The system for welfare services

All citizens in the Nordic countries are entitled to access to health and social care services. These services are financed, for the mostpart, through taxes and to a certain degree by client fees. Distinctions are made between health care (health centres, dental clinics and hospitals etc.) and social care services (care for older people, care for people with disabilities, support for persons with drug dependencies, asylum reception centres, etc.) The responsibility for health care often falls on the regional county or health care district, while responsibility for social care services is often local - and falls on the municipality.

Unlike the health care, where everyone can seek care directly at a health centre, social care is means-tested. This generally means that each social care matter is examined and decided on individually (fundingdecision) in the municipality where the person is a resident. Even municipalities with freedom of choice systems require a funding decision before a person can make their customer choice and receive, for example, home care services.

Reforms have paved the way for private providers

The system for welfare services in the Nordic region has gradually opened up to alternative care providers as various reforms have been implemented to improve quality, accessibility and effectiveness in health and social care.

The most important reforms since the 1990s are those that involve municipal responsibility for health care organisations and financing, as well as the new regulations that have been developed to govern and facilitate freedom of choice and procurement of municipal services. Municipal reforms in the Nordic region were particularly significant as greater responsibility for social care was placed on the municipalities as well as in principle divided funding decisions and procurement from the providing of social welfare services. This laid the foundation for the customer-provider system that currently exists in certain municipalities, which has given alternative providers the opportunity to be able to offer their services. The concept of alternative providers includes private companies together with associations, foundations and non-profit organisations, the latter of which is more common in Denmark, Norway and Finland than in Sweden.

Attendo’s customers

Attendo’s customers are mainly municipalities. Design and length of the contracts vary depending on the contract’s model and the type of service. The services that Attendo provides are mainly used by clients and patients that either chose Attendo via their own care choice or if their municipality has chosen Attendo through a tender process for the health and social care services.

The Swedish care system

In Sweden 290 municipalities are responsible for social care services and care for older people and 20 regional authorities for health, medical and dental care. Attendo’s customers in Sweden are primarily municipalities with responsibility for social care services and care for older people. The municipalities have three main models for procurement of private welfare services: procurement of contracts in existing operations, procurement of framework agreements and customer choice. Attendo’s competitors among private providers in Sweden are, among others, Vardaga/Nytida, Förenade Care, Aleris, Humana and Frösunda.

Customer choice is growing in significance

The Act on System of Choice in the Public Sector (LOV) was introduced in 2009. With this a framework for procurement of public services where the client or patient, themselves, chooses their provider from those that the funders (municipality or regional authority) have approved. In Sweden, the municipalities and regional authorities decide whether or not to introduce a system of freedom of choice. However, from January 1, 2010, all regional authorities must have a system for freedom of choice in their primary care. With municipal operations, it is up to each municipality to decide on, if and in what way, LOV shall be introduced. Many municipalities have introduced LOV. In these municipalities, private providers apply to the municipality for approval. After a funding decision is reached, the client can choose between a public and an alternative provider. Remuneration is the same for both the alternative provider and the municipal provider. The System for freedom of choice is most common within home care services but can also be found in assisted living, group homes and daily activity centres covered by LSS (Law on Support and Service to Certain Functionally Disabled Persons).

The Finnish care system

In Finland, the care system is decentralised with 320 municipalities responsible for primary care, social services and care for older people as well as 20 hospital districts that each offer specialist care to several municipalities. Attendo’s customers in Finland are primarily municipalities and hospital districts that offer their inhabitants care for older people and care for people with disabilities. Similarly to Sweden, the municipalities have extensive responsibility for welfare service financing and there are three main models for procurement of private services: procurement of fixed contracts, procurement of framework agreements and a form of customer choice through vouchers. Attendo’s competitors among private providers in Finland are Mainio Vire, Esperi, Coronaria and Mehiläine etc.

Laws, options and diversity of nursing homes in the Nordic countries

Source: Attendo

The Norwegian and Danish care systems

In the Norway with 428 municipalities and Denmark with 98 municipalities, the health care system is decentralised with the municipalities being responsible for primary care, social services and care for older people. Most of Attendo’s customers in Norway and Denmark are municipalities that offer their inhabitants care for older people in the form of nursing homes and home care services. Procurement of private services mainly occurs through contracts in existing operations, negotiations of framework agreements and customer choice. Attendo’s competitors among private providers are, among others, Aleris, Norlandia Care and Uni Care in Norway, as well as Aleris and Förenade Care in Denmark.

Sweden and Finland have come the farthest

Development in the Nordic countries has come far with regard to freedom of choice in health and social care. Sweden and Finland are the countries that resemble each other the most in important areas such as social and health care organisation and the alternatives providers’ share of the system for care and health care services. They even have similar requirements for competitive procurement and incentives for freedom of choice. Denmark has a system of choice for home care services with the free right of establishment of private providers for those who meet certain quality requirements. In 2012, the requirements for municipalities were tightened to increase the share of alternative providers in home care services, which resulted in the volume of new contracts on procurement having recently increased. Norway has no clear regulations and incentives for increased private elements in social services care. A certain amount of procurements occur, particularly in the Oslo region, but only a minor share of care for older people has a freedom of choice system.

Laws, options and diversity of home care services in the Nordic countries

Source: Attendo