Background Privatisations of public sector organisations are not uncommon, and some studies suggest that such organisational changes may adversely affect employee health. In this study, we examined whether transfer of work from public sector hospital units to commercial enterprises, without major staff reductions, was associated with an increased risk of long-term sickness absence among employees.
Methods A cohort study of 962 employees from four public hospital laboratory and radiology units in three hospitals which were privatised during the follow-up and 1832 employees from similar units without such organisational changes. Records of new long-term sick leaves (>90 days) were obtained from national health registers and were linked to the data. Mean follow-up was 9.2 years.
Results Age- and sex-adjusted HR for long-term sickness absence after privatisation was 0.83 (95% CI 0.68 to 1.00) among employees whose work unit underwent a change from a public organisation to a commercial enterprise compared with employees in unchanged work units. Further adjustments for occupation, socioeconomic status, type of job contract, size of residence and sick leaves before privatisation had little impact on the observed association. A sensitivity analysis with harmonised occupations across the two groups replicated the finding (multivariable adjusted HR 0.92 (0.70–1.20)).
Conclusions In this study, transfer of work from public organisation to commercial enterprise did not increase the risk of long-term sickness absence among employees.
- Organizational change
- Disability < Organ system, disease, disease type
- Longitudinal studies < Methodology, speciality
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- Organizational change
- Disability < Organ system, disease, disease type
- Longitudinal studies < Methodology, speciality
What is already known on this topic
Organisational changes, such as privatisation, have been shown to be associated with impaired health and work disability among affected employees.
These studies are typically focused on organisational changes accompanied by staff reductions.
What this paper adds
Transfer of work units from a public sector organisation to a commercial enterprise without major staff reductions was not associated with an increased risk of long-term sickness absence among employees.
The Whitehall II study of British civil servants showed that commercialisation and privatisation of organisational units during late 1980s and 1990s were associated with adverse changes in employees’ self-evaluated state of health, blood pressure, weight control and work ability as indicated by long-term sick leaves and retirement on health grounds.1 ,2 This organisational change was accompanied with staff reductions and the authors of the study suggested the observed health effects may be due to increased stress and insecurity. Other studies have found that large organisational changes, such as organisation mergers and downsizing, may also induce stress3 and contribute to poor health and sickness absenteeism among employees.3–8
In this study, we examined the risk of sickness absence lasting 90 days or longer among employees of commercialised operational units in three public hospitals. The reference group comprised employees in similar units which did not undergo organisational changes during the follow-up.
Privatisations of four laboratory and radiology units were carried out in three hospitals participating in the Finnish Public Sector Study. One unit (n=381 employees) was privatised in the beginning of 1999, two units (n=325 and n=93) in the beginning of 2004 and one (n=163) in September 2004. In total, these units included 962 employees with a job contract for at least 3 months before and after the privatisation.
The non-privatised reference group consisted of laboratory and radiology employees, in total 1832 men and women, from three other hospitals taking part in the Finnish Public Sector Study but not undergoing privatisations between the beginning of 1999 and September 2004. The inclusion criteria were the same as those for employees in privatised units.
Long-term sickness absence
The participants were linked to sickness absence records drawn from the national register kept by the Social Insurance Institution of Finland using personal identification numbers. These records were available up to 31 December 2011 for all respondents. All Finnish residents aged 16–67 years are entitled daily allowances due to medically certified sickness absence. After the first 9 days of sickness absence, compensation is paid for a maximum of 1 year. A medical certification is required for each sick leave; the start and end dates are recorded to the register.
We classified employees with a sick leave (or retirement on health grounds) lasting a minimum of 90 consecutive days as work disability cases. Non-cases were those with no or shorter periods of sickness absence, and employees who retired due to old age. On average, employees were followed for 9.2 years (range 10 days to 13.0 years).
Covariates were age, gender, occupation (laboratorian/radiographer/other), socioeconomic status (upper-level non-manual worker/lower-level non-manual worker/manual worker), type of job contract (permanent/temporary), wealth (indicated by the size of their apartment) and baseline health status, measured as the number of days on sick leave during the 2 years preceding the privatisation/beginning of sickness absence follow-up.
