Administrative challenges in the Finnish alcohol and drug treatment system

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1 Kristiina Kuussaari & Airi Partanen Research report Administrative challenges in the Finnish alcohol and drug treatment system Introduction Addiction treatment systems can be examined at different levels. At the micro level, information is needed about existing alcohol and drug treatment methods. At the meso level, the focus is on treatment systems organisations, and at the macro level, interest centres on policy frameworks for the treatment system. (WHO Technical Consultation 2006, 6). It is the macro level, the impact on the treatment system by policy frameworks, that is the focus of our article. We will discuss how the different ongoing nationwide plans and guidelines may influence the content and structure of the Finnish alcohol. Patterns of change in the addiction treatment system vary from one country to the next. The requirement for more cost-efficient systems seems to be the only common argu- Declaration of conflicting interests Development manager Airi Partanen has acted as one of the expert secretaries in the process of preparing the MIELI plan. She is also involved in the implementation of the plan. Submitted Initial review completed Final version accepted A B S T R A C T K. Kuussaari & A. Partanen: Administrative challenges in the Finnish alcohol This article examines the National Plan for Mental Health and Substance Use Work (the MIELI plan), published in Finland in We place the plan into a wider context of changes in Finnish social and health services and have also studied responses to the plan. The data is provided by national documents, complemented by an online enquiry and some journal articles as feedback material. The MIELI plan is implemented in conjunction with a municipal and service system reform in Finland. While the proposals of the plan clearly carry a potential for change in the treatment system, there are also great challenges. For instance, to what extent can this kind of plan influence reality? Can the proposals really change anything in the treatment system, or does the potential change emerge from elsewhere? Responses to the plan indicate that referral-free access to treatment, the principle of a single entry point and primary-level services in general were considered important proposals in the MIELI plan. At the other end of the scale, the implementation of the plan and its medical orientation were received less positively. NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

2 Key words addiction treatment system, change, mental health problems, national plan, substance misuse ment behind most changes. In most other respects, arguments and the directions of the changes are different. In Denmark, for example, the treatment system has been decentralised, while the trend in Norway has been toward a more centralised and medically oriented structure (Stenius 2010). The Netherlands and Canada are examples of treatment systems in which reform has focused on the integration of mental health and substance abuse work (Schippers et al. 2002; Rush 2009). Babor and colleagues (2008) have found that decisions on treatment systems reforms are often made without considering their implications for specific groups or for the population as a whole. Another observation is that there appears to be little or no scientific research behind the reforms. Change is rather driven by other kinds of arguments. Furthermore, the evaluation of the reforms leaves a lot to be desired. Schippers et al. (2002) have outlined the Dutch substance abuse treatment reform, discussing the elements of successful change in addiction treatment systems. The main challenges clearly arise from implementation. According to Schippers et al. (2002), adequate funding must be available for implementing a reform. It is also essential that the initiating administrators are committed to the changes. It is further important to involve the professionals in the field in the process to ensure that changes really reach the grass roots level. Professionals may also need different treatment skills than before and they may therefore require additional training and intensive supervision. There should be a feedback mechanism in facilitating implementation, and representatives of patients/clients should be actively involved in the process of reshaping the system. Finally, it is noted that successful implementation takes time. (Schippers et al. 2002, ; also Torrey et al. 2001) In Finland, a National Plan for Mental Health and Substance Use Work (known as the MIELI plan) was submitted in 2009 (Mielenterveys- ja päihdesuunnitelma ). As implementation of the plan has just begun, it is yet too early properly to evaluate its impact on the Finnish treatment system or to say anything about its success or failure. In this article, we will focus instead on describing the content of the plan and put it into the wider context of changes in social and health services in Finland. In addition, we have studied 668 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

