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BDJOpen www.nature.com/bdjopen ARTICLE OPEN Public Dental Service personnel facing a major health care reform in Finland 1,2 3 1,4 Eeva Widström , Hannele Tiira and Anders Tillberg OBJECTIVES: A health care reform will replace the health care and social services centred on public provision with a market- oriented system and enhanced competition between public and private sectors. The aim was to ascertain Public Dental Services (PDS) changes personnel anticipated and how dental services in the new “public” undertakings could be made more cost-efﬁcient. MATERIALS AND METHODS: An electronic questionnaire was sent to the Chief Dentists of a random sample of 12 PDS units in southern and northern Finland for distribution to their personnel; 71.0% responded. RESULTS: Most respondents (64.3%) believed that their PDS unit would not change. However, 45.4% foresaw a merger with another unit. More dentists (51.2%) were aware of market- and competition-oriented organisational forms to be introduced in the public sector than dental hygienists (35.0%) and dental assistants (27.3%; p < 0.01). Only 12.4% thought of moving to the private sector. To increase cost-efﬁciency in the new system, a majority suggested improvement in preventive care (79.8%) and increased use of dental hygienists (75.7%). A smaller proportion suggested longer opening hours (23.1%), higher patient fees (17.9%) or more paying patients (12.4%). DISCUSSION: Public sector employees had little knowledge and understanding of the coming reform and were badly prepared for competition with the private sector. BDJ Open (2019) 5:5 ; https://doi.org/10.1038/s41405-019-0012-1 INTRODUCTION the purchasers. This will also apply to dental care. By introducing Finland has a long tradition of universal, tax-ﬁnanced health care a provider-purchaser split and demanding the formation of and social services centred on public provision. An impending business enterprises from the public care providers the Govern- reform will change the structure of organising, provision and ment hopes to increase efﬁciency and effectiveness and to ﬁnancing of these services including dental care. In 2015, the improve cost control. Much of the planning during the ﬁrst years Government proposed establishment of 18 counties as early as (2015–2016) concentrated on deﬁning the numbers of county July 2017 and transfer of the responsibility for organisation of councils to be established, their borders, the future hospital health care and social services from the existing almost 200 network and its new hierarchical structure. municipalities to the new counties as of 1 January 2019. Later, Historically, a municipal school dental service offering free, tax- both the establishment of the county councils and the change of ﬁnanced dental service for school children, started the Public responsible service organisers have been postponed to January Dental Service (PDS) in Finland in 1956. Since 1972, the PDS has 2021. The planned reform is the biggest in Finnish health care in been part of the primary health care system run in municipal 50 years and it follows the global wave and international policy health centres. Initially, only children and adolescents were movement towards marketing and competition as a way of covered, but in the 1980s young adults were given access to challenging the public services, today often seen as “inefﬁcient subsidised services in the PDS and, after that, access was slowly and unresponsive” and politically out-dated. People have moved expanded to include middle-aged adults. In 2002, all age groups from the countryside to towns and cities and a large proportion were given access to the PDS. Alternatively, adults could use the of the municipalities have become too small to administer more expensive private sector dental services partially reimbursed health and social services. In addition, care and service needs by the Social Insurance Institution. have changed as the proportion of elderly has grown in the Dental professionals often feel challenged by health care population. reforms, e.g. public dentists in Sweden had difﬁculty coping Parts of the planned reform are copied from neighbouring with changes in their work environment caused by a reform