Mann–Whitney and χ2 tests were used to compare baseline characteristics of the privatised and non-privatised groups. Follow-up for work disability started on the day when the commercialisation was implemented and ended 31 December 2011, on the day when an employee was granted a disability compensation lasting at least 3 months, retirement due to old age or death, whichever came first. Cox proportional hazards regression was used to examine the association between privatisation and work disability, expressed as HRs and their 95% CIs. The models were sequentially adjusted for age, sex, occupation, socioeconomic status, type of job contract, income and the number of sick leave days 2 years prior to work disability follow-up. In a sensitivity analysis, only laboratorians and radiographers were included in both groups and 1212 were left out in order to obtain as homogenous a group as possible. All analyses were carried out using the V.20 of the SPSS statistical software.
As shown in online supplementary appendix table S1, employees who underwent change to a commercial enterprise were older and more commonly women than those who did not experience such changes. Those in privatised units were also more likely to be laboratory staff rather than radiography staff, from lower socioeconomic position, with permanent job contract, live in smaller apartments and have had more sick leaves during the past 2 years.
A total of 503 new cases of long-term sickness absence were recorded during 25 726 person years at risk (incidence 1.96 per 100 person years). Long-term sickness absence was more common among older employees, women, manual workers and lower-level non-manual workers, those with permanent job contracts and those who had had most sick leaves over the previous 2 years.
Table 1 shows the association between privatisation and subsequent risk of work disability. In a model adjusted for age and sex, HR for work disability among employees who underwent change to commercial enterprise 0.83 (95% CI 0.68 to 1.00) was comparable with the reference group of employees who did not experience such changes. Further adjustment for occupation, socioeconomic status, type of job contract, the size of apartment and sick leaves during the two previous years had little impact on this HR. In a sensitivity analysis of laboratorians and radiographers whose workplace underwent change from public to commercial enterprise and those laboratorians and radiographers whose workplace was not privatised, the corresponding age- and sex-adjusted HR was 0.90 (95% CI 0.70 to 1.15). Further adjustments had no significant impact on the observed association.
In this study of Finnish laboratory and radiology employees, we found no elevated risk of long-term sickness absence among employees whose units were transferred from a public hospital to a commercial enterprise without major staff reductions. In fact, the relative risk of long-term sickness absence was marginally lower in the privatised group. Thus, our results contradict those of the Whitehall II study that showed a twofold risk of future work disability among employees after a commercialisation accompanied with staff reductions.2
The differences in findings of the current investigation and the Whitehall II study need to be interpreted cautiously. In contrast to Whitehall II, staff reductions were not accompanied with the privatisation process of our study. Our outcome was long-term sickness absence which might in part be affected by factors other than health and disability. We obtained the information on privatisation from the official documents of the studied hospital organisations. Each participant was linked to sickness absence records drawn from a national register. In contrast, self-reported data on organisational change and work disability were used in the Whitehall II study. We ran a sensitivity analysis limited to two employee groups only. The findings were unchanged suggesting that differences in educational background and the content of work are unlikely to mask the association. The employees in the Whitehall II study represented a much wider range of different occupations than those in our study.
Our mean follow-up was over 9 years as it has been previously shown that the latent time period to observe prospective work-related health effects might be long but not necessarily more than 10 years.9 ,10 Nevertheless, with only a relatively modest number of cases, we acknowledge that the results of this study should be validated in further studies with larger samples and other sectors of working life.
Transfer of work from a public organisation to a commercial enterprise, without major staff reductions, was not associated with an increased risk of long-term sick leave among employees.
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Files in this Data Supplement:
- Data supplement 1 - Online table
Contributors LK, guarantor for the paper, with MV, JP, JV and MK designed the hypothesis, analysed the data, and wrote the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. MK is supported by a professorial fellowship from the Economic and Social Research Council, UK. MV is supported by the Academy of Finland (grants 258598, 265174).
Competing interests None.
Ethics approval The study was approved by the Ethics Committee of the Finnish Institute of Occupational Health.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
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