Occupational medicine is in demise
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5905 (Published 11 November 2015) Cite this as: BMJ 2015;351:h5905
All rapid responses
Response to Comments by Susan Stocks, 25 November 2015
Core Research Fellow, NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester
By
1 Anne Raynal, independent occupational physician, UK
2 Alexis Descatha, Professor in occupational medicine, epidemiologist, emergency doctor
Paris Hospital (AP-HP), Versailles St-Quentin University (UVSQ), Inserm; Occupational Health Unit, EMS (Samu92), Inserm UMS 011 UMR-S 1168
Stock’s interesting commentary [1] questions Raynal’s evidence in comparing occupational health systems, due to the non-availability of standardised occupational disease incidence data with other European countries. However, Raynal [2] did not state that some European countries are managing occupational health better than the UK; she did state that Great Britain (GB) is the only major European country that does not have a legal requirement for the provision of occupational health services, by the state or employers [3][4]. This means that nearly all workers in other major European countries have access to medical surveillance by occupational physicians, except for the small percentage who are self-employed, and even they are likely to have access through their university teaching hospital’s occupational medicine departments, funded by their health services [4]. Since the demise of the Employment Medical Advisory Service, this does not exist in GB, where coverage is only 13% [5], as access here is at the employer’s discretion [4].
Stocks is also mistaken in believing that GPs in this country can refer their patients, who have suspected occupational diseases, to a specialist occupational physician. Unless the employer (or patient) pays the fee, this is not available. As access is a key component in assessing the adequacy of a health system it would appear that the other major European countries are indeed better in this respect.
Furthermore, in November 2015 Professor Michael Marmot, the doyen of health inequalities, noted that that the rising level of occupational illness is threatening economic recovery in England [6]. We are not aware of public health leaders making such statements in other European countries.
It also appears that the role of occupational physicians in other European countries is protected in terms of reporting work related illnesses [4]. Venables has provided further testimony that intimidation of occupational physicians when they provide unwelcome advice to employers is not uncommon in GB [7].
Nearly all the responses agree that occupational disease prevention in GB is failing, along with recruitment of doctors into specialist training. The time has come to consider how we can do this better; there is much to be said for incorporating access to occupational health services for all working people into the NHS at the primary, secondary and tertiary levels [8] and ensuring that occupational physicians are protected when they report cases of occupational illness.
Even more important than all these issues, is that the Health and Safety Executive must fulfil its role [9] in ensuring that current work conditions do not create future cases, by enforcing the control of hazardous exposures when shorter latency occupational diseases are reported.
References
1 Stocks S. Re: Occupational medicine is in demise. www.bmj.com/content/351/bmj.h5905/rr-4
2 Raynal A. Occupational medicine is in demise. BMJ 2015;351:h5905.
3 M Rigby, R Smith, T Lawlor, et al. Preventive services in occupational health and safety
in the European Union: alternative strategies or missed opportunities? http://bus.lsbu.ac.
uk/resources/CIBS/european-institute-papers/papers2/496.PDF.
4 Nicholson P. Wilson N. Re: Occupational medicine is in demise. http://www.bmj.com/content/351/bmj.h5905/rr-3
5 Berra Y. Organisation de la Médecine du Travail en Europe et de la Santé et Sécurité au Travail Avec revue de détail de six Etats membres 2009. www.inma.fr/files/file/.../dip_mem_2009-01_berra.pd
6 Matthew Limb ‘Poor working conditions in England pose threat to health, says expert’: BMJ 2015;351:h6445 (citing Institute of Health Equity. Marmotindicators2015.www.instituteofhealthequity.org/projects/marmot-indicators-201
7 Venables KM. Re: Occupational medicine is in demise. http://www.bmj.com/content/351/bmj.h5905/rr-7
8 Descatha A. Re: Occupational medicine is in demise: THE KlNG IS DEAD, LONG LlVE THE KlNG! | http://www.bmj.com/content/351/bmj.h5905/rr-0
9 Watterson A. Andrew Watterson. ‘Health and Safety Executive’s failed record on occupational medicine.’ BMJ 2015;351:h6437
Competing interests: Anne Raynal was previously employed as a Medical Inspector and Senior Medical Inspector by HSE between 2001 and 2011.
It is difficult to imagine that occupational health is fit and well, but its demise may not be imminent. I believe the future of occupational medicine rests with GPs. They know the patients and, more than any other doctors, are aware of their lives as well as their health. OH physicians understand about the patients’ work in a similar way, but rarely know about their family and home lives, which generally are interconnected. When a person becomes unable to work due to illness or injury, their first contact is almost invariably with their GP. “Fit notes” are issued by the GP – not always on the basis of good understanding of capacity for their job – before any suggestion of specialist advice being sought. Most health related absence from work is dealt with entirely by GPs.
