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The development of Finnish occupational health services during the past ten years

The employee coverage of occupational health services has been 90% for a long time. However, entrepreneurs and companies with less than five employees still have poor access to occupational health services. For example, according to the law on farmers' pensions, only about 20 - 46 % of the farmers who have insurance - depending on county - are covered by occupational health services. With entrepreneurs who are working alone, the proportion is even lower.

The decade-long transformation of the service system will doubtless continue. The number of occupational health service units that are run by employers will diminish, as will the numbers of customers using municipal health care centres. Private clinics on the other hand, will strengthen their position. There are a number of on-going projects throughout Finland which are aimed at developing the system. These include various joint projects of municipalities, the privatization of the occupational health service units of municipal health care centres, or the joining of forces to form larger units.

The number of occupational health service personnel has risen throughout the 1990s.

Surveys focusing on work atmosphere and projects for improving the functioning of work communities have increased in number over the past years. In 2003 about every second employee had witnessed either one or both of the above activities at their work place.

The satisfaction of customers regarding occupational health services has improved during the past six years, service providers are seen as unbiased, and their services are perceived to ensure confidentiality and to protect the security of patient data.

The statutory nature of occupational health services

The Act on occupational health services (21.12.2001/1383) aims to advance the prevention of work-related illnesses and injuries, the health and safety of work and the work environment, the health and work ability of employees at different stages of their work careers, and the functioning of the work community. The law obligates the employer to adhere to the act on Occupational Safety (738/2002). Entrepreneurs and self-employed persons are covered by the law regarding the provision of occupational health services whenever applicable.

The occupational health service personnel carry out workplace surveys, health examinations, and provide information and guidance, as well as carry out activities aimed at maintaining the employees' work ability. These activities promote and support the work ability and physical and mental capacity of working-aged people.

According to good occupational health practice (i.e. activities that are in accordance with accepted occupational health conventions) occupational health services also include 1) proposals for actions improving health and safety at work, 2) following-up how disabled employees are able to cope at work, advice regarding their rehabilitation and their referral to medical or occupational rehabilitation, 3) provision of first aid, 4) cooperation with the authorities, e.g. on occupational health, education, administration, social insurance and welfare, as well as industrial safety. Good occupational health practice especially emphasizes the importance of 5) monitoring and evaluating the quality and effectiveness of the services.

The employer can also organise other health care services to the employees in addition to those mentioned above, but these are voluntary.

Service coverage

Despite the economic depression of the 1990s, occupational health services still cover quite well the part of the population to whom the services are intended. The coverage of the services seems to have decreased slightly after 1992, but this is most likely due to the fact that in Finland there is an increase of the so-called micro companies (1 - 4 employees). These entrepreneurs do not acquire occupational health services for themselves, nor for their employees. The coverage of farmers on the other hand has been on the rise, but for the other entrepreneurs the situation has not really changed. According to the survey on occupational health services in Finland, 85% of the employees had access to the services at the turn of the millennium.

Personnel resources

During the past decade the personnel resources in occupational health services have increased, except for paramedical staff. The average number of customers per full-time occupational health nurse and doctor decreased in all the other models of operation except in company-run occupational health units where the number of staff is still considerably lower than in other types of units (Table 1). In the follow-up period of 1992 - 2000 the occupational health resources, i.e. specialist staff in municipal health care centres have always been the poorest. For example, in 1992 the average number of customers per occupational health nurse in municipal health care centres was 1319, whereas for doctors it was 5223.

Table 1. The customers of occupational health units per full-time nurse and doctor in 2000, according to service provider.

Occupational group	n	Average	Range	Mean
Nurses
Municipal health care centre	211	1253	372-10 545	1138
Company-owned occupational health unit	286	604	139-2 468	549
Occupational health unit owned jointly by companies	45	740	346-1460	689
Private clinic	141	884	113-2 458	801
Physicians
Municipal health care centre	202	7312	1070-47 693	4321
Company-owned occupational health unit	275	1864	185-21 226	1480
Occupational health unit owned jointly by companies	42	1828	532-4 317	1651
Private clinic	137	1510	117-8 891	1266

Occupational health services

In 2002 occupational health services consisted of 4 510 400 health care visits, 984 000 health examinations, 5 165 700 laboratory tests and 377 400 X-rays. Of the health care visits, about 2.7 million (60 %) were to a doctor. From 1995 onwards the number of health care visits to a nurse has remained stable, whereas visits to a doctor have increased. Health care visits to a doctor per 100 employees did not increase between 1991 and 1994, but from 1994 to 2002 the increase has been 38 % (fig. 1). The number of health examinations per 100 employees fell in the early '90s. After the reimbursement reform came to effect in 1995, the number of health examinations rose significantly (45% from 1994 to 1995), but thereafter the number has remained stable until to 2002 when their number reduced from 62 to 52 per 100 employees (fig. 1).

Figure 1. Statutory and voluntary health examinations conducted by doctors or nurses, and visits pertaining to them, and visits to a doctor's (specialist's) surgery per 100 employees, 1990-2000.

