Abstract
BACKGROUND:
Employers are required to get expert advice whenever needed to ensure a safe work environment. Providers of Occupational Health Services (OHS) could be such experts, but their services are usually used to provide health-related support to individuals, not preventive Occupational Health and Safety Management (OHSM) or other group-focused interventions.
OBJECTIVE:
To investigate how contracts with OHS providers in Sweden are established and implemented.
METHODS:
Written OHS contracts were reviewed, and follow-up interviews were conducted with Human Resource (HR) managers, management, safety representatives, and OHS professionals in seven organizations.
RESULTS:
Generally, the HR departments drew up the contracts with the OHS providers. The contracts were not integrated with the companies’ occupational health and safety management. Managers lacked knowledge on how to utilize services offered by their OHS provider. Terms and conditions of contracts were found to be inconsistent with services actually utilized.
CONCLUSIONS:
The procurement and implementation process promotes reactive rather than preventive interventions. Employers should include managers and safety representatives in procurement- and implementation processes and define relevant and measurable goals regarding the collaboration.
Keywords
Introduction
In Europe, there has been a significant reduction in work related accidents over the last 25 years, but work related health problems and sick leave continue to be a common problem throughout EU [1]. Employers have a statutory responsibility for the work environment and occupational health and safety of their employees; within the EU, these key principles are defined in a European Council Directive [2]. In the Swedish Work Environment Act, it states that employers must cooperate with employees and their safety representatives concerning the work environment in a systematic manner in the Occupational Health and Safety Management (OHSM). When employers lack specific competence, they are required to consult an external resource, such as an Occupational Health Service (OHS) provider. It is stated that employees and safety representatives should be given the opportunity to participate in the procurement of the OHS provider and in decision-making on the structuring and discharge of the assignment. The OHS provider should be at the disposal of both the employer and the employees [3]. As it in Sweden not is mandatory to use OHS, the responsibility to purchase and collaborate with OHS providers lies entirely on the social partners. For a thorough background and description of the current situation regarding occupational health care in Sweden, we refer to a previous article published in Work by Schmidt et al. 2015 [4]. This and other studies identify several key factors for a successful collaboration with the OHS provider and their client companies. One key factor is that the client company has a well-functioning structure for OHSM and that the OHS provider is given an independent expert and consultative role [4]. Other key factors are good and long-term relationships that enable constant ongoing dialogue that targets different organizational levels within the client company [4–7].
In public sector such relational factors may be difficult to consider in the procurement process due to restrictions imposed by the legislations and policies. In Sweden, public procurement is governed by the Swedish Public Procurement Act [18], which is largely based on an EU Directive concerning public procurement. According to the regulations, the organization can choose either the tender with the lowest price, or with the best price in relation to quality. If qualitative aspects are taken into account, this must be clearly stated in the tender documentation, as well as how the award criteria are weighted mutually. The weighting must also be kept within a certain interval in order to ensure that the procurement law principles are upheld; the price must always constitute an important selection criterion. Examples of quality criteria may be that the supplier ensures certain accessibility or specified competences. Factors such as good relations, or that a OHS provider offers a good dialogue, would open up to an overly arbitrary assessment, and the tender documentation would then conflict with the principles of equal treatment and transparency.
Other studies highlight different factors that can make the purchase and collaboration difficult. The business of OHS providers is perceived as intangible and difficult to understand and the perceptions regarding the remit and benefits of OHS provision may differ among the various stakeholders such as management, HR departments, employees and OHS professionals [8–10]. For example, managers can expect healthcare efforts, while HR does not think that the company should be responsible for such costs, but that such should be referred to general health care.
The services and interventions provided by the OHS are also difficult to evaluate in a structured, systematic and scientific manner, which contributes to different perceptions of benefits and the purchaser does not know what the interventions have resulted in or what effects are, neither for the individual, nor for the organization [11–14].
The overall legal intensions regarding OHS is thus to support employers in their OHSM. It has long been recognized that services rendered by OHS providers are often utilized for individual services such as health examinations and reactive services such as healthcare and rehabilitation, rather than on supporting preventive OHSM and group-focused interventions as intended by the law [4, 15]. The overall aim was to study the reasons thereof, in a Swedish setting. What services do employers contract OHS-providers for? How is the collaboration determined, established and evaluated? How do the different stakeholders perceive the situation regarding the employers’ use of OHS, especially in relation to the law’s intentions?
