In this section, we draw attention to the implementation of the neoliberal reforms, from two meso-level perspectives.
Firstly, we examine the ‘rationalisation’ of municipal home care through policymaking, of which the City of Helsinki is used as an example. Secondly, we study how the trade unions representing health care professionals defend the agency of the care worker.
IMPLEMENTATION OF TRANS-SECTORAL HOME CARE
The national-level institutional restructuring of the welfare state in Finland has implied a profound change in the con-tent and scope of elderly home care, speeded up by the lack of resources. We argue that this institutional restructuring at the municipal level is equally profound. In the late 1990s and early 2000s, most municipalities reorganised public home care. Especially the larger cities implemented some ‘trans-sec-toral’ model of elderly home care. This meant that what was earlier known as ‘home nursing’ emerged as the key element in the new institutional matrix for home care. The emphasis on health care refl ects the aim of replacing rather than post-poning expensive residential care with the means of elderly home care.
Our previous examination of the home care reform im-plemented by the City of Helsinki showed concretely how diffi cult it is to both save money and to carry out a merg-er of social and health care into one integrated form of smerg-er- ser-vice (Wrede & Henriksson 2004). The experiences gained from this cost-effective restructuring show that home care in some cases is more expensive than residential care (also Ala-Nikkola 2003). Such observations did not, however, disrupt the overall direction of change towards the increasing medicalisation of home-based services. In the model that is currently being im-plemented the City of Helsinki has gathered different forms of home care for the elderly into one service under the city health authority. The service is, however, still divided into three separate streams: home help, home nursing and the in-tensive home care unit. This three-fold structure also appears as a hierarchy of expertise, as the home care units are expect-ed to function as a part of the so-callexpect-ed care chain in health services.
The changes resulted in severe organisational and cultur-al constraints for the employees. The new mediccultur-alised and managerialist ethos undermined the expertise of frontline carers, even though it is they who encounter the client di-rectly. One of the key reasons for this development was the
implementation of the hospital-like hierarchic division of la-bour in municipal home care. The frontline care worker, in turn, was assigned the task to only provide ‘basic care’, which generally referred to the care of the client’s body. The service was reorganised according to the medico-managerial logic that approaches home care from the perspective of how to develop its logistics. This approach resulted in the omission of socially defi ned care and the related skill and competence.
Consequently, the social needs of the client were neglected.
Practical care work was to be based on general and specialised nursing (Wrede & Henriksson 2004).
UNIONIST ATTEMPTS TO RECLAIM PROFESSIONAL MANDATES IN ELDERLY CARE
In the face of the managerialist pressures to reorganise wel-fare services and lower and disrupt occupational boundaries, the trade unions representing care workers appear to share the goal of trying to ‘bring the state back’ into welfare service policy. The return of the state would imply that the autonomy of the municipality as a employer and a local service produc-er would be narrowed down as a result of the increasing state regulation. In their statements, the unions representing chief-ly health care occupations have argued that the impending shortage of labour cannot be solved with what is referred to as local task displacements in national policy agendas. Instead the unions demand national regulation to guarantee the qual-ity of the services and to steer an ‘adequate’ division of la-bour among care professionals, i.e. one that respects tradi-tional occupatradi-tional boundaries and credentials. Furthermore, the unions attack the municipalities for their ‘unethical’ em-ployment policies.
The introduction of the ‘trans-sectoral’ practical nurse has challenged organisational and professional boundaries in many senses. In its response to the new policies, Tehy, the union mainly representing nurses, repeatedly argued for the need to ‘respect occupational boundaries’. Apparently, howev-er, an even greater threat than the trans-sectoral occupation for
Tehy was the practice of allowing personnel lacking health care qualifi cations to perform nursing tasks on the basis of work-place level permits. ‘[The old style] home helpers out of nurs-ing’ (Tehy 2003) was a slogan used by the union in the local campaign when trying to defend the mandate of nurses.
The trans-sectoral model for organising elderly home care has, however, also been perceived as a threat by nurses. The loudest reaction against integrated home care came from pub-lic health nurses. The union feared that pubpub-lic health nurses would be forced to accept supervision from managers exter-nal to their profession, i.e., from either nurses or social care professionals. The union further claimed that public health nurse vacancies were abolished and replaced with nurse va-cancies, refl ecting the marginal role of preventive care in Finnish health policy since the 1990s. Instead of challeng-ing that policy, the union stated that the elderly needed sup-port in the form of health education if they were to be ‘active senior citizens’. In addition to what can be characterised as their traditional strategy of referring to their role as experts in health promotion, the union sought to safeguard the jobs and the competence of the group. The change in their mandates was legalised after ‘prolonged negotiations’ (Terveydenhoitaja 2002). In 2002, the publication jubilantly announced that a new double credential now qualifi ed them both as nurses and as public health nurses, which also followed the EU stan-dards.
Our analysis of the views and claims of the public health nurses’ union shows that policy making concerning the pub-lic sector workforce often has an indirect impact on the organ-isation of elderly home care. When considering, for instance, recent personnel policy, it is evident that the main attention in the national elderly care policy has focused on nurses and medical doctors. Frontline care workers, like practical nurses, have hardly been mentioned, except in terms of recruitment problems. The union that represents the majority of practi-cal nurses (SuPer) has frequently tried to draw attention to the mismatch between social policy, labour market policy and
education policy and to the confl icting pressures these poli-cies create when combined with the realities of working life.
The major threats to their occupational mandate have derived both from below and from above the occupational hierarchy.
Even though the union publication of SuPer constantly raised the problem of inadequate staffi ng as an important policy concern, its fi rst and foremost interest appeared to be to up-hold strict boundaries towards the uneducated care workers.
In the early 2000s, SuPer repeatedly claimed that, due to staff-ing pressures, practical nurses had a hard time in establish-ing their positions in the labour market, and in gettestablish-ing rec-ognition in the workplace. From SuPer’s point of view, when
‘tasks [were] taken from the hands [of practical nurses]’ (SuPer 2002) the problem was that the new trans-sectoral occupation was unknown and the skill and competence undervalued. The pressures from above were related to nurses. Particularly in the late 1990s, public-sector vacancies at this level were replaced with nurse vacancies.
SuPer has tried to improve the position and esteem of the practical nurses. There have been, however, severe obstacles to those pursuits. Firstly, the new vocational qualifi cation was truly non-uniform and, in many cases, uneven. The stan-dardisation of education has not been a priority for policy-makers. Secondly, SuPer itself has faced internal pressures that have forced its leaders to mediate between, for instance, the former and the new types of practical nurses. SuPer that was established around one occupation has faced new challenges to create a united front with the traditional members based in health care and hospital work and the newcomers working in diverse care settings (Henriksson 2008). To succeed, the policy claims of the union need to refl ect this diversity; at the same time it is likely that the internal power relations within the union play a major role in its strategies. This balancing act is probably refl ected in the fact that the union has constantly focused more on opposing the devaluation of practical nurses in hospitals than on defending them as providers of socially defi ned care.