Actions aimed at improving the working conditions (workplace surveys, information and guidance, consultations and contacts with the workplace, as well as health education) increased throughout the 1990s, but after the reimbursement reform the rate of increase has been lower. After the reimbursement reform the activities have been recorded only as statistics on hours whereas before it they were recorded only as numbers of visits. From 1990 to 1994 the number of activities increased by 42%, and from 1995 to 1999 the number of hours by 20%.

Surveys of the work climate and projects improving the functioning of work communities have increased in the past years. In 2003 about every second employee reported such activities at their work place. At the same time, the role of occupational health staff in these activities has diminished; they participated in about 40% of the surveys or projects. Even though occupational health services suffer from a lack of resources, according to the survey on occupational health services in Finland, people were willing to invest in mental well-being without reducing their other activities.

Medical treatment is usually included in occupational health services, and among those whose health care is provided through occupational health services about 50%, of all visits to a doctor are visits to an occupational health physician. At the turn of the millennium, health care services were provided for 80% of the companies that are obligated to organise occupational health care for their personnel. In 1992 the corresponding percentage had fallen to 76%.

In Finland the promotion of workplace health has manifested itself for over a decade in the form of programs to maintain work ability. However even before the labour unions had reached a general agreement (1990) regarding the maintenance of work ability, and before the Act on Occupational Health Services (1978), preventive occupational health services have played an important role in making workplaces healthier and safer.

The organisation of the maintenance of work ability (TYKY) has changed since 1992 when TYKY-acitivities were first defined by the Ministry of Social Affairs and Health, and when the first survey on occupational health care in Finland was completed. Special, so-called TYKY task forces have been set up, usually together with the occupational health personnel, the employer and the employees, as well as other experts. Since 1997 the share of the TYKY-task forces in planning, initiating and follow-up has surpassed the share of the employers and that of the safety representatives. This is probably due to the above-mentioned change in the organisation of functions.

The Work and health in Finland 2003 population survey revealed most dissatisfaction with the availability of surgery appointments. The question was posed to people whose occupational health services covered also medical care. In 2003 a rating of good/excellent was given by 65% of the respondents. People were happier with the availability of surgery appointments in the state and the private sector than in the municipal sector: a rating of good/excellent was given by 74% of people employed by the state and 72% by the private sector, whereas only 49% of the employees in the municipal sector did so. The availability of surgery appointments depends on the resources at the disposal of the occupational health services. The number of customers per every full-time occupational health- physician or nurse has been on average greater in the municipal sector than in the other employer fields (Räsänen et al. 2002).

The employer-clients' views of occupational health services were charted in the municipal sector in 2001 (Töyry et al. 2001). The results of an interview study on the personnel managers in the social, health care and educational fields, industrial safety managers and municipal sector managers are in line with the results of the "Occupational health care in Finland 2000" survey. Both studies show that more activities should be targeted at work communities by: 1) disseminating information on the welfare of employees 2) launching activities based on this information, and 3) offering support to work communities undergoing changes.

The occupational health service system and its development

Privately organized occupational health services are increasingly popular. Large chains of private clinics are expanding their territories throughout Finland, and investing resources in occupational health services. Although the majority (61%) of companies acquired their occupational health services from municipal health care centres in 2000, an increasing share (33%) had turned to the private sector. Company-run occupational health units have been increasingly outsourced; their share of company clients being 2% and of employees 25%. In 2000, public health care centres covered 37% of employee customers, and private clinics covered 32%. The share of company clients in units run jointly by companies was 4%, and their share of employees was 6%.

Municipal occupational health services are developing actively at the moment. The development activities come in many forms but the most central ones deal with the advancement of regional cooperation. Its advantages include the more effective functioning of larger units, increased specialist know-how, and improved quality of the services.

Cooperative projects currently being implemented include e.g.

• agreements between municipalities to arrange occupational health services jointly.
• municipalities buying the services from a private provider.
• registered associations formed by municipality and a private occupational health services provider.
• regional cooperation by forming networks.

In all development activities it is always important to recognise the local needs and circumstances. One should try out the best possible ways of organising occupational health services in practice. This, nevertheless often calls for reforms or changes to the legislation.

References

Räsänen K. (toim.). Työterveyshuolto Suomessa vuonna 2000 - 1990-luvun kehitystrendit. Työterveyslaitos, STM, Helsinki 2002. (English summary).

Työterveyshuolto ja työsuojelutoiminta. Kirjassa Työ- ja terveys Suomessa 2003. Työterveyslaitos, Vammalan kirjapaino 2004.

Töyry S, Kankaanpää E, Peurala M, Piirainen H, Räsänen K. Kunta-alan henkilöstön työterveyshuolto työnantajapuolen arvioimana. Kuntien eläkevakuutuksen julkaisuja 1/2001.

