A musical day

My first meeting today was at 8am with Marika from the customer service development unit. She is a forward-thinking and dynamic person. She is very pleased that the hospital district has moved its focus from the municipalities to the patient over the past 4-6 years. Her role involves improving the patient care / customer services. Last week she organised a patient event to find out from patients what information they needed when they came into hospital. They asked for feedback and comments on their map, website, patient invitation letters and general feedback. It was a very successful event with 140 patients attending. Marika mainly talked about "customer service" recognising that patients are customers with rights but also needing the care element too. She felt that many of the questionnaires that they used did not give the answers that service areas needed. They have adopted a service design approach which uses the concept of a board game. She outlined that process they had used for the first of these with patients who had a sarcoma.

Initially a hand-drawn service journey map was produced which showed the patient pathway. From this staff  were interviewed to include their views of this journey. The next stage was to produce a board game version of the journey starting with the patient's entry and ending with their discharge. Patients were then interviewed using this tool. They were asked to take wooden figures and place them on the board to show where people had been very good or bad - this was for all aspects of their life during this time, not just the hospital experiences. They also had wooden discs which represented events and they did the same with these. Marika and a colleague from the university then collated and analysed this information and from this developed design drivers to improve services in the future. This brief outline does not really do justice to her work as it was quite radical and very visual but certainly completely patient or customer focused and obtained real meaningful feedback and then implemented the findings.

I then met with Alpo Karila, a finance director. I was a little wary as my knowledge of finances is not great. However, it was really useful to understand better how the money comes from the municipalities. The municipalities carry out the basic healthcare at the health centres and the rest is in the specialist hospitals. Every municipality has to be a member of a specialist health care area. The municipalities join together to obtain these specialist services. Generally they are geographically decided but sometimes those on the edges of the groups can move to another group. The Tampere area - Pirkanmaa district is the second largest in Finland, being second to the Helsinki district. He showed me lots of balance sheets which generally showed that the district is in quite a good financial positions at the moment, but it could be better and like everywhere there are serious concerns for the future. They have started to discuss with the municipalities whether they need to introduce some cost-cutting measures.

My last meeting was at the Acuta (A&E). I met Timo who is second in charge of the unit. Timo is a nurse but he has now moved into management. He keeps his clinical skills updated by spending time with the paramedics at weekends. He explained the triage system that they have adapted from the American Emergency Severity Unit. As I mentioned before their Acuta treats both urgent and minor illness / minor injuries. The triage nurses are the most experienced nurses and they do get about an extra 100 euros for this work. They assess the patients as they arrive and decide whether they need to go to the basic health care or the specialised hospital care. They still have paper records that follow the patient so they have to print out all of their documents that they complete electronically but this is supposed to stop in January next year. As I had already had the tour of the unit Timo spent some time explaining to me the nurse education system in Finland. They have the two levels of nurses - the practical nurses who come straight from school and study for 3 years. In their final 6 months they can chose to specialise. They do not have the same academic requirements for their course and would not be able to administer medications or I-Vs. There are no untrained staff in the hospitals! Registered nurses go to the universities after completing high school or some go on from being practical nurses. They study for 3 years and then specialise for their last 6 months. Generally they decide what they want to specialise in when they begin their course. Some of the options are community health nursing - this is a health promotion role, working with pregnant women, families and children to the age of 18; midwifery; paramedics. Finland has only just adopted a national registration system - Valvia which records all health professionals qualifications (including massage nurses!). They do not have Emergency Nurse Practitioners but in the evenings and weekends they have nurses who are more qualified who can see certain conditions and manage some minor illnesses and injuries. Their main role is issuing work certificates  - for those people who cannot work due to ill health. They can issue these for up to 5 days. It is ironic that generally they do not have anywhere near the autonomy of English nurses, particularly Advanced Nurse Practitioners, but where we cannot issue sick notes they can! they are starting to develop specialist nurses but still have a long way to go.

My next appointment was with the piano in the dining area. For our presentation we have an Olympic theme and I am looking at some music so I had a play. I think the late diners were a bit surprised. No one said anything - they probably thought I'd wandered in and decided to play! It was really good to play the piano again.

