What can we learn from Finland’s health care system?

The NHS is fighting fires on all fronts. Faced with an ageing population that requires more and more healthcare, it remains short of 40,000 nurses and 8,0000 doctors. Thanks to Covid, the waiting list for surgery or other hospital procedures has reached more than seven million. The lack of integration between health and social care means that at any one time, 14,000 patients who are fit for discharge cannot leave hospital because there is no care package available for them.

Yet the UK isn’t alone in the challenges it faces. Finland also has a publicly-funded, universally accessible health care system and an ageing population, as well as a shortage of nurses. This year, however, it introduced a major structural reform, which involved consolidating 195 health and social care organisations and 22 rescue (ie ambulance and fire service) departments into 23 combined regional health, social care and rescue organisations. The idea is that each organisation is focused on the needs of the patient: as soon as a patient comes into contact with the service, there is a multidisciplinary assessment of the patient’s needs for care, so they can receive the appropriate support. Services are fully digitised so that patients can access their own health data and share data, such as that gathered through Fitbits, with health professionals.

Every patient record is electronic – and the Finnish health service has a complete patient register with a unique identifier for each patient. A government pot of money launched in 1967 to fund innovation has enabled the health technology sector to flourish – there are 36 health tech startups specialising in artificial intelligence (AI) alone. HUS Helsinki University Hospital’s archive of 20 million digital images has enabled it to develop AI algorithms to identify diseases such as brain haemorrhage, reducing the burden on radiologists and speeding up the patient’s access to treatment. Contrast with the UK, where some hospitals are still using paper records and, even where digital systems are in place, they often don’t work together.

A culture of trust

Because electronic medical records (EMRs) have been in place for decades, in both primary and secondary health care, says Päivi Sillanaukee, special envoy for health and well-being at Finland’s Ministry for Social Affairs and Health, there is a “culture of trust” in the country. The government does not sell the health data, and people know that their personal medical information is safe. “We have comprehensive digital infrastructure in our country, and people learn to use digital devices and tools already at school and nowadays at daycare,” she adds.

Finland’s EMRs are organised in modular fashion: there are different regional EMR systems, but a single national archive, known as Kanta, which takes data every day from each EMR. If a patient attends a new health care organisation, their data goes with them. Using their phones, patients can access their own data in Kanta. Once the country has finished digitising social services records, it plans to integrate with the EMRs. Kanta is also used to provide national indicators and statistics. Every health event in the archive is coded using the international disease classification (ICD), making it easily usable for research.

Perhaps Finland’s most impressive achievement, however, is its biobank. While several countries, including the UK and the US, now have biobanks, the Finnish biobank is unique. It includes tissue samples from 500,00 patients – 10% of the population.

A unique population isolate

Because the Finnish health service has a complete patient register with a unique identifier for each patient, it is possible to link the biobank data with half a century’s worth of patient data. More serendipitously, Finland has what’s known as a “population isolate,” which means that the population is largely genetically homogenous, having been isolated from external influences. This homogeneity has enabled researchers to derive insights that would be impossible in other countries – and raise hope of developing treatment options based on patients’ genetic make-up rather than simply on their diagnosis.

Study of the biobank data has enabled the large-scale FinnGen study, running since 2017 and funded partly by the taxpayer and partly by the pharma industry, to investigate different diseases. Samuel Ripatti, the director of the Finnish Institute for Molecular Medicine (FIMM) which runs the study, explains: “We want to utilise genetic research strategies to understand disease mechanisms. So why do some of us get diabetes? What are the mechanisms leading to the disease? And what is the role of genetics?”

Why do they need such a large-scale project?  “After a decade of banging our heads to the wall with small numbers of patients and smaller-scale studies, it became very clear that if we want to crack and understand the genetic background of common complex diseases, those diseases that matter most to us as a society, we need simply large datasets,” Ripatti says. “At the same time, when the research community started to realise that we need these large data projects, the pharmaceutical industry understood they needed to be faster in turning their favourite molecules into medications.”

So far, FinnGen researchers have carried out comprehensive genetic analyses for more than 1,900 diseases, and identified almost 2,500 genomic regions that are linked with at least one of these diseases. They include 29 genetic variants not previously linked to any disease. One example is a variant in a gene called TNRC18 that predisposes people to inflammatory bowel disease and other inflammatory conditions.

Researchers have also identified variants that increase the risk of hypothyroidism, hearing loss or endometriosis, and variants that offer protection from arthrosis and glaucoma. Probably the most significant discovery so far, reported in Nature, is that 5.5% of Finns have a genetic variant located on the MFGE8 gene that protects against heart disease by slowing down the ageing process in the veins. This variant is 70 times more common in the Finnish population than in the European population at large.

Personalised medicine

Findings such as these have the potential to change scientists’ knowledge and understanding of the interplay between genetics and disease, and enable doctors to develop treatment options based on a patient’s genetic make-up rather than simply on their diagnosis, Ripatti says: “We use our technologies to try to characterise the individual patients as well as we can. What is the genetic background? What is the cancer tumour like? What are the potential medications that seem to affect the samples from the tumour that we have here?

“We have a drug screening facility – we can test almost every single drug that is on the market on the patient’s sample and maybe get hints about what combination of medications, or which medication, works best for these patients. And then we return as much as possible of this information to the doctor treating the patient.”

Because there is so much data coming out of the project, the FinnGen team allow themselves a one-year grace period to analyse it, but after that they make the results available to the worldwide research community. This means that most of the research papers being published about the FinnGen data come from outside Finland, accelerating the speed at which new insights about genetics and disease are made available.

Many elements of the Finnish model, such as its homogeneous population, are impossible to emulate. Neither is it possible for other countries to go back in time and create a national registry with 50 years’ worth of patient data. Finland’s approach to digitisation, its integration of health and social care and its heavy investment in innovation may, however, point the way forward – not just for the UK, but for any country that wants an agile health system that can respond to the changing demands of the 21^st century.