Kolmas sektori mielenterveystyön hallinnassa : Yhdessä julkisen ja yksityisen sektorin kanssa

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Kolmas sektori mielenterveystyön hallinnassa

Yhdessä julkisen ja yksityisen sektorin kanssa

Jaakko Nykäsenoja

9b,7g6.,5-$

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Politiikan ja talouden tutkimuksen laitoksen julkaisuja 26 (2015)

Yleinen valtio-oppi

© Jaakko Nykäsenoja

Kansi: Riikka Hyypiä

Painettua kirjaa myy:

Unigrafia Kirjakauppa

http://kirjakauppa.unigrafia.fi books@unigrafia.fi

PL 4 (Vuorikatu 3A) 00014 Helsingin yliopisto

ISSN-L 2243-3635

ISSN 2243-3635 (painettu)

ISSN 2243-3643 (verkkojulkaisu) ISBN 978-951-51-1029-9 (painettu)

ISBN 978-951-51-1030-5 (verkkojulkaisu)

Unigrafia, Helsinki 2015

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Sisällysluettelo

Tiivistelmä………. 3

Abstract……… 4

Esipuhe: sulkemisesta avohoitoon ja takaisinoton estäjiin……….. 12

1. Johdanto……….14

2. Tehtävänasettelu……… 21

2.1 Tieteellinen tutkimusongelma ja paikannus tieteenalaan………… 21

2.2 Tutkimuksen tavoitteet……… 24

2.3 Tutkimuksen empiirinen rajaus……… 24

2.3.1 Hallinnan problematiikka mielenterveyden hoidossa…… 26

2.4 Tutkimustapa ja tutkimusasetelma……… 28

2.5 Tutkimusaineistot……… 30

2.6 Tutkimuksen jäsentely……….. 33

3. Mielenterveystyön historia ja genealogia sekä mielenterveyden häiriöiden hoidon laajuus Suomessa..………...35

3.1 Historian alkulähteillä………...……….35

3.1.1 Michel Foucault´n ”hulluuden historia”………36

3.1.2 Sulkeminen ja kontrolli…..………38

3.1.3 ”Hulluuden” hoidon vaiheet klassisella aikakaudella..……39

3.1.4 Hoitolaitoksen ja vankilan synty………...………..40

3.1.5 Freud ja psykoanalyysin synty ja hiipuminen. ………42

3.2 Aivotutkimus ja mielenterveyden häiriöt………... 43

3.3 Mielenterveyshäiriöt ja niiden hoito Suomessa………...46

3.3.1 Työkyvyttömyys, sairauslomat, itsemurhat ja päihdekuolemat……….46

3.3.2 Lasten ja nuorten psykiatrinen hoito ja häiriöiden hallinta 62 3.3.3 Mielenterveys erityiskonteksteissa: varusmiespalvelu ja työ- yhteisöt………..71

