Older people in residential care in Finland experience a much looser, less regulated environment than in the UK

Mark Lloyd’s comparison of older people’s care in Finland with that in the UK begs the question of whether we have sacrificed quality of life to safety and regulation

“Regulation stifles the heart and soul.” The words of our host Juha Metso, director of social services and health care for Espoo,  it home as we completed a two-day study visit to review the delivery of older care services in Finland. The Kent Community Housing Trust (KCHT) specialises in dementia care services and is keen to learn from best practice in other countries.

We recently sent seven staff to visit a range of state, private, and voluntary sector run care services for older people in the Espoo region. Espoo is a regional authority close to the capital Helsinki and has a population of 230,000. Since 1993 Espoo has had a combined health and social services department employing about 6,000 staff. Some regions have combined departments while others don’t – it is a local rather than central government decision.
 
As in England the local government department is responsible for the purchasing and providing of services, including a universal free nursery provision. But it has a refreshing older care system that does not distinguish between nursing and social care in terms of funding criteria and need. At no time during the visit were we aware of any divisions in health and social care. It was clearly evident that they had made shared information through computerised care plans for all professionals a reality.

We were very interested to see the delivery of registered care services. Our first visit was to Villa Lyhde, a home providing dementia care. In entering the villa we were immediately struck by the non-institutional feel of the building and fabric. It has small personalised living areas, wooden floors with rugs, and a great view over a lake. Three residents were on their way out for a morning swim in the lake: an exercise that was spontaneously agreed without recourse to a risk assessment.

The villa has a mission statement on the wall, which reads: “Joy, laughter, intimacy and closeness, slowness and time, all within a unique community.” A photograph next to the mission statement shows three people arm in arm portraying and symbolising this was from the heart.

It was here that Metso made the comment about regulation stifling the heart and soul. He was well qualified to say this, given his department runs the regulatory offices.

Some building requirements and staffing levels are required, but otherwise his department only visits after complaints. Homes survived based on reputation. Metso says: “It is the freedom of the heart that matters in delivering care.”

The many layers of paperwork in the riskaverse culture of England, relating to care plans, risk assessments, health and safety, and regulation were kept to a minimum. Care plans are in effect life plans focusing on a person’s history and interests and are put together by family and friends with the individual. Daily notes are kept short and only record changes in medical condition. But what if someone falls, is an incident form needed? “No,” says Metso, “we pick the person up – of course, 80-year-olds have accidents.”

This freedom from paperwork means staff have more one-to-one time with residents. A key phrase in all the homes is “make time to talk and listen and enjoy company”.

Across all the homes we visited the lead manager was nurse qualified and worked with nurse assistants who had a two-year qualification. A key criterion to become a member of staff is the ability to be creative. Paper qualifications are not held to mean the person is necessarily good at communicating with residents.

All the Finnish homes recognise the importance of both mental as well as physical wellbeing. Full-time physiotherapists are in every home leading active lives programmes. This includes regular use of gyms, feet and shoulder massage, and activities designed to test and where possible to improve the memory, such as the use of Montessori techniques.

Some homes have clever prompts, for example drawings of fishing scenes on walls included real fish-hooks hanging from the ceilings – again no risk assessment for the hook. People’s bedrooms are heavily personalised with walls covered with photos of loved ones and memories, and furniture including rocking chairs.

Rather than “going into care” and losing their identity, residents’ new identity and role in their new community is recognised. There are daily living prompts to help residents achieve as much independence as possible – paste on a toothbrush, assistance with cleaning their own room as needed rather than relying on an army of domestics. CCTV was used to minimise risk, rather than pages of risk assessments. Given the moral debates regarding civil liberties we have in England it was refreshing to see CCTV within a care setting being fully supported by families, without being seen as contentious but as allowing greater independence.

Every service we visited recognised the importance of small groups of no more than 10 older people living together. This was the case whether the home was run by the state such as Taavinkoti, a dementia home, private ownership such as Villa Lyhde, or voluntary including a Salvation Army home. Living spaces had risks: exposed heaters, rugs that could be tripped on, exposed cookers, and saunas as you would expect in Finland. But the communal areas are normal in appearance.

Regulation exists in all the homes – all homes have fire sprinklers, but people are not wrapped in cotton wool with risk assessments and limitations on what they could do. Whatever their mental state people are still living their lives to the best of their ability and are genuinely empowered. Yes, things go wrong but the culture accepts this rather than apportions blame.

Despite all my years of experience I realised that the culture of care in Finland – if Espoo is at all typical – is about the heart and soul and real choice within a sensible regulatory framework.

In England the Commission for Social Care Inspection is making a welcome move towards a lighter regime of inspection for high performing registered care providers. And the Health and Safety Executive is encouraging organisations to be more adventurous in risk taking.

KCHT is now looking to enhance our care culture while meeting regulatory requirements to see if we can learn from visits such as this one. Reducing paperwork, creating greater time for managers and staff to interact with residents and thinking about different models of service delivery which acknowledge the individuality of each person is at the heart of our thinking.

I attended a recent national care forum conference where two stories were told about service users. The first concerned a woman who had had her cat taken away when the care home deemed it a health and safety risk. The second concerned a 97-year-old man whose last remaining wish was to go water-skiing.

In Finland the cat and the water-skiing would have been a reality.

MARK LLOYD is director of the Kent Community Housing Trust, a specialist provider of both older and young people’s services. A former senior local government officer, he has worked in the voluntary sector for the past decade. He is also chair of the Inspire Community Trust, a direct payments agency.

TRAINING AND LEARNING
The author has provided questions about this article to guide discussion in teams. These can be viewed at  www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected
training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

ABSTRACT
This article provides a comparison of older care in Finland and the UK, based on a study visit by staff from Kent Community Housing Trust to the combined health and social services department in the Espoo region. The article concentrates on lessons to be learned for older care – particularly residential – in the UK. It focuses on the benefits of nursing and social care combined services, contrasting Finland’s guiding principle that “regulation stifles the soul” in older care, with the UK approach of overregulation.

Further information
Espoo – Social and Health Service
Kent Community Housing Trust

This article appeared in the magazine on the 26th October, under the headline Let people loose