OH is an interesting specialty, and it is particularly suited to doctors wanting flexible, part time, or ‘office hours’ work patterns. Generally it is well paid. Why do we not attract more applicants? Perhaps because we keep such a low profile within the profession as a whole, and because the more academic aspects of practice dominate what is still a very practical branch of medicine. Furthermore, current medical post–graduate training militates against broader practice, and makes career change almost impossible. Twenty years ago, one could move from general practice to OH specialist over several years, without having to move house, but this could not be repeated today. However, OH benefits from wider clinical experience, and, as the majority of its practice in the past has shown, it is easily and usefully incorporated into general practice. There is a need for an introduction to OH, which should be part of every GP trainee’s portfolio. Since we are unlikely to meet the working population’s needs with specialist practitioners, should we not disseminate knowledge and understanding to those who already carry much of that burden? Occupational Health needs to go to General Practice, since the other direction is, for most, effectively blocked.
Competing interests: I have worked as a GP and consultant occupational physician in the NHS, and as an independent occupational physician. I am now retired from practice and have relinquished my licence to practice.
Some interesting points have been made in response to Anne Raynal’s Personal View on the demise of occupational medicine. I was an academic and therefore on the periphery of service occupational medicine but, as a researcher and educator, was in contact with many occupational physicians, in a variety of industries, for 35 years. No-one yet has commented on a key point in the article: the lack of statutory protection for occupational physicians in the UK. There is also another point implied in Dr Raynal’s article but not made explicit: the lack, in the UK, of specialist referral services for occupational medicine.
If the UK government wished to be effective in making occupational disease a priority, one thing it could do would be to ensure statutory protection. Contrary to the assertions made in some responses, intimidation of occupational physicians is not uncommon. Most doctors outside occupational medicine are not aware that it is the employer, rather than the doctor, who reports a reportable occupational disease. I know of instances of occupational physicians being ‘leaned on’ not to write, or to rephrase, internal memoranda because if the employer does not ‘know’ about a case of an occupational disease, there is no need to make a report. This intimidation extends to other areas and I am also aware of occupational physicians being instructed by their employer to remove from their letters of advice any mention of the possible alterations the employer could make to the workplace or to work practices.
Secondly, the UK is one of the few developed countries that does not have a niche within its healthcare system for specialist referrals in occupational medicine. There is no recognised referral pathway for a GP who suspects that a condition might be work-related, or who wants specialist advice on another occupational topic. There are some hospital consultants in the NHS who have a sub-specialty interest in occupational diseases, e.g. within dermatology or respiratory medicine. But these are tertiary referral services, largely taking referrals initiated by other consultants (although the GP may make the actual referral to satisfy current referral rules). The services are often ad hoc, having arisen because of the interests of one particular consultant. If occupational diseases are to be taken seriously in the UK, there should be outpatient clinics and investigatory services to which GPs can refer. As Dr Raynal implies, to some extent the Employment Medical Advisory Service fulfilled this role in its early days.
Some responses have focussed on the multi-disciplinary nature of occupational health services. But I did not see Dr Raynal’s argument as in any sense opposed to multidisciplinary services. It is the same as in, say, surgery. An effective surgical service depends on a great many individuals from a variety of disciplines. The specialist surgeon is in a minority in the team. But that fact does not detract from the necessity of fostering the education and supporting the professional independence of the specialist surgeon.
Competing interests: No competing interests
We took five main messages from Anne Raynal's personal view: the government and employers are not doing enough to identify cases of occupational disease; a small proportion of the U.K. working population has access to occupational health services; the role of specialists in occupational medicine is changing from preventing and diagnosing occupational disease to protecting employers from litigation; occupational health nurse advisors undertake work previously done by medical specialists in occupational medicine; and the specialty is dying. We would like to respond to the author and suggest some solutions.
There has been a huge decline in mining and manufacturing industries in the UK in recent decades. In the UK we have a good understanding of the occupational diseases associated with these industries however the new generation of occupational physicians will have less exposure to these working environments and consequent diseases. Newer industries bring new exposures and potential harm to health. We need to review the distribution and expertise in occupational medicine provision so that established and emerging occupational diseases are identified, diagnosed and workplace exposures eliminated or reduced to safe levels.
