Primary Care System

Today I was meeting with staff members from the Centre of General Practice. This unit is accommodated in TAYS hospital site but is completely separate. Their focus is on developing the health centres within the Pirkanmaa district. I met with the Chief Physician who explained that this was the first unit in Finland and is now the model for other areas. They have a major input into GP training. The doctors work at the health centres and do their training on the job and this is then recognised by the University, so Doris supervises their training and ensures that they are competent at the end of it. Another function is to develop the co-operation between primary and secondary care working with the 24 Pirkanmaa municipalities and the 18 health centres in that area and then the 43 health centres in the whole TAMK hospital district.

The municipalities provide public health care (primary and secondary care). They may run their own health centre or do so with several other municipalities depending on size. One municipality has only 1200 people whereas Tampere has 200,000. Some purchase nearly all their services from private providers. The health centres seem to be much larger than ours - they cover medical treatment, out-of-hours care, maternity and child welfare, school health care, occupational health, health promotion, dental care and have wards for inpatient care. Next week I am going to visit one so that will be really interesting.

The Pirkanmaa hospital district contracts with the municipalities to provide public health care. Another initiative that has been set up is the Pathway Messenger. This allows staff to spend a week in another setting - it is well used by primary care professionals to come and work in secondary care but not so much from secondary to primary. One of the expert nurses arranges the programme for the week and ensures that there are specific objectives and goals for the week and that at the end these have been achieved.

A further part of the Unit's work is developing Integrated Care Pathways which really do involve both primary and secondary health professionals. I explored this more at my next meeting. Doris showed me a model (I have just tried to find it on the internet but not succeeded so will try to reproduce!) which demonstrates the different levels of support that patients need:

Hard

                            Support                                                Ongoing relationships

Coping

                            Poor use of time                                   Co-operation

Easy

                             Low                                                       High

                                       Complexity of care and finance

This doesn't really show it very clearly but the general view is that those who have minor health / social care needs which have low costs and input are not those that should be focused on as they can sort out their own needs. However, those who are struggling to cope and have multiple needs and are a major drain on resources need a high amount of support and this should be given on an ongoing basis. Doris equated this to the work of our community matrons. This model is used to inform their interventions in health care.She is also trying to propose that when these patients go to secondary care they should be in one place and the various specialist involved should come to them at one appointment - quite a practical but very radical approach!

I then met with Leena, one of the two "Expert Nurses" who work in the unit. She explained the care chains to me. There are two levels of pathways - the Kaypa Hoito which are national care guidelines which then inform the specific local chains - Hoitoketju. She went through the type 1 diabetes chain with me. It was incredibly detailed demonstrating  clear responsibilities for primary and secondary care. It did feel rather prescriptive to me and I did wonder where clinical judgement came into this. I also considered this was needed because of the training of their primary health care practitioners. With the GPs having a locally set training programme if they needed much clearer guidelines. The pathways are also used by occupational healthcare which is much stronger here in Finland. The pathways even include what should be put in a referral letter to secondary care and in discharge letters! They list the personnel involved which I thought would be a logistical nightmare keeping this up-to-date, but she assured me this is done every 6 months and works so maybe they don't have the same turnover of staff.

The pathways are developed by multi-disciplinary teams and involve input from the various locations and professions. Their next pathways will include patient input.

I then went for lunch with Leena and met some of her colleagues. This was a very nice dinning area and I wished I had found this before! Pirjo had shown it to me on my first day but I had forgotten where it was. I had a really nice lunch including a Finnish type of pancake with berries. It was good to chat informally with them about nursing and life in Finland. Leena explained that she had been a head nurse in a health centre but had decided she wanted a new challenge and so had moved to the General Practice Unit. However, in doing so she had taken a large reduction in her salary, even though she would seem to have much greater strategic responsibility now.

After lunch I met with Maarit, who is the Chief Physician for Health Promotion. She is responsible for implementing the 2011 Health Care Act in the municipalities and so has drawn up a regional plan to do this. A major strength of the system is that because the municipalities manage all areas including health and social care, education and culture, technology and environment, and administration there are not strict budgetary rules. Therefore there is much better integration and joint working possible.  She showed me some research carried out by Koskinen and Martellin which compared the prevalence of health problems between people with a tertiary level of eduction and the rest of the population. If the whole population shared their levels of health the prevalence of health problems would be markedly reduced. For example there would be a 50-70% reduction in respiratory deaths, 30-50% in coronary heart disease deaths and 30% reduction ion the prevalence of diabetes. The clear message was that this higher educated group were more aware of their own health and took measures to remain healthy. Part of the regional plan is therefore to improve dietary and exercise understanding and hopefully activities to redress this balance. Maarit believes that diet and exercise are the most cost-effective health promotion activities, far more than smoking and alcohol, particularly because children do not drink alcohol or smoke but if they can be helped to eat healthily and exercise they will continue to do this for life and so be healthy at all stages through their life.

Cycling is a major form of transport - the bikes outside my apartment block

However, she too recognised that it is often difficult to demonstrate these benefits and although there has been a very good screening and monitoring system for children and adults over the ages of 40 many of these programmes are now being cut by the municipalities.

The most positive message though was this "inter-sectoral co-operation" which they see as fundamental to helping all groups form children, to the unemployed through to the elderly. The fragmentation that I so often see works against this and so it was really interesting to see it working well here.

In the hospital lobby - Joy; Worries; Hope; Security

It has been a very wet day today. I started walking back to my apartment and saw the ambulances by the Acuta and thought this would have been a good picture for yesterday so I thought I would put it here:

This is my last week where I will be based at TAYS. Next week I shall spend my final week visiting some of the other hospitals and a healthcare centre. It is amazing that I have been here for nearly three weeks. I have seen so much and experienced so much too. 

The grounds of TAYS