Contract care in dentistry: sense-making of the concept and in practice when multiple institutional logics are at play
Abstract
In 2009 contract dental care was introduced into Sweden's Public Dental Service under a programme called Dental Care for Health (DCH). Previous research has revealed a possible dilemma whereby dental care professionals had the role of insurance agent foisted upon them, as they were assigned the task of ‘selling contracts’. Using qualitative interviews, this study explores how these professionals make sense of contract dental care today. Drawing on the concepts of occupational and organisational professionalism, in combination with the institutional logics perspective, we discern that dental care professionals are entangled in multiple rationalities when reasoning about and dealing with DCH. A professional logic comes into play over health issues and preventive care, while market and corporate logics are present in relation to selling contracts and taking responsibility for the financial aspects of DCH, all of which creates tensions in these professionals. Overall, dental care professionals in the welfare sector respond both to an organisational and an occupational professionalism.
Introduction
Professionals employed in the welfare sector have been subject to new steering techniques in recent decades, such as performance management, financial control and competition, which have affected their daily practices (Brunsson and Sahlin-Andersson 2000). New management ideals expose professionals to new norms and values (Cloutier and Langley 2013) and, when managed by objectives, individual practitioners are guided towards achieving goals that may oppose their professional ethics (Evetts 2009, 2011). In Sweden, as in many other countries, welfare professionals have been challenged by hybridisation, wherein organisations incorporate different, and sometimes contradicting, rationalities that allow and restrain social actions and practices (Pache and Santos 2013, Thornton and Ocasio 2008).
In this context it is interesting to study the case of dental care professionals in Sweden. In Sweden dentistry is divided into the private and public sectors. However, public dentistry is subject to market competition with fees that are not reduced to the same extent as in other welfare services, such as medical care, which are more heavily subsidised by tax revenues. Thus, public dental care has been subjected to marketisation for a long time and has simultaneously been challenged by new management ideals during the last decades (cf. Bejerot 1998, Bejerot and Astvik 2009, Franzén 2009, Ordell 2011).
A recent change in the Swedish Public Dental Service (PDS) was the introduction of a national payment system in 2009. Dental Care for Health (DCH), also referred to as prepaid dental care, the capitation system (Strand et al. 2015), contract dental care or dental insurance (Hallberg et al. 2012), is an optional way for patients to pay for dental care. According to Johansson (2009) the name reflects not only the fact that the initiative offers an alternative way to pay compared to traditional fee-for-service payment (FFS), but also that it is a unique dental care system. A study conducted prior to the introduction of DCH showed that dentists and dental hygienists within the PDS ‘faced a moral dilemma’ over the possible consequences of the implementation of the new programme, since the payment system was to introduce an ‘insurance agent’ role; informing and selling contract care to patients was perceived as challenging to the professional role (Hallberg et al. 2012).
This article explores how, some years after the introduction of DHC, dental care professionals make sense of the initiative as a concept and in their daily practice. We also examine whether these professionals have a coherent interpretative frame or still experience a moral dilemma. Thus, the article examines the ways in which these professionals understand, legitimise, act on and criticise the DCH reform.
The empirical study consisted of 16 qualitative interviews with dental care professionals employed in the PDS. In the theoretical analysis we departed from Evetts’ (2009, 2011) concepts of occupational and organisational professionalism and, in order to reach a more dynamic and complex theoretical understanding, we also made use of the institutional logics perspective developed by Thornton et al. (2012, cf. Thornton and Ocasio 2008). The moral dilemma, as described by Hallberg et al. (2012), can be theoretically explained as a clash between institutional logics, with market logic striving for profit, versus professional logic motivated by care for the common good (Franzén 2009). However, the present study shows that the professionals managed to ‘make sense of equivocal inputs and enact this sense back into the world to make that world more orderly’ (Weick et al. 2005: 410). The analysis is presented in two major themes – that of the concept and the practice – and shows that the practitioners made sense of DCH in nuanced ways, both as a means of health promotion and as a way for the organisation to secure their client base and meet their financial goals. The practitioners activated various rationalities to legitimise, act on and criticise the initiative and they reasoned not from the stance of a moral dilemma, but in an integrated and complementary way. Hence, occupational and organisational professionalisms seemed to co-exist.