3 the feedback that the plan has received. In conclusion, we will discuss the plan s potential impact. We will particularly discuss the following questions: 1) What is the larger reform background to the proposed reforms of the mental health and addiction treatment systems? 2) What are different treatment system actors attitudes to and expectations on the reform? The main material consists of the national documents, such as the MIELI plan and the National Development Programme for Social Welfare and Health Care, Kaste. An online enquiry and some journal articles are used to analyse feedback to the plan. In the analyses of online enquiry, we made use of data frequencies, cross-tabulations and content analysis. Journal articles were analysed with content analyses. Restructuring of municipalities and social and health services The Ministry of Social Affairs and Health (MSAH) is in charge of the overall functioning of social and health services in Finland. The Ministry decides on the general development guidelines for the services, drafts legislation and steers reform processes. It monitors the implementation and quality of services through the Regional State Administrative Agencies (AVI) and the National Supervisory Authority for Welfare and Health (Valvira). At the beginning of the 1990s, the Finnish social and health service system was decentralised, which restricted the role of central government to the level of strategy. Today, the responsibility for organising social and health services, including alcohol and drug treatment, lies with the 342 independent municipalities, which have, for example, taxation powers and which decide how the tax revenue is distributed. The social and health service system is organised on two levels: 1) municipal primary-level services (primary health care, social welfare services) and 2) specialised medical and hospital care. Each municipality belongs to a particular hospital district area. Both addiction treatment services and mental health services are regulated by law in Finland. The Act on Welfare for Substance Abusers (41/1986) defines the scope of responsibility from the promotion of well-being of the substance users to the treatment and prevention of problems. The act states that the municipality shall see to the provision of addiction treatment services in accordance with the needs in the municipality. Addiction treatment services can be provided as part of the general social and health care services and/or as specialised addiction services. The act emphasises outpatient services, easy accessibility, flexibility and diversity of the services. Mental health services are regulated by the Act on Mental Health (1116/1990), which looks broadly at the mental health work, from the promotion of the mental well-being to preventing, curing and alleviating mental illness and other mental disorders. Municipalities have the responsibility to organise mental health services as part of public health care and social welfare. Joint municipal boards for hospital districts are appointed as providers of the mental health services which are regarded as specialised medical care in their particular geographical areas. At present, addiction services are placed NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 mainly within the social welfare sector, while mental health services are mostly based within the health care sector. It is a challenge to provide welfare services in Finland now that the population ages, the post-war baby-boom generation retires, internal migration increases, and external economic changes in the wake of globalisation, for example pose serious challenges to the municipal economies. In addition, mental health problems and increased alcohol and drug use test not only the social and health services but also many other sectors in the society. In order to secure welfare state services in the changing circumstances of the future, a major reform was launched in Finland in 2005, aimed at restructuring municipal social and health services. The goal is to create a system which ensures high-quality municipal services for all in the future and which will still be viable in Particular focus is on the structural and financial foundation of the system. The project targets include reducing the number of municipalities by merging the smallest municipalities into larger units, and developing the structure of the administrative areas. Also, collaboration between primary-level health services and specialised hospital care should be improved, as should their collaboration with the social services. (Kokko et al. 2009) The number of municipalities has already reduced from 432 in 2005 to the present 342, and the aim is to continue to merge small municipalities. Finland is geographically a large country, but mostly rather sparsely populated, with a population of 5.4 million. Of these, 68 per cent live in municipalities with 20,000 inhabitants or more. Most of the Finnish municipalities (84%) have, however, fewer than 20,000 inhabitants. The social and health care structure is still undergoing a process of change. Various models for the future structure have been proposed. A recent political debate ended in a compromise by allowing pilot social welfare and health care districts to provide both basic-level services and some specialised hospital care, with the aim of strengthening basic-level social and health services. The collaboration between social welfare services and health care services will be developed within co-operation districts. (Ministry of Social ) In a recent evaluation 1 of the reform of 2005, Kokko et al. (2009) concluded that in the future most of the Finnish population will live within a co-operation district of integrated social and health services. There was also a special focus in the evaluation on integrated services, such as mental health and addiction services. Social and health care legislation is also undergoing several changes. A new Health Care Act (HE 90/2010) was introduced in 2010, with paragraphs for substance abuse work and mental health work. Revision of social affairs legislation has started in 2010 (Progress report by the working group 2010), and the above acts on substance abuse treatment and mental health will be revised along the wider revision of social and health care legislation. Addiction treatment services responding to alcohol and drug consumption Alcohol consumption has shown a longterm increase in Finland since The latest sharp rise started in 2004 when excise taxes on alcoholic beverages in Fin- 670 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 land were lowered by 40 per cent and the price of all alcoholic beverages fell. The per capita consumption of pure alcohol has stabilised within the last two years, totalling 10.2 litres in 2009 (Alkoholijuomien kulutus 2009). The rise in alcohol consumption has increased social and health-related alcohol harms and problems in Finland. Alcoholrelated mortality among the population aged years has increased from 56 deaths per 100,000 persons of same age in 2003 to 79 deaths per 100,000 persons of same age in 2008 (SOTKAnet 2010). Liver damage has been a prominent cause of rising levels of alcohol-related mortality. There is also some increase in addiction treatment demand. Figure 1 shows that there has been an increase especially in the number of clients in outpatient addiction care. The number of clients in short-term detoxification has increased by 10 per cent since 2003, but the number of clients in long-term residential addiction treatment has not risen. There is a slight increase in the number of clients in overnight shelters. (Yearbook of Alcohol , 99) The overall trend in the number of clients in housing services in Finland has been rising (Kuronen & Tuomola 2009). However, the number of substance users in the housing services has remained stable over the last few years (Yearbook of Alcohol , 99). There is no reliable statistical data on outpatient treatment in health care. Altogether 16,042 patients with an alcohol-related disease as a primary diagnosis were treated in hospitals or primary health care wards in The most common conditions were liver diseases and psychoorganic symptoms. (Yearbook of Alcohol , 98) The prevalence of experimental drug use has increased since 1995, but this has stabilised over the last few years as has hospi- Number of clients A-clincs Youth stations Needle exchange services Detoxification units Rehabilition units Housing services Over night services Alcohol related 1st diagnoses Drug 1st diagnoses Figure 1. Number of clients in specialised alcohol and drug treatment units and number of clients in alcohol and drug-related hospital wards NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

