Health and social services: living together apart
International Journal of Integrated Care, 25 June 2009 - ISSN 1568-4156
Health and social services: living together apart

Unemployment, conflicts in the workplace, divorces, child rearing problems, lack of food, income and housing accommodation, discrimination, a death in the family, the onset of a chronic disease, generational conflicts, trouble with the neighbours, violence and intimidation, they all belong to the category of social problems. These problems exist in a large variety. Finding out what causes the problem (unemployment? cultural factors? family related issues? working circumstances?) and helping clients cope with these problems is difficult: there are so many causes. It is the job of professionals in the social services to help clients signal the problem, to analyze the real causes and to find solutions or suggest coping strategies to deal with the social problems.

Adaptation, running away, becoming aggressive, praying to the Lord, being cynical, using alcohol or drugs and developing health problems: these are all coping mechanisms to deal with social problems. To specify what I mean by health problems, I am referring to issues such as high blood pressure, problems with the auto-immune system, stress symptoms, sleeping problems, depression, complaints about the digestive system, and so on. A lot of co-occurrence exists between social problems and health problems. However, there are social problems without health problems as well as health problems that exist without social problems. Health problems have their own etiology in the human body and their own causes when you take into consideration heredity, lifestyle and environment. Finding a diagnosis and offering therapy is difficult. It is the fob of doctors and other professionals of the health services.

Because of the high co-incidence of health problems and social problems, many countries try to integrate health and social services at the level of primary health care. I refer also to the World Health Report from autumn 2008, which contained an argument for the strengthening of primary health care and for intersectoral collaboration as an important strategy in this connection [1]. The best example of cooperation between health and social services is given by Finland, which is described elsewhere in this Journal [2]. Although the Finnish concept looks beautiful, Simo Kokko mentions two challenges that make it suboptimal. First, there was and is an income problem. General practitioners within the health centres compare themselves with medical specialists within hospitals. However, in Finland their income is much lower. That creates a context wherein medical students do not choose for a GP career, it creates a shortage of GPs and long waiting times to get an appointment. The lesson I learned after reading the Kokko paper in this Journal and after a study visit to the Finnish Board on Health and Welfare in Helsinki in April 2009 is the following one: if a country wants to develop an income policy for medical professionals, do not only lower the income of GPs, but also that of medical specialists. If the last option is not possible, don’t cut the income of GPs alone. Within the Finnish health centres the income of GPs is, in turn, much higher than that of the professionals who handle the social problems. This creates a pressure on multidisciplinary teams who cooperate to help patients with both health problems and social problems. However, this seems to me to be a smaller problem than having a health centre without GPs.

The second challenge is that many GPs in Helsinki and other bigger cities—see the paper of Kokko—want to work outside the health centres in a stand alone setting which deals only with health problems. Although not explicitly mentioned in the Kokko paper, I suppose that Finnish GPs do not readily identify themselves with a centre where health problems are not the only core business: they do not feel at home. A solution may be that structures, work processes and buildings for health professionals and welfare professionals are not completely integrated in teams: a concept which in Finland, as well in Holland is called: Living Together Apart.

On 16, 17 and 18th of June 2010, just before the beautiful Midsummer night of June 21, the International Network on Integrated Care (INIC) will hold its tenth conference on integrated care for researchers, policy makers and leading professionals. Themes will be: integrated primary health care centres, as mentioned by Simo Kokko, community mental health services, integrated family and youth centres and integrated care for the elderly. The ideal country to host this conference is Finland: they have the best practices, the experts and the experiences. Please, keep reading this Journal about integration of health services and social services. Surf to to inform yourself on international conferences and study trips around this topic.

Guus Schrijvers Professor of Public Health and Health Economics at the University Medical Center, Utrecht and Editor-in-Chief of the International Journal of Integrated Care

Van Lerberghe W, Evans T, Rasanathan K, Mechbal A. The world health report 2008: primary health care now more than ever. Geneva: World Health Organization; 2008.
Kokko S. Integrated primary health care: Finnish solutions and experiences. International Journal of Integrated Care [serial online] 2009 Jun 25; 9. Available from: