The 1990s: a time for change and opportunity in Finnish mental health services

Abstract

This Guest Editorial comes from a north-European country, Finland. Finland is not situated at the top of the world, but it is far enough to have its unique characteristics in terms of culture, language and everyday life. Finland was quite an isolated country until it joined the EU in 1995, perhaps because of its historical background. The country is sparsely populated with approximately 5.2 million people, only 91 000 without Finnish citizenship. Therefore, our population is culturally homogenous: 93% speak Finnish, a language which differs greatly from other languages, and 86% belong to the Lutheran Church. Like in other Western countries, the population in Finland is getting older. About 14% of the population are over 65 years of age, and 5.9% are over 75 years old. By the year 2010 the number of people over 85 years will have increased by one third. Our average population density is no more than 17 inhabitants per square kilometre (Statistics of Finland 2000). This may be the reason why we enjoy quietness, peace and relaxation, which can be offered for example by the sauna. Unfortunately, perhaps our clannish characters together with isolation have made mental problems amongst the most serious health problems in today’s Finland. For example, the use of antidepressants continue to increase. In 1999, the consumption increased by 16% (National Agency for Medicines and Social Insurance Institution 2000). The most typical reasons for retirement because of mental health problems are mood disturbances and neurotic and schizophrenic disturbances, and the most common reason for early retirement among young persons has been schizophrenia (Social Insurance Institution 2000). Protection for the wellbeing of individuals and families and financial safety have traditionally been provided by the Government through social programmes and services (e.g. social insurance, unemployment benefits and maternity policies). However, economic downturn and changes in support services in the early 1990s decreased the level of individual citizen’s wellbeing, especially of those who need special support to manage their everyday life. For example, the number of unemployed persons tripled in a short time. At the end of July 2001 there were 317 600 unemployed job seekers registered at the employment offices. The first group to be affected by unemployment was 15–24-year-olds, whose number nearly quadrupled. Because of missing work opportunities, people migrated from rural areas to urban centres. Rates of suicides, mental problems of children and adolescents, violence and drug problems increased dramatically. AIDS is now a new health problem. The number of HIV cases has increased during the last five years but is still quite low compared with other European countries. By the 8th of August 2001 we had 1307 registered HIV cases (The National Public Health Institute 2001). There has been a tendency in Finland to isolate people who show deviant behaviour. The consequences were that in the 1980s Finland had over 20 000 beds in psychiatric hospitals: 4.2 beds per 1000 population, which was perhaps the world record. Because of the economic burden placed on health services, health care and social services financing changed at the beginning of the 1990s. Finnish legislation obligates the communities and municipalities to take responsibility for organizing social and health care for the resident population. However, the law does not regulate the content, extent or organization of the services in detail, and therefore big differences in the structure of health and mental services can be found in different parts of Finland. Because of economical and ideological reasons, the structure of mental health services has also changed dramatically during the last two decades. The number of psychiatric beds has dropped from 20 036 in 1980 to 6400 in 1995, and the average length of stay has been reduced from 166.8 to 45.7 days between 1980 and 1999. However, the structure of outpatient services has not been developed accordingly. Despite these structural changes, the total expenditure on health services in general still increased after 1996 (44 842 FIM million) to 47 432 FIM million in 1998 (Statistics of Finland 2000). Some people have evaluated that mental health services actually paid the price of the economic burden in Finland. Even more savings and structural changes in health organizations will happen in the health services in the future. One positive outcome of these structural changes in mental health may be that the number of hospital beds was reduced, often by over half, the average number of hospital beds currently being about 20 per ward. Today patients enjoy more privacy, which may have a calming effect on the ward atmosphere. Many hospitals have also renovated their existing premises and patient rooms resulting in a more comfortable hospital environment. The fact that the educational level of the Finnish population is generally very high, especially among young people, may have facilitated the adaptation to societal change. Finnish women are more active than men in committing themselves to all levels of education, which may be related to the strong emphasis on gender equality in Finland. This may because Finland granted women the right to vote in 1906, as one of the first countries in the world. Today, about 70% of women are employed outside the home. Equal employment opportunities between women and men in public offices indicate that women are considered equally when selecting candidates and the number of women and men are equal in positions of trust. Along with the Finnish society, nursing education has changed during the last decade. Nursing occupations remain among the most favoured ones for women. As practical mental nurses are no longer trained in Finland, registered nurses graduating from the 28 polytechnics around Finland attend to mental health work as well. Unfortunately, the content and structure of the curricula vary, which can also lead to a variation in the degree of competence. However, every