6 tal treatment for illicit drugs. The number of patients with a drug-related disease as a primary diagnosis has remained at a level of about 5,000 annually. (Yearbook of Alcohol , 98) Needle exchange services started in Finland in 1997, and the rapid increase in the number of these services and of the clients using them has also stabilised over the last few years (see Figure 1). Substitution treatment provision for opiate users has also gradually increased within the last ten years. The number of drug-related deaths has been on the rise from the year (Rönkä & Virtanen 2009; Salasuo et al. 2009) It is actually quite surprising how little change there has been in the use of addiction treatment services during rapidly increasing alcohol consumption. There has been some increase in the number of patients in outpatient and short-term inpatient detoxification treatment but almost no increase at all in long-term inpatient treatment. One possible explanation is that the recession has caused the municipalities to limit the allocation of financial resources to long-term inpatient addiction, as was the case also in the 1990s. Such policies have arguably resulted in growing numbers of children taken into custody and a substantial increase in the number of alcohol-related deaths. At the beginning of the 2000s, Finland chose a new approach to the growing drug problem. Control, treatment and harm reduction were developed side by side. This seems to have been an effective policy in terms of limiting illicit drug use and related harms. The Finnish society seems to take a different view to alcohol and related problems: the liberalised alcohol policy is not accompanied by treatment provision and harm reduction measures sensitive enough for the circumstances. Increase in alcohol consumption has led to increasing numbers of serious alcohol problems. Some cross-sectional information about the total alcohol and drug-related social and health service use can be drawn from a one-day survey on intoxicant-related cases in social and health services 2, the latest carried out in The total of 12,070 intoxicant-related visits in social and health services were reported during one day. About one third of the visits took place in health care services. About half of the visits were paid to special addiction treatment services, including the so-called A-Clinics (outpatient, free access, both public and run by NGOs), detoxification and rehabilitation units, substance user day-care centres and housing services. In 2007, altogether 62 per cent of the visits occurred in outpatient services. In the latest surveys, the number of clients who were intoxicated while they entered the outpatient services has decreased. It has become more difficult than before to access treatment without a prior appointment. These findings indicate that it is now more complex than before to gain access to outpatient addiction services. (Nuorvala et al. 2008, ) Today, about half of the specialised addiction services are provided by the public sector, while the other half are run by non-governmental organisations (NGOs) or private organisations, although funded by the municipalities. A Finnish specialty, in addition to the addiction services provided at the general social welfare and health care units, are the specific addiction treatment units all over the country, referred to as A-Clinics with detoxifica- 672 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

7 tion and rehabilitation units, as well as various kinds of housing and harm reduction services. (Kekki & Partanen 2008) The way that addiction treatment services are organised differs from the organisation of mental health services, which are mainly provided and funded by the public sector, and to a large extent by specialised medical and hospital care. Access to specialised psychiatric care is based on a referral system. Differences in the organisation of addiction services and mental health services have resulted in a service system where a client may drop out if she/ he has problems related both to substances and mental health. (Mielenterveys- ja päih desuunnitelma 2009) According to Kokko et al. (2009), coordination of the two services is poor. However, integrated mental health and addiction services or psycho-social services have developed especially in municipalities where mental health services have been provided by the municipality, not the hospital district. The report on the municipal survey noted also the uneven distribution of specialised addiction services, which were scarce in rural areas. The conclusion was that services such as detoxification and housing could be provided on a regional rather than a municipal level. (Kokko et al. 2009) The National Plan for Mental Health and Substance Use Work (the MIELI plan) The National Plan for Mental Health and Substance Use Work was drawn up on the initiative of the Parliament in 2004 (Toimenpidealoite 2004). The Ministry of Social Affairs and Health included the plan in its strategy (Sosiaali- ja terveyspolitiikan strategiat 2006, 16), incorporating also the issue of substance use work based on the experiences of some large development projects on both mental health and addiction services. The Ministry had previously already steered the joint development of the mental health and addiction services by targeting national development funding to projects which aimed at regional development and the integration of mental health and addiction services for adults in collaboration between social and health care services (Ministry of Social , 30). However, as late as , there were separate national projects for the development of social services (Ministry of Social 2003a) and health care services (Ministry of Social 2003b), with varying optimism about and interest in the issue of their integration (see also Oosi et al. 2009; Ministry of Social 2008; Ministry of Social ). The MIELI plan was written by a working group appointed by the Ministry in Different kinds of existing research material were discussed while the plan was being prepared. The challenges in the mental health service system (undeveloped outpatient services, inpatient oriented services, and prevalence of non-voluntary treatment) arose mainly from the research (for example, Pirkola et al. 2009; Wahlbeck & Pirkola 2008). Diverse data about the addiction treatment system (such as register and statistical data, surveys of intoxicantrelated cases in health and social services) were also used while preparing the MIELI plan. The plan starts from the premise that mental health and substance abuse problems have great significance for the public health. Arguments in favour of the plan NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

8 included the rise in premature retirement due to mental disorders, the increase in per capita alcohol consumption, and the fragmentation of community services for people with mental disorders and/or substance use problems. (Mielenterveys- ja päihdesuunnitelma 2009, 3, 4, 13) The MIELI plan has four main goals/ perspectives: 1) empowerment of service users, 2) mental health promotion and prevention of mental health and substance use problems, 3) organisation of mental health and substance abuse services for all age groups in a way that emphasises primary care, basic and outpatient services, and 4) various steering tools to implement the national plan. The plan contains 18 proposals for the development of mental health and substance use work. The goals of the plan rose partly from a policy background (ongoing structural changes in health care and social service systems) and partly from research. The proposals related to the empowerment of the service user emphasise that individuals with mental health problems and substance abuse should be ensured equal access to services and, while receiving services, be treated equally to all other service users. There should be easy access to the treatment system. The clients should be involved in the planning, implementation and evaluation of mental health and substance abuse work. The plan introduces the concept of a single entry point, referring to basic-level services with a low threshold of entry and good expertise in mental health and addiction services. There are also proposals on the minimisation of involuntary psychiatric treatment, on producing a common framework act containing provisions regarding limitation of the right of self-determination in social and health care, as well as on introducing a second opinion practice in involuntary psychiatric treatment. The economic aspects are touched upon in a proposal on the social security needs of mental health rehabilitees seeking to re-enter the labour market. The proposals on the promotion of mental health and the prevention of mental health and substance use problems and harms focus on preventive measures and the importance of strategy work. The plan proposes three measures: alcohol taxation should be increased, social cohesion and empowerment of citizens should be improved, and intergenerational transmission of mental health and addiction problems should be prevented. It is suggested that every municipality should have a mental health and substance abuse strategy and full-time staff should be recruited to co-ordinate promotion and prevention actions regionally. The proposals concerning the treatment system as a whole start with an emphasis on the role of the local authorities in coordinating public services, NGO activities and private services in order to ensure a well-functioning comprehensive addiction treatment service system. Another proposal emphasises basic services and outpatient services. Access to services should be improved through measures such as establishing 24-hour services and mobile outreach services, and by merging mental health and substance abuse outpatient services. It is further suggested that separate mental hospitals could be shut down and hospital inpatient psychiatric services established at general hospitals instead. Mental health and substance 674 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

