Traditionally consigned to the fringes of the hospital – clinically, organisationally and often physically – occupational health services are due for a renaissance
Gordon Parker
Consultant Occupational Physician
Lancashire Teaching Hospitals NHS
Foundation Trust
President
Society of Occupational Medicine
Honorary Clinical Lecturer
University of Manchester
The profile of occupational health provision in health services is still too low compared with other medical specialties, and occupational health is often associated in the minds of healthcare workers with pre-employment health questionnaires and vaccinations. How then should occupational health services in the healthcare industry raise their profile and add value to their host organisations?
The answer is probably threefold. First, occupational health services need to recognise and respond quickly and inventively to emerging problems and new challenges. These include changing patterns of work-associated ill-health and changing management practices. The conventional practices of pre-employment assessment of fitness for work, and routine vaccination – although important – must now be simply background activity, with proactive management of emerging hazards and risk taking centre stage. Secondly, occupational health needs to be fully integrated with risk management and human resource development. Keeping people at work and helping them to return to work after illness and accident is vital. Although it is now something of a cliché, the staff really are the health service’s greatest asset, and keeping them engaged (and developing them) depends on keeping them healthy. Thirdly, occupational health services need to be more outward looking, and need to work with primary care services in dealing with the health–work interface for all people of working age.
Current and emerging hazards and risk
The “traditional” hazards of healthcare work – biological, chemical and physical – have not disappeared, and attention still needs to be paid to preventing work-related ill-health arising from them. But the nature and epidemiology of the threats are changing. For many years, occupational health services concentrated on blood-borne viruses; the risk of transmission of hepatitis B, hepatitis C and HIV, from patients to staff or from staff to patient, have exercised occupational health services. But in recent years chickenpox, tuberculosis and even measles in healthcare workers have created increasing concern. A mobile healthcare workforce means that workers who are susceptible to these diseases may come to work in the UK and Western Europe, become ill themselves and put their patients at risk.
UK Department of Health guidelines have tried to keep up with both the epidemiology of disease and the changing employment environment, and have required occupational health services to alter their health surveillance routines.[1]
A resurgence of measles and mumps in young adults, partly related to poor uptake of MMR vaccine in the UK, means that diseases that were thought to have “disappeared” are now a real threat to healthcare workers and vulnerable patients. Musculoskeletal problems attributed to work in the health and social work sector continue to be reported.[2] In the UK, lower-back pain accounts for around 13% of all reports from occupational physicians of work-related illness, and just less than a third of all reported musculoskeletal disorder. Risk reduction strategies for lower-back pain – more moving and handling aids and training – and better clinical management of back pain are now embedded in health service culture, but other musculoskeletal disorders attributed to ergonomic hazards at work are more difficult to manage ergonomically and clinically.
Upper limb problems attributed to computer use and to the use of specialist equipment are frequently seen. For example, radiographers and sonographers report neck and upper limb symptoms attributed to poor posture and poor equipment design,[3] and other ergonomic and organisational factors may be relevant, including demands (workload) and lack of control (rest breaks). However, plausible ergonomic workrelated causes for upper limb pain do not always exist. Self-reported work-related upper limb pain depends on personal belief, which may be unreliable, and lead to an overestimate of the incidence and prevalence.[4] Poor self-reported health and higher mental health indices are strong predictors of both new and persistent arm pain in adults. Persistence of upper limb pain is also predicted by beliefs about causation and prognosis, including whether the pain is attributed to work or stress.[5]
It is this interaction between ergonomic, organisational and psychological factors, and the coexistence of physical and psychological symptoms, that make these disorders difficult to assess, prevent and manage in occupational health practice. Musculoskeletal disorders reported by occupational physicians in the UK from 1996 to 2004 showed an estimated annual change of +1.5%, but reported mental ill-health increased by around 13% per year.[6] Does this mean that occupational-health-services should concentrate more on the assessment and management of work-related psychological disorder?
If physical and emotional disorders were so closely linked, would managing organisational “stress” and individual mental health influence the incidence of both physical and mental disorders?