With the increase in service industries in the UK, occupational medicine has seen a shift away from industrial diseases such as pneumoconiosis, mesothelioma and other work related cancers. In the healthcare sector we see staff where pre existing symptoms are influencing ability to attend work or perform in work, and where work is implicated in causing symptoms. The most frequent problems are musculoskeletal and psychological. We now use the bio-psycho-social model of disease more often than the purely biological model of the past. We disagree with the author that we are 'protecting the employer from litigation'. Specialists in occupational medicine are bound by GMC rules and ethical guidance from the Faculty of Occupational Medicine. In the NHS we work hard to remain neutral, supporting both the staff member and their manager to resolve problems where workplace exposures are affecting health and where health is affecting an employees ability to do their job.
The author comments that 'most employers now use occupational health nurses to undertake medical assessments that would have been done by occupational physicians 20 years ago' but does not expand on this observation. Along with many other specialties, occupational health has expert nurse advisors who contribute to the multi-disciplinary team case management. Indeed with the reduction in biological occupational disease, doctors are not always the most crucial members of the team.
Finally, we agree that the small number of trainees entering the specialty is a concern. Occupational medicine can be a fascinating and rewarding career for someone with an inquisitive mind who is interested in what people do all day in various jobs, what drives them, and how the workplace can enhance, or jeopardise, someone's physical and mental health. We encourage junior doctors to consider this career option.
Dr Sian Williams
On behalf of members of the London Consortium of Occupational Health Practitioners in the NHS (LCOHP).
Competing interests: No competing interests
Raynal's commentary and the responses to it do indeed reflect the parlous state of Occupational Medicine. Perceptions about this worthwhile and interesting career choice must alter before things can change. We can and should do more to inform beneficiaries of effective Occupational Medicine about what it is. This must include education of the public, workers, medical students, junior doctors, general practitioners and consultants in other specialties. As long as we are referred to as 'drain doctors' and 'occy health' the image of Occupational Medicine will remain in the shadows.
Competing interests: No competing interests
Raynal expresses the opinion that some European countries are managing occupational health better than the UK but I am curious to know on what evidence this is based? To answer this question reliably requires measurements of the true incidence of work-related diseases in different countries. European Occupational Diseases Statistics have not been collected since 2009 following a decision by the Health and Safety at Work Statistics Working Group on the grounds that the large variation in the data quality made it unreliable for cross-country comparisons. [1] Certainly some European countries fund occupational health services through private or state insurance premiums with the worthwhile goal of making employers pay for the costs of work-related diseases. In practice, however, this can result in a bureaucratic system that might penalise the worker. For example a worker may choose not to make claim during an economic recession or an insurer might decide to withdraw a benefit. Without some reliable data I am not convinced that one approach can be judged to be superior to another.
I agree with Nicholson’s point of view that concomitant changes in the types of work and exposures are a major factor in the “demise” of occupational medicine. To adapt to these changes, occupational physicians could work closely with GPs to take advantage of the increasing interest in occupational medicine among GPs described by Heron. For most patients in the UK the GP is the first point of contact in the healthcare system yet a patient’s occupation is rarely recorded in their health record. Why not record occupation routinely alongside other predictors of ill-health and exposures such as blood pressure, BMI, alcohol consumption and smoking status? The option to do so already exists in primary care electronic record systems. If recording occupation were to be incentivised in the same way as recording smoking status, the majority of patients could well have their occupation recorded in their electronic record within a few years. [2] This would increase awareness of occupational exposures and occupational medicine among GPs thereby benefiting patients with work-related diagnoses managed by their GP as well as increasing referrals to occupational physicians. Furthermore we would develop a better understanding of the relationship between health and occupation.