The remainder of the article is organised as follows. In the next section we outline the background of DCH. We then set out the theoretical frame, followed by a discussion of methods. Thereafter follows a description of our findings, which are presented based on two major themes, the concept and the practice, each with subsequent sub-themes. The article ends with a discussion and some concluding remarks.
Dental care for health
In the Western world, enhanced public dental health has been sought after for more than a century (Exlay 2009, Nettleton 1998). In Sweden public dental insurance was introduced in 1974 to provide equal dental care to all citizens (Statens offentliga utredningar [SOU] 2007). Due to financial cuts in the public sector in the 1980s and 1990s national dental insurance was diluted and adult patients had to pay more themselves. Visit propensity is related to costs (Exlay 2009), and the deregulation of prices led to a decrease in regular check-ups, especially among young adults (aged 20–29 years). For this reason, and others, the Swedish PDS launched DCH as an alternative to the traditional FFS. In Sweden, approximately 40 per cent of all adults and approximately 95 per cent of all children are registered at a PDS clinic (Andås 2015). In Region Västra Götaland, where this study was conducted, a slightly higher proportion of adults are registered (46 per cent), approximately a third of whom had chosen DCH as at 2014 (Strand et al. 2015).
DCH is marketed as contract dental care at a fixed price, with the aim of maintaining or improving oral health (PDS 2015) and encouraging patients to take more responsibility for their oral health (Hallberg et al. 2012, Strand et al. 2015, Zickert et al. 2000). Under DCH, patients are offered a 3-year contract and pay a monthly premium according to a risk classification. Moreover, the DCH contract includes a preventive self-care programme for the patient to follow. At the end of the period a new risk assessment is performed and the contract is renegotiated. The patient may then continue under DCH or go on to pay according to the traditional FFS payment system.
Hallberg et al. (2012) revealed that the professionals feared a potential moral dilemma in which financial considerations would challenge their professional role and promotion of oral health. The practitioners were worried about classifying patients too low and hence risk losing compensation. However, on average, the income from capitation patients was higher than related expenditures and the costs for technical work were also lower than under the FFS system (Zickert et al. 2000).
Occupational and organisational professionalism
Dentistry became an organised profession in the late 19th century (Bejerot 1998, Nettleton 1988). Professions are considered to comprise bodies with expertise knowledge, ethical codes and a strong professional identity (Greenwood 1957). Professional jurisdiction guarantees control of work planning and performance and decisions over treatment and diagnosis. (Abbott 1988). Researchers claim that these values and practices are under threat from new management ideals, such as new public management (NPM) (Evetts 2003, Fournier 1999).
The challenges that welfare professions have met in the wake of NPM have been addressed by Evetts (2003, 2009, 2011), who claimed that new organisational conditions have led to diversified discourses of professionalism. Evetts distinguished two ideal types. Occupational professionalism is manifested by autonomy, discretionary judgement, identity and self-monitoring of work. Organisational professionalism, developed within NPM, draws on organisational values and ideals and emphasises rational authority, hierarchical structures, standardised work procedures and practices, and managerial control through measurable targets and performance reviews. This has also been described as a set of disciplinary techniques (Fournier 1999) where management utilises ‘soft control’ (Dent 2006, Franzén 2009).
The concepts of occupational and organisational professionalism explain the degree of autonomy and jurisdiction for practitioners that exist in different organisational contexts. However, the concepts say less about how situational contexts impose ‘higher order meanings, values, norms, and/or rules that frame how individual make sense’ (Cloutier and Langley 2013: 361). Thus, by combining professionalism with the institutional logics perspective we may create a more dynamic and complex theoretical framework.
The institutional logics perspective situates the actor in contexts and stresses that sense making takes place within a frame of reference (Thornton et al. 2012, cf. Weick et al. 2005). Institutional logics are embedded patterns of practices, values and beliefs that help individuals to manoeuvre in their socially constructed reality and provide them with ‘vocabularies of motives and sense of self (i.e. identity)’ (Thornton and Ocasio 2008: 101). Institutional logics articulate valid norms and values, and thus influence individuals with regard to who they are and how they ought to act. However, different institutional systems, such as states, professions and corporations, have their own sets of principles and foster different ways of thinking (Thornton et al. 2012). For instance, market logic stresses the importance of transactions and the signing of contracts, commodification, and converting activity into revenue, while the logic of professions acknowledges expertise, autonomy, and professional jurisdiction and the common good. However, organisations today are characterised by hybridisation, in which multiple institutional logics are at play (Pache and Santos 2013). Thus, individuals in organisations are subjected to various, sometimes contradictory, institutional orders that regulate beliefs and practices (Thornton and Ocasio 2008).