Methods
Study design
We began by studying written contracts in order to get a sense of important contractual terms and conditions and how elements regarding goals, cooperation on OHSM and evaluation were expressed. Thereafter, we conducted follow-up interviews with management, HR managers, safety representatives, and OHS professionals for a more in depth understanding. Qualitative data have been shown useful in exploratory studies for understanding attitudes, to provide in-depth information, and to increase comprehension of processes [16].
Data collection
Initially, we contacted different OHS providers to gain access to various examples of unidentified contracts. However, this turned out to be difficult, due to the confidentiality agreements with the customers.
Instead, we contacted a number of Swedish employers directly and asked if they would participate in the study. An absolute majority, of the total 23 requested, 17 employers chose to participate in the study, just a few private companies denied participation due to lack of time. The study objects were selected on the basis of expectations about what they had experienced from OHS providers and also on the basis of representing employers of different sizes and sectors. The selection was not random, but can be described as information-oriented.
We aimed to include urban as well as rural employers, from both the private and the public sector. We also wanted both in-house and external OHS units to be represented. For the sake of simplicity, both private businesses and public-sector organizations will hereafter be referred to as organization. All the included organizations provided access to their OHS contracts and to their OHS contact person. Of the reviewed contracts ten related to private-sector companies and seven to organizations in the public sector. One OHS provider was in-house, and the rest were external.
Seven of the included organizations also agreed to be interviewed (Table 1), while the rest refrained due to lack of time. Interviews were carried out with the contact person responsible for the contract, often a member of the HR department or the owner of the company. In five of the organizations, focus group interviews were conducted, in which respondents were managers, employees, and safety representatives. Each focus group consisted of three to four respondents. In the remaining two organizations (university and private business), only a manager was available for an interview. All interviews were conducted at the respondents’ premises, lasting approximately one hour and were recorded after having received consent from the respondent. The corresponding OHS providers agreed to participate, and interviews were carried out with the managers or contact persons responsible for the contracts.
Characteristics of interviewed study participants
Characteristics of interviewed study participants
Size of business defined as M: Medium = 50-249 employees; L: Large = more than 250 employees.
The research team designed semi-structured interview guides for the various respondents, with predefined topics covering specific questions (Table 2). Questions such as preparatory work, knowledge, and awareness of the content of the contract were addressed to the respondents. The needs assessments, formulation of the agreement, if and how the OHS provider was involved in the client organization’s preventive OHSM were requested. Questions were also posed regarding the kinds of services and support purchased from the OHS provider and how their results were evaluated. When necessary, new and emerging questions were raised.
List of topics from the interview guides
Initially, the research group carefully read and discussed the contracts. Specific content in the contract was highlighted, such as if specific objectives were defined, if collaboration regarding OSHM was mentioned, and what services and support were offered. Furthermore, routines for collaboration, follow-up and/or assessment or evaluation were noted. Similarities and differences in the contracts were identified and discussed.
All tape-recorded interviews were transcribed and the interviews were reviewed several times and discussed within the research team to improve the quality of the analysis. The analysis was focused on how the procurement process had been implemented and how the content of the contract had been decided. Deductive coding based on the interview questions was carried out in NVivo (version 10), and content analysis was carried out in collaboration with the research group [17]. The data material was compiled and summarized.
Results
Contract review
The review and analysis showed a great variation regarding both scope and specificity, depending on the type of customer, as illustrated in Table 3.
Description of studied contracts and collaboration
Description of studied contracts and collaboration
*Interview conducted, **Including focus group interviews.
The contracts with the public sector organizations were typically comprehensive and orderly, due to legal requirements of documentation. The contracts contained ambitious objectives, often using well known legal terminology:
“OHS shall support the municipal managers and employees regarding preventive and rehabilitating efforts concerning health and safety.”
or:
“ The OHS provider shall be an independent counseling partner in our ambition to be an attractive and healthy workplace, formed by professionalism and equal rights.”
The role of the OHS provider in the organization's OHSM was often mentioned. However, only one of the contracts had specified a specific service, in the form of attendance at the health and safety committee.
In private business, the contracts were mostly based on a short standard contract developed by the OHS provider, which was suitable for all types of customers. Objectives were seldom mentioned in these standardized contracts, which very briefly described different services the OHS provider was able to offer. The collaboration or contribution to the company’s OHSM was mentioned in a few contracts.
The payment model was of two main types, occurring in both the public and the private sector: subscriptions and call-off contracts. Subscriptions provided access to predefined or prepaid services, such as health examinations or the opportunity for the employees to have a certain number of non-specified visits to the OHS provider per year. In some of the subscriptions, an annual fee was prepaid and services were required until the allotted amount was used up. Call-off contracts were defined as contracts where no services were included or prepaid, with every service being ordered and paid for when required. Sometimes these contracts specified what services were available, as shown in Table 3.
