Weekly Briefing, Vol. 26. No. 3 (LT) February 2020
Lithuania tightens the regulation of dentists through the legislation changes on state-controlled licensing
After the lengthy debates which took more than two years concerning the tightening of licensing of dentists and dental care professionals in Lithuania, the Parliament concluded them by approving just before the end of the last year the amendments to the Law on Dental Practice. According to the latest changes to the law (in effect as of May), the licensing of dental professionals will return to the state. The self-governing body of dentists, the Dental Chamber of the Republic of Lithuania, has lost the mandate to license dentists and dental practices. The government decided that this prerogative will be part of the functions of the State Health Care Accreditation Agency under the Ministry of Health, which performs licensing, supervision, and accreditation in the case of all other health care providers and organisations. This decision made Lithuania from one of the least regulated to the most state-supervised countries in the EU in the field of dental care. The opponents of these changes even argued that this motion indicates that Lithuania is adopting certain governance practices akin to the systems of socialism and is moving against the trend of deregulation of dentistry across Europe.
Below is an outline of the current situation of the dental health provision in Lithuania, as presented by the national and European professional bodies of dentists and the government, trying to identify the main issues which led to these cardinal changes in the governance of the dental professionals in Lithuania.
After the restoration of Lithuania’s independence and with the introduction of the free market in the country (formally, as of May 1990 when the Law on Enterprises was adopted), odontology was one of the first health care sectors which very rapidly became predominantly driven by the private sector. Low setup costs, higher pay, and the availability of dental graduates (Lithuania still is among the leading countries in the EU in terms of the number of dentistry graduates – more than 6 per 100000 inhabitants) ensured that individual dental professionals more often chose to go into private practice.
The spur for the expansion of the private sector in dental health care came in 1999 when the dental treatment in public hospitals became partially paid (except for children until 18 years old and the persons receiving social support). Dental care is free of charge if a person consults a dentist who works under a contract with one of the territorial health insurance funds, which cover the costs of labour but not materials such as fillings, which, however, constitute the majority of the costs incurred by the patient.
During less of a decade since this change, more than 60 percent of the patients chose to go to the private clinics to receive dental health care due to the higher quality of service perceived. A decade later, the private sector became dominant in dental health care. In 2019 it was reported that around 80% of the dentists in Lithuania have a private practice, and the patients fully meet their costs.
The sector had become a self-regulating professional service industry in 2004 when the Law on Dental Chamber established a self-regulating body with the main task to license dentists and dental practices. At the start of 2019, there were altogether 4023 dentists, 1191 dental hygienists, 1737 dental assistants, 1196 dental technicians registered with the Lithuanian Dental Chamber. However, such a high proliferation of dental practitioners did not automatically mean the increased level of dental health in the country. According to the healthcare activities statistics, Lithuania is having the third-highest number of consultations of dentists per inhabitant. In Lithuania, on average, a person visits the dentist 1,6 times per month were between 2012 and 2017, the average rose by 0.7 and 0.4 consultations per year, respectively. These statistics are boosted by the increased number of visitors from the Lithuanian community living and working abroad who organize trips to the home country for medical and dental check-ups and treatment due to the lower costs of the services provided.
The dental sector in Lithuania is fragmented into a large number of individual dental professionals who, having obtained a license from the Dental Council, work on their own or with few other dentists and dental care professionals alongside with very little or no direct supervision or quality control from the public health authorities. The licensing process and the treatment of complaints have been entirely self-regulated through the Dental Chamber. It is fully based on trust. A similar model works with the General Dental Council in the United Kingdom, which has been put under pressure recently to address the impact of growing consumerism.
The self-regulation system can function, as is argued in the literature, as long as the central precondition upon which it is based is met, namely: the trust relationship of the dental professionals with society. It is achieved through the social contract, which is at the core of the principle of self-regulation of all so-called liberal professions (such as lawyers, notaries, engineers, architects, doctors, pharmacists, and others). Self-regulation is a requirement for the dental profession to exist within such a contract with society. According to the social contract theory, as argued by the international expert on dental ethics A.C.L. Holden, the dental profession is empowered by society’s need for the profession’s ability to alleviate suffering related to oral disease. In exchange for the skills associated with the treatment of oral malady, the dental profession is given higher social and moral status, higher income and legal protection of skills specific to the practice of dentistry.
An essential aspect of the social contract in the case of dental health care maintains that society’s confidence in the profession is an expectation that the dental profession will self-regulate. However, the requirement that society needs help to discern efficient from poor treatment still exists. In other words, the critical differentiator between the professional dental service from any other service is the trust the patient places in a dentist in good faith that the dental professional would put the patient first, even if this would come at the cost of profitability or other commercial motivations.