Actors’ sense making, as well as the different expressions of professionalism, need to be understood in relation to the institutional logics that provide a frame of reference. Thus, depending on the organisational context, different institutional logics come into play that may lead actors to adopt different types of professionalism. The point of departure for our analysis is the idea that dental care professionals employed in the welfare sector are under the influence of multiple institutional orders. Three interrelated institutional systems may govern attitudes and actions and frame sense making. These institutions are the profession, since dentistry, including dentists and dental hygienists, are recognised professions (Franzén 2009, Nettleton 1998), the corporate style, as dentistry in the welfare sector has developed in a more business-like style, and in recent years has been subject to NPM (Bejerot 1998, Ordell 2011) and the market, as dentistry is subject to competition between the private and public sector (Bejerot 1998, Ordell 2011). These systems relate to, and are expressions of, either organisational or occupational professionalism.
Methods
The PDS in Region Västra Götaland in Sweden employs approximately 900 dentists and 500 dental hygienists. Between April and May 2015 we conducted 16 qualitative semi-structured interviews with dental care professionals employed at six different PDS clinics in the county. The targeted clinics varied in size between 20 and 40 employees. The clinics were selected strategically in order to achieve a geographical spread, and to cover different neighbourhoods in the larger city, Gothenburg, as well as those situated in smaller municipalities in the county. Thus, the selected clinics differ according to the clients’ socioeconomic status, as well as the composition of native Swedes and immigrants. Two or three dental care professionals in each clinic were interviewed. We initially decided to start with 17 interviews. One of the selected participants reported sick but the remaining 16 agreed to participate. Once these interviews had been conducted, we had reached saturation and decided not to conduct any more interviews. The final selection showed variations of gender, age and experience, and profession and the location of clinics (Table 1).
| Age, years | n | Experience, years | n | Male/female | n | Profession (female) | n | Clinics location | n |
|---|---|---|---|---|---|---|---|---|---|
| ≤35 | 8 | ≤10 | 7 | F | 12 | DH | 5 (5) | City | 2 |
| 36–50 | 4 | 11–20 | 6 | M | 4 | D | 11 (7) | Large municipality | 2 |
| ≥51 | 4 | ≥21 | 3 | Small municipality | 2 |
- D, Dentist; DH, dental hygienist. City (≥450,000 inhabitants), large municipality (20,000–450,000 inhabitants), small municipality (<20,000 inhabitants).
The interviews were conducted by Ulfsdotter Eriksson and Berg and took place at the clinics in which the practitioners were employed. The duration of the interviews ranged from 36 to 65 minutes. At the beginning in each interview the participants were informed on the ethical guidelines for the research, such as the purpose of the study, the voluntary nature of their participation and the fact that their responses would be kept confidential. We asked the interviewees if they knew why they had been selected but none of them did. Since the heads of the clinics had chosen the participants, we endeavoured to secure their anonymity. For this reason, we use fictitious, gender-neutral names and do not indicate whether the interviewee was a dentist or a dental hygienist, or any other revealing details. However, this approach has led to certain limitations. The location of the clinic, as well as the profession, tended to be important in terms of how DCH was perceived and dealt with, which suggests that it could have been useful to include the respondents’ information in the analysis. However, in order to maintain the interviewees’ confidentiality and anonymity we were not able to conduct such an analysis and include that type of data.
The interview guide was constructed by the authors and was structured around three major themes: DCH as a concept, as a practice, and from a professional perspective. The questions were asked in a semi-structured way, which allowed additional information to unfold. The interviews were recorded and transcribed verbatim by Ulfsdotter Eriksson and Berg, who are the only people to have access to the data and to have read the entire transcripts.
Ulfsdotter Eriksson and Berg also conducted the analysis, read the transcribed interviews repeatedly and coded openly and inductively. When familiarity with the material was reached and a number of codes had been identified, we brought together our codes to discern themes (Braun and Clarke 2006). The analysis was organised into two general themes: the section on the concept captures how the practitioners perceived DCH with regard to what it is, why, and for whom; and that on the practice covered perceptions of how DCH works in daily application. Within each of the major themes, we sought sub-themes and expressions of different institutional logics in how the respondents understood and made sense of the concept and managed the challenges it entails.