I came back to my flat and cleared a lot of the paperwork I had been given. As I was on my luggage limit coming here I need to be strict what I take with me. I phoned my Dad to wish him a Happy Birthday. Then  Pirjo was picking me up to take me to a concert.

I went to the concert at the Tampereen Tuomiokirkossa (the Tampere cathedral). It is a very beautiful church and I later read that it has been voted as the most beautiful church in the country. It has a Finnish romantic style and is built from grey granite.

 It has amazing frescoes which were painted by Hugo Siomberg and Magnus Enckell. The latter painted the alter fresco - the resurrection (although it was not obvious to me that this is what it represented!)

The light does not do justice to the stained glass which was really attractive.

The Garland of Life

The Snake

The concert was being given by Thomas' music school - many of the players were from the senior school and were extremely accomplished musicians. This was their traditional end of term concert as the schools all finish tomorrow for the summer. They will be off for 10 weeks (sorry James and Hev, no we're not moving to Finland!). The concert included several pieces by Sibelius making me realise there is much more than Finlandia although there were similarities in style. There was a full string orchestra with flutes for Vaughan Williams' Fantasia on Greensleeves and also a trumpet group, recorders, guitars, piano accordions who played Bach's Prelude and Fugue in C, a piano, violin and vocal piece by Bach, two pianists, one of whom was incredible I am sure that he will become a professional and then the headmaster's orchestra. the concert ended with a trqaditional Finnish hymn which Pirjo explained is always sang at the end of the year and most of the audience joined in.

It was a really enjoyable evening and in a very lovely setting.

Visit to Ylinen

Today - I have at last caught up with my blog! My first meeting was at 8am with Hanne and Mikko. This was to look at some more data collection. At last this started to make more sense as I got a better grasp of how the funding system worked. Hanne was responsible for extracting the figures from the various systems to produce the monthly reports which showed where the income from the municipalities was being spent. The report is then presented to the board and it was at this point that I could start to understand it as this is part of our board meetings. Mikko then went into more detail about how they receive their monies and the expenditure showing me the very detailed budgeting and cost breakdowns.

I then met Pirjo back in her office. It was great to see her again and catch up after my days away. Pirjo then drove me to Ylinen to the Care of the mentally disabled hospital of Ylojari.  I then spent time with Liisa, the physiotherapist and Carita, the psychologist. The hospital has 226 residential long-term clients and 22 short-term. There is also an out-patient clinic at Tampere which has over 3,500 patient contacts a year. I discovered that there are two types of nurses - Practical nurses who have done two and a half years of training and Registered nurses who have done a further year. It would seem very similar to our old RGN and EN system.

The clients range from a few months old - and I met the youngest one, a baby of about 6 months to elderly patients in their 80's. The thinking now is that clients should only stay in units like this if they really cannot be maintained in the community and so the site will close and they will move to a new area in 2 years time which will only have 80 long-term residents. There are two schools on the site one which is for the severely disabled and this also has a behavioural unit for excluded children and a vocational school which only has 5 places. The Finnish system does not put mentally disabled people who are convicted of crimes in prison - they come to Ylinen and are placed on one of their secure, locked units. They showed me around the site:

Me in the sauna - note the sexy footwear!

The hydrotherapy room

Some of the equipment in use

I then met with the speech therapist whose aim is to try to help the clients improve their communication skills in a functional way so that they can be understood. She went through several methods that are used including the AAC method - augmentative alternative communication, which can also be used by people with stroke and dementia. She may use signing or Bliss symbols. I liked this system - it is a series of pictograms such as \ means pen, * is a star, and a basic house outline means a house but if a heart is put next to the house it means home. However, this is quite a complex method of communicating which is often only suitable for clients with conditions such as cerebral palsy. The most popular method used is PCS (picture communication symbols) and there are many ways of using this from simple picture cards to electronic recorders and voice software programmes. The most important part of the speech therapist's work has been to ensure that ward staff are on board and continuing these communication methods with the clients. She is also starting to introduce an intensive interactive UK programme developed by Hewitt and Caldwell which is based on reflective behaviour techniques to try to engage the client and enter alongside them in their world by copying the behaviours that they are demonstrating. This establishes a relationship which can then be developed. She is shown below with one of the new t-shirts which had a first pictogram stating (in Finnish) "I am..." and then there are pictures showing different moods.

