Physicians in the workplace
Chris Dyer reviews research into the role of occupational health physicians.
A central theme of the HSC's strategy for workplace health and safety in Britain until 2010 is the need to improve occupational health (see "All dressed up", but where will the HSC's strategy go?). The HSC concedes that there is "a huge job to do"; of the 40 million days lost to occupational ill health and injury in 2001/02, 33 million were attributable to ill health. Furthermore, the HSC/E's traditional interventions are less effective when dealing with health than with safety.
Occupational health (OH) services - including health promotion, health protection and continuous evaluation of the healthcare needs of the working population - help to provide the knowledge and evidence necessary for continuous improvement in workplace health management. Within OH teams, physicians should have a major role, but if they are to make the maximum contribution to employees' working ability and health at work, they need to have the right skills.
Occupational physicians' professional competence is acquired through education, training and experience. In the UK, specialists in occupational medicine undergo academic as well as practical on-the-job training under the auspices of university academic departments, hospital-based clinical units and the Faculty of Occupational Medicine. This means that it is still largely academics who define the skills of the occupational physicians employed by industry. The specific skills that public and private organisations need from the occupational physicians who are paid to look after the health of the workforce have not been evaluated.
Useful advice
Research commissioned by the HSE and the Engineering Employers' Federation1 has asked the opinions of employers, employees and health and safety specialists about the competencies or skills needed by these physicians to maximise their efficiency. The research shows that there are barriers to the use of occupational physicians, and highlights the issues that employers consider when contemplating using occupational physicians to aid health and safety management.
The study assessed the health at work issues faced by employers and employees and the sources of advice and support used to tackle them. Government sources, particularly the HSE website and publications, are considered the most useful and reliable. But employers are concerned by what they perceive to be the conflict between the HSE's advice and enforcement role (see Pick 'n' mix: the HSC names its intervention ingredients). Employers also use commercial sources and information from trade bodies and industry associations.
The consensus was that for a source of advice to be useful it should:
have industry-specific knowledge and be aware of needs and circumstances;
have a fast response;
be well informed in health and safety;
be up-to-date on the latest developments;
have access to a good network of contacts;
suggest timescales to resolve issues;
have credibility both inside and outside the company;
have an objective stance;
be easy to understand; and
be supportive of the business.
Few bodies are perceived to meet all these needs, especially for small businesses. Employers address some issues through the use of OH professionals, including occupational physicians, to provide advice and support. Employers use OH professionals because prevention is better than cure and they are able to obtain the best advice on (personal) health, minimise risk to staff, assess fitness for work and recognise workplace hazards. This has the additional benefit of making staff feel valued.
But the study confirms that there is a low level of access to OH support services, particularly for smaller organisations: 48% of small companies, 20% of medium-sized companies and 9% of large companies indicated that they had no access to an occupational physician; and 23% of large companies reported that they had a full-time occupational physician. Medium-sized companies tend to use an occupational physician "as and when required".
Barriers to use
The study found employers, employees and health and safety specialists perceive barriers to using OH professionals to improve health and safety management, including:
the OH professionals' inability to understand business implications;
a shortage of OH professionals;
a lack of information and solutions;
a conflict of interest;
little perception of added value;
low recognition of local issues; and
the perceived expense.
The OH professionals most used by participants were OH nurses, occupational physicians and local general practitioners (GPs), while the least used were health promotion specialists and occupational hygienists.
Occupational physicians were regarded as being a medical monitor and information provider. Few of the participants were prepared to cite the benefits of using an occupational physician; the majority agreed that a physician would be a real asset to the company but would be too expensive. Employers, employees and health and safety specialists were concerned about the conflict of interest between the advice they produce and the legal requirements. They could not decide "whose side" the physician was on. Both employers and employees believe there is too little understanding of the consequences of the actions advised. The perceived lack of impartiality makes staff less likely to present the true extent of their illness for fear, at worst, of losing their job.
Associated with this are the different relationships that employees have with an occupational physician and their GP. Whereas a GP is regarded as a friend who has knowledge of their personal and medical history, an occupational physician does not project the same image of approachability and understanding, with the result that employees tend to distance themselves. Health and safety specialists said that, ideally, occupational physicians should be trade union-affiliated or independently funded by the NHS, which would afford the degree of impartiality required.
A lack of communication
Many participants in the study complain about the lack of communication between the physician and management or employees. The main area where they are seen to be lacking is in their reporting skills. They often criticise the findings of physicians as inconclusive, and their reports as unhelpful in making a decision about an employee's needs. This lack of an end-result can lead to an under-valuing of the occupational physician's role.
Union safety specialists said that as well as improved reporting methods, clear communication is needed during assessment and advice procedures when dealing with both employers and staff. Better performance in this area would help to open the channels of communication, which in turn would improve the occupational physician's image of approachability and impartiality.