The move of Lithuania’s government towards the more tight regulation of dentistry has to be viewed as part of the overall effort of the Ministry of Health to decrease the burden of health care on population and increase the health care quality. The Eurostat survey of households in 2017 showed that the financial burden of medical care in Lithuania is above the EU average with the main burden related to dental health care. According to the survey data, Lithuania is among the top 5 countries in the EU, where the dental care costs create the highest-burden for the population. More than half of the respondents in the survey in Lithuania have been experiencing financial burden to meet their dental care costs: 28,6 percent of the respondents reported that they experience a high burden, and 31,7 percent indicated that they felt some burden. Only 39,7% percent of the respondents agreed with the statement that they felt no burden to cover the costs of dental services.
The increasing costs of the private dental care sector driven by the demand and the high cost of materials and the rentals have put the sector under scrutiny. On the 27th of November, 2018 the Health Committee of the Lithuanian Parliament registered the draft of amendments to the Law on Dental Chamber that would abolish the mandatory membership, licensing dentists, auxiliaries, and clinics while the Ministry of Health would handle continuous professional development. This motion initiated a two-year-long debate on the issue. President of the Council of European Dentists wrote the letter to the President and the Government of Lithuania advocating for no change. The amendments were put on hold for the time being. Meanwhile, the Council of European Dentists (formerly EU Dental Liaison Committee) itself, experiencing a push of the national regulations for its member organisations, has pushed for the definition of the concept of the liberal profession in the EU in an attempt to address the new regulatory wave.
The European Court of Justice defined the concept of “liberal professions” as “activities which, inter alia, are of a marked intellectual character, require a high-level qualification and are usually subject to clear and strict professional regulation. In the exercise of such an activity, the personal element is of special importance, and such exercise always involves a large measure of independence in the accomplishment of the professional activities.” Already in 2013 jointly with other professional federations (Federation of Veterinarians of Europe, the Standing Committee of European Doctors and the European Council of Engineers Chambers), the Council of European Dentists agreed on the Charter for Liberal Professions “to show how liberal professions protect trust by providing high-quality services.” In this charter, the signatory organizations declared that liberal professions are a critical social and economic factor in all Member States of the European Union. Since Europe is developing into a knowledge-based service society in which liberal professions are becoming more and more critical for the state and citizens due to the increasing complexity of society, they deserve to retain the status of autonomous self-regulating bodies.
By significantly diminishing the power of the professional body of dentists and dental care professionals to self-regulate their profession, Lithuania’s government sent out a signal that the profession has partially eroded the trust with the state if not altogether with society. It also reflects changing public attitudes. The users of dental services are becoming more consumerist behaving more like customers rather than clients. The changing attitudes drive the expectations that dental services have to provide value to the customer. In this context, the state has stepped in as a mediator between the dental health service providers and the customers, thus, in essence, confirming that the dental profession in Lithuania has lost a special status it held among other medical professions and will become an integral part of the state-regulated health care system.
References:
- The Parliament of the Republic of Lithuania, “Seimas priėmė naujos redakcijos Odontologų praktikos įstatymą” (The parliament adopted the newly revised Law on Dental Practice), a press release; https://www.lrs.lt/sip/portal.show?p_r=35435&p_k=1&p_t=269246
- Eurostat, “Healthcare activities statistics – consultations“, https://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_activities_statistics_-_consultations#Consultations_of_dentists
- Council of Dental Practice, Anthony D. Kravitz et al, “Manual of Dental Practice 2015: Lithuania”, edition 5.1, Febr. 2015; available to download from: https://cedentists.eu/library/eu-manual.html
- Pūrienė et al., „Privati ar valstybinė odontologinė gydymo įstaiga? Lietuvos pacientų nuomonė ir patirtis“ (Private or public dental care institution? The patients‘ opinions and experience in Lithuania), Medicina 2008 (10), 805-811; https://publications.lsmuni.lt/object/elaba:5234409/
- C. L. Holden, “Self-regulation in dentistry and the social contract”, British Dental Journal 221 (2016), 449-451; DOI: 10.1038/sj.bdj.2016.771
- Eurostat, “The burden of healthcare on households’ budget”, 19 February, 2019; https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190219-1
- European Economic and Social Committee, “Opinion of the European Economic and Social Committee on The role and future of the liberal professions in European civil society 2020”, INT/687, 25 March 2014; https://www.eesc.europa.eu/en/our-work/opinions-information-reports/opinions/role-and-future-professions-european-civil-society-2020
- Standing Committee of European Doctors, “Charter for Liberal Professions”, 24 Nov. 2013, CPME 2013/140 FINAL; https://www.cpme.eu/index.php?downloadunprotected=/uploads/adopted/2013/CPME_AD_EC_10102013_140_Final_EN_Charter_Liberal_Professions.pdf