9 abuse work for children and young persons, and the promotion of their wellbeing and a healthy life should primarily take place in their everyday environments. Primary services should be supported by specialised services. The role of occupational health care in early detection and intervention, as well as the means to support employees working ability through health checks and occupational rehabilitation are emphasised, with an aim of ensuring improved access to the labour market for people with disabilities due to mental disorders and substance use problems. Preventive measures and treatment opportunities should also be targeted to old people. The plan discusses a number of steering tools, including the need for the development of education and training, information delivery related to the development of mental health and substance use services, mental health impact assessment, and general funding related to mental health and substance use work. A proposal for integrating the Mental Health Act and the Act on Welfare for Substance Abusers is also presented. (Mielenterveys- ja päihdesuunnitelma 2009) The response of the field to the proposals concerning the treatment system in the MIELI plan The results of the Substance Barometer 4 (Järvinen et al. 2009) indicated that representatives of municipalities and nongovernmental organisations were already familiar with the MIELI plan. The data for this survey was collected by the Finnish Centre for Health Promotion only a few months after the national plan was published. Of the municipalities, 35 per cent said that they had already addressed some of the proposals to some extent. In NGO responses, the proportion was even higher at 41 per cent. Only about one in five respondents was not familiar with the plan. One in ten municipalities had already integrated some of their substance abuse and mental health work. (Järvinen et al. 2009, 23 24) At least the biggest municipalities were well aware of and generally positive to the MIELI plan in 2009 (THL kuntien 2009). In this section we will concentrate on analysing two different types of data; the quantitative online enquiry data collected by the National Institute for Health and Welfare (THL) in May 2009 and the qualitative data of professional journals in the autumn of The online enquiry had four groups of statements 5 (empowerment of client, promotion and prevention, development of service system, steering tools) related to the main proposals in the national plan. There was also an open question about the implementing plans of the respondent s organisation and an open space for other comments. Altogether 246 persons replied to the enquiry. It is not possible to determine the response rate of this enquiry, because the information letter was sent to a wide range of recipients and organisations. This is a common problem in online enquires in which it is not possible exactly to define the actual population of the study (for example, Kuusela & Paananen 2010). The respondents mainly came from the public sector and NGOs, but also represented a variety of other groups, such as professional organisations, development organisations and private enterprises. In this article, we are mainly interested in feedback on propos- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

10 als for the treatment system. In addition to online feedback, we have also produced a brief overview of the public debate about the plan among professionals in the sector. We found ten articles related to the plan published in Finnish professional journals Sosiaalitieto and Tiimi (representing social work), Super (a journal for nurses), Duodecim and Suomen Lääkärilehti (journals for medical doctors). Some of the articles were introductions to the content of the plan, while others represented a more critical perspective. Half of the articles had a medical or health care orientation while the rest were socially oriented. More than 90 per cent of the respondents to the online enquiry thought that direct access to treatment is an important issue in the treatment system. Representatives of addiction treatment services and of integrated mental health and addiction treatment services, in particular, emphasised the importance of referral-free access to treatment. The principle of a single entry point was also widely supported, especially by representatives of integrated mental health and addiction treatment services. Nearly 80 per cent of the respondents rated this as an issue of rather high importance or higher. (Partanen 2010) In the online enquiry, primary-level outpatient services, too, were regarded as a very important issue in the treatment system. This also came up in an article published in Duodecim, in which a professor of psychiatry and a director at THL said he was content with the growing responsibility of public health care for substance abuse treatment. He writes (translated by the authors): In public health care, it is possible to discuss the health impact of alcohol in person with almost all Finns. In health care services, it is also possible to identify a patient s substance abuse. Furthermore, it is also a cost-effective way to make an intervention.// In the future, prevention and treatment of substance abuse will be a natural part of health care services. He clearly finds primary health care an extensive and cost-effective system in the treatment of substance users. (Lönnqvist 2009, ) The questionnaire produced some hesitating responses on questions of integrated specialised outpatient services and the provision of psychiatric services at general hospitals. Representatives of mental health services and of integrated treatment services, in particular, emphasised the importance of primary-level outpatient services. The strongest support for integrated treatment services came from representatives of integrated services and from general social and health services, while the least support came from representatives of addiction treatment services. Concerns were also expressed about addiction treatment services becoming more narrowly based, about growing medicalisation and neglect of social work, and about the specific needs of patients with either mental health problems or addiction problems not being met in the integrated system. Issues concerning integrated services also emerged in the journal material but the perspective was slightly different. An expert on social work underlines that the integration of different service orientations should be understood more broadly than just as an integration of administration (translated by the authors): Integrating the management will not be enough. As there are two different types of work orien- 676 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

