The results of the present study show that people using primary health care services in Finnish health centres are generally fairly satisfied with them. Nevertheless, overall satisfaction diminished during the 14-year study period. Likewise fewer patients reported good access to and continuity of care.
The findings here provided no support for the hypothesis that the recent reforms and improvements in Finnish health care would have improved patients’ satisfaction with care on the whole – and especially with regard to access to and continuity of care.
This was the first longitudinal, systematic inquiry into patient satisfaction in primary health care in Finland. The strength of such a repeated sample was that all 65 centres in the district were invited to participate, and 76% participated in at least six out of eight rounds. During the fourteen-year study period we were able to gather an extensive sample of patient opinions. In this study area of 1.2 million inhabitants there are small rural health centres and large health centres in the conurbations. According to the official Finnish health and statistical registers, our study area seems to represent the rest of the country quite well in terms of level and time trends in volume and costs of primary health care as a whole and the health centre visits in particular. As the patients who chose to answer our inquiry were those who had an opinion and wanted to express it, the respondents’ views cannot be taken to represent those of the whole population of Finland but presumably those of the section using health care services in health centres.
The idea for our questionnaire came originally from European patient satisfaction studies  and was applied to the Finnish health care system and validated in our pilot study in 1998. We were aware of the challenges involved in studies using a questionnaire survey . Reliance on personnel to distribute questionnaires is flawed as a mechanism and involves some kind of sampling bias. This notwithstanding, the same flaws apply to the data throughout, and it is thus reasonable to conclude that the comparison over time remains robust. The low overall response rate (45%) was a limitation of this study. Nevertheless, we consider that our data and the process of assessing patients’ views were feasible and comprehensive . The comparability of different study years was ensured by implementing the questionnaire identically every study year.
A number of factors influence patient satisfaction [15–17, 20–22]. They may be related to patient characteristics or to features of the health care system. On the other hand, patient satisfaction alone is not a guarantee of good and efficient health care. Good communication during consultation increases satisfaction . This aspect was not included nor analysed in our study.
Many studies have shown that patients’ age, gender, perceived health status at the time and socioeconomic status have an effect on their satisfaction with health care services. According to the official health registers the variables mentioned did not change significantly in Finland over the period covered. The most marked decrease in patient satisfaction noted here was in the group over 64, who tend to have multiple diseases in long-term conditions – and also an increased need of health services.
Patients in primary care appreciate ease of access and continuity of care [2, 7, 8, 15, 20]. Ratings of the access to the health services were conspicuously low, eminently in the last study year 2011 and among the elderly. Also ratings of the continuity of care had declined by 2011 and the variation between the health centres in satisfaction with the accessibility and continuity of care was significantly high. Elderly patients with chronic diseases attach particularly great importance to the continuity of care and a long treatment relationship with a particular doctor.
Finnish health care centres underwent a number of changes during the study years [24, 25]. This may partly explain the falling trend in patient satisfaction with the services in general and with the accessibility and continuity of care in particular. Some of the changes in question were influenced by societal change, financial austerity and a lack of experienced primary care professionals.
In the 1990s the Ministry of Education radically reduced student intakes in the medical schools, since when the shortage of family doctors and GPs in primary health care has become more acute. This deficit – also associated with demanding working conditions, heavy workload and ageing and demanding patients – has led to smaller numbers of GPs working in primary health care. The consequent poor accessibility and continuity of care has led to a decrease in patient satisfaction. At the same time young doctors have preferred a career in hospitals and in occupational or private health care instead of working in health centres.
During the study period, occupational healthcare was growing strongly, and the municipal health centres were struggling to get their share of the total health care resources. In ten years since 2000, the absolute number of non-urgent physician visits in health centres went down by 20% nationally. This, in turn, has led to a substantial increase in waiting times for non-urgent care . Between 2000 and 2010, there was a net increase of about 25% in the total number of active physicians in Finland. However, this growth was directed almost totally to other parts of Finnish health care, not to the municipal health centers .
Legislation on maximum waiting times has existed in Finland since 2005. There is, however, no indication so far that the new modes of procedure have had a positive effect on the accessibility of primary health care. While the legislation sets the framework for how and when certain medical conditions ought to be diagnosed and treated, it may also exacerbate inequality of care. The legislation on maximum waiting times raises expectations in the general public which may not always be met since it only covers specified medical conditions. The proportion of non-urgent visits has decreased over the years. Regarding resource allocation, the legislation may result in more resources being allocated to emergency outpatient clinics and specialized care. At the same time care for patients with chronic illnesses and complicated psychosocial problems may receive even less resources than before. The poor access to health centres has proved a marked drawback, and recent efforts have focused on developing a call-back technology to ease access to services.
The implemented and planned national health care programmes and legislation in Finland were designed to improve the health services. The general strategic reforms with weak implementation methods might not have been able to resist the strong pressures within the service provision system.
For health care policy to be successful the system should focus on providing more people with better accessibility and personally focused, humanely conceived comprehensive and coordinated primary care . Policy-makers and health care professionals should collaborate in efforts to narrow the gap between public expectations and patients’ experience . One of the latest development programmes is a new way to organize long-term care and freedom of choice in the health care services. The chronic care model [29, 30] and freedom of choice for the population  draw patients, professionals and decision-makers together in improving the quality, fairness and effectiveness of and satisfaction with care, and may help to focus on those patients who are most in need of care.