year the number of those wanting to enter the field of nursing exceeds the intake capacity of the institutions, and there is currently an oversupply of newly qualified nurses. Although the number of unemployed nurses decreased from 5558 in April 1999, the number of unemployed was still 4044 in April 2001 (The Finnish Ministry of Labour 2001). Therefore, it is no surprise that thousands of qualified nurses are today working abroad, such as in Norway, Sweden, England, Ireland and Germany. However, the future need for nurses in Finland will be acute when the baby boomers, i.e. those born after the Second World War, retire in 10 years. Education in nursing science started at the university level in 1985. Today, nurses can study nursing science/health care administration at university level after nursing registration at five different universities in Finland: the University of Tampere, University of Turku, University of Oulu, University of Kuopio, and Âbo Akademi; the latter is for Swedish-speaking students. In September 1999, we had in total 1908 graduated masters, 153 licenciates (a degree between the master and doctoral degrees), and 86 doctorates. The University of Tampere is the only one to have a special education for master students in the field of mental health. Unfortunately, the number of persons at university level courses with experience in the field of mental health is still low compared with other areas. The 1990s was a time for supporting Finnish citizens’ and especially patients’ rights in health care. In general, the equality of the Finnish citizens is guaranteed by the Constitution (731/1999). The position of patients in health care is supported by the Patients’ Status and Rights Act (785/1992), and the new Patient Guardian Act (442/1999) protects patients’ financial rights. In addition, the Medical Research Act (488/1999) secures the status of patients in medical research, and the Personal Register Act (523/1999) endeavours to guarantee the security and confidentiality of personal data. The Mental Health Act (1116/1990) is currently being reformed. Despite the different means to support the status and rights of individuals, mental illness still carries a stigma. This restricts equal access to education and work for people suffering from mental health disorders. As the educational attainment average continues to rise, the significance of education in the increase of inequality has grown during the past years. In Finland, the generational differences in educational attainment are big, which threatens to weaken the relative position and health of young people with only a basic level of education. In general, the educational attainment of those suffering from serious mental disorders is low compared with the general population. Along with the increasing trend towards offering societal services on the Internet, those with low incomes and a low level of educational attainment may run the risk of marginalization and social exclusion. We can conclude that in Finland large and dramatic changes have taken place during the 1990s in the field of mental health services and education. Despite the location of Finland being in the far north, membership in the European Union has brought it closer to other countries and made people and services more mobile. This means that nurses today need a knowledge and experience of transcultural nursing to support the individual needs of those with a different cultural background. There is an urgent need in Finland to develop mental health services and different programmes to prevent mental health problems. Mental health patients' involvement and rights should be supported in order to reduce stigmatization. The welfare of children and adolescents should be supported in families whose lives are affected by employment, problems with alcohol, family crises and mental health problems. There is also a strong need to support the family members and informal carers of persons with mental problems. The presence of the informal carer often enables the patient to stay at home. Still, economical or emotional support for the informal caregivers is inadequate. In the future we need opportunities to change the structure of mental health services based on individuals’, families’ and population needs, and health care personnel should meet their clients in the clients’ natural environment. Adequacy of mental health services is always dependent on political decisions. Therefore, policy makers should be more aware of how their decisions affect the health and wellbeing of individuals, families and communities. Our responsibility is to inform policy makers of areas in need of further development. Therefore, more research in the future is needed to evaluate the effectiveness of different nursing and health care interventions. Continuous quality assessment and analysis of the efficiency and efficacy of actions should be conducted to ensure the most cost-effective and yet highest quality mental health care. Co-operation between education and working life should be developed to ensure the availability of competent staff. Degree curricula should be clarified and developed into a more uniform direction nationally to provide graduates with equal starting points for satisfactory career development. It would be desirable to see more mental health specialists with a master's or doctorate degree in order to develop the mental health service delivery system and expand research activities within the field. In addition, registered nurses’ exodus should be prevented. Although cultures may differ, it is possible to see global problems and similarities between cultures and countries in the field of mental health. Therefore, international collaboration in clinical and educational issues should be encouraged between health care organizations, educational sectors, and countries to enlarge our understanding of mental problems. Today, we have more opportunities for multiprofessional and multilevel co-operation because of new information technology, more positive attitudes towards international collaboration in clinical practice and a real need for collaboration.