11 tation and two different types of treatment tradition, it will be challenging to integrate these. It takes time and a great deal of effort to build totally new work orientations. New frameworks or multi-professional work will not be enough. (Kananoja 2009, 18 19). The same kind of argument was also presented by a medical doctor in Suomen Lääkärilehti: The plan is a failure because it deals with mental health and substance use treatment exclusively as an administrative question. (Viinamäki 2009, 686). Further, a third commentator points out that there is no evidence of integrated mental health and substance treatment guaranteeing better treatment for the clients (Hursti et al. 2009, 6 8). Concerns for the status of social work in substance treatment services were also expressed in the journal material. The writers highlighted the fact that socially oriented substance use treatment has a long history in Finland and that there is a great deal of expertise in this field. As a social work expert commented (translated by the authors): Society and social context have greatly influenced socially oriented substance use treatment. Can we afford to lose this? (Hursti et al. 2009, 6 8). The legacy of socially oriented work is considered to be important in the future, too, and a scenario of medically oriented treatment is understood to be a threat at least in some sense to extensive substance treatment. As was noted in the article by Schippers et al. (2002), implementation is a great challenge. The issue of implementation also emerged in the online enquiry and the journal material. A majority of respondents to the online questionnaire (74%) stated that they would implement the plan in some way in their organisation. There were also various, more detailed suggestions to clarify the plan in its implementation phase. The respondents would have welcomed concrete tools for developing services, such as descriptions of good practice and explicit recommendations. There were also suggestions for the follow-up and evaluation of the national plan. Many respondents would also have wanted binding regulations included in the plan. However, some respondents emphasised that local and regional features needed to be taken into account. There were also suggestions about the organisations to be involved in the implementation (including client organisations) and those accountable for the implementation (such as hospital districts, separate addiction services). Multi-sectoral implementation was emphasised. Two themes emerged as to the implementation of the plan as discussed in the journal material. Firstly, there was the question of resources, as was also discussed by Schippers et al. (2002). Implementation needs resources. An expert argues the following (translated by the authors): Extra resources for implementing the plan are necessary. Without extra money it is not possible to execute the plan or even to maintain the present level of services (Hursti et al. 2009, 6 8). Originally, no extra resources were provided directly to implement the MIELI plan, which was clearly regarded to be a challenge. Secondly, there was discussion about the abstract nature of the plan: The proposals are abstract. No effort to outline an operational model. The implementation of the plan will be difficult. (Heinonen 2009, 17). Babor and colleagues (2008) have argued that there is usually a lack of scien- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

12 tific analysis (or any analysis of the present system) behind reforms. This is also true in the Finnish case. No analysis of the present treatment system was carried out. Furthermore, the present system s history, its strengths and weaknesses were not analysed or discussed in the plan. An expert in social work argues that the plan is full of assumptions: There are plenty of assumptions presented in the plan. However, none of the arguments behind these assumptions was presented. (Kananoja 2009, 18 19). Implementation and funding of the MIELI plan The National Institute for Health and Welfare (THL) and the Ministry of Social Affairs and Health are the key actors responsible for the implementation of the MIELI plan. The THL has a specific implementation plan, which includes numerous actions and projects related to the development of the mental health and substance use work at THL. Many of the actions or projects are not mental health or substance use specific. In addition to a broad range of more or less specific actions, there are some key themes and core projects named in the implementation of the plan. Two main projects focus on improving the client s position: strengthening the client s involvement in the treatment system and limiting the use of involuntary psychiatric treatment. Strategy work and the prevention of intergenerational transmission of mental health and addiction problems are designated as core projects in developing preventive work. Easily accessible, basic-level services together with a monitoring and follow-up of changes in the treatment system are central projects in the development of the treatment system. As to the steering tools, the core projects include providing information by an expanded website on mental health and substance use (www. thl.fi/mielijapaihde), through improved co-ordination of preventive work, and the provision of expert support for the drafting of legislation in this field. There is no specific, targeted funding for the implementation of this plan, which will therefore be carried out in conjunction with the general national development plan for social welfare and health care , including about 25 million euro in annual ear-marked funding for the municipalities. The Ministry of Social Affairs and Health allocated about 25 per cent of the 2010 funding directly to broad, regional projects for developing mental health and addiction services. About 14 million euro of programme funding has so far been allocated to the development of mental health and addiction work in There are also some other funded projects closely linked to mental health and addiction work, notably in the development of services for children and young people. The Ministry of Social Affairs and Health has appointed a national, cross-sectional steering group for to support the implementation of the plan. Other relevant ministries, research and development organisations, mental health and addiction experts and NGOs are represented on the steering group. As mentioned, there are also several legislative processes in progress related to the restructuring of the services, which will have an impact on the way mental health and addiction services are organised. 678 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

13 Discussion The MIELI plan is being implemented in the wider context of a municipal and service system reform in Finland. It can be said that over the years the role of the government has shifted from focusing on structure and content (for example, premises and personnel) to processes (such as evidence-based medicine, good practices). The management tools are today limited to legislation and other regulations, funding in the form of general state subsidies, and information management, including quality recommendations and national programmes such as the MIELI plan. Although local authorities are now primarily accountable for organising sufficient services, there are numerous other actors in the field, including hospital districts, NGOs and private enterprises. NGOs have two kinds of roles, the role of service provider and the role of expertise emerging from clients own experiences. NGOs give a voice to the clients and their families, and develop peer support work. There are also private enterprises that provide a wide range of services both in the mental health and addiction field. Because of the high number of service providers, the social and health care system has become fragmented and may not respond fully to the client s needs. On a political level, agreement has not been reached on the division of labour between local and regional levels. There is naturally a risk that this decentralised approach may lead to an even more fragmented treatment system. However, at present, there seems to be a broad consensus that the clients find mental health and addiction treatment services not close enough and that a wider reform of the service system might improve the situation. Furthermore, it could be said that the MIELI plan was introduced at a rather opportune time. The major reform of the social and health care services as a whole enables reforms also within the substance abuse and mental health sectors. In mental health services, outpatient visits have increased but the emphasis is still too strongly on specialised services (Statistical yearbook on Social 2009), and the number of patients with dual-diagnosis has grown (Nuorvala et al. 2008; Aalto 2007). An increase in alcohol consumption also impacts on the entire treatment system. This implies that new ways of treatment provision are called for. The MIELI plan has raised considerable interest among decision makers, management and development professionals, social welfare and health care personnel, and the NGOs. All of them generally consider referral-free access to treatment, the principle of a single entry point and the importance of primary-level services to be important proposals in the MIELI plan. These proposals carry a potential for change in the treatment system. There are, however, also great challenges. For instance, to what extent can such plans actually influence reality? Can the proposals really change anything in the treatment system, or does the potential of change emerge from elsewhere? The MIELI plan also points out the dichotomy between medical and socially oriented substance abuse treatment. Substance use problems are complicated, long-term problems on an individual level, but they also have an impact on the people around the individual, and the problems are influenced by NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