I then met with the occupational therapist who discussed some of the work that she is starting to take on as she has only been there 3 weeks. She showed me the gym room above and the programme that she had set up for her next client. It was fascinating to learn that many of the wards and support services will be closing now for the summer so she cannot implement many of her treatments until they reopen in 4-5 weeks.

Liisa and Carita then took me round the rest of the site visiting the units or wards. We went to one ward which used the system of Privilege and Stepwise that they had mentioned to me at the start. This focuses on accountability (responsibility for actions), therapy and community spirit. The chart shows the weekly programme which includes all of these elements:

Two of the clients who were young teenage boys wanted to show me their rooms. They were interactive and sociable and enjoyed talking about the chart and the sanction system. It later transpired that they had severe behavioural problems. However, the unit structure helps them to control and manage their own behaviour. The staff also use Aggression Replacement Training which is a cognitive behavioural intervention programme to improve social skill competence, moral reasoning, anger management and reduce aggressive behaviour.

The environment was very peaceful and beautiful as the next pictures show:

one of the units

One of the units focuses on the OIVA model a Finnish process which means Participation through Interaction. It has some links with the intensive interaction theory and each patient has a passport which shows pictures of them when they are happy and what makes them happy and the same for when they are sad and angry. They video tape interactions between staff and clients to recognise what improves or impedes relationships.

We then walked down to the lake where they often have summer events including BBQs:

It was a really interesting afternoon and I was very grateful to my hosts. I think I know far more about current mentally handicapped care in Finland than I do in the UK!

Liisa and Carita

I then had a taxi ride back to Tampere and Pirjo picked me up to go to Tuomas' concert. It was a trumpet concert for his music school held at his day school. The building was very beautiful and I met Pirjo's husband too.

The central hallway and staircase

The impressive glass ceiling

The weather has changed today - it is much cooler and quite overcast. However, it was lovely to sit out in the grounds of the school and listen to young people performing a wide range of trumpet pieces including Brahms, George Michael and Gershwin. Tuomas played "Keltainen lintu" - Yellow bird and his parents were very proud of him.

Pirjo, Tuomas and I then went into Tampere and had a really nice meal and a quick visit to the shops to buy Vilpo a shirt to go with his new suit for his confirmation next month. I then came back and have now, at last, caught up with my blog. Another early start tomorrow so off to bed now!

Helsinki - Day 2

I was almost tempted to title this "Hungover in Helsinki" but thought that might be unkind! The others had a very good time at the karaoke bar and came back quite late. There were not many of us at breakfast and when we met to go back to Orton some seemed a little fragile. Steve had a really sore throat from singing! We caught the tram back to the hospital and met up with Arto again to spend the morning on our presentation. We did not make as much headway as I would have liked - but that's my way of working. I like to get everything done and sorted as soon as possible, I think the others are more laid back and relaxed. It did make me realise that actually the focus is on what I have gained from the experience and learnt not the final presentation!

After lunch we visited the Institute of Health and Social Welfare. In 2009 they combined public health, the national research centre and health and welfare which is a great way of integrating all of these elements. There are a lot of challenges - demonstrating how to achieve a healthy and long life expectancy; reducing social inequalities, smoking and alcohol; promoting a healthy diet and exercise; improving working life productivity; improving the functional capacity of the elderly. We were informed that Finland has one of the most rapidly ageing populations in Europe. The department works with the municipalities to deliver research programmes and statistics which can then inform government policy.

We were then given a presentation about an elderly care research project which compared the care in public, private and municipality nursing homes. The results showed that where employees had greater autonomy they had increased job satisfaction and used less restraints and medications in their care. The work stress was much greater in large units where the workers felt they had high demands for giving psychosocial care, they had role ambiguity as there were not clearly defined roles and responsibilities, and they had a greater incidence of pressure ulcers. Where there was a low ratio of staff to patients they used more drugs, there was a higher incidence of reports of pain, much higher sickness levels and staff taking early retirement. The problem is implementing the findings of the research though as the municipality system does not make this easy. They do not necessarily want to pay out more money to rectify the problems.