Interviews reflected that the HR person or department mainly managed the procurement process, both in the private and the public sectors. In the public sector, the procurement process, including the preparation of tender documentation and the signing of the contract, was quite comprehensive and managed by the HR department with support from the purchasing department. In the private sector, the contracts were entered into, and extended, without any deeper analysis. Discussions regarding various solutions or choices and the final decision concerning the specific OHS provider was solely a decision made by the HR department, or if there were no HR function, by the owner of the company. Respondents from the private sector HR departments described there being a lack of time for a more developed procurement process. Issues arising from the organizations' OHSM were not the focus of preparatory discussions, regardless of the sector. Moreover, other documented information on work-related issues were not used to better identify current requirements.
One public sector HR manager described discussions in the preparatory phase as follows:
“No, the analysis of the employee survey does not matter and that is because the OHS provider does not serve employees, only the employer. We discussed important competences in the OHS provider and what kind of services we [in the HR department] thought we needed.”
The focus group interviews revealed that the managers and safety representatives typically were not involved in the procurement preparations.
Implementation and use of OHS services
Communications about the contract and the services available to the organization was managed in different ways, mostly by making the contract available on the organization’s intranet. Sometimes it was communicated via e-mail or occasionally in a formal meeting with information shared with the managers. In those cases, where the employees were authorized to contact the OHS provider directly, the contact was limited, ranging from 1–3 appointments per year without prior management approval. Respondents in the focus group interviews perceived the content of the OHS contracts as hidden or unknown. Managers stated that they were aware that an OHS provider existed, but that they were not informed in detail about what support and services were available. Furthermore, they had not comprehended of any overall objectives or goals regarding the collaboration with the OHS provider. For example, in one municipality with an in-house OHS provider, the agreement stated that all services were available, but the interviews revealed that the managers did not know of any detailed plan on how the services should be utilized to target their OHSM.
In another municipality with a call-off agreement, where no specified services were included, each request had to be ordered by a manager. However, the focus group interviews revealed that the managers were not informed about the content of the contract or available services and that there had been no instructions on when and how to utilize the support. One manager described the situation as follows:
“No, I don’t know. When I have a situation in which I require support, I have to find out [what’s available]. I know we have an OHS provider.”
All in all, it was quite evident during the interviews that the terms and conditions of the contract bore little relation to the utilization of services in the studied organizations. An illustrative example was a public sector organization with a comprehensive contract that stated that the OHS provider should primarily be used for preventive group-focused interventions. However, the accounting summary of used services during the year showed that approximately 95% of both time and money spent were on interventions related to services with individual focus.
Evaluating OHS services
The contracts typically did not mention any achievable or measurable goals, other than regarding very specific demands such as access to a physician or other support within certain time limits. The OHS efforts were mainly assessed in general terms at 2–4 follow-ups or planning meetings per year in the public sector, more seldom in the private sector (0–2 meetings per year). These meetings presented a summary of what services had been used, at what cost, and customer satisfaction. There was no clear process on how this evaluation affected the further collaboration, or upcoming procurement process.
The provider perspective
Interviewed OHS providers stated that procurement and contract negotiations with their client organization were sometimes difficult and frustrating, both in the private and the public sector. Several of the OHS providers stated that their customers had little knowledge of their own requirements for services, resulting in e.g., ambitious objectives in the contract, but only a few defined services possible and available to order and purchase. From their perspective, customers were too focused on the cost instead of how the OHS provider and their services could be utilized to contribute to the customer's OHSM. It was also difficult to understand the customers’ actual needs in OHSM because their contacts with managers and safety representatives were limited, with most communication going through the HR department.
Different strategies for planning and feedback were described, depending on model and range of the contract. Annual planning meetings were quite common, sometimes combined with follow-up meetings either monthly or quarterly, where statistics on sick leave and utilization of OHSs services were discussed. Commonly the contact person and an HR representative participated in these meetings. Several OHS provider representatives highlight long-term and close relationships as one way to get a bit closer to management and work environmental issues.
“ We have learnt that the more feedback we give, the easier it is for the managers to understand that the services we do have an effect, that it is good. ”
Discussion
This explorative, limited scale study show, in accordance with previous studies [4, 15], that the OHS expertise is not used as suggested by the law. The support from OHS provider is used in reactive matters rather than in preventive.