The concept
Contract, subscription and insurance
Dental Care for Health is dental care for a fixed price. It is a concept that [goes] beyond knowing that you get regular examinations; it is also a small insurance covering … unforeseen expenses based on [a] risk calculation.
(Robin)
I do not know if you will benefit from it. It is like any insurance … . It could be a whole year that you do not benefit from it, when you pay for more [than] you have used.
The institutional logics perspective stresses the presence of multiple interrelated institutional logics, and the above definitions of the concept illustrate this (Cloutier and Langley 2013, Pache and Santos 2013, Thornton et al. 2012). A professional logic is voiced when health aspects and regularity are emphasised. The subscription metaphor and the contract both capture a corporate logic, as they focus on DCH as a steady income and as entailing a regulated relationship between the PDS and the patient. DCH is a kind of private insurance, and when the professional's emphasise the financial benefits for the individual, market logic is expressed.
The purpose: health, financial and governance
Well, it's a spur to regular dental care. If you have already paid you are less inclined to postpone the visit. It's also a way to notice damage before it get too large.
(Robin)
Emphasising health issues expresses values anchored in the logic of the professions (Greenwood 1957, Evetts 2009). Ethical guidelines for dental care professions also stress that the main purpose is to act for the patients’ health and wellbeing (Sveriges Tandhygienistförening 2015, Sveriges Tandläkarförbund 2014).
At the end of the day it's the economy. Our organisation is driven by financial interests, so I guess, it's about making money … . I think that you are naive if you don't think that is has to do with finances.
(Kim)
They say that 60 per cent of the patients should be DCH patients. You get a little worried. [If] we are going to make it [financially], it's really important that we set the right premium. All of a sudden, we must sell DCH to the patients and we have these yearly demands to enhance the number of DCH patients. We must sell a certain number [of contracts] each year. Each clinic receives a calculated goal based on the clinic's size and number of practitioners.
(Ty)
On the other hand, the capitation system enhances the clinics’ ability to oversee revenues and expenses. ‘We get a steady income. You know that this money is coming in’ (Michelle). The DCH patients were also seen as easier to plan for, since they are known and the risk classification functions as a way to foresee the cost of treatments. As Lo explained: ‘Since the patients are classified depending on their dental status, you know roughly how long the treatment will take’.
Apart from being examples of market-oriented and corporate-oriented logics within the PDS, the quotes above show the presence of organisational professionalism (Franzén 2009). Responsibility for the clinics’ finances is manifested in concrete actions. In some clinics, the numbers of DCH contracts agreed upon are reported openly and there are indications that the numbers of contracts are related to wage-setting: ‘Well, we understand that it's part of the wage-setting and then you don't dare to say what you think. That's why I asked about anonymity’.
Contract care: for everyone’, the young and the healthy
It's especially for young people [who] are about to start paying for dental care. When they understand what it costs, well, a lot of them disappear. They stop coming. So this is a way to keep them coming.
(Hol)
Some patients are hard to predict – what will happen to them – those with high risks. It's hard to do the assessment … . Essentially, the system is not for them but for the healthy ones.
(Michelle)
It's especially the lower premium groups that are signed in. When it comes to the higher premium groups it's always a risk both for us and for the patient. Because it [the high premium] costs so much and if nothing happens the patient ends up paying far too much. But it is so much money that we risk a lot financially too [by signing them in].
(Lee)
Those with the greatest need, and perhaps even with weak financial standing, cannot afford to pay [at] these [high-risk] levels. So basically, it is people who have more money that benefit from this.
(Inge)
The practice
Informing about options or selling insurance
It's like we are a company and we want to sell a product … and you sell a service and it is insurance, just as you sell other insurances … I have some sale techniques that I use.
(Rene)
Some interviewees were concerned with having the role of a ‘salesperson’, but others were not. Ty felt that they had become salespeople, saying, ‘I didn't train to be a dentist so that I could sell dental care’. This relates to the way that identity is expressed in different institutional logics (Thornton et al. 2012). In the market you can be a faceless salesperson, while acting out a profession places greater demands on a coherent professional identity (Evetts 2009, Ulfsdotter Eriksson and Linde 2014).