[1] Stocks SJ, McNamee R, van der Molen HF et al. Trends in incidence of occupational asthma, contact dermatitis, noise-induced hearing loss, carpal tunnel syndrome and upper limb musculoskeletal disorders in European countries from 2000 to 2012. Occup Environ Med. 2015;0:1–10. doi:10.1136/oemed-2014-102534
[2] Taggar JS, Coleman T, Lewis S, Szatkowski, L. The impact of the Quality and Outcomes Framework (QOF) on the recording of smoking targets in primary care medical records: cross-sectional analyses from The Health Improvement Network (THIN) database. BMC Public Health 2012, 12:329 doi:10.1186/1471-2458-12-329
Competing interests: The THOR project, which provided some of the data in reference 1, is partly funded by the UK HSE. Any opinions and conclusions expressed in reference 1 and this letter are solely those of the author(s). The author of the letter is not, and never has been, a grant holder on the THOR project and has not received any payments from the HSE. [Added on 22 December 2015 by Sharon Davies, The BMJ]
We agree with Raynal’s opinion that occupational medicine is in demise (1) but we attribute causation to several other conditions as well as absent regulation to mandate access to occupational health services. The Health and Safety Executive (HSE) Employment Medical Advisory Service has been decimated over recent decades, and this may have reduced demand for specialist occupational physicians. Only around 13% of UK labour force can access a specialist occupational physician. However, there are other factors which have reduced both supply and demand for our specialty. It is in the main employers who have the statutory duty to protect their workers from risks at work and consequently from occupational disease. The world of work has changed phenomenally as a result of trends such as globalization and off-shoring of manufacturing jobs. Whereas most people used to work for large employers that could afford to provide in-house occupational health services now over 99% of British employees work for small and medium sized enterprises (SMEs) employing 0-249 people (2). It is not practicable for SMEs to employ their own occupational health staff, and and even less practicable to provide occupational medicine trainee posts which have all but disappeared along with British industry.
The number of specialists in occupational medicine is falling and the specialty has a low profile in medical schools and among junior doctors. The General Medical Council observed that the number of occupational physicians fell by almost 5% during 2010-13 and that occupational medicine had more doctors over 50 years old than any other specialty (3). Consequently half of current specialists in occupational medicine could retire within a decade. Not only are occupational physicians reaching retirement age, but they are not being replaced. It is generally acknowledged that there is a crisis in training with recruitment of trainees in recent years being at an all time low. Faculty of Occupational Medicine Annual Reports state that recruitment is at half the long-run average. In 2011 the Centre for Workforce Intelligence reported that significant recruitment issues remain (4). The Chief Medical Officer England’s 2013 Annual Report identified lack of access to specialized occupational healthcare and includes a policy suggestion that ‘the numbers of doctors being recruited into occupational medicine should be extended’ (5). Health Education England committed to an intake of 46 OM trainees in England this reporting/fiscal year (6) , yet in the first recruitment stage in 2015 only 12 trainees were recruited. More must be done by those responsible as a matter of urgency.
At its annual representative meeting this year the BMA noted with concern the crisis in occupational medicine in the UK caused by an alarming fall in the number of qualified occupational physicians and of doctors entering the specialty; and reaffirmed the urgent need to increase the number of trainees and accredited specialists. The meeting demanded that:-
i) occupational medicine specialist training posts are wholly centrally funded;
ii) salary protection is clarified and better publicized to attract those doctors who may wish to change career and commence training in occupational medicine.
We believe that action is needed on several fronts to increase both supply and demand for specialists in occupational medicine. These actions include enforcing current regulation by the HSE, central funding for more posts, improved salary protection, more varied and hybrid training rotations including mandatory non-NHS elements in industry, higher education and the armed forces, dual time credits for appropriate primary care and other training placements, less than full time training options, increased efforts to retain senior specialists and to attract doctors with a diploma to take the plunge into specialist training.
1. Raynal A. Occupational medicine is in demise. BMJ 2015; 351.
2. Rhodes C. Briefing paper. Number 06152, 16 November 2015. Business statistics. House of Commons Library. www.parliament.uk/briefing-papers/sn06152.pdf
3. The State of Medical Education and Practice in the UK. General Medical Council. 2014. http://www.gmc-uk.org/SOMEP_2014_FINAL.pdf_58751753.pdf
4. Medical Specialty Workforce Summary Sheet. Occupational Medicine. Centre for Workforce Intelligence 2011
5. Public Health Priorities: Investing in the Evidence. Annual report of the Chief Medical Officer 2013. Department of Health September 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
6. Investing in people for health and healthcare. Workforce plan for England. Proposed Education and Training Commissions for 2015/16. Health Education England.
Competing interests: No competing interests
Anne Raynal rightly highlights challenging times for Occupational Medicine (1). However, to parody Mark Twain, “reports of our demise have been greatly exaggerated”.
It is true that there has been a steady decline in the medical resources within the Health and Safety Executive (HSE) dedicated to the prevention of work-related ill health. While some would argue that this mirrors a change in the nature of work within the United Kingdom over the past 25 years, exposure to harmful conditions at work remains a cause for concern, especially for 4.6million workers who are self-employed (2) and those who work for smaller employers e.g. bakers, vehicle paint sprayers, beauticians and hairdressers (3) (4). The recent announcement of a new Workplace Health Expert Committee by the HSE, which will provide expert opinion on emerging issues and trends, may offer a renewed focus where access to specialist medical advice about the effects of work on health is particularly limited (5).