We then went back to the hotel and collected our luggage and set off back to our places of work. It was nice to come back to Tampere. The only problem was that I had a train journey of nearly 2 hours and I was travelling alone. I had not brought my Kindle and was worried I might fall asleep. I contacted Helen and asked her to send me a message 20 minutes before my train was due into Tampere, and if she did not hear back to text me and then to phone me. It was a relaxing journey and the time passed quite quickly. Helen sent me a message and I informed her I was awake! Unfortunately my phone battery was dying and so I did not get her next message - to let her know that I was off the train. I arrived in Tampere and got off the train only to find that Dian and Lorraine had caught the same train and were now changing to go back to Jyvaskyla! I had had a booked open ticket so had got straight on my train at Helsinki. I went to the bus stop and then my other phone was going mad - it was Helen panicking that I was still on the train! I assured her I had got off and was now going back to my flat. I had a quiet, relaxing evening catching up on my blog and The Apprentice!

Helsinki Highlights

The previous night in Molly Malone's!

Monday 28th May - our mid-evaluation meeting in Helsinki. This is an opportunity for all seven of us in Finland to meet with the Finnish national co-ordinator, Arto, to review our visits and prepare for our final presentation in Berlin. One of our group Steve, chose to have a bath rather than come to breakfast as it was such a luxury to have a room with a bath. Arto had arranged for us to visit the Finnish parliament. Unfortunately he had not been able to book us a tour but we met with a colleague of his from the civil service who gave us a presentation about the parliament in an adjoining building.

A strawberry plant sculpture

A side view of the parliament building

The presentation we were given had taken the theme that parliament is like theatre and so it described there being 200 "leading actors" (MPs) with parliament being the "main stage" for Finnish politics. The Finnish political system is very different to the British. They held the election for their President last April and only after he was elected did they then hold their general elections for the rest of parliament. The President is seen as being above party politics having to be independent and somewhat separate from the day-to-day dealings of parliament. There are 8 main political parties ranging from the very left wing Green party to the very right wing Christian Democrats of "True Finns". After the elections were held last year the candidates who were elected then formed a government. There is never a complete majority but the party with the most votes starts the process. The National Coalition party had the most and then were joined by 5 of the other parties to form the government. The other two parties - including the extreme right party chose to be in opposition. The MPs term of office is for 4 years. The elections last year saw the biggest shift of power to the far right. They had had 5 seats and then gained a total of 39 seats.

Generally MPs vote according to their party line. However, there have been two votes where they were allowed to vote according to their personal views. In 2002 on the issue of civil partnerships and this was carried and then in 2007 where they voted to allow the expansion of the use of nuclear power. There has recently been some speculation as to whether there will be a vote on euthanasia and it was thought this would be an individual vote, but many think that this will not come to the political arena for voting.

The government are actively involved in working on health and social care issues including developing a healthy workforce.  Some of the proposals are to make young people finish their studies quicker so that they become a part of the workforce sooner. There is are initiatives to support post-retirement work, allowing people to remain part-time in work and so retain their productivity and their experience in the workplace.

It was suggested that there is still a lot of resistance to change and a tendency to work in traditional ways. For example, in public health which includes maternity care, the nurses work a standard 8-4 day. However, most women who attend for appointments are still working and so they should considering offering appointments out of work hours so that their working life is not interrupted. This has occurred in dentistry to allow people to have their treatment in their own time rather than needing to take time out of their working time.

We then travelled to Orton hospital which is a specialist orthopaedic centre. It was established during the war for young disabled people and also offered a vocational education. It has developed as a major orthopaedic centre with a rehab unit, state supported vocational unit with a school for the disabled and the company Respekta is based there which is a leading producer of prosthetics and equipment. We met our host, Heikke, who gave us a brief explanation of the hospital's work and we spent the rest of the afternoon working on our presentation for Berlin.

At about 5pm Heikke collected us and took us up to a room - there was a pianist playing and there was food and wine. It felt slightly surreal being in a hospital having a musical soiree! Heikke sang some traditional Finnish songs to us whilst we ate, and then the pianist carried on playing a variety of music including "My Way"!

The pianist

Our group enjoying the wine

Heikke performing

We had been thinking about the music from Chariots of Fire for our presentation. We asked the pianist if he knew this. He did not so then Lars downloaded the music on his ipad and I played it - it was great fun! We then left the hospital. The group felt inspired by then singing to go on to a karaoke club - I was too tired and also wanted to speak to my Dad after his knee operation so I went back to the hotel. I had thought I would restart blogging but the internet was down. I started to wonder if I would manage to catch up, but I am almost there now!