in Sweden, which in 2010 introduced a so-called Choice Reform in the mid-1990s that aimed at a more cost-efﬁcient PDS. In Finland, Health Care. Also, in Finland free choice between public and the public dentists strongly opposed the reform in 2002 that private services is planned. According to the Government’s gave older adults access to the public services, mainly due to proposal, the former health administrative ofﬁces in the old perceived lack of resources. In Switzerland, recent plans for a system will become purchasers. Hospitals and primary health mandatory dental care insurance to improve population access services may become semi-autonomous “trusts” that sell their and early use of dental services has faced opposition from services and compete with the private sector for contracts with dentists’ associations. 1 2 3 Department of Clinical Dentistry, Arctic University of Norway, Tromsø, Norway; National Institute for Health and Welfare (THL), Helsinki, Finland; Metropolia University of Applied Science, Helsinki, Finland and Public Dental Health Service Competence Centre for Northern Norway, Tromsø, Norway Correspondence: Eeva Widström (firstname.lastname@example.org) Received: 7 April 2018 Revised: 31 October 2018 Accepted: 26 November 2018 © British Dental Association/Macmillan Publishers Limited 2019 Public Dental Service personnel facing a major health care reform in. . . E. Widström et al. Half of the 4200 dentists (47%), and slightly more than half 10 11 (60%) of the 1700 dental hygienists and 3000 dental assistants are currently working in the PDS as a salaried work force. In the reform, their work contracts will be cancelled and they will have to ﬁnd new employments in the county-owned undertakings, the regional “County Council Limited Companies” to be established, or in private companies or they have to start their own businesses. This means that about 6000 dental professionals are at risk and the occupants need to prepare themselves for a changed work environment. AIM The study aimed to ﬁnd out whether the personnel working in the PDS were aware of coming changes in their work environment and what kind of changes they anticipated. A second aim was to study how they thought the new county-owned undertakings (the former public dental services) could be made more cost-efﬁcient in the future. Comparisons were made between personnel groups: dentists, dental hygienists and dental assistants. METHOD Ethical approval for a study about working conditions, job demands and impending changes in the PDS was granted by the Ethical Board of the National Institute for Health and Welfare (THL) (THL; protocol excerpts 8/2014). This article is based on two questions about possible changes in the dental care provision system in connection with the planned health care reform. They were formulated based on what could be anticipated in 2016 and had structured answer options: “Will the impending health care reform introduce changes in the PDS unit (health centre) where you work?” and “The present Government emphasises increased cost-efﬁciency in all work places. How can this be achieved in your PDS unit (health centre)?”. Three statements from the basic questionnaire were also used: 1. “I would like to work in my present work place to the end of my career”,2. “It is likely that I move to the private sector”, and 3. “The number of dentists, dental hygienists and dental assistants is sufﬁcient in relation to the numbers of patients and their treatment needs (after the older adults have received access to the PDS)”. For all questions space was provided for open comments or explanations. Of the 90 health centres in the selected areas in northern and southern Finland, 12 PDS units were randomly selected. A link to an anonymous electronic questionnaire was sent to the Chief Dentists of be further distributed to their employees (dentists, dental hygienists and dental assistants; 438 persons according to the chief dentists). Altogether 311 PDS persons, 129 dentists, 61 dental hygienists and 121 dental assistants responded. This was 71.0% of the total number of personnel in the 12 clinics. There were 24 male dentists, all other respondents were women. All statistical analyses were performed using the IBM® SPSS® statistics 25 for Mac personal