The Society of Occupational Medicine (SOM) and the Faculty of Occupational Medicine (FOM) welcomed the Department for Work and Pension’s proposal for a “Fit for Work” service to extend much-needed access to advice about health on our ability to work. But we also cautioned that the new service needed to be funded to provide a gateway to quality-assured specialist occupational health advice for all those who need it (6). For most people their work is a key factor in their self-worth, personal identity and family life - yet too many people are not able to access the specialist help they need to get back to work quickly enough when they become sick.
We join Raynal in calling for increased training in occupational medicine and argue that it should begin in medical school, as well as be included in core training for general practice. There is increasing evidence of GP interest in Occupational Medicine, with 150 applicants sitting the FOM’s Diploma in Occupational Medicine qualification exam this year - the highest on record. Recruitment into the specialty is also on the increase, with all available training posts oversubscribed and filled in the last two rounds of national recruitment.
Although trainee numbers have stabilised over the past 2 years, more training posts are indeed needed to refresh an ageing cohort of occupational physicians who are likely to retire from full-time practice over the next 5 years. This year the FOM reintroduced the Associateship of the Faculty of Occupational Medicine (AFOM), as a key stepping stone towards specialist accreditation. We are also actively engaged with Health Education England regarding the funding needed to meet increasing demands.
The FOM are also working closely with NHS England (NHSE) on their new “models of delivery”. In his Five Year Forward View, NHSE Chief Executive Simon Stevens specifically asked for the support of the Faculty in describing the occupational health needs of the future (7). It is increasingly recognised that helping people stay in “good work” contributes not only to personal health and wellbeing, but also that those in employment are less consumptive of already stretched healthcare resources (8). A key measure of success for any “health and care model” should be return to function for the 31 million people employed in the UK. We should always be asking the question – “did you return to work?”
As doctors who took the Hippocratic Oath, our first obligation will always be our patients. I am sorry to hear that some doctors feel threatened in the course of their duty; this is certainly not the case for many occupational physicians, whose employers value their independent advice and who have developed exceptional communication skills to enable their balanced advice to be understood and accepted by employee and employer alike. While it is true that the number of complaints to the General Medical Council (GMC) against occupational physicians have risen over recent years, those that progress to investigation or sanction are amongst the lowest of all specialties (9).
Occupational physicians should be assured that their desire to prevent occupational illness, detect occupational disease and successfully rehabilitate those who are recovering from illnesses is no less noble a cause than it was in the 19th century - and no less important in the 21st!
Dr Richard Heron
President, Faculty of Occupational Medicine
Dr Robin Cordell
President, Society of Occupational Medicine
References
1. Raynal, A. Occupational medicine is in demise. BMJ 2015; 351.
2. Office for National Statistics. Self-employed workers in the UK - 2014. 20 August 2014. [Cited: 18 November 2015.] http://www.ons.gov.uk/ons/dcp171776_374941.pdf.
3. The Health and Occupation Research Network. Actual and estimated cases of conatct dermatitis and asthma by most frequently reported occupations. data request no: 2015-03-THOR, Centre for Occupational and Environmental Health, University of Manchester, 2015.
4. The Health and Occupation Research Network. Contact Dermatitis numbers and rates by Occupation. October 2015. [Cited: 18 November 2015.] http://www.hse.gov.uk/statistics/tables/index.htm#thor.
5. Health and Safety Executive. Press Release: HSE launches new workplace health expert committee. 22 June 2015. [Cited: 18 November 2015.] http://press.hse.gov.uk/2015/hse-launches-new-workplace-health-expert-co....
6. Faculty and Society of Occupational Medicne. Press Release: Society and Faculty welcome today’s announcement of the provider for the Government funded new Health and Work service. 28 July 2014. [Cited: 18 November 2015.] http://www.fom.ac.uk/wp-content/uploads/14-07-25-Health-and-Work-Service....
7. NHS England. Five Year Forward View. October 2014. [Cited: 18 November 2015.] http://www.england.nhs.uk/ourwork/futurenhs/.
8. Waddell, G and Burton, K A. Is Work Good for Your Health and Wellbeing? London: TSO, 2006.
9. General Medical Council. The state of medical education and practice in the UK, 2014. London: GMC, 2014.
Competing interests: No competing interests
The HSE’s response to Dr Raynal’s paper on GB occupational medicine neither addresses any of her key points nor contests any of her statistics on occupational medicine’s demise within the HSE. There is mention, rightly, of some good occupational health work underway in the HSE but the big picture failures are yet again glossed over or ignored.
