Finnish Older Care – ‘Let People Loose’
February 26, 2009
“Regulation stifles the heart and soul.” The words of our host hit home as we completed a two day trip to review the delivery of older care services in Finland. Our host was the Director of Health and Social Services for Espoo.
Espoo with a population of 230,000 since 1993 has had a combined health and social services department employing some 13,000 staff and is one of several local authority regions in Finland that borders the capital Helsinki. Similar to England the local government department is responsible for the purchasing and providing of services, including a universal free nursery provision, and a refreshing older care system that does not distinguish between nursing and social care both in terms of funding criteria and need. Throughout the visit at no time where we aware of any divisions in health and social care, indeed the reality of shared information through computerised care plans for all professionals to use through a reliable IT system was evident to see.
The Finnish experience
Our first home was the Villa Lyhde providing two floors of care for 24 people many with diagnosis of dementia. In entering the Villa we were immediately struck with the non-institutional feel of the building and fabric with small personalised living areas, wooden floors with rugs, and the benefit of an excellent view over one of the 60,000 lakes in Finland. Three residents of the home were on their way out for a morning swim in the lake. Such an exercise was spontaneously agreed without recourse to a risk assessment.
The villa had a mission statement on the wall, translated the key words were “Joy, laughter, intimacy and closeness, slowness and time, all within a unique community.” A photograph next to the mission statement showed three people arm in arm portraying and symbolising this was from the heart. It was here that our host made the comment about regulation stifling the heart and soul. He was well qualified to make this statement given his department runs the regulatory offices. Limited building requirements and staffing levels were required, but otherwise his department only visited on receipt of complaints. Homes survived based on reputation and delivery. “It was the freedom of the heart that mattered in delivering care.”
As a consequence the many layers of paperwork experienced in the risk adverse culture of England, relating to care plans, risk assessments, health and safety, and regulation were kept to a minimum. Care plans were life plans focused on a person’s history and interests and put together by family and friends with the individual. Daily notes were kept short and brief and only recorded changes in medical condition. But what if someone falls do you need to fill out an incident form? No, we pick the person up, was the answer, of course 80 year olds have accidents. The consequence of this freedom of minimal paperwork was the increased one to one time spent by staff with residents. A key phrase in all the homes was ‘slowness of time’ or make time to talk and listen and enjoy company. In practice this changed the culture of the homes with attention to detail and time given to residents – again in England with the process driven culture and fast pace of living do we really make time to spend with older people in care? Or is it onto the next target?
Across all the homes visited the lead manager was nurse qualified with nurse assistants holding a 2-year qualification working un-uniformed, in recognition of minimising any power relationship between staff and residents. A key criterion for appointment was the ability of candidates to be creative, paper qualifications were all well and good but did not necessary mean the person was good at communicating with residents.
All the Finnish homes recognised the importance of both mental as well as physical well-being. Full time physiotherapist’s were evident at every home leading an active lives programme including regular use of gyms, massage of feet and shoulders, and activities designed to test and where possible to improve the memory including the use of Montessori techniques. Clever prompts were used in some of the homes. Drawings of fishing scenes on walls included real fish-hooks hanging from the ceilings – again no risk assessment for the hook. People’s bedrooms were heavily personalised with walls of photos of loved ones and memories, and furniture including rocking chairs – again with no risk assessment.
Rather than ‘going into care’ and loosing your identity, recognition was made of your new identity and role in your new community. Throughout daily living prompts were made to help residents achieve as much independence as possible – paste on a toothbrush, assistance with cleaning your own room as needed rather than relying on an army of domestics. And to minimise risk not pages of risk assessments but the use of CCTV. Given the moral debates regarding civil liberties we have in England it was refreshing to see the reality of CCTV within a care setting being fully supported by families and not seen as contentious and allowing greater freedom for people to retain independence. Some one falling at night in their rooms was immediately recorded and acted upon.
Every service visited whether run by the state such as Taavinkoti a 60 bedded dementia home , private such as Villa Lyhde, or voluntary including a Salvation Army home recognised the importance of small groups of no more than 10 older people living together. Living spaces had risks, exposed heaters, rugs that could be tripped upon, exposed cookers, and saunas as you would expect in Finland, but the communal areas were normal in appearance – life is about risk. Regulation did exist in all the homes for example all homes had fire sprinklers, but the point is people were not wrapped up in ‘cotton wall’ with risk assessments and limitations of what they could do, people what ever their mental state were still living their lives to the best of their ability and were genuinely empowered – yes things went wrong but the culture accepted this rather than blamed.
An interesting variation to risk concerned the spread of MRSA within care homes rather than place older people with MRSA a new specialist unit for MRSA existed. Whether this isolationist approach works and is indeed right will be interesting to see.
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