computer. Chi-squared was used for categorical variables to analyse differences between groups. A p-value of <0.05 indicated a statistically signiﬁcant difference. All respondents did not answer all questions, thus there is some variation in the n-values in the tables. RESULTS Anticipated changes in the work places Although two-thirds (64.3%) of the respondents believed that their own PDS unit would not change in the reform, almost half of them (45.4%) thought that it could be merged with another unit (health centre) (Table 1). Dentists (51.2%) were statistically signiﬁcantly more often aware that market- and competition-oriented organisation forms could be introduced in the public sector than the dental hygienists (35.0%) and the dental assistants (27.3%; p < 0.01). Almost BDJ Open (2019) 5:5 1234567890();,: Table 1. Positive answers (yes, most likely and yes, possible) to the question “Will the impending Health Care Reform introduce changes in the PDS unit (health centre) where you work?” by personnel group and geographical region in number and proportion (per cent) Dentists Dental hygienists Dental assistants All North South n (%) n (%) n (%) p-value n (%) n (%) n (%) p-value My PDS unit will most likely not change 86 (66.7) 35 (58.3) 77 (64.7) n.s. 198 (64.3) 138 (69.0) 60 (55.6) * My PDS unit will most likely be merged with another PDS unit 61 (48.0) 29 (48.3) 49 (41.1) n.s. 139 (45.4) 80 (40.2) 59 (55.2) * My PDS unit will become a municipal business enterprise or a regional limited company 65 (51.2) 21 (35.0) 32 (27.3) ** 118 (38.4) 62 (31.3) 56 (52.3) ** Part of the activity in my PDS unit will be privatised 54 (42.9) 29 (48.3) 31 (26.1) ** 114 (37.5) 73 (36.7) 41 (38.7) n.s. My PDS unit will be closed down 18 (14.2) 9 (15.0) 14 (11.8) n.s. 41 (13.6) 23 (11.5) 18 (16.8) n.s. Valid proportions by respondent group, dentists: n = 126–129; dental hygienists: n = 60; dental assistants: n = 118–119; northern Finland: n = 198–200; southern Finland: n = 106–108 n.s. Not signiﬁcant *p < 0.05; **p < 0.01 Public Dental Service personnel facing a major health care reform in. . . E. Widström et al. Table 2. Responses to the following statements “I wish to work in my present work place/clinic to the end of my career”, “I will probably move to the private sector”, “Task sharing between personnel groups works well in my work place/clinic”, “The number of dentists/dental hygienists/dental assistants in relation to numbers of patients is on the right level” Dentists Dental hygienists Dental assistants All North South n (%) n (%) n (%) p-value n (%) n (%) n (%) p-value Engagement with the present work place/clinic Wishes to work in the present work place/clinic to the end of career Yes 75 (59.0) 30 (49.2) 70 (57.9) 175 (55.4) 113 (56.5) 62 (56.9) Cannot say 19 (15.0) 11 (18.0) 18 (14.9) 48 (16.0) 25 (12.5) 23 (21.0) No 33 (26.0) 20 (32.8) 33 (27.2) n.s. 86 (28.6) 62 (31.0) 24 (22.1) n.s. Thinks of moving to private sector Yes, sure 3 (2.4) 2 (3.3) 0 (0) 5 (1.6) 3 (1.5) 2 (1.9) Yes, possible 22 (17.3) 7 (11.7) 4 (3.4) 33 (10.8) 19 (9.5) 14 (13.1) No 102 (80.3) 51 (85.0) 115 (96.6) ** 268 (87.6) 177 (90.0) 91 (85.0) n.s. Opinions on personnel Task sharing works well in my work place/clinic Yes 82 (64.1) 30 (50.0) 83 (68.6) 185 (60.9) 123 (61.5) 72 (66.1) Cannot say 12 (9.4) 3 (5.0) 12 (9.9) 27 (8.1) 18 (9.0) 9 (8.3) No 34 (26.5) 27 (45.0) 26 (21.5) * 87 (31.0) 59 (29.5) 28 (25.6) n.s. Number of dentists in the clinic Too few 90 (70.3) 33 (55.0) 77 (63.6) 200 (62.9) 129 (64.5) 71 (65.1) Satisfactory 36 (28.1) 24 (40.0) 39 (32.3) 99 (33.5) 67 (35.5) 32 (29.4) Too many 2 (1.6) 3 (5.0) 5 (4.1) n.s. 10 (3.6) 4 (2.0) 6 (5.5) n.s. Number of dental hygienists Too few 76 (59.8) 38 (62.3) 74 (61.2) 188 (61.1) 123 (61.2) 65 (60.2) Satisfactory 48 (37.8) 23 (37.7) 44 (36.3) 115 (37.3) 75 (37.3) 40 (37.0) Too many 3 (2.4) — 3 (2.5) n.s. 6 (1.6) 3 (1.5) 3 (2.8) n.s. Number of dental assistants Too few 75 (59.1) 31(51.7) 76 (62.8) 182 (57.9) 114 (57.0) 68 (63.0) Satisfactory 50 (39.3) 25 (41.7) 43 (35.5) 118 (38.8) 83 (41.5) 35 (32.4) Too many 2 (1.6) 4 (6.6) 2 (1.7) n.s. 8 (3.3) 3 (1.5) 5 (4.6) n.s. Valid proportions by respondent group, dentists: n = 127–129; dental hygienists: n = 60–61; dental assistants: n = 120–121; northern Finland: n = 200–201; southern