It is of course difficult to defend the indefensible. HSE seems to argue that the 2015 assessment of its overall occupational health and safety performance, when compared with the rest of Europe, can somehow be reduced to and presented as evidence of ‘safety’ leadership (1). They do not comment on the EU occupational ill-health record figures. Much of the data available are also of limited value when trying to make such European comparisons. Yet HSE’s commentary on work-related health sick leave in this report, interestingly not mentioned explicitly in its response to Dr Raynal, highlights GB’s apparently good record - on a par with Italy - albeit worse than Romania, Bulgaria, Malta, Greece, Lithuania, Turkey and Ireland . A more likely explanation for these figures would be that those EU countries who consider occupational ill-health as a priority have more staff, pick up more cases and act on them than those who neglect the subject. Again, in this respect, Dr Raynal’s analysis with just 0.13% of the working population having statutory medical surveillance looks correct and for whatever reason HSE appears to adopt the old saw of ‘don’t look, or don’t have the staff and resources to look, don’t find so there’s no problem’. Other data available presents a far tougher and more accurate assessment of GB’s failed record on occupational disease prevention and its inability to regulate effectively (2).
HSE is locked into management jargon that fails to answer the charges made against it. In several respects such language compounds the problem and reveals further inadequacies in its policies and practices. A ‘goal-based self-regulatory approach’ for HSE could easily be viewed as a mechanism for justifying staff and resources cuts especially within HSE occupational medicine. This again would support Dr Raynal’s analysis of no prosecutions for not reporting occupational diseases or related deaths under statutory regulations in the last five years. However, the evidence for self-regulation goals as a substitute for effective regulation in occupational health and safety is minimal and may cloak all manner of shortcomings (3).
There are of course alternatives to the smoke and mirrors approach of HSE on occupational ill-health. They could include placing health and safety at work on an equal footing with quality and environmental protection (4). We need workplaces effectively regulated by HSE where “management of the working environment is implemented in close interaction with public regulation….” (5).
(1) Health and Safety Executive (2015) European comparisons: summary of UK performance http://www.hse.gov.uk/statistics/european/european-comparisons.pdf
(2) Watterson A (2015) The Politics of Occupational Health. Occupational Health at Work. June/July 12(1)28-32
(3) Hazards (2014) September Don’t pimp our watchdog. Hazards special online report. Sheffield.
(4) Sandberg A (ed). Nordic Lights 2013. SNS Förlag Box 5629 SE-114 86 Stockholm, Sweden
(5) Annette Kamp and Klaus Nielsen in Sandberg 2013. P319
Competing interests: No competing interests
Validity of comparisons of occupational health and related services between the UK and other European countries
Dear Editor
To substantiate her assessment of the demise of occupational medicine (OM) in the UK, Raynal [1] alludes to certain differences in occupational health (OH) law and service provision models in force between the UK and other European countries. The critical Rapid Response Letter on the part of the Health and Safety Executive (HSE) [2] questioning her conclusions and their validation, on the one hand was met with opposing arguments [3] (based partly on presentation of OH morbidity and manpower statistics of European Union (EU) countries), but on the other with support [4].
We claim that any occupational health services (OHSs) and OH care systems should mainly be assessed by their effectiveness (i.e. the measurable improvement of the level of working people’s wellbeing) and by the popular approval they receive, rather than by European comparisons. To this end, we highlight reasons why comparisons of the extent and quality of OH between the UK and EU countries may be invalid.
Such comparisons are of limited value because they are confounded by differences depending on the following circumstances: the degree of completeness of diagnosing, reporting, recording cases of occupational diseases (ODs) (reduced by being restricted, in some countries, to ODs that are acknowledged as reportable only if they incur national insurance benefits), and of adequacy of presentation of OH statistics (which is contingent on sufficient records linkage, analysis and collation of data); the extent of concealment of occupational ill-health and related litigation; the workforce distribution by age, type of work and of employment; the country’s types of economic activities. By using selected specific trends or statistics in international comparisons, one can support either of two opposite arguments and reach an erroneous conclusion about the level of health at work in a country.
Traditionally, the level of occupational health and safety has been measured by diagnosed occupational injury and disease statistics, which may be biased: The number of reported cases of ODs in a country depends also on the number of physicians competent to diagnose them and also on the state of the economy. A case in point is Greece, where OM specialists diagnosed 2,326 cases of occupational dermatoses in the period of 2006 to 2012 [5], whereas the under-reporting of cases of all compensatable ODs (including skin diseases) to the Greek National Insurance Scheme in 2001 [6], regressed to no cases of ODs having been reported to it since the beginning of the economic crisis in 2009.
