always a qualified member of staff to give advice, for example, near to the prescription area.
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In the Vuosaari Pharmacy, situated in the Columbus shopping centre on the edge of Helsinki, which I was able to visit, all these medicines were visible but kept behind the prescription counter, and customers did not have direct access to them. Products such as nutritional supplements, herbal preparations, skin preparations, those for oral hygiene and dressings and bandages were kept in the customer area beyond the counter. |
 Health promotion is an important part of the pharmacy services offered in Finland |
Health promotion is an important part of the pharmacy services offered in Finland, and national health campaigns have been instituted in pharmacies since 1988. An "ask about your medicines "campaign has been operative in Finland since 1994, but pharmacists have also been involved in other initiatives such as smoking cessation, management of obesity, diabetes, hypertension and asthma, needle and syringe exchange schemes, medicines awareness for conscripts in the Finnish armed forces and information for secondary school pupils on the adverse effects of drug and alcohol abuse. All pharmacy projects are designed to be integrated with national health promotion programmes.
In relation to health promotion, there is something of a difference of opinion between the pharmacy associations and the authorities in that the authorities want pharmacies to focus on medicine supply and not to be involved in screening, such as blood pressure measurement. The area of concern is the difference between screening used for diagnostic purposes, which the authorities judge to be the doctor's responsibility, and screening used for follow-up, where the authorities agree that a pharmacist can be involved.
Another part of health promotion in community pharmacies is the customer magazine Terveydeksi (For Your Health). Produced by the AFP's publishing company (PharmaPress Oy) and distributed three times a year, it provides up-to-date information on drugs, management of illnesses and health promotion.
According to Mr Kostiainen, Terveydeksi has one of the best reputations of all the health magazines in Finland, mainly because its advice is deemed to be sound and unbiased.
One issue for the future is electronic prescribing, for which the legislation — but neither the system nor the standards — is now in place. The AFP is working with various bodies, including the social insurance institution, the national agency of medicines, the ministry of health and the medical association for standards in this area, and a pilot project of electronic prescribing is running in western Finland.
In Finland developments in information and communications technology have been particularly rapid. Within Europe, Finland is second only to Iceland in ownership of mobile telephones, and nearly half the population has access to the internet. However, according to Mr Kostiainen, Finns appear to be relatively uninterested in electronic commerce, although this is likely to change. If properly regulated, e-commerce should be seen as an opportunity rather than a threat to community pharmacy, he believes. Currently, a major study is being conducted in Finland to find out how e-business can be used to improve pharmacy services. The AFP believes that e-commerce in medicines should be an integrated part of pharmacy services, rather than an independent operation, and should be one that ensures safety of medicine and protection of patients.
One of the most recent developments in the area of mobile communications was launched in July by the pharmacy association and the Finnish telephone network, Sonera, in which people can use their mobile telephones to find out where the nearest pharmacy is to access its contact information. Perhaps Finns will soon be using this technology to order and buy their medicines and access health information from the pharmacy.
1. Koivusalo M. Decentralisation and equity of health care provision in Finland. BMJ 1999;318:1198-1200.
Pamela Mason is a pharmacist and freelance writer from Sydenham, South East London