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Rapid response to:

Views & Reviews Personal View

Occupational medicine is in demise

BMJ 2015; 351 doi: (Published 11 November 2015) Cite this as: BMJ 2015;351:h5905

Rapid Response:

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


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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. [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. [Cited: 14.4.2020].

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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.
[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, [Cited: 14.4.2020].

11. World Health Organization (WHO). ICD-11 for Mortality and Morbidity Statistics (Version 04/2019). QD85, Burn-out. [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. [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. [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. and [Cited: 14.4.2020].

16. International Occupational Medicine Society Collaborative (IOMSC). Advocating for Occupational and Environmental Medicine: A Toolkit for Occupational Medicine Societies, 2018.. in: [Cited: 14.4.2020].

Competing interests: No competing interests

16 April 2020
Dr Theodore Bazas
Consultant Occupational Physician 1., Honorary Visiting Professor in Occupational Medicine 2.
Professor Theodoros Constantinidis 2,, Dr Efthymios Thanassias 2.
1. Committee of Health and Welfare, Occupational Health Advisory Office, Municipality of Philothei Psychiko (Athens), 2. Program of Postgraduate Studies [MSc] “Health and Safety in Workplaces", Medical School, Democritus University of Thrace, Greece
Committee of Health and Welfare, Occupational Health Advisory Office, Municipality of Philothei Psychiko (Athens), Psychiko, Greece