The institutional restructuring of the Finnish welfare state in the direction dictated by the neoliberal ideology kicked off in the early 1990s with the decentralisation of the responsi-bility for welfare budgets, planning and organizing welfare services to the autonomous municipalities. (3.) The new wel-fare-mix matrix, implemented through legislation in 1993, encouraged municipalities to purchase health and social ser-vices from other service providers rather than providing them directly. The reorganisation of service production was accom-panied by education policy aiming at shaping a fl exible work-force for the diverse settings of service provision.
Four important ideological starting points directed the ne-oliberal reforms of Finnish elderly home care. Firstly, the care provided by a family member was defi ned as the favoured solution in elderly care. Accordingly, from the year 1988 to the year 2002 the volume of family-based care assistance did,
indeed, increase by 49 % (Vaarama & Noro 2005). Secondly, the idea of a welfare mix was to be implemented with the aim of achieving cost-effi ciency for the municipality and availabil-ity of choice for the elderly. Refl ecting this idea, the role of the public sector was to a large extent reorganised corresponding to the so-called purchaser-provider model (Kovalainen 2004, Vaarama & Noro 2005).
Thirdly, in search of effi ciency in the use of municipal resources, national policy makers promoted trans-sectoral home care services, merging socially-defi ned care with medi-cal care, as the favoured solution to the challenge of disman-tling institutional care. Home nursing was assigned the cen-tral role in making home care capable of taking over clients that previously would have been cared for by institutions.
Furthermore, instead of recognising comprehensive responsi-bility, the role of the public sector was restricted to producing
’basic services’ that were ideally provided through a welfare mix. Our earlier study indicates that policy makers privileged medical needs when defi ning which services were recognised as ‘basic’ (Wrede & Henriksson 2004). Accordingly, the re-framed elderly home care was underpinned by an ethos that Wærness (1992) defi nes as professional medical culture (see also chapter 5).
The fourth starting point for the neoliberal reforms in home care was promoting the deinstitutionalisation of care.
Home care was assumed to combine the goals of providing both more affordable as well as a more humane and client-centred form of elderly care than institutional care. However, contrary to the goal of developing home care into a well-built service that readily replaces other more expensive forms of care, municipalities did not in the 1990s generally invest in this service. Instead many municipalities shifted resourc-es from both municipal home care and rresourc-esidential homresourc-es to service housing (Vaarama & Noro 2005). The establishment of service housing units was expedited through state spon-sorship and great ideological expectations were directed to-ward this service. Service housing was to provide a choice for
the client, thus promoting the emphasis on service quality.
However, under the severe fi nancial pressures, municipalities grasped the opportunity to use the service housing concept to shift a substantial part of the costs of residential care to the clients and to the state (through sickness insurance). The mu-nicipalities also reorganised residential homes as service hous-ing units (Suoniemi et al. 2005).
It has been calculated that during the 1990s municipali-ties relocated nearly 4000 municipal home-help workers from home-based services to service housing units (Vaarama et al.
2001, MHSA 2004, 25). This implied a major change in the use of personnel resources. This restructuring, together with the fact that the clients who presently are covered by mu-nicipal home care need a bigger number of visits than was the case earlier, has meant that the municipalities cater to a much smaller proportion of the elderly than was the previ-ously. By 2003, the percentage of over 75-year-olds receiving regular home help had gone down to 18.7 %, from 31.5 % in 1988. The decline for the period 1988–2002 was 40.6 % (MHSA 2006, 176), providing evidence of the rapid narrowing down of public responsibility for elderly home care. In 2004, the Finnish government adopted a rather modest goal accord-ing to which elderly home care should cover at least 25 % of the elderly over 75 years old (MHSA 2006, 178).
In contrast to the problems of enhancing elderly home care produced by the municipality, the goal of creating a private market was successfully implemented. The number of pri-vate providers of home care increased by 70 % in the period 1997–2001 and in 2001, raising the number of private pro-viders to 376, of which 70 % were fi rms and 30 % voluntary organisations (Finnish Government 2003). This creation of a welfare mix in home care involves care workers both as em-ployees in different kinds of care organisations and as small-scale entrepreneurs (Kovalainen 2004). In 2002, already more than 20 % of the care personnel in Finland worked in the private sector, in contrast to less than 13 % in the late 1980s (MHSA 2003). This suggests that profound changes have
occurred also in the structure of the care work labour market and in employment relations.