Tallinn Take Two

I was heard saying that this was probably my first and last couch-surfing experience. However, this was not a reflection on our hosts at all. I think it is really a younger person's thing and I am not known for my skills in "roughing it"!! Having said that I would not have missed it for anything. It was a great experience and I really enjoyed meeting Aron and Nisa and hearing about real life in Estonia.

With our Couch Surfing hosts

I was all for getting going straight away. However, Dian pointed out this would be quite rude especially as Nisa had prepared pancake mix for breakfast. I did feel better after a shower and thought coffee would be nice. Dian was right - we learnt much more from them. They are starting on a journey in two weeks which will take them 2 months. They are cycling from Estonia to Latvia, Lithuania, Germany, Poland, Holland, France - stopping off to climb Mont Blanc!, through Austria and Switzerland to finally end up in Milan where a friend will have driven their car and their possessions. Their spirit of adventure was admirable and in some ways I envied them their lack of attachment to anything material and their desire to explore the world.

They also told us more about Estonia, including that the sea freezes in winter and they actually make an ice road across the ice. The one rule is that you do NOT wear a seatbelt as there is more chance of you going through the ice and so needing a quick escape than hitting another vehicle!!

We then caught the tram back to the old town but went via a beautiful park. It was very peaceful and green.

The old wall

We went back into the walled city. It was Pentecost Sunday and the church services were in full swing. We went to the Russian Orthodox Church - it seemed rather incongruous that the mass was being celebrated but tourists were freely walking in and out of the church.

The Russian Orthodox Church

The Estonian Parliament building opposite the church

We then went back to the shops to buy anything we felt we still wanted to buy. We did check the shoe shop but it was shut! We were tired and decided to sit in the town square. There were seats for watching the stage so we at and listened. Although it was in Estonian we guessed it was another church service. It was being televised. An elderly lady came and sat in front of me. I was talking to Dian and Lorraine. She turned round and said "Ah! British English". She then explained that this was a Pentecostal church service. She had been living in Tallinn for 2 years, previously having lived in a more rural area. She talked briefly about the Russian occupation when everyone had to learn Russian. Interestingly she said that they churches had been very strong and more vibrant then.

We had lunch and then walked back for the ferry. By the harbour Dian noticed a market stall selling suitcases. The case was 28 euros - back in Tampere she had also seen an offer at Lidl for 58 euros so I decided to buy one to replace my ripped case. It is not the best (and indeed when I got back to day the handle was not quite as it should be!!) but it will suffice for my travels. As long as it gets me to Berlin and then Birmingham I'll be happy! I had gone to Tallinn with a backpack and came back with a large suitcase - sums up my travelling light really! We were all tired :

A quick power nap!

We got back to Helsinki and joined the others in our group at Molly Malone's bar! Then we went to get some food. By the time we got back to the hotel it was 11.50pm. Again I felt my age - I really can't keep this pace up for long!! I was panicking about doing my blog. I think I was getting blog withdrawal! I think I've caught up a bit and will continue tomorrow now - I need some relaxation before I am back into my action-packed programme in Tampere.

Estonian Escapade!

On Saturday I was going on another adventure with Dian and Lorraine. We had booked the ferry from Helsinki to Tallinn and were then going to watch the Eurovision song contest in Tallinn and stay the night using "couch surfing" - more about that later!

I got up at 6.15 (aware that Dian and Lorraine were leaving Jyvaskylla at about the same time to meet me at Tampere). We met on the train at Tampere and caught up on our 2 weeks so far in Finland. We arrived in Helsinki and took out luggage to the hotel where we would be staying on Sunday for the mid-evaluation meeting with the other Finland participants.Then we caught the tram down to the harbour and boarded the boat for Tallinn. Dian then told us that many Finns use this journey to travel to Estonia to buy alcohol. Alcohol is very expensive in Finland - the government have set a minimum tariff to try to reduce the incidence of heavy drinking. However, there will always be those who find ways around. This was born out by the fact that there were many people with very light suitcases which were then full on the way home the next day with their purchases! They also started buying alcoholic drinks the moment they had boarded the boat. When I went to the toilet the person in front of me emerged from the cubicle with her glass of wine!