3.3.4 Paradigman muutos: sairaalahoidosta avohoitoon………..76

3.3.5 Lääkekulutus……….82

3.4 Yhteenveto mielenterveyden hoitokokemuksista ja hallinnasta…..88

4. Hallinta julkisen, yksityisen ja kolmannen sektorin johtami-

sessa………...93

4.1 Mitä on hallinta?... 93

4.1.1 Yleisiä määreitä………. 93

4.1.2 Erityisiä määrityksiä aiheesta hallinta………. 95

4.1.3 Parlamentaarinen hallinta………. 98

4.1.4 Verkostot, kumppanuudet ja hallinta……… 99

4.1.5 Verkostoesimerkkejä………....102

4.2 Julkinen sektori mielenterveystyössä………102

4.2.1 Suomen mielenterveyshoidon historiaa………102

4.2.2 Houruinhuoneiden aika 1300-1700 –luvuilla…….. …..103

4.2.3 Valtion vastuu alkaa 1800-luvulla………...………..104

4.2.4 Kunnallinen mielisairaala………...105

4.2.5 Ensimmäinen mielisairaslaki…...………... 106

4.2.6 Mielisairaanhoitopiirit ja A- ja B-mielisairaalat….…...106

4.2.7 Avohoito laajenee………....………106

4.2.8 Mielisairaslain uudistus 1978.………...……107

4.2.9 Psykiatrian ja somatiikan yhdistyminen, uusi mielen- terveyslaki ja valtionosuusuudistus………...108

4.2.10 Julkinen hallinta………...………108

4.2.11 Julkinen sektori………...….109

4.2.12 Palveluvastuu, hoitotakuu ja sen mittaaminen….……….118

4.2.13 Pakkohoito ja sen kriteerit………...…………122

4.2.14 Kriminaalipotilaat……….……...………127

4.3 Yksityinen sektori mielenterveystyössä……….…128

4.3.1 Yksityinen sektori mielenterveyspalvelujen ja yleisten terveyspalvelujen hallinnassa………..….128

4.3.2 Työterveyshuolto……… ……131

4.3.3 Psykiatrit………. ..…135

4.3.4 Psykoterapia………...…136

4.3.5 Psykiatriset asumispalvelut………..139

4.4 Kolmas sektori hallinnassa ja mielenterveystyössä………141

4.4.1 Kolmas sektori hallinnassa………...142

4.4.2 Kolmannen sektorin luonne ja erityispiirteet………..…145

4.4.3 Kolmannen sektorin lisätunnusmerkkejä……….…….. 149

4.4.4 Kolmas sektori työllistäjänä………. 153

4.4.5 Kolmas sektori ja kansanliikkeet………. 155

4.4.6 Kolmas sektori ja hyvinvointivaltio………156

4.4.7 Kolmas sektori välittävänä verkostona……….. 159

4.4.8 Sosiaali- ja terveysalan keskusjärjestöt………161

4.4.9 Mielenterveystyön keskusjärjestöt………..163

4.4.10 Paikalliset mielenterveysyhdistykset……… 172

4.4.11 Omaistyö……….. 176

4.4.12 Luterilainen kirkko……… ...177

4.4.13 Yhteistyö mielenterveysjärjestöjen kesken…………. …179

4.5 Raha-automaattiyhdistys (RAY)………180

5. Pohdinta ja päätelmät……….. 184

5.1 Ydinlöydösten pohdintaa………...184

5.2 Tutkimuskysymykset: vastauksia ja jatkokysymyksiä……….190

5.2.1 Mielenterveystyön hallinnan historia ja nykytila……… 190

5.2.2 Sektoreiden väliset ostot…..………193

5.2.3 Kolmas sektori mielenterveystyön hallinnassa………….194

5.3 Arviointikriteerit ja jatkotutkimusaiheet………195

6. Ajatuksia tutkijan roolista ja loppusanat………...………..202

LÄHTEET ………....207

SÄÄDÖKSET……….... 221

VUOSIKERTOMUKSET …...……….. 224

LIITE 1. Luettelo haastatelluista henkilöistä ja heidän edustamistaan organisaatioista ………..225

LIITE 2. Haastattelulomake ……….227

LIITE 3. RAY:n avustukset järjestöjen mielenterveystyöhön ………229

LIITE 4. Sosiaali- ja terveydenhuollon indikaattoreita ………..233

KUVIOT Mielenterveystyön vaikutuskanavat, kuvio 1………28

Yksityisellä sektorilla alkaneet työkyvyttömyyseläkkeet työkyvyttömyyden syyn mukaan 1980–2009, kuvio 2.. ………49

Yksityisen sektorin voimassa olleet työkyvyttömyyseläkkeet sairauspääryhmän mukaan vuosina 1980–2009, kuvio 3... ………..50

Yksityisen ja julkisen sektorin työkyvyttömyyseläkkeensaajat ja eläkkeelle siirtyneet sairauspääryhmän mukaan vuosina 1996–2011, työeläkkeet, kuviot 4 ja 4a… ………..50-51 Ennenaikaiselle eläkkeelle jääneiden 16–34 -vuotiaiden työpanosmenetys milj. euroa ja henkilöitä vuonna 2008, kuvio 5... ………...53

Vuonna 2012 alle 30-vuotiaina työkyvyttömyyseläkkeelle siirtyneet sairauspääryhmän mukaan, kuvio 6... ……….54

Mielenterveyden häiriöiden ja muiden sairauksien perusteella alkaneet sairauspäivärahakaudet 1990–2010, kuvio 7..………...55