Others simply considered DCH as part of the daily practice – somewhat similar to discussing alternative treatment and prices with patients paying for service – and did not even interpret it as a sales situation: ’ The idea, I think, is that we should make an offer. This is an option – another concept – so it is more about providing information than making sales’ (Sasja). Thus, the dental care professionals made sense of the tasks of informing and selling in various ways. One approach was to frame it within the context of organisational professionalism, thereby emphasising corporate and market values, while the other was to hold onto the role of an occupational professional and stress their professional identity (Evetts 2009).
Risk classification: computerised assessment adjusted
I can say to a patient that ‘The computer wants you to be in risk group six’. I don't say ‘I think that you are in risk group six’ because they could then say ‘I'm not’. But if you say that ‘ … due to the values that you have, or that we have put in, the computer thinks that you are in risk group six’ … they accept [it].
Almost always, you need to adjust upward. Based on your own assessment, and the fact that the cheapest risk premiums covers like one examination every second year, and if something else happens during that period of time, all the insurance cover is gone. So to get coverage you need to adjust a bit.
(Kim)
And it can be like, well ‘you grind your teeth, and you will probably need an acrylic splint, and then I need to adjust upwards to cover for [additional] expenses’.
(Alex)
We have a certain pressure from management to sell, and it looks good to sell a lot of DCH; therefore, you are not that inclined to place patients in high-risk groups.
(Kim)
In this case, the presence of multiple institutional logics in dentistry caused some tension for the practitioners between signing enough contracts to achieve the clinics’ financial goals with the risk of putting patients in a category of premiums that is too low, on the one hand, and concern about not having enough financial coverage for the care that must be performed within the contract period, on the other. The practitioners’ perceptions of their responsibility for the clinics’ financial wellbeing can be interpreted as a result of well-implemented NPM and incorporated corporate values. However, there is a similarity and a parallel construct with the FFS system.
The mutual contract and its challenges
I guess that if we were going to get tough on the part that the patients should manage their contract, we would have to tear up 90 per cent of all contracts.
(Lee)
What you should do to achieve good oral health is part of the information [you get] when signing up to Dental Care for Health and it's related to all those things that you can do to keep the teeth healthy. And you will be placed in a lower group.
(Michelle)
As the above quote shows, some professionals used the self-care programme and the potential for a future lower premium class for the patient as way to promote the DCH. The dental staff in Hallberg et al.'s (2012) study also acknowledged the possibility for patients within DCH to reduce costs: ‘if the patients followed the advice of the dental care staff, they could be placed in a low-premium group with limited costs’ (p. 153). However, Zickert et al. (2000) showed that 67 per cent of the patients who were reassigned to another risk group were placed in a higher risk premium category. The dental care professional interviewed here described similar tendencies: ‘[They are] mostly [moved] up. It's not often that someone is downgraded’ (Lo); ‘It's very seldom it's a cheaper group’ (Inge), ‘Most of the time it's adjusted upwards, or the same. Adjust downwards … I have not seen that many’ (Denis).
The reason for upgrading a patient could be due to their deteriorating oral health or because the patients have been initially assigned to a lower risk group than they should have been for their dental status (cf. Zickert et al. 2000).
Some clinics treat DCH patients a bit like VIP clients. And one can think of that as an ethical dilemma. There may be patients with much greater need for treatment who have to stand back.
(Mika)
Those without contract[s] must stand back. Is that equality in care? … It's particularly offensive if it's officially set out from management that it's good to give priority to [DCH] patients. I think it's unequal, yes.
(Ty)
This aspect of the new payment system limits timely treatment for all citizens and may even contradict ethical guidelines emphasising equality and the right to service (Michailakis and Schirmer 2010). Ordell (2011: 19) stated that dentistry performed in the public sector has ‘a moral obligation to provide service to all, and the success might be measured as the degree of utilisation by different parts of the population’. The quote above shows that the corporate logic counteracts professionals’ values of equality (Evetts 2009, Greenwood 1957). Thus, dental care professionals may experience tension since, as Larsson (2007: 14, our translation) argues: ‘It is fundamental for professional ethics that altruistic or universal values, such as health, justice or truth, precede strict economic values’. The Swedish law that regulates dental care postulates that the dental care must be of good quality and be delivered on an equal basis to all citizens. However, research on the issues is lacking, and one may wonder how the different clinics prioritised the patients before DCH.