Trying to take with all of us (me far left!)

leaving Helsinki

Arriving in Tallinn

It was very sunny and warm and was a very relaxing journey. There was a free bus up to the old city. The old city is definitely "old" and dates back to the Hansa times.Most of the streets were cobbled and the buildings very old and traditional.

one of the old gates

part of the old city wall

There was an event going on in the Old Market Square - "old city days" so there was a stage and various groups of children and choirs were performing.

We enjoyed browsing all the many tourist souvenir shops - very different to Tampere and even to Helsinki. We adopted a policy of looking today and coming back to buy tomorrow if we still wanted it to avoid those impulse buys!

Dian spotted a pair of glitter-covered brogues in a very exclusive shoe shop. We went in and she ttied them on and it was love at first sight:

Dian in love!

However, they were quite expensive and she apparently has a lot of shoes so she felt she needed to ask her husband, Pascale's permission. Unfortunately she could not get a wi-fi connection. We then went to have a late lunch in the square.

Throughout the food Dian was mulling over the shoes. Between our dinner and dessert she went to find McDonald's so that she could access the wi-fi. She sent him a message and we waited with bated breath for the reply. Our lunch was quite traditional Estonian food - I had salmon which was really nice and then we had a blue cheese cheesecake which was "interesting"! We went back to McDonald's to get the reply and finally it came back - Yes! We walked back up to the shoe shop only to find that it was closed and would not be open on the Sunday. Poor Dian! They were in the window but despite hammering on the door, no one was there. We managed to drag her away and walked up to the top of the town.

one of the many churches

We carried on round and found an amazing viewpoint over the whole city:

We were all flagging a bit so we sat in the warm, sunny evening and enjoyed the view. We then walked back down toward the square, passing another of the old gates:

In the square we were meeting our "Couch-surfing" hosts. This is a network whereby people can offer their couch for others to stay. It is an amazing idea and is obviously great for anyone travelling on a tight budget.
Dian had suggested this and we had gone along with the idea but by now were all feeling a bit apprehensive. We decided that we did not have to go through with it and could always go and find a hotel room. However, as soon as we met our hosts we felt very comfortable with them. Aron, was an Estonian software designer and is wife, Nisa, was from Turkey. They had met in England and were very well travelled. It was really interesting chatting to them as we walked to the bar, hearing about life in Estonia and some of their travels. Aron had lived briefly in Mapperley in Nottingham and Nisa had been an au pair in King's Langley near Watford. We were meeting with other couch surfers at the bar to watch the Eurovision Song Contest! One of the surfers had posted a notice on the website to meet there if anyone wanted to join us. During the evening about 15 young people, mainly from Estonia arrived. I did feel quite old and was also feeling very tired - it had already been a long day. We decided to eat at the bar and I thought some food might help my flagging energy levels. It was quite a traditional Estonian bar with traditional food too, away from the tourist track. I had the Russian meat soup and some Estonian cheese and biscuits. Due to the time difference the contest did not even start until 10pm! We were on a raised area by a television but it was almost completely obscured by a shell chandelier!

Left to right - Nisa, Aron, Stuart, Dian and Lorraine (many more came later)  complete with chandeliers!

There was a very large screen in the centre part of the bar and unfortunately the sound was coming from that but it was out of synch with our picture - all added to the fun! I survived the 26 songs but thankfully we decided to go to the apartment to hear the votes! The apartment belonged to Aron's mother and was quite traditional. At first I was a bit taken aback and unsure. However, I was overwhelmed by Aron and Nisa's hospitality. They lived a very simple life and what they had they shared with us.

Couch on the right, floor on the left!

Dian ready for her couch surfing experience

Lorraine on my bed!

Dian and Lorraine were also very generous and took the floor and let me have the couch.  I did hear the final result of the Eurovision that Sweden had won but soon fell asleep. Poor Lorraine has had a chest infection and at one point in the night was coughing vehemently. She had a good swig from her cough mixture and then slept well! I woke up about the same time needing to go to the loo - Russian Revenge from my Russian soup!!! We all settled back down. I woke up first and hand wrote my blog in my journal so that I would remember our experiences!