The narrowing down of the public responsibility for elderly care was carried out by limiting access to services. A popular way to carry out this task was by classifying clients, using in-dexes based on primarily geriatric knowledge on aging. When previously elderly people with what were identifi ed as ‘medi-um heavy needs’ would mainly have been cared for in resi-dential homes or inpatient primary health care, in the new classifi cation they were to be provided home care, with em-phasis on basic care, i.e., help with personal bodily care, nu-trition or mobility. Those identifi ed as requiring specialised and continuous nursing care where classifi ed as clients with
’heavy needs’. For this group, the policies continued to secure publicly produced care, either in the form of so-called intensi-fi ed home care or, as a last resort, as residential care. The poli-cies expressed a keen interest in hindering the elderly from turning into clients with ‘heavy’ needs. Considering this, it is perhaps surprising that after the neoliberal reforms, the elder-ly who were considered to have ‘light needs’, and who would earlier have been eligible for home help, were no longer in any way a public concern (Vaarama et al. 2001).
In contrast to the universalist era, the policy documents of the early 2000s thus emphasise the last-resort nature of the public services. The role of publicly provided care is often re-ferred to as the provision of temporary solutions, fi lling in when family-based care for is not adequate or if the care recip-ient is unable to buy the substitute services from the market (MHSA 2001, 14). The policy rhetoric continued to reduce the traditional homemaking culture by stating that the person, not the home, was to be the focus. The new element is that household chores are not only excluded from the defi nition of care but reframed as essentially a private concern.
Even though the scope of public elderly care has dimin-ished and the public sector in important ways has withdrawn from responsibility, the municipalities still have considerable power to regulate the services that they produce. According to
the legislation that is currently being implemented, the per-sonnel employed by the private service providers are expected to fulfi l qualifi cation criteria corresponding to those required by municipal employees. Additionally, the service providers themselves need to acquire formal approval for their practice from the local authorities. Acquiring such approval presumes that the service provider has not been subject to disciplinary actions for malpractice, or had serious fi nancial diffi culties (MHSA 2005, 29–31). The legislation on the supervision of service provision places municipal and other service provid-ers in unequal positions, as the municipality has the author-ity to issue other service providers permits to operate. Thus it not only controls the market but regulates the activities of the other service providers. By way of contrast, the munici-palities themselves are only subjected to retroactive supervi-sion through complaints that citizens can make to the coun-ty government. This is an important issue from the point of view of monitoring the adequacy of the personnel resources and divisions of labour.
The national restructuring of the public sector in the 1990s also concerned the vocational education and qualifi cation for elderly care. Most importantly, new occupations were created in the 1990s, refl ecting the belief in fl exible, trans-sectoral so-lutions also inspired by life-long learning agendas of educa-tion policy. At the core of the reform was the creaeduca-tion of the vocational qualifi cation in social and health care, for which the occupational title is offi cially translated into English with the term practical nurse. Practical nurses are frontline care workers, who as a member of a multi-professional team were supposed to provide both socially defi ned care and general nursing in elderly home care. (4.)
The new occupation disrupted the previous division of la-bour in elderly home care, at least at the level of credentials.
Two previously separate educational orientations preparing for care work, the one for the social-sector homemakers and the other for the health-sector practical nurses (or auxiliary nurses), were merged. The new care worker was included in
the legislation on the registration of health care profession-als as one of the groups authorised to nursing care at a level defi ned by their formal skill and competence. (5.) The rheto-ric of education policy was to broaden the scope of practice and to reach a better match between education and the la-bour market (Vuorensyrjä et al. 2006). The policy was aimed at implanting the idea of fl exible professionals into the care sector (Wrede 2008). However, at the workplace, the occupa-tional roles of the newcomers have remained turbulent (see Chapter 6).
Though the practical nurse was established as a new care-worker category more than a decade ago, it is still diffi cult to recruit young people to elderly care. The high levels of drop-outs refl ect the mismatch between educational policies and working life practices. The problems of front-line care work have been raised as a national policy concern (MHSA 2001, MHSA 2006). The relatively easy access and the shortness of the education, its practical emphasis, and the varying oppor-tunities to obtain partial credentials tempt policy makers to use the education programme as a social policy instrument.
Long-term unemployed and other groups, particularly the young and ethnic minorities, who for some reason are threat-ened by marginalisation are directed to the occupation by of-fi cials. Research indicates that particularly the young view the occupation of the practical nurse mainly as a temporary, low-paid job that competes poorly with a permanent one with a better salary (Pitkänen 2005).