DCH in treatment: better or cheaper care?
There's always a cheaper alternative to a porcelain crown produced by a dental technician. It's always cheaper to press down a clod of composite plastic. Naturally, that's cheaper for us and no payment [is made] to the dental technician. I'm afraid that when we have a lot of Dental Care for Health patients, the quality of care will be lower.
(Ty)
It's easier. Let say that a repaired tooth breaks – then you can try to do a new repair, which is a smaller operation. If that does not last, then I know that it's not the repair that's not good, but that the patient bit down too hard or something – and then we can make a crown … We can try out different ways.
(Rene)
You don't have to consider the cost and think, ‘Oops, now that tooth broke and it will cost you a lot’ but instead, ‘Well, you will get the care you are entitled to’.
(Dominique)
Summary and conclusions
The aim of this study was to explore how dental care professionals make sense of the payments system known as DCH. Previous research identified the possibility of a moral dilemma arising due to the introduction of DCH, where professionals feared that they would be trapped between contradictory values and norms: a tension between providing professional dental care at the same time as acting as insurance agents and selling contracts (Hallberg et al. 2012). However, the present study shows that the professionals have found ways to cope with the different demands, and that these approaches are underpinned by a range of values, norms and rules.
The institutional logics perspective encourages the search for multiple and interrelated higher order meanings that influence actors’ sense making (Cloutier and Langley 2013, Thornton et al. 2012). The empirical findings were interpreted in the light of institutional logics relevant for the case. In Table 2, we summarise our main findings and show how they relate to three different logics and the two forms of professionalism. Note that none of the interviewees argued from one strand only, nor can all the different kinds of sense making be applied to all interviewees.
| Occupational professionalism | Organisational professionalism | ||
|---|---|---|---|
| Inst. Logics → | Profession logic | Corporate logic | Market logic |
| Empirical Themes ↓ | |||
| The concept |
Subscription Contract |
Insurance | |
| Purpose |
Oral health Health promotion |
Govern/manage Increased patient stock |
Increase profit Extend market shares |
| For whom? | Those who need it | Those we profit most from | |
| Main task | Odontology | Informing about payment options | Sales agent |
| Risk classifications | Jurisdiction | Standardised, computerised | Premium risk-oriented |
| The contract |
Self-care programme Regularity in visits |
Continuity in revenues |
Market advantages Sales argument |
| Treatment | Best dental care and solution |
Risk premium and treatment considerations Extended use of dental hygienists |
Increased efficiency and profit |
DCH as a concept was anchored in both organisational and occupational professionalism. Corporate and market logics generated meanings of corporate governance, an increased market share, competition and financial considerations. However, its purpose was also framed in a professional logic, which highlights DCH as a means to enhance oral health. Thus, the practitioners voiced co-existing ways to make sense of the concept.
Conflicting logics were discerned regarding who DCH was designed for. Firstly, as professionals, the interviewees emphasised a professional logic of their duty to provide care for all and, when forced to choose, to give priority to those in greatest need. However, the organisational logics imposed on them within DCH may underpin the impression that they are required to call and treat DCH patients before the FFS patients. Secondly, the professionals argued that the patients must be healthy enough to qualify for DCH and, moreover, thought that the high cost of some premiums hindered those with poor oral health from signing up. Hence, the professionals were aware of socioeconomic differences in accessing oral health and, accordingly, differences in ability to pay for expensive dental care (Exlay 2009, Hjern et al. 2001, Nettelton 1998).
The new task of informing patients and recruiting them to DCH contracts caused a degree of tension for some practitioners. However, even if it was present it was not salient, and it seems as though the professionals managed to relate to different logics. Hence, the dilemma that Hallberg et al. (2012) described as a moral one seems to be something of an internal conflict within the individual, where professional and corporate logics clash. However, the concerns expressed in Hallberg et al. refer to apprehensions rather than experiences, since that study was conducted before the implementation of the new system.