As workplace “stress” becomes a more “acceptable” diagnosis – and appears more frequently on medical certificates of incapacity (sick notes) – more attention is being paid to assessment of the workplace in terms of demands, control, role, relationships, support and change, and to risk reduction. In response to the perceived problems of stress at work, the Health and Safety Executive in the UK has developed and promoted management standards for stress.[7] This risk assessment approach to preventing workplace mental ill-health is one that occupational healthservices can assist with, but given the complex psychosocial factors that determine whether an individual reports “work-related stress” hard outcomes such as reduced morbidity and lost time are difficult to predict. Against this background, it is essential that research into work and health continues to be funded and developed, and that interventions aimed at improving the health of the working population, improving attendance and reducing attrition are properly evaluated.
Integrated risk management and human resource development
If occupational health services are to contribute fully to reducing risk in healthcare in the broadest sense, they need to be integrated with physical and clinical risk management. Too often, these strands of risk management are organisationally separate. Physical risk management deals with traditional safety issues, clinical risk management tackles adverse events and near-misses affecting patient care, but even though rootcause analysis is at the heart of reducing risk, the effects of employees’ health, their perceptions of their wellbeing and – conversely – the effects of adverse events on psychological health, morale and motivation are not commonly assessed and recorded as part of any investigation.
Occupational health services can add real value in this area; risk management should be a “one-stop shop” for managers needing advice on health and safety. Preventing a recurrence of accidents – physical or clinical – must involve an assessment of the psychosocial dynamics of the workplace and the workers who were involved. In addition to integrating risk management, staff and leadership development should include elements of occupational health. Managers and leaders need to understand something of the interaction between health, health/illness beliefs, the availability and quality of medical support and the interaction between work and family. These are the main determinants of whether someone remains at work or finds it easy to work after illness or injury.
Psychosocial indicators of prognosis in lower-back pain (the “yellow flags”) are now well known, but managers now need to understand the importance of psychosocial and organisational barriers to rehabilitation after minor mental health problems. Occupational health services should have the expertise and knowledge to assist human resource departments, a “training” role and opportunity that may have been overlooked in the past.
Occupational health, primary care and the working age population
Finally, some mention needs to be made of occupational health practice in the wider context. The publication in the UK of Dame Carol Black’s review of the health of Britain’s working age population, “Working for a healthier tomorrow”,[8] has stimulated those bodies involved with occupational health to look at standards of practice, models of delivery of occupational healthcare and relationships with other medical specialties and primary care.
In the UK, the Faculty of Occupational Medicine is looking at standards and accreditation of occupational health providers. Professional development, best practice and audit are also promoted through the Society of Occupational Medicine, the Association of National Health Service Occupational Physicians (ANHOPS), NHS Plus (a network of occupational health services based in NHS hospitals), the Royal College of Nursing and the Occupational Health Clinical Effectiveness Unit at the Royal College of Physicians.
Both the Faculty and the Society of Occupational Medicine are working with the Royal College of General Practitioners to improve the knowledge of GPs in relation to the work–health interface. The Society of Occupational Medicine sees the importance of bringing competent occupational health advice to everyone of working age through their general practitioners – something that has been lacking in the UK from the inception of the National Health Service. It seems likely that occupational health services based in the health service will play an important role in developing this service, perhaps commissioned by primary care organisations, and closer relationships between occupational health providers and primary care teams will need to develop.
Occupational health services in the healthcare industry presently have a great opportunity to research and respond to new clinical challenges, to respond to organisational needs, and to deliver good-quality occupational health advice to the whole working age population. This is the path towards renaissance for the specialty of occupational health.
References
1. Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: new healthcare workers. London: Department of Health. March 2007.
2. Walsh L, Turner S, Lines S, et al. The incidence of work-related illness in the UK health and social work sector:
The Health and Occupation Reporting network 2002-2003. Occup Med 2005;55:262-7.
3. Morton B, Delf P. The prevalence and causes of MSI amongst sonographers. Radiography 2008;14:195-200.
4. Palmer KT, Reading I, Calnan M, Coggon D. How common is repetitive strain injury? Occup Environ Med 2008 May;65(5):331-5.
5. Palmer KT, Reading I, Linaker C, Calnan M, Coggon D. Population-based cohort study of incident and persistent
arm pain: role of mental health, selfrated health and health beliefs. Pain 2008 May;136(1-2):30-7.
6. O’Neill E, McNamee R, Agius R, et al. The validity and reliability of diagnoses of work-related mental ill health. Occup Environ Med 2008;65:726-31.
7. http://www.hse.gov.uk.uk/stress/ index.htm
8. Working for a healthier tomorrow. London: TSO. March 2008.