The authors

Peurala Marjatta, PHN. OHN, MSc, Researcher,
Manninen Pirjo, Chief physician,
Kankaanpää Eila, Researcher, Finnish Institute of Occupational Health, Department of Research and Development in OHS

The Education of an Occupational Health Nurse in General
The Act on OHS

Public health nurses working in occupational health care

A licensed public health nurse working full-time in occupational health care shall be a qualified public health nurse and shall have passed the specialist studies in occupational health care at a polytechnic or a minimum of seven credits in occupational health care studies within two years of transferring to occupational health care.

A person who works in occupational health care for an average of 20 or more hours per week is considered to be working full-time.

Specialist studies in occupational health services at a polytechnic (30 credits)

In Finland there are about 5 polytechnics which regularly educate occupational health nurses. These are situated in Helsinki, Tampere, Seinäjoki, Jyväskylä and Kuopio. Other polytechnics educate irregularly; not every year. The programmes vary depending on the place of education.

It is possible to conduct the education in 2 years; 2 days per month; partly out of hours e.g., on Saturdays. This education is directed only to the nurses.

The Finnish Institute of Occupational Health (10.5 credits)

The Finnish Institute of Occupational Health (FIOH) educates most OHNs. It has three different types of education; 1) nurses together with doctors, 2) nurses, doctors and physiotherapists 3) nurses only. The courses consist of 23 days and 5 modules.

Between modules are working days so that the whole education is over in three month. There are 6 Regional Institutes of FIOH, and of them Oulu as well as Helsinki has regularly many courses in a year. Also Kuopio and Tampere organize courses, but irregularly.

The programme of Kuopio Regional Institute

Module 1: Introduction: Operational environment and good occupational health practice.

1. day

• environment
• business idea
• customers' segmentation
• productization

2. day

• information retrieval and information service
• the core of occupational health services
  - collaboration
  - multiprofessional teamwork and partners in cooperation

3. day

• the Act on Occupational health, good occupational health and the commencement of occupational health activitie
• assessment of risks at the workplace
• Exercises for next module

Module 2: The physiological and mental loading at work

4. day

• Ergonomics and the physiological loading; orientation to the issue
• legislation and the physiological loading
• ergonomic of the work environment
• heavy manual work and its loading
• load handling at work

5. day

• the loading of working position
• repetitive work
• the improvement of working conditions of handicapped workers
• TIKKA - the assessment tool for loading at work

6. day

• the ergonomic of visual display unit work and the assessment of working environment
• vision at work and the need for special spectacles at of visual display unit work
• mental well-being at work - the Act on industrial safety and the supervision of authority
• mental loading at work

7. day

• intoxicants (drugs) at work
• the improvement of work community and case examples
• to be able to work in work life (jaksaminen työelämässä)
• harassment and interventions in the harassment at the workplaces

8. day

• leadership and work community's well-being
• the development of work community, drama exercise
• exercises for next module

Module 3: Occupational diseases, safety at work, toxicology and industrial hygiene

9. day

• The legislation of the industrial safety , collaboration and the action programme of industrial safety
• HTP (detrimental for health) percentages (for substances used in production)
• the activities for developing work communities
• becoming acquainted with Kuopio Regional Institute of Occupational Health
  - becoming acquainted with Laboratory of Physics
  - becoming acquainted with Laboratory of Ergonomic
  - becoming acquainted with Laboratory of Microbiology
  - becoming acquainted with Industrial Hygiene and Toxicology
  - becoming acquainted with the Centre of Farmers Occupational Healt

10. day

• occupational diseases and the practice of compensation
• occupational skin diseases
• work-related asthma
• TULE- (supporting tissues and musculo-sceletal disordes) diseases as occupational diseases)
• examination and care of other work-related illnesses

11. day

• workplace's inside air
• toxicology for occupational health personnel

12. day

• chemical exposure and the legislation
• hygienic measurements at work
• bio-monitoring
• biological hazards at work and their prevention

13. day

• physical hazards at work
• noise as an occupational disease

Module 4: Workplace surveillances

14. day

• personal protection at work
• industrial hygienic measurements, practical trainings and - becoming acquainted with exhibition of personal protection equipments

15. day

• assessment of health hazards
• risks of accidents as a part of workplace surveillance
• workplace surveillances of occupational health services
• preparation for workplace surveys

16. day

• workplace surveys
• report writing of workplace surveys

17. day

• presentations of reports of workplace surveys and conversation about findings
• how to use operational safety bulletin and reports about industrial measurements

18..day

• special disquisitions in occupational health services
• information retrieval as an ancillary tool for workplace surveys
• Profile of work environment - a new method for risks assessments and promotion of working conditions

Module 5: Health examinations, assessment of work capacity and rehabilitation services, disability pensions. Economy of occupational health services and improvement of activities. The future of occupational health services.

19. day

• health examinations of occupational health services
• occupational health services in agriculture
• compensation of the costs of occupational health services
• guidance and counselling of occupational health

20. day

• economy of occupational health services
• improvement of occupational health services; quality of services

21.day

• prerequisites of employee pension
• assessment of work capacity and services of rehabilitation

22. day

• review of the exercises
• discussions about exercises

23. day

• evelopment of regional occupational health services
• visions of future work life
• panel discussions concerning the future of occupational health services