Primary Care Services

Today was focused on primary care so this was of great interest for me. My first meeting was with Elina, a mental health service psychologist. Patients are referred for counselling by the primary care doctors. She works alongside a psychiatric nurse and together they receive referrals from 3 health centres in the west of Tampere. Although, they have different qualifications and different backgrounds they both provide similar services and decide between them who will take each referral, mainly depending on current workload and the patient need. However, Elina has a more specialist knowledge and so is paid considerably more than her psychiatric nurse partner. They offer up to 20 one hour sessions for people with depression, anxiety, and what she termed as "life crises". If patients need longer they are then referred to other services funded by KELA. The service is for patients aged 20-65. Those over 65 are seen by the third sector Senioripysakki Keskusteluapua seniorelle - literally "Senior shop". Elina has a relatively high rate of patients not attending for appointments due to the nature of their problems. At present there is no charge for these but it is being considered and it already happens in the psychiatric clinics where they have to pay about 38 euros for missing an appointment.

The appointments are generally one-to-one as most people do not want to access group support. Elina is doing some further study at Turku which she is self-funding but feels it will extend her knowledge and skills. She is studying constructive psychotherapy. The service inputs data to the Pegasos system but many only record information from the first, mid and final sessions. They mainly use the Beck depression tool. There is a treatment chain that they follow. It is a Monday to Friday 8-4 service and so people may access services nearer to their work place rather than their home through their occupational health service. This service tends to pick up those who do not have access to any other services. We were discussing the different forms of counselling and the approaches and Elina described it as being like "Alice in Wonderland" for both patients and other health professionals but that the key was the relationship with the patient.

I then went to the telephone health service where I spent a very informative and enjoyable morning with Mervi. She is one of the nurses who mans the telephone lines. They are trying to be the first point of contact for all of the population in Tampere and also Valkairkoski area in the south, about 40 km from Tampere. The service has been running for about 50 years now and so is well established. They provide a 24 hour service advising patients and carers what action to take to manage their healthcare problem. They will give information and advice where possible and then make appointments at the health centres when required. They cover 10 health care centres in Tampere plus 2 private clinics who buy their service and 4 healthcare centres in Valkairkoski. Many of the health centres are only open from 8 - 3.30 (3pm on Fridays) and so then they would refer patients to the nurse-led triage system at TAYS in the Acuta. Many of the health centres close for the summer and so in July there are no routine appointments available, only emergency ones so the last couple of weeks have been very busy as people get anything routine sorted and also before they too go away to their summer cottages.Mervi said "Finland closes for the July and the city is silent"! The phone operators are all nurses, mainly from acute care backgrounds. They have a target to answer 80 calls for each 8 hour shift. When I was there the display board showed that of the nurses working they had already answered over 400 calls but over 350 people had hung up before being dealt with. They have asked for more staff to deal with these huge numbers of people who do not manage to speak to someone but so far there has been no further funding from the municipalities. The average waiting time though is only about 7 minutes though at busy times it can be much longer. At the weekends they also manage the emergency dental service. Merki does not really enjoy this as she says she does not feel she really has the skills to assess these patients. Often patients will travel up to 100 km for these appointments so they must really be in pain!

There is no regulated training and they learn on the job. There are no pathways or algorithms. Mervi told me that when she had worked at the emergency call centre they did have these and she is hoping that maybe she can introduce them to this service. They also run a "net nurse" service where people can post questions on the net and these will be answered by the nurses, although the telephone calls take priority. Apart from the Acuta there are no other out-of-hours service providers so many patients end up waiting long times there. They did have one 24 hour healthcare centre but this was closed and all services transferred to the Acuta.  Elderly patients are often referred to the "Kotitori" - elderly care office which I visited yesterday.

Pirjo then collected me and took me to the Hervanta Health Centre. This is set in a busy residential area in the east of Tampere.

The health centre is on the left opposite the library

The entrance

The main reception area

Unfortunately the nurses were very busy as there were 2 staff away. I met with one of the nurses who had 20 minutes to briefly explain the system. Patients register at the health centre according to the residential address. They are allocated to a doctor and a nurse. She worked for 2 doctors. Each doctor had a list of about 2,500 patients and the nurses about 4,000-5,000. Their service is open from 8 - 3.30 and they see a wide variety of patients. The nurses roles are somewhere between a treatment room and to practice nurse. They do not have any that are working at the level of an advanced practitioner. They receive additional training that is run by the practice. The nurses see booked appointments and on-the-day patients. Many of these will have been booked by the telephone nurses. They do injections, vaccinations, dressings, minor illness and injury advice. They are not allowed to diagnose. They have 15 minute appointments. 

The second nurse in her treatment room

I then went to the other nurse. She was still busy seeing patients and so I observed her seeing two patients, reviewing some INRs (anticoagulation results), contacting patients after the doctor had seen these results to inform patients of the need to change their warfarin doses and then writing up her notes from the morning as she had been too busy then. The first patient was a young child who came with her mother, 2 siblings and an interpretor. I think they may have been Somalians. She had some inflammation on her scalp and so the nurse had a quick look and recommended some hydrocortisone cream which they would buy from the pharmacist. The second patient was a man who had ongoing generalised pain and had been seen for this by a doctor recently. He had contacted the telephone service but there were no doctor appointments available and so they had booked him in with the nurse. She did not feel she could help and so made him an appointment for the next day with one of the doctors.

Pirjo collected me and we went back to her office and had a coffee together. We had planned to go to a museum but her son is unwell and so she rightly needed to be with him. I decided to walk up to the north lake again but by the hospital this time. The sun was very warm and it was a lovely walk to the lake through the forest area. I passed some football pitches. Young boys were arriving for training sessions and on th way back the men had arrived too.

Sorry Hev - all boys, not sure how strong girls football is in Finland!

I arrived at the lake - it was very beautiful and so peaceful. I found a rock to sit on right by the water's edge and read my kindle, a really relaxing time.

Self-photo!

A really beautiful place

I then walked back through the forest to the hospital.

The forest

Helen (my older daughter) had a job interview this afternoon so I texted her to wish her well and was thinking of her. She sent me a message that it had all gone well and they were sorting out her CRB check and she would receive an offer letter by post. I am really delighted for her as it will be great experience for her and fill in some time in her long summer break and also give her some money!

I am now going to have my tea and get ready for tomorrow as Pirjo is collecting me at 5.40am to catch the 6.05 bus to Mantta which is in Upper Pirkanmaa!!