14 societal and structural problems in society. A treatment system requires many different kinds of expertise. The MIELI plan emphasises the role of health care while leaving out or playing down the role of social work in the treatment system. In the future, it will be a challenge to maintain the role of social work in the treatment system. This is particularly important for the clients, who are entitled to proper treatment for different kinds of problems. Although the MIELI plan has been criticised, it has already been used as a guideline to developing mental health and addiction services. The plan also seems to have some steering power. In evaluating its impact as a guideline, we may ask what the similarities or differences or the potential strengths and weaknesses of the plan are in terms of the lessons learned in other countries where similar reforms have been implemented. The premises of the MIELI plan underline a public health perspective and the cost of mental health and addiction problems to society, and so do many other similar plans or strategies in other countries. The plan also has similar weaknesses (for example, Schippers et al. 2002, Babor et al. 2008): it did not systematically evaluate the existing situation or mental health and addiction service system, the proposals in the plan are rather general, and there was originally no specific funding allocated for the implementation of the plan. The MIELI plan gives proposals not even recommendations for the development of mental health and addiction services. It can be said to be a relatively weak tool. Furthermore, recently introduced models for the future structure of social and health services were ambiguous. These two facts together may leave the field open to different interpretations and different solutions in re-structuring the mental health and addiction services. This may also strengthen the role of municipal policy making, and it remains to be seen whether it will lead to a better, more client-oriented and fairer service system for clients with mental health and/or addiction problems. More than before, there is now more emphasis on a systematic follow-up of the implementation of the plan and its impact on the well-being and health of the population. There is as yet no such systematic follow-up research plan, which is a remarkable weakness. Implementation will in any case play a key role when the proposals are put into practice. The implementation plan for has now been introduced, and some funding has been allocated from the general social welfare and health care development resources into improving mental health and addiction services. Some priorities are presented in the implementation plan introduced by the National Institute for Health and Welfare, while the Ministry of Social Affairs and Health is paying particular attention to legislative issues. Implementation in a wider sense, including issues outside the Ministry s remit will be clarified in the course of the work of the national steering group appointed by the Ministry. The voice of the clients in developing the services will be heard through the NGOs, which are represented in the national steering group. The potential is there for a successful implementation, but it will require systematic monitoring and long-term commitment. 680 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

15 Kristiina Kuussaari, Development manager National Institute for Health and Welfare (THL) P.O. Box 30, Helsinki, Finland Airi Partanen, Development manager National Institute for Health and Welfare (THL) P.O. Box 30, Helsinki, Finland NOTES 1) The two-part survey was carried out as on online enquiry in March The enquiry included both structured and open-ended questions. The first part of the survey dealt with the basic choices and arrangements to meet the minimum population base. The second part looked at how the general objectives of the Act on Restructuring Local Government and Services were being met in the provision and organisation of services. The second part included questions on integration and co-operation between social and health services, on the possibilities to cross municipal boundaries in using services, and on which services continue to be available as locally based in the smallest municipalities and which can be provided on a regional basis. The survey was sent to all municipalities in Finland (excluding the region of Kainuu and the Åland Islands). 318 municipalities responded to part one of the survey, 313 municipalities to part two. (Kokko et al. 2009, 18 21) 2) Finland has conducted surveys on intoxicant-related cases in social and health services since Every four years, one weekday in October, the survey lists all intoxicant-related cases in social welfare and health care services (except children s day care). The survey intends to provide cross-sectional information on the intoxicant-related use of social and health services. (Haavisto et al. 1997, 5) 3) The members of the working group, chaired by the Ministry of Social Affairs and Health, included civil servants from the Ministry, experts from the national research and development organisations in social welfare and health care, representation of regional government agencies, the Association of Finnish Local and Regional Authorities, the Finnish Association for Mental Health (NGO), an NGO providing training, information and services for substance users (the A-Clinic Foundation) and three large development projects on mental health and substance use (Mielenterveys- ja päihdesuunnitelma 2009, 3 4). 4) The Substance Barometer is a survey of alcohol and drug use and of the services for substance users. The barometer seeks to map the views of municipalities and non-governmental organisations about the substance abuse situation and the availability of substance-abuse-related services. The survey is conducted biennially. The Substance Barometer, with eight open-ended questions, was compiled via telephone interviews. One hundred municipal representatives in charge of substance abuse treatment and 37 directors of nongovernmental organisations responded to the questions. The response rate was 76%. (Järvinen et al. 2009, 10) 5) A five-step scale was used in the enquiry (high importance, rather high importance, some importance, no importance, don t know/no answer). REFERENCES Aalto, M. (2007): Päihdehäiriö ja samanaikainen muu mielenterveyden häiriö kaksoisdiagnoosin hoidollinen haaste. Duodecim 123 (11): The Act on Mental Health (1116/1990) URL:<http://www.finlex.fi/en/laki/ kaannokset /1990/en pdf>. Cited 4 November, 2010 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