Finland: n = 108–110 n.s. Not signiﬁcant *p < 0.05; **p < 0.01 half of the dentists (42.9%) and dental hygienists (48.3%) but only a dentists (62.9%), dental hygienists (61.1%) and dental assistants quarter of the dental assistants (26.1%; p < 0.01) believed that part of (57.9%) in relation to the number of patients and their treatment the present tasks of the PDS could be privatised. A smaller needs. About two-thirds (60.9%) of the respondents felt that task proportion of the respondents (13.6%) was afraid that their clinic sharing between personnel groups worked well in their clinic. Dental could be closed down (Table 1). hygienists (50.0%; p < 0.05) were, however, statistically signiﬁcantly In the north, where there are fewer private dental clinics, the less satisﬁed (Table 2). trust in continuity and stability was greater than in the south (69.0% versus 55.6%; p < 0.05) (Table 1). Some respondents Means to improve cost-efﬁciency in the future PDS commented the questions saying that dental personnel were As can be seen in Table 3, a great majority of the respondents not told about the reform plans locally. A few more respondents thought that changes in the clinical treatment of the patients e.g. made remarks saying that because commercial companies were improvement in emergency care (84.5%), periodontal treatment not able to run at a loss, redundancies by notice were to be (79.8%) and the introduction of comprehensive treatment for all expected by the personnel if the PDS was going to be changed to adults (75.2%), would improve cost-efﬁciency. The respondents a business enterprise. thought that more continuing education (63.5%) for the personnel and better task sharing between personnel groups (60.5%) would Working conditions in the present work place be needed. Dental hygienists (68.3%) had most conﬁdence in the Slightly more than half of the respondents, 59.0% of the dentists, beneﬁcial effects of increasing the division of labour between the 49.2% of the dental hygienists and 57.9% of the dental assistants various professional groups. About half of the respondents, 54.2% (p= ns) responded that they would like to work in their present in the south and 42.9% in the north (p = ns), thought that greater work place to the end of their careers. Dentists (19.7%) and dental patient ﬂow would help to increase income in the PDS. Longer hygienists (15.0%) were signiﬁcantly more likely to consider moving opening hours (23.1%), catering for more paying patients (12.4%) to the private sector than the dental assistants (3.4%; p < 0.01). More and higher patient fees (17.9%) received little support from the than half of the respondents claimed that their PDS unit had too few respondents (Table 3). BDJ Open (2019) 5:5 Public Dental Service personnel facing a major health care reform in. . . E. Widström et al. BDJ Open (2019) 5:5 Table 3. Answers to the question “The present Government emphasises increased cost-efﬁciency in all work places. How can this be achieved in your PDS unit (health centre)?” by personnel groups and geographical region Dentists Dental hygienists Dental assistants All North South n (%) n (%) n (%) p-value n (%) n (%) n (%) p-value Measures related to the performance management Giving the personnel continuing education aiming at a well-functioning working unit 78 (60.9) 39 (65.0) 78 (65.2) n.s. 195 (63.5) 136 (68.3) 59 (54.6) * Making more use of the specialised dentists or employing more specialists 75 (58.6) 27 (45.0) 56 (47.1) n.s. 158 (52.0) 111 (55.8) 47 (43.5) * Reorganisation of the activities using various performance management tools such as Lean# 55 (43.0) 29 (48.3) 39 (32.5) n.s. 123 (40.2) 68 (34.3) 55 (50.9) ** Introducing recalls for adult patients 37 (28.9) 17 (28.8) 26 (21.0) n.s. 80 (26.2) 50 (25.1) 30 (28.3) n.s. Measures related to the treatment of patients More immediate treatment of dental emergencies 107 (83.6) 48 (80.0) 104 (86.7) n.s. 259 (84.5) 167 (83.5) 92 (85.2) n.s. Introducing comprehensive treatment for all age groups 92 (72.4) 47 (78.3) 89 (76.7) n.s. 228 (75.2) 148 (75.9) 80 (74.1) n.s. Measures related to the quality of clinical work Increasing periodontal and preventive treatment for adult patients 108 (84.4) 50 (83.3) 87 (73.1) * 245 (79.8) 162 (81.4) 83 (76.9) n.s. Improving