Carriage Driving in the forest

I had a busy work day today (some of you may be thinking about time too!!!). I started the day with a meeting with one of the data managers who told me more about the integrating of their databases and the setting up of the national database. He told me a bout IHE - Integrating the Healthcare Enterprise which is an international standardising organisation who also offer advice on connecting different systems. I have decided that there is another language that is as complex and hard to understand as Finnish - "IT speak"! So much of it really is a foreign language to me and I cannot guess at what the concepts are! I then met with the Acquisitions Manager and really remained out of my depth! He is responsible for their outsourced services and negotiates the contracts for these. It is a complex process and their is a significant fear that suppliers will take them to court if they do not win the contract. For any services over 30,000 euros they have to put in a tender and their is strict legislation given in the 2007 Act on Public Contracts which stipulates how this process must be done. However, the Pirkanmaa hospitals also have an underlying philosophy that they must offer "good purchasing" and they will only use suppliers who pay their taxes and use only Finnish suppliers for their clinical services (although they do purchase some doctors from Estonia and Russia). They buy in many services including cleaning and laundry. At the moment they are looking at buying shares in a laundry company so that they then would not have to make a contract to get this service. Anti said that they are realising that as people are getting older and living longer they will need more services.

My next meeting was with Paivi from HR and I felt more in my comfort zone. She is currently the project manager for a large HR project to digitalise all their records so that they have all of their HR policies and forms electronically and on one part of their intranet. They do have problems recruiting clinical staff including nurses. Many nurses are not working as nurses due to the levels of pay so they would like to attract these back into nursing but do not have any financial incentives to do this. She also pointed out that the Finnish nurses do not have a standardised training as we do with the NMC. Therefore, they cannot guarantee that a nurse trained outside of the Tampere area will have the skills that they require. Paivi stated that in the future they need doctors and nurses to integrate better and work more closely rather than staying in their traditional hierarchical roles. They too have the issues of how to communicate effectively with all staff but felt that the onus was on individual staff members to keep themselves informed. She did speak a bit more about the summer holidays - many staff take 3-4 weeks during the summer as many get 38 days annual leave a year and so would then take the other days off during the autumn or winter, or save them for other years or put them towards an early paid retirement.

In the afternoon I met with Kirsti a COPD consultant. We had a discussion around smoking cessation initiates in Finland. There is a clear guideline which is updated every year and has government backing and funding. They have had legislation about tobacco since 1976 - starting with restricting advertising, preventing smoking in public places, 2 years ago this was extended to include restaurants and also raising the legal age to buy cigarettes to 18. Generally the numbers of people smoking has decreased. Health promotion plays a major part of the hospital strategy including smoking, alcohol, diet and parenting. She explained the hospital's local project to try to tackle smoking. They have 3 pathways for patients. The first is for very brief interventions and requires all clinicians to ask about smoking habits and record this. The second is  a more detailed history and finding out if the patient is willing to think about stopping and the third reflects their current guidelines and is based on the Prochaska and DiClemente model of change. They also use the Swedish tool developed by Karl O Fagerstrom, to determine what level of nicotine replacement therapy to use. They do not have specialist services but expect all clinicians to be carrying out this health promotion. We then talked about COPD and again they have their own pathway. They have recently started pulmonary rehab and at the moment this is only avail;able in the hospitals but they would like to implement it in primary care. They also want to increase the amount of rehabilitation available on the wards and to develop guidelines for primary care to ensure the right patients are referred. They only use self-management plans for patients with asthma but may look at doing these for COPD. A big concern is that as patients are living longer they are needing more treatment and so the costs are continually rising. However, they have found that the expected increase in admissions due to COPD is not happening at the moment. Rather the biggest concern is  around obese patients who are being admitted for non-invasive ventilation problems and this is rising sharply.

My final meeting was with Auli looking at diabetes. I was amazed to discover that Finland has the highest prevalence of Type 1 diabetes in the world. Some possible causes for this are cow's milk or entero-viruses but they do not really know why. She has been involved in the FIN-D2D project which focused on the prevention of type 2 diabetes. Like many other countries the rate of obesity is rising in Finland and so also the prevalence of type 2 diabetes. This project was an attempt to reduce the costs of diabetes care caused mainly by complications by trying to reduce the numbers of people developing type 2 diabetes. It has been recognised that if this problem is not addressed the current level of healthcare is not sustainable and so a more proactive health promotion approach is needed. Thus it was decided to look at lifestyle modifications such as weight reduction of >5%, moderate fat <30%, low saturated fat <10%, high fibre >15g/1000 kcal, and physical activity >30 mins/day. All of these measures are really a normal "healthy" lifestyle. Having worked with a group of over 10,000 patients who were identified as high risk of developing diabetes it was found that after 3 years their risk of developing type 2 diabetes was 58% lower than in the control group. This was achieved by using tools to help patients identify their risk factors - FINDRISC and then offering interventions and goal setting. Interestingly most people wanted to have individual interventions rather than group which matches the Finnish culture. One particularly successful aspect was setting up activity programmes for inactive men - SuomiMies seikkailee. This included co-operation from the municipalities offering reduced rates and special classes for men and is now a national programme. They developed lots of patient information booklets and leaflets. They had a lot of media support to publicise this and ensure that people were given as much information as possible using special events, looking at hospital restaurants, pharmacists. They developed the T2D care chain for the Pirkanmaa district and this has a focus on client centredness but also links into the wider regional strategy.

After this lengthy session I rushed home to get changed to meet Pirijo and Pia to go back to the stables for my carriage driving lesson. It was another really warm sunny day and the drive into the forest was beautiful.

The pregnant Fjord - due next month

Pirjo with the kitten (Hev - thought you would like this!)

At the stables Josse was ready and waiting for me to brush him down and clean is hooves. Then he went out and Janette harnessed him to the carriage.

I got to hold his head still while Janette strapped him into the harness

Janette then took the carriage into the arena and demonstrated walking, trotting, galloping and turning. It all looked very effortless and natural. Then it was my turn!

Me in action!

And off into the forest

coming back to the stables

It was a brilliant experience but I really had to concentrate. The slightest movement of the hands tells the horse something. We went round the arena going past cones, turning doing figures of eight and then walking, trotting and even galloping - it was fantastic. Once Janette felt I had sufficient control we then took the road out of the stables area into the forest which was wonderful - it was a warm, sunny evening and the forest was very peaceful and beautiful. I was slightly disconcerted when I first went uphill as Josse suddenly started trotting fast - Janette explained horses go much faster uphill. I had wondered what I had pulled or said but it was just him managing his load more efficiently! 

Afterwards we saw the foal who had been born just a week ago - he was very lively and sweet.

We then drove back. We had hoped to stop at a restaurant in the forest by a lake but it was not yet open on weekdays to we went back to the petrol station but sat outside (Pirjo eventually let me take her picture!):

It's now nearly 10.30 and I haven't had my tea yet so time to stop writing my blog, eat, and get ready for another full day in Tampere tomorrow!