16 The Act on Welfare for Substance Abusers (41/1986)URL:<http://www.finlex.fi/fi/laki/ ajantasa/1986/ >. Cited 4 November, Alkoholijuominen kulutus 2009 (2010): Terveyden ja hyvinvoinnin laitos. URL:<http:// >. Cited 18 May, 2010 Babor, T. F. & Stenius, K. & Romelsjö, A. (2008): Alcohol s in public health perspective: mediators and moderators of population effects. International Journal of Methods in Psychiatric Research 17 (S1): S50 S59 Haavisto, K. & Ahtola, R. & Kaivonurmi, M. & Kaukonen, O. & Metso, L. & Simpura, J. (1997): Surveys of intoxicant-related cases in health and social services in Finland National Research and Development Centre for Welfare and Health. Themes 2 Heinonen, J. (2009). Yksi ovi, matala kynnys: Tiimi (2): 17 Hursti, T. & Nystrand, V. & Suojasalmi, J. (2009): Mitä mieltä mielenterveys- ja päihdesuunnitelmasta? Tiimi (2): 6 8 Järvinen, A. & Jokinen, N. & Ketonen, T. & Laari, L. & Opari, P. & Varamäki, R. (2009): Päihdebarometri Kuntien ja järjestöjen näkemyksiä päihdetilanteesta. Terveyden edistämisen keskuksen julkaisuja 6/2009. URL:<http://www.sosa.fi/upload/ p%c3%a4ihdebarometri09.pdf>. Cited 3 December, 2009 Kananoja, A. (2009): Kansallisia suunnitelmia ei niellä purematta. Sosiaalitieto (6 7): Kekki, T. & Partanen, A. (2008): Päihdepalvelujen seudullinen kehitys Stakes, Työpapereita 38/2008 Kokko, S. & Heinämäki, L. & Tynkkynen, L.-K. & Haverinen, R. & Kaskisaari, M. & Muuri, A. & Pekurinen, M. & Tammelin, M. (2009): Kunta ja palvelurakenneuudistuksen toteutuminen. Kuntakysely sosiaali- ja terveyspalvelujen järjestämisestä ja tuottamisesta. Terveyden ja hyvinvoinnin laitos, Raportteja 36/2009. URL:<http://www.thl. fi/thl-client/pdfs/eaf43d23-6dd0-4e42-b4f6-5b8243c3386e>. Cited 9 March, 2010 Kuronen, R. & Tuomola, P. (2009): Sosiaalihuollon laitos- ja asumispalvelut Terveyden ja hyvinvoinnin laitos, Tilastoraportteja 16/2009. URL:<http://www.stakes. fi/tilastot/tilastotiedotteet/2009/tr16_09. pdf>. Cited 8 April, 2010 Kuusela, V. & Paananen, S. (2010): Verkkokyselyissä on paljon virhelähteitä. Helsingin Sanomat 8 March, 2010 Lönnqvist, J. (2009): Alkoholipolitiikka Suomessa. Duodecim 125 (8): Mielenterveys- ja päihdesuunnitelma. Mieli 2009 työryhmän ehdotukset mielenterveysja päihdetyön kehittämiseksi vuoteen Sosiaali- ja terveysministeriö, Selvityksiä 2009:3. URL:< me=dlfe-7175.pdf>. Cited 28 April, Published also in English: Plan for Mental Health and Substance Abuse Work. Proposals of the Mieli 2009 working group to develop mental health and substance abuse work until Ministry of Social Affairs and Health, Reports 2010:5. URL:<http:// derid= &name=dlfe pdf> Ministry of Social Affairs and Health (2003a): Sosiaalialan kehittämishanke. Toimeenpanosuunnitelma. (Development Project for Social Services. Implementation Plan). Sosiaali- ja terveysministeriö, Monisteita 2003:20 Ministry of Social Affairs and Health (2003b): National project to secure the future of health care. Access to health care and waiting list management. Sosiaali- ja terveysministeriö, Työryhmämuistioita 2003:33. Ministry of Social Affairs and Health (2004): Valtionavustuksen hakeminen sosiaali- ja terveydenhuollon kehittämishankkeille vuosina Hakijan opas. Sosiaalija terveysministeriö, Oppaita15 Ministry of Social Affairs and Health (2008): Final report by the Monitoring Group on the National Health Care Project. Actions in Sosiaali- ja terveysministeriö, Selvityksiä 5 Ministry of Social Affairs and Health (2010): Kunnille mahdollisuus sosiaali- ja terveydenhuollon aluemallien toteuttamiseen. URL:<http://www.stm.fi/tiedotteet/tiedote/ view/ >. Cited 27 May, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