There is no OHSs index, so that its value could be used for valid assessment of comparisons and trends. For such an index to be calculated, certain measurable indicators could be considered, in combination, at a national level: Coverage of occupational health services; qualitative and quantitative coverage of injury and disease compensation systems; coverage of legal and inspection services; number of OH Institutions and relative numbers of OH specialists i.e. qualified doctors, nurses, ergonomists, hygienists, psychosocial experts, inspectors, safety and health engineers (and the ratio of these to the number of workers they care for); funds and resources spent for preventive services compared with those for unsuccessful treatment of ODs, and with economic costs of non-action [7]; proportion of workers injured at work returning to work [8], without contemporaneous increase of sickness absence attributable to work accidents and ODs; extent of contribution of other Primary Health Services to OH care. To facilitate reliable periodic comparisons of OM between European countries, an electronic, structured template as a tool for recording measurable national data on OH in a uniform way has been proposed and is being worked on, at the Section of Occupational Medicine of the European Union of Medical Specialists (UEMS OM) [9], of which the UK is a member. It is pointed out, that information revealing several inadequacies in recording relevant data and deficiencies in actual OH care in certain European countries might not be forthcoming, possibly e.g. for reasons related to national pride or data protection.
To put OH and OM in a societal perspective, we note that the right to work in safe and healthy working conditions has not yet been included in the ILO’s framework of the four fundamental principles and rights at work (which are based on the fundamental ILO’s Conventions ratified also by the UK). However, its Governing Body decided, in 2019, “to give due consideration to the procedural road map” for possibly including it in the future [10].
Furthermore, in 2019, burnout was the first and only work-related mental health disorder ever recognized by WHO and classified as a syndrome (i.e. not as a disease), the diagnosis of which is made by certain specific criteria (ICD-11) [11]. By contrast, in recent years, diagnosed actual cases of mental health disorders are well documented [12] and constitute one fourth of the total cases of the four diagnostic categories of work-related diseases most frequently reported annually to the UK voluntary national “Health and Occupation Research Network“ [13]. However, they are not included in the lists of compensatable or officially “reportable” ODs in the UK, or, in, the sole ever made, EU Commission recommendation for a European schedule of ODs [14].
In this connection, the UEMS OM recognising the value of effective advocacy for the advancement of OM and OH, has established a Working Group, with the following objectives: To define and prioritise positions and tasks for advancing OM in European societies within the scope of OH (some of which might not have been recognized in actual legislation); to support and reinforce actions pertaining to the specialty of OM (mobilising appropriate stakeholders to undertake them); to advance OM, with ultimate benefit for health at work for all [15]. Advocacy can also help educate the public about the critical role of OM specialists in health protection and promotion at work [16]. We suggest that the concept of health hazards existing at work and the possibility to be protected against them be introduced in the British curricula of preschool, elementary and general secondary school education to successfully promote broadscale OH in the long term.
Theodore Bazas, MD, PhD, MSc(London), DIH(Conjoint Engl),
Specialist in Occupational Medicine (JCHMT, UK), Fellow (and Recognised Dissertation Assessor), Faculty of Occupational Medicine, Royal College of Physicians, London, Honorary Visiting Professor, Program of Postgraduate Studies “Health and Safety in Workplaces”, Medical School, Democritus University of Thrace, Greece,
BMA Member, ICOH Member, IOMSC and UEMS (OM Section) National Delegate,
Former WHO (FT] Regional Adviser on Noncommunicable Diseases
Theodoros Constantinides, MD, PhD
Specialist in Occupational Medicine,
Coordinating Professor, Program of Postgraduate Studies “Health and Safety in Workplaces”, and Director of the Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Greece,
Efthymios Thanassias, MD, MPH, MSc
Specialist in Occupational Medicine, Scientific Collaborator, Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Greece,
Lead Auditor of the International Standards Organization (certified by the German Agency for Quality Certification - DQS) for ISO 9001, ISO 45001, ISO 1522, for Greece and Cyprus
REFERENCES
1. Raynal A. L. Occupational medicine is in demise. BMJ 2015;351:h5905. doi: https://doi.org/10.1136/bmj.h5905 [Cited: 14.4.2020].
2. Curran A. Rapid Response. Re.: Occupational medicine is in demise. https://www.bmj.com/content/351/bmj.h5905/rapid-responses. [Cited: 14.4.2020].
3. Watterson A. E. Rapid Response. Re.: Occupational medicine is in demise. https://www.bmj.com/content/351/bmj.h5905/rapid-responses. [Cited: 14.4.2020].