Further, the practitioners accepted, and sometimes even preferred, using computerised risk classifications and did not express any concern over the de-professionalisation in which standardisation is assumed to result (Evetts 2009). Hence, there was no conflict expressed between professional jurisdiction and discretion and the corporate logic (Larsson 2007). However, the market logic in risk classification was perceived as problematic and put pressure on the individual practitioner's responsibility for the clinic's economy. This finding is in line with previous research on dentists in the PDS, which has stressed the perceived conflict between making money for the clinic and providing good dental care (Franzén 2009).
The mutuality of the self-care programme is an example of corporate and market logics overruling professional values. Follow ups to self-care are considered less important than other needs and tasks. According to Strand et al. (2015), DCH entails ambitions to improve the quality of dental care and oral health by means of emphasising preventive actions and health promotion. Because most oral diseases can be prevented, one of the major theoretical arguments behind DCH is to increase and improve preventive actions in dental care at PDS clinics in order to more efficiently and cost-effectively decrease the prevalence of certain issues (in particular, caries and periodontitis) on a population level (Zickert et al. 2000). Recent research findings have indicated that patients enrolled in the DCH programme are at less at risk of developing caries than those in the traditional FFS payment model, when controlling for other risk factors such as income, educational level, previous caries experience and age (Andås, 2015).
Concluding remarks
It is clear from the findings that the professionals did not reason from a single point of view, but rather were entangled in at least three institutional systems. An occupational professionalism is present, and expressed by values and norms anchored in a welfare state system (dental care for all), as well as the logic of professions emphasising health-care issues. Nevertheless, either as an effect of the new management ideal or as an inbuilt aspect of the fact that dentistry carries its own costs to a higher degree than other welfare services, the professionals also made sense of the new payment system with reference to corporate and market-oriented logics. It seems that these kinds of values have fostered an organisational professionalism.
Dental care professionals acknowledge and can relate to the multiple institutional logics at work within the PDS. The fact that market and corporate logics do not cause increased tension may be a result of the fact that these logics were probably present long before the implementation of DCH. It should be noted that dental care organisations in Sweden have largely adopted NPM techniques over the past 25–30 years (Franzén 2009) through, for instance, enhanced competition, user choice and higher monitoring of dentistry and other professionals through local management (Bejerot and Astvik 2009, Ordell 2011). Hence, NPM was incorporated by PDS before DCH was implemented.
However, one could look at the issue from another angle and provide an alternative interpretation of the seemingly successful sense making. As argued by Pache and Santos (2013), incompatibility between logics may be managed by decoupling strategies. Hence, organisations may ‘symbolically endorse practices prescribed by one logic while actually implementing practices prescribed by another logic’ (Pache and Santos 2013: 974). The present study shows that some professionals perceived that the health aspect was decoupled when DCH was put in practice. DCH was seen as a programme for already reasonably healthy or affluent patients, as a means for the organisation to gain control over income and expenditure and to enhance their market share. Some professionals also thought that the follow ups on the self-care programme were deprioritised when handling DCH patients. Moreover, the professionals believed that they did not have enough time to focus on preventive care and patient relations. Hence, dental care professionals in the PDS may feel a lack of power and limited in their pursuit of health. However, these aspects may also be true for the other payment model, FFS.
To summarise, the present study shows that the professionals manage to make sense and manoeuvre in organisational settings characterised by the presence of multiple and sometimes conflicting logics. Thus, the professionals argued both from the point of view of occupational professionalism, stressing values and beliefs underpinned by a professional logic (health promotion, oral health, dentistry and the common good), but also from an organisational professionalism perspective, emphasising values and beliefs anchored in the corporate world (contracts and patient stock) and market logics (insurance, finance, sales agent).
A limitation of this study is the absence of a comparative analysis due to the need to secure the confidentiality and anonymity of the interviewees. We have seen some differences in sense making with a tendency for dental hygienists to be slightly more positive about DCH than dentists, and for senior professionals to question it more. The socioeconomic status of the neighbourhood in which the clinic is placed also seems to affect perceptions of DCH in various ways. Therefore, we suggest that further research should follow up this study with a survey study to reveal such differences.
Acknowledgements
Thanks to the anonymous reviewers for their helpful comments that enabled us to improve the article, and to Bertil Rolandsson and Bengt Larsson for reviewing an earlier draft. The data collection was funded by the Public Dental Service, Region Västra Götaland, and analysis and writing by the Deptartment of Sociology and Work Science, University of Gothenburg.