17 National Development Programme for Social Welfare and Health Care (Kaste). Programme of the Ministry of Social Affairs and Health. URL:<http://www.stm.fi/en/ strategies_and_programmes/kaste>. Cited 27 April, 2010 New bill for Health Care Act (HE 90/2010) URL:<http://www.eduskunta.fi/triphome/ bin/thw/?${appl}=akirjat&${base}=akirja t&${thwids}=0.58/ _37693&$ {TRIPPIFE}=PDF.pdf>. Cited 4 November, 2010 Nuorvala, Y. & Huhtanen, P. & Ahtola, R. & Metso, L. (2008): Huono-osaisuus mutkistuu kuudes päihdetapauslaskenta Yhteiskuntapolitiikka (73) 6: Oosi, O. & Wennberg, M. & Alavuotunki, K. & Juutinen, S. & Pekkala, H. (2009): Assessment of the Development Project for Social Services. Sosiaali- ja terveysministeriö, Selvityksiä 12 Partanen, A. (2010): Toimijakentälle suunnattu kysely toimeenpanosta keväällä In: Partanen, A. & Moring, J. & Nordling, E. & Bergman, V.: Kansallinen mielenterveys- ja päihdesuunnitelma Suunnitelmasta toimeenpanoon vuonna Terveyden ja hyvinvoinnin laitos, Avauksia 16/2010. URL:<http://www.thl.fi/thl-client/ pdfs/53837d85-321b ad-a2332abaea71>. Cited 2 November, 2010 Pirkola, S. & Sund, R. & Sailas, E. & Wahlbeck, K. (2009): Community mental health services and suicide rate in Finland: a nationwide small-area analysis. Lancet 373: Progress report by the Working Group preparing a reform of social welfare legislation. Ministry of Social Affairs and Health, Reports 2010:19. URL:<http://www.stm. fi/c/document_library/get_file?folderid= &name=DLFE pdf>. Cited 4 November, 2010 Rush, B. (2009): Tired frameworks for planning substance use service delivery systems: Strengths, limitations and implications for needs-based planning models. Paper presented at the 2009 thematic meeting of Kettil Bruun Society on Models, Implications and Meanings of Alcohol and Drug Treatment Systems, Stockholm, October 7 9, 2009 Rönkä, S. & Virtanen, A. (eds.)(2009): Huumetilanne Suomessa Uusin tieto, uusimmat kehityssuuntaukset ja erityisteemat huumeista. European Monitoring Centre for Drugs and Drug Addiction. Terveyden ja hyvinvoinnin laitos, Raportti 40/2009. URL:<http://www.thl.fi/ thl-client/pdfs/ dd a- 0d441c4fd5ba>. Published also in English: Rönkä, Sanna & Virtanen, Ari: Drug situation in Finland European Monitoring Centre for Drugs and Drug Addiction. National Institute for Health and Welfare, Report 45/2009. URL:<http://www.thl.fi/ thl-client/pdfs/9bf86f3e-9b30-48a1-bc56- b32981cf0575>. Cited February 17, 2010 Salasuo, M. & Vuori, E. & Piispa, M. & Hakkarainen, P. (2009): Suomalainen huumekuolema Poikkilääketieteellinen tutkimus oikeuslääketieteellisistä kuolinsyyasiakirjoista. Terveyden ja hyvinvoinnin laitos, Raportteja 43 Schippers, G. M. & Schramade, M. & Walburg, J.A. (2002): Reforming Dutch substance abuse treatment services. Addictive Behaviors 27: Sosiaali- ja terveyspolitiikan strategiat 2015 kohti sosiaalisesti kestävää ja taloudellisesti elinvoimaista yhteiskuntaa. Sosiaali ja terveysministeriön julkaisuja 2006:14. URL:<http://www.stm.fi/c/document_library/get_file?folderId=28707&name=DL FE-3798.pdf>. Cited 27 May, 2010 SOTKAnet Statistics and indicator bank. Alcohol mortality among population aged per 100,000 persons of same age. URL:<http://uusi.sotkanet.fi/portal/page/ portal/etusivu/hakusivu?group=195>. Cited 10 April, 2010 Statistical Yearbook on Social Welfare and Health Care National Institute for Health and Welfare, SVT URL:<http://www.stakes.fi/tilastot/tilastotiedotteet/2009/julkaisut/sosteri2009.pdf>. Cited 4 November, 2010 Stenius, K. (2010): Päihdepalvelut Pohjoismaissa. In: Partanen, A. & Moring, J. & Nordling, E. & Bergman, V. (eds.)(2010): Mielenterveys- ja päihdesuunnitelma Suunnitelmasta toimeenpa- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

18 noon. Terveyden ja hyvinvoinnin laitos, Avauksia 2010:16. URL:<http://www.thl.fi/ thl-client/pdfs/53837d85-321b ada2332abaea71>. Cited 15 December, 2010 THL kuntien tukena (2009): Raportti kuntakierrokselta Terveyden ja hyvinvoinnin laitos, Avauksia 26/2009. URL:<http:// 4b32-43c3-89bb-184c86de4869>. Cited 17 February, 2010 Toimenpidealoite. Kansallinen mielenterveysohjelma (2004) URL:<http://www.parlament.fi/triphome/bin/thw.cgi/trip/?${APPL }=utptpa&${base}=faktautptpa&${thwids }=0.11/ _138937&${TRIPPIFE}= PDF.pdf>. Cited 26 May, 2010 Torrey, W.C. & Drake, R. E. & Dixon, L. & Burns, B. J. & Flynn, L. & Rush, J.A. & Clark, R.E. & Klazker, D. (2001): Implementing Evidence-Based Practices for Persons with Severe Mental Illnesses. Psychiatric services 52 (1): Viinamäki, H. (2009): Mielenterveys- ja päihde suunnitelman kannanotot ovat epäonnistuneita. Suomen Lääkärilehti (8): 686 Wahlbeck, K. & Pirkola, S. (2008): Onko jo aika sulkea psykiatriset sairaalat? URL:<http:// groups.stakes.fi/nr/rdonlyres/da29659c A60D-2CC4A91CE058/0/ M269WahlbeckPirkola.pdf>. Cited 1 November, 2010 WHO Technical Consultation on the Assessment of Prevention and Treatment Systems for Substance Use Disorders. Report December 2006, Geneva, Switzerland. Department of Mental Health and Substance Abuse. URL:<https://www.who.int/substance_abuse/activities/saims_report_2006. pdf>. Cited 25 March, URL:<http://info. stakes.fi/mielijapaihde/fi/index.htm>. Cited 1 November, Yearbook of Alcohol and Drug Statistics National Institute for Health and Welfare, SVT URL:<http://www.stakes.fi/ tilastot/tilastotiedotteet/2009/paihde/paihdetilastollinen2009.pdf>. Cited 15 February, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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