4. Stocks S. J. Rapid Response. Re.: Occupational medicine is in demise. https://www.bmj.com/content/351/bmj.h5905/rapid-responses. [Cited: 14.4.2020].
5. Zorba E., Karpouzis A., Zorbas A., Bazas T., Zorbas S., Alexopoulos E., Kouskoukis K., Zorbas I., Konstantinidis T. Occupational Dermatoses by Type of Work in Greece. Safety and Health at Work, 2013, 4:142-148. https://doi.org/10.1016/j.shaw.2013.06.001 [Cited: 14.4.2020].
6. Axelopoulos C.G., M. Valassi, Drivas S., Behrakis P. . Under-registration of occupational diseases: the Greek case. Occupational Medicine, 2005, 55:64-65. https://doi.org/10.1093/occmed/kqh126 [Cited: 14.4.2020].
7. Takala J. Message from the President, Newsletter. International Commission on Occupational Health – ICOH, 2017,15 (1):1-2. http://www.icohweb.org/site/pdf-viewer/viewer.asp?newsletter=icoh_newsle... [Cited: 14.4.2020].
8. Heron R., Cordell R. Rapid Response to: Raynal A. Occupational Medicine is in Demise. BMJ 2015;351:h5905 https://www.bmj.com/content/351/bmj.h5905/rapid-responses [Cited: 14.4.2020].
9. UEMS OM Section. Finalisation of the country information template. National Report Template: Draft for Consideration and discussion. Bazas T. Minutes. Item 8: Meeting, Oslo, 2.6.2018. Minutes. Item 17.Meeting,Bilbao, 10.11.2028.
https://uems-occupationalmedicine.org/wp-content/uploads/2019/05/annex_t...
and https://uems-occupationalmedicine.org/wp-content/uploads/2019/05/minutes...
and https://uems-occupationalmedicine.org/wp-content/uploads/2019/08/Minutes...
[Cited: 14.4.2020].
10. International Labour Office (ILO). Governing Body 337th Session, Geneva, 24 October–7 November 2019. GB.337/INS/PV/Draft Minutes Institutional Section INS. Decision by the ILO Governing Body, item no. 86 “Follow-up to the resolution on the ILO Centenary Declaration for the Future of Work: Proposals for including safe and healthy working conditions in the ILO’s framework of fundamental principles and rights at work (GB.337/INS/3/2)”pp 16-18, https://www.ilo.org/wcmsp5/groups/public/---ed_norm/---relconf/documents... [Cited: 14.4.2020].
11. World Health Organization (WHO). ICD-11 for Mortality and Morbidity Statistics (Version 04/2019). QD85, Burn-out. https://icd.who.int/browse11/l-m/en#http%3a%2f%2fid.who.int%2ficd%2fenti... [Cited: 14.4.2020].
12. Heron R., Greenberg N. Mental health and psychiatric disorders. In: Fitness for Work. The Medical Aspects. Edit. Palmer K.T., Brown I., Hobson J.. Fifth Edition. Oxford University Press, Oxford, 2013, pp 132-154.
13. The Health and Occupation Research (THOR) Network. Annual Report, August 2019. Data request no. 2019-03-OPRA, and The Health and Occupation Research (THOR) Network. University of Manchester.
http://research.bmh.manchester.ac.uk/epidemiology/COEH/research/thor [Cited: 14.4.2020.]
14. European Commission Recommendation of 19 September 2003 concerning the European schedule of occupational diseases (notified under document number C(2003) 3297). Official Journal of the European Union, English edition. L 238, Volume 46, 25 September 2003, pp 28-34. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=OJ:L:2003:238:FU... [Cited: 14.4.2020].
15. European Union of Medical Specialties UEMS). Section of Occupational Medicine. Working Group 2 Minutes and Bazas T. Proposal: Actions for advancing Occupational Medicine. Meeting, Bilbao, 9.11.2018. https://uems-occupationalmedicine.org/wp-content/uploads/2019/05/bilbao_... and
https://uems-occupationalmedicine.org/wp-content/uploads/2019/05/annex_t... [Cited: 14.4.2020].
16. International Occupational Medicine Society Collaborative (IOMSC). Advocating for Occupational and Environmental Medicine: A Toolkit for Occupational Medicine Societies, 2018.. https://static1.squarespace.com/static/5b92888aee175944bdd937ed/t/5cd598... in: https://www.iomsc.net/ [Cited: 14.4.2020].
Competing interests: No competing interests