Sweden's occupational healthcare service is dealing more and more with work environment and preventive issues and less with traditional medical services. A change to the Work Environment Act, proposed in March 1998, will confirm this tendency and also clarify the employers' responsibility for providing occupational health services.
In 1992, the Swedish Employers' Confederation (Svenska Arbetsgivareföreningen, SAF) terminated the collective agreement on the work environment with the Swedish Trade Union Confederation (Landsorganisationen, LO) and the Federation of Salaried Employees in Industry and Services (Privattjänstemannakartellen, PTK), which had governed the organisation of occupational healthcare in the whole private sector. Shortly after, the then Liberal-Centre-Conservative Government proposed legislation providing that the state subsidies, which were granted for occupational healthcare services fulfilling detailed criteria as regards organisation and staffing, should be abolished. According to the Government, the state should not prescribe how occupational healthcare should be organised, as long as it manages to fulfil its objectives. Parliament adopted the bill although the Social Democratic Party, at that time in opposition, and the Left Party voted against it. Thus, since January 1993 occupational healthcare has worked under market conditions.
Medical treatment or prevention?
In March 1998 a working party within the Ministry of Labour presented a memorandum proposing new changes in the legislation with the aim of clarifying the objectives of occupational healthcare and increasing the employer's responsibility for providing such services (Ds 1998:17 Företagshälsovård En resurs i samhället). Strictly speaking, the Work Environment Act today obliges an employer to provide occupational healthcare only if the tasks of its employees are particularly trying and hazardous. The proposed changes would imply that occupational healthcare should be an integrated part of the employer's work environment policy wherever the working conditions so require.
One of the most debated issues over the years has been the balance between medical services and preventive work environment measures in occupational healthcare. For many workers, occupational healthcare has served as a convenient means to see a doctor whenever they need one. However, the specific objectives of the occupational healthcare system are prevention of work-related ill health and rehabilitation of workers, while medical treatment primarily is the objective of the general health and medical services. The proposed changes will better define these objectives, according to the memorandum. The proposal also aims at reinforcing the cooperation between the occupational healthcare service, the social insurance offices and the general health and medical services.
The proposal is now being circulated for consideration, but a bill is not due before the general election in September 1998.
Changed focus
The working party has partly based its work on a study of the occupational healthcare service today, conducted by the Swedish Agency for Administrative Development (Statskontoret, Safad) and published in January 1997 (Företagshälsovården i dag1997:2).
The report indicates that occupational healthcare centres have already begun to change their focus. They deal more and more with work environment-related syndromes, such as stress and psychosomatic illnesses. They also deal a lot with musculo-skeletal disorders. Another important part - one third - of the work is information and education of employees.
According to the report, an overwhelming majority - 73% of all employees - have access to an occupational healthcare centre. There are, however, differences between categories of workers. Almost all state employees have access to an occupational healthcare centre, compared with only 66% of private employees. In the private sector, ` the size of the workplace is the major determining factor for employees' access to occupational healthcare. Almost all employees in enterprises with more than 500 workers have access, compared with only 36% of those in companies with fewer than five employees.
Employees in manufacturing, financial mediation, education and health and social work have the best access, while those employed in retail trade and those working in farming and forestry have the least. In general those working in high-status professions are better off than those working in low-status jobs. There are no significant differences between men's and women's access to occupational healthcare centres, but the in the year the study was undertaken (1995), men visited them more frequently than women did.
The figures are derived from a survey undertaken by Statistics Sweden (Statistiska Centralbyrån, SCB), and there is no comparable survey which could make it possible to decide if there has been any change in workers' access to occupational healthcare since then.
Advantages and disadvantages
The Safad report is more outspoken on other aspects of the change in the rules governing occupational healthcare. The deregulation has meant adjustment to the market, structural changes and cuts in personnel - and, as the report says, "of course this has had its effects."
In 1994, Safad concluded that the productivity of occupational healthcare had increased after deregulation and, as there was no sign of impaired quality, the conclusion was that the efficiency had increased too.
The new report points out both advantages and disadvantages of the present situation.
- There is a dialogue between the occupational healthcare centres and the enterprises/customers, and the dialogue is becoming more and more profound.
- The cooperation between particular occupational healthcare centres has increased, as has cooperation between those centres and other professions.
- On the other hand, the influence of workers' representatives and also of the joint safety committees may have decreased.
- The employee's free access to occupational healthcare is sometimes restricted by the contract between the enterprise and the occupational health care centre.
- There are concerns that the occupational healthcare centres cannot always, when being dependent on the market, operate professionally and independently.
The personnel of the centres do, however, feel that deregulation has made their work more interesting and stimulating.
The costs for occupational healthcare has decreased considerably: today it costs SEK 2 billion to SEK 2.5 billion per year and occupies 7,000 employees; while in 1990 it occupied 10,000 employees and cost SEK 3 billion to SEK 4 billion, of which SEK 1 billion consisted of state subsidies.
Commentary
"Occupational healthcare for all" (Företagshälsovård för alla) was once the title of an official report - a "slogan" representative of the early 1980s but never heard of these days. The question of the balance between medical services on the one hand and preventive measures on the other is however as topical as always. Even if occupational healthcare has placed more emphasis on the latter in recent years, there may still be a long way to go. (Claes Leo Lindwall, NIWL)