This seems to depend partly on the fact that HR persons or departments manage the procurement process, with little insight in the organizations' OHSM and other work-related issues in the organization. Managers and safety representatives, who have greater knowledge about current needs for expertise and support in the OHSM, are not involved in the purchasing process. They are the intended end users, but rarely use OHS and not so familiar with the agreements. Since managers and safety representatives are not aware of what services are available and there are no ongoing dialogue targeting different organizational levels they typically do not perceive the OHS provider as a source of support in OHSM, but rather as a source of support in case management.
The interviews showed a general lack of defined, achievable, and measurable goals regarding services from the OHS provider. This means that the evaluation can only consider the economical or summary perspective such as “How many sick-listed have been taken care of this year?” “How much did we spend on health examinations?” This will make it difficult for the employers to put the efforts of the OHS provider in a wider perspective, such as “In what way, or how much, have the OHS interventions enhanced the work environment or employee health this year?” Here, the OHS providers also hold a great responsibility. Historically, they have not made enough efforts to measure quality or to scientifically prove positive long-term effects of their preventive (and other) services [11–14]. The return of investment is not assured, and the customers remain reluctant to invest in preventive interventions. The benefits of support from experts to managers and HR in individual cases are easier to understand and appreciate, and the cost is just to be accepted. Evaluating the results may be of particular importance in the public sector, where relations may not be taken into consideration when procuring. As concluded in a Dutch setting almost 20 years ago, to achieve a real improvement of quality management, employers and employees should be demanded to make clear agreements about the desired OHS output and to carefully monitor if the agreed output quality has been achieved [14].
Ten out of the 17 employers chose not to participate in the study interviews. This is an interesting result in itself, as it indicates that the procurement of an OHS provider is not a prioritized issue and that the support from the OHS provider in the OHSM (and perhaps not the OHSM in itself) is obviously not perceived as crucial for a healthy work place or productivity.
The fact that we were not provided with the contract through the OHS-providers as planned is worth reflecting upon. It demonstrates the protectionism that still characterizes the industry, where competition is about price rather than about performance or quality. This does not lead to quality development, as in industries where competition is seen as something positive and beneficial for the industry as a whole.
Regarding future perspectives, by highlighting the current situation, we hope this study will put further attention on the fact that employers do not use OHS expertise as support in the OHSM. The results of this study have been nationally recognized after publication in a Swedish report. Both the Swedish Association of Local Authorities and Regions (an employers’ organization and an organization that represents and advocates for local government in Sweden) and the industry association of OHS providers in Sweden have issued procurement guidelines for OHS, aimed both at the public and the private sectors [20–22], which underline a broad involvement during the procurement process, with a focus on OHSM. We hope that this can contribute to the parties’ joint efforts to define how the OHS provider's expertise could be best put in to use and evaluated in terms of, for example, improved working environment or more efficient processes in work environment and rehabilitation.
Methodological considerations
The method used for the study – a mixture of reviewing OHS contracts and follow-up interviews – was chosen in order to offer different perspectives, given the complexity of the research question. We contacted companies that we knew had contracts with an OHS provider. The selection was thereby not random. We had no prior knowledge of whether they were satisfied with the OSH provider or not. The interview results do not suggest a selection bias toward satisfied or particularly engaged employers. Even if this is the case, the challenges inherent in contracting with an OHS provider have seemingly not been overcome, which then would underline the fact that there are major concerns in this area, even among engaged and/or satisfied employers. Only one medium sized company and no small size company agreed to be interviewed. The results from the interview part therefor represent larger organizations and may not have been the same if smaller companies were represented as well.
Conclusion
If there is a strive for a more preventive use of OHS provider expertise, as intended by the law, managers and safety representatives should be more involved in the procurement process and provided with the knowledge on how and when to contact the OHS. More contact areas between the OHS provider and different parts of the organization contribute to a closer relationship and better collaboration, promoting mutual knowledge and understanding of how preventive measures can reduce the need for reactive interventions. The OHS providers should strive to compete for something more than price and get better at showing their customers what effects preventative work can have.
This is a limited scale study, with the aim to get a general impression of what factors are discussed and considered when buying services from the OHS. We hope this will inspire further and improved studies in the field.
Conflict of interest
None to report.
Footnotes
Acknowledgments
This work was supported by a grant from The Swedish Social Insurance Agency and Forte, the Swedish Research Council for Health, Working Life and Welfare. We would like to thank the participating OHS providers and client organizations for so generously sharing their experiences. The authors would also like to thank Åsa Axelsdotter Hök for discussion, consultation, and advice.