Itsemurhat sekä alkoholi- ja huumekuolemat 1970–2012, kuvio 8..……….…58 Psykiatristen sairaalapalveluiden käyttö, 0–6 -vuotiaat, 1994–2010,

kuvio 9.. ………64 Psykiatristen sairaalapalveluiden käyttö, 7–12 -vuotiaat, 1994–2010,

kuvio 10 ………65 Psykiatristen sairaalapalveluiden käyttö, 13–17 -vuotiaat, 1994–2010,

kuvio 11 ………66 Psykiatrisen laitoshoidon 0–12- ja 13–17 -vuotiaat potilaat 1000 vastaavan ikäryhmän asukasta kohden sairaanhoitopiireittäin vuonna 2010, kuvio 12 …68 Psykiatriset sairaansijat 1980–2010, kuvio 13………...………77 Psykiatriset sairaansijat 1000 asukasta kohden 1980–2010, kuvio 14…………78 Keskimääräinen hoitoaika psykiatrisissa sairaaloissa 1950–2010,

kuvio 15………..80 Psykiatriset hoitopäivät 1000 asukasta kohden sairaanhoitopiireittäin

2009–2010, kuvio 16……… 81 Mielenterveyshuollon avohoitokäynnit 1997–2010, kuvio 17 ...………..82 Masennuslääkkeiden kulutus apteekkimyynnin perusteella vuosina

1990–2012, kuvio 18 ………..84 Parlamentaarinen hallintaketju, kuvio 19...………...99 Sosiaali- ja terveysministeriön hallinnon ala 1.8.2010, kuvio 20…………... 110 Suomen terveydenhuollon hallintokaavio 2011, kuvio 21………...111 Suomen terveydenhuollon hallintokaavio 1990, kuvio 22 …….………...…113 Terveyden ja hyvinvoinnin laitos 2014, kuvio 23………...………….115 Terveydenhuoltolain mukaiset hoitoon pääsyn enimmäisajat lasten ja

nuorten (alle 23 v) mielenterveyspalveluissa, kuvio 24…….………...120 Kelan järjestämän harkinnanvaraisen psykoterapian saajat ja kustannukset 2000–2009, kuvio 25 ………138 Välittäviä organisaatioita Suomessa, kuvio 26………...160 Mielenterveyden Keskusliiton organisaatio, kuvio 27 ………165 Suomen Mielenterveysseuran hallinto- ja toimintaverkosto, kuvio 28……… 168

Erityisdiakonian hoitoketju Helsingin seurakuntaryhmässä, kuvio 29 ………179

Raha-automaattiyhdistyksen organisaatio 2012, kuvio 30………….………..183

Mielenterveyspalvelut ja toimijat, kuvio 31 ………187

TAULUKOT Täyden eläkkeen suuruista työkyvyttömyyseläkettä saavat iän mukaan 31.12.2012, taulukko 1… ………..52

Sairausvakuutuskorvaukset 2012, taulukko 2…. ……….56

Itsemurhien kansainvälinen vertailu, taulukko 3………..………60-61 Alaikäiset psykiatrisessa sairaalahoidossa 1994, 2002 ja 2010, taulukot 4–6... ……….………..67

Sairaanhoitopäivien ja potilaiden määrä psykiatrian erikoissairaanhoidon alalla 1970–2010, taulukko 7...………...79

Keskeiset hermostoon vaikuttavat lääkkeet, kokonaiskustannukset (1000 €) 2008–2012, taulukko 8.. ………87

Psykiatrista erikoissairaanhoitoa odottavien määrä 2008–12, taulukko 9...….120

Pakkohoitotoimien käyttö 2005 ja 2010 tulotavan mukaan, taulukko 10...….125

Pakkohoitotoimenpiteet 2005 ja 2010 pakkopäivien mukaan sairaanhoitopiireittäin, taulukko 11..………..………126

Terveyspalveluyrityksiä 2011, taulukko 12...……….……..………133

Suomen psykiatrit vuonna 2012, taulukko 13 ……….……135

Psykiatrian asumispalvelut 1995–2010, taulukko 14...………. 139

Sosiaali- ja terveysjärjestöjen keskusliitot 2011, taulukko 15 ………..162

Mielenterveystyön keskusliitot 2011, taulukko 16 ……….164

Paikalliset mielenterveysyhdistykset, taulukko 17 ………171

Helmi ry:n keskeiset tiedot, taulukko 18……… 175 RAY:n avustukset sosiaali- ja terveysjärjestöille 2008–2013, taulukko 19.181-182

Sektorit, tekijät ja rahoittajat mielenterveystyössä, taulukko 20…………...…193

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