Customers' needs
For occupational physicians to make the optimum contribution to good management in healthy enterprises, the needs of the customers must be taken into account when planning OH services. Indeed, the main objective of the study was to establish the priorities of UK employers, employees and their representatives (the customers) regarding the competencies they require of occupational physicians.
Participants were provided with a list of competencies that occupational physicians are expected to have at the end of their training and were asked to arrange them in order of their importance. Customers regard all of the established competency areas of occupational physicians as important, but their ranking of the relative importance of these competencies differs substantially from the physicians' views, which has implications for the future training of occupational physicians. The competencies were as follows:
Fitness. Participants claimed that training in the assessment of disability and fitness for work was fundamental to the physician's skill set. They believed that physicians need good training to be able to advise people on returning to work, to establish the parameters of work that an employee can perform, to identify the effect on other employers and also to advise on long-term disability and discrimination legislation. But employers believed that occupational physicians are not always objective in their assessment of disability and fitness for work; in particular, they claim that physicians can be vague as to the employee's condition and try to hide behind professional ethics.
Hazards. All groups, except small businesses, considered identification and assessment of occupational hazards to be a critical component in the training of occupational physicians. Small businesses perceived this role to be primarily that of a health and safety manager. Generally, participants believed that physicians need to be familiar with hazards and their effects so that they can detect patterns of illness and play a preventative role in this area. Few of the participants said they had experience of occupational physicians doing this. Physicians were seen to have a more reactive role. Participants also said that the advice given by the physicians was not always sufficiently tailored to the business environment.
Promotion. Employees and employers thought that health promotion in the workplace is one of the most important areas of occupational physician training, although health and safety specialists and public sector employers see this as more appropriate to an OH nurse or health promotion specialist. Small businesses regarded this as a matter of individual responsibility, with only gentle encouragement from the company being required.
Exposures. Most participants did not consider training occupational physicians to advise on the effect of environmental exposures essential; they felt it more appropriate to service managers and health and safety specialists. None of the participants had used an occupational physician for environmental exposure advice. But some employees and employers thought training in this area was as important as identifying and assessing hazards. They believed companies lack expertise in this area and that expert advice could be sought from an outside source, such as a physician.
Communication. Health and safety specialists, small businesses and public sector employees considered communication skills to be one of the most essential skills for physicians. They said that training in this area is needed so that advice is clear, jargon-free and given within a commercial framework. Private sector employees and employers considered training in this area less important because they assume that it should be part of all physicians' training - a basic competency.
Research. The participants did not rank training occupational physicians in the use of research methodologies as very important, seeing it instead as a specialist area. But they did expect physicians to have the basic skills needed to interpret research. Small businesses and health and safety specialists rate this area more highly as they expect physicians to be able to provide advice in this area.
Law. The participants rated advising on OH law and ethics as of medium to low importance. They expected to use consultancy instead, believing legal sources to be a cheaper alternative; they also saw a potential conflict between advising on health and on the law. Nevertheless, fear of litigation means that it would be helpful to receive medico-legal advice directly from the physician, and some training in this area would be important.
Management. All participants considered training for occupational physicians in performing managerial duties to be of low importance. Doctors were not perceived as good managers in general; there was some feeling that this skill was important but only within the confines of their own OH service department, not within the organisation.
Low-level support
Employers, according to the study, feel they are encumbered by increasingly varied health and safety issues with significant implications for the wellbeing of employees and the business. These include what they perceive to be the mounting burden of legislation and a rapidly growing "claims culture". The range of issues is such that they need advice from reliable multidisciplinary sources. There are very few sources of advice that can meet the needs of all businesses in all circumstances. Reservations about the HSE's enforcement role meant that the preferred sources of advice were from trade or industry bodies, followed by in-house company consultants and specialists.
Employers and employees said that the most frequently used OH professional was the OH nurse, followed by OH physicians and local GPs. There is an overlap between the competencies of OH nurses and other providers of OH services, but no single discipline has all the competencies required by customers. The study found that there is a need for the provision of multidisciplinary occupational health and safety support to work in collaboration with management and the employees. The study validates the competency areas of the training of occupational physicians, but it points to a need for a change in emphasis so that it is more aligned with the needs of their customers.
The study confirmed the low level of OH support to British industry and concludes that there is a need for improved access to OH and safety support, including to occupational physicians, particularly for small and medium-sized enterprises. Commenting on the research, Elizabeth Gyngell, head of the HSE's better working environment division, said: "Our new strategic programme, the Better health at work partnership programme, shows our commitment to working with a wide range of partners in a voluntary way to improve access to OH support, especially for small firms. OH physicians, trained to deliver what their customers need, will have a key role to play in those partnerships."
Chris Dyer is editor of HSB and a freelance journalist.
1 "Competencies of occupational physicians: the customer's perspective", RR427, HSE Books, ISBN 0 7176 28639, £25 or free from www.hse.gov.uk/research.