the quality of clinical work 71 (56.8) 36 (60.0) 64 (54.2) n.s. 171 (56.4) 114 (58.2) 57 (53.3) n.s. Measures related to improving the economy of the PDS unit Increasing patient ﬂow 62 (48.4) 33 (55.0) 48 (41.0) n.s. 143 (46.6) 85 (42.9) 58 (54.2) n.s. Higher patient fees 34 (26.4) 11 (18.6) 10 (8.4) ** 55 (17.9) 24 (12.0) 31 (29.0) ** Catering for more paying patients 14 (10.9) 9 (15.3) 15 (12.6) n.s. 38 (12.4) 26 (13.1) 12 (11.2) n.s. Staggering the opening hours of the clinics 25 (19.7) 17 (28.3) 29 (24.6) n.s. 71 (23.1) 38 (19.3) 33 (30.6) * Measures related to the division of labour between personnel categories Increasing the work effort of dental hygienists in the clinical work 86 (67.7) 52 (86.7) 93 (78.8) * 231 (75.7) 154 (77.8) 77 (72.0) n.s. Increasing the work effort of dental assistants in the clinical work and in motivating patients 86 (67.2) 48 (80.0) 72 (61.0) n.s. 206 (67.3) 127 (64.1) 79 (73.1) n.s. in home care Increasing the division of work between dentists 71 (55.9) 41 (68.3) 72 (61.9) n.s 184 (60.5) 110 (56.1) 74 (68.5) * Valid proportions by respondent group, dentists: n = 125–128; dental hygienists: n = 59–60; dental assistants: n = 118–120; northern Finland: n = 195–200; southern Finland: n = 106–108 n.s. Not signiﬁcant *p < 0.05; **p < 0.01 Public Dental Service personnel facing a major health care reform in. . . E. Widström et al. A third of the respondents (31.5%; 47 dentists, 32 dental groups, aspects they were most familiar with. It is true that hygienists and 19 dental assistants) provided comments on the regarding periodontal care and oral hygiene, the quality of Finnish 15,16 statements in the open space reserved for this. Most of the dental care has been inadequate. However, it is more comments (n = 61) complemented the statements about pre- interesting that few respondents suggested longer opening hours, ventive treatment, quality of clinical treatment, task division to facilitate working adult patients or increasing the numbers of between personnel groups and about “Lean management” aiming paying patients and raising fees, probably because these 14,17 to improve organisations’ efﬁciency and quality through small strategies would be inconvenient for the personnel. Thus, incremental changes in processes; this was a popular subject for the suggestions of stronger leadership in the new county-owned continuing education at the time. Typical comments were: “There undertakings (former PDS organisations) by a number of should be more dental hygienists than dentists in the clinics” and respondents probably were wise as it was apparently difﬁcult for “the patients should be obliged to perform home care for example public employees to envisage the business side of the enterprise. with a written consent.” In addition, 19 respondents highlighted Recently, the Finnish Nurses Association conducted a ques- the perceived shortage of personnel in their PDS unit and eight tionnaire study among their members about the planned health respondents felt a need for “investments in the well-being of the care reform. The results showed that even the nurses anticipated personnel”. Ten respondents longed for better leadership in their great changes in their work in the future. Few respondents PDS unit. believed that the reform would fulﬁl its goals: improve access to care (21%) and inhibit cost increases (17%). Most respondents (87%) thought that free choice between public and private DISCUSSION treatment providers would create new problems and 58% In oral health care, private provision of services has been greater believed that the reform would lead to fewer job openings. than in the general health care. The PDS has catered for almost all Big reforms inﬂuencing people’s terms and working conditions 5–7 the young (<18 years) and about half of the adults who visited a cause stress and are poorly received by the personnel involved. dentist in the course of a year (about 50%) and the private sector This study indicates that dental personnel in the PDS was not the other half. The private sector has provided regular and more much involved in the planning of the new county-owned dental expensive care and recall appointments whereas the public sector, organisations where they are most likely to ﬁnd work. It has to be with low (set) fees, has provided adults with more emergency mentioned that during recent years, private practitioners have services and long waiting lists for non-emergency care. increasingly been selling their practices to dental chains and are When this survey was conducted in the autumn of 2016, there becoming employees of the chains, to be better prepared for was little concrete information on details of the health care reform competition from the public sector of the future contracts with the and the coming changes except that the principle of a purchaser purchasers. provider split and increased competition with the private sector would be introduced. This might have contributed to the high response rate to this study. However, the responding dentists CONCLUSIONS made up just above 12% of all public dentists in the areas Dental personnel expected major changes in their working considered. Corresponding percentages for dental hygienists and conditions, especially in southern Finland where the private dental assistants can be estimated to be in the same order of sector has a greater market share than in the northern parts of magnitude and therefore the results must be interpreted with the country. Dentists and dental hygienists seemed to be more some caution. Because of the vague plans for the future dental awareof possiblemarket-oriented changes than dental assis- care, it was not surprising that most dental professionals tants. Public sector employees seemed to have little under- participating in this study (64%) believed—or hoped—that their standing of how the work could be made more cost-efﬁcient own PDS unit would not need to change. It was also obvious that and were thus badly prepared for increased competition with PDS employees did not wish to move to the private sector. theprivatesector. In the new system, county councils will choose or select the oral health care producers either using a tendering process or (more likely) by setting certain criteria to be fulﬁlled by the applicants. ACKNOWLEDGEMENTS We would like to thank the publication fund of the Arctic University of Norway for The suppliers will be paid by means of capitation for all or most their ﬁnancial support of the author-side payment. dental care of children and adolescents and for some basic care of adults. For as yet undeﬁned subsidised treatment measures, adults will pay the same fees regardless of the treatment sector. These AUTHOR CONTRIBUTIONS are, however, most likely to be fewer and more expensive than E.W. and A.T. planned and designed the study. E.W. and H.T. organised the before. For non-subsidised treatment measures, both the public practicalities and the data collection. A.T. analysed the data. E.W. and H.T. performed and the private sectors will be free to set fees and this part of the literature search. E.W. drafted the manuscript. H.T. and A.T. helped to interpret the work will be critical for the economy of both sectors. It seems results and write the manuscript. All authors read and approved the ﬁnal paper. obvious that to survive, the new county-owned undertakings (former PDS organisations) will need to take a closer look at the numbers of dental personnel to be employed as adults’ use of ADDITIONAL INFORMATION services may drop due to higher patient fees. Among other things, Competing interests: The authors declare no competing interests. remuneration of the staff and opening hours of the clinics probably will need to be reviewed too, as private companies are Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims 13,14 much better prepared for competition. in published maps and institutional afﬁliations. In principle, dental care can be made more cost-efﬁcient by decreasing inputs (personnel and other costs) and increasing outputs (income from paying patients and rapid ﬂow of capitation REFERENCES patients). However, in order to increase cost-efﬁciency, all 1. Ministry of Health and Welfare. Social services, Health Care and Regional Gov- personnel categories in this study suggested, in the ﬁrst place, ernment Reform Put Before Parliament. https://alueuudistus.ﬁ/en/frontpage. Accessed 2 March 2017. measures to be taken in patients’ clinical treatment such as more 2. Finnish Government. 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