Journal of the New Zealand Medical Association, 21-January-2011, Vol 124 No 1328
The workplace: a missing link in occupational medicine?
When peer reviewing the occupational mortality paper1 in this issue of the NZMJ I remarked that it was well overdue because there is, still, despite many reviews of the problem, no valid system for monitoring of occupational mortality or morbidity in New Zealand. This hard data “showing marked differences between occupational groups...not accounted for by socioeconomic deprivation” may indicate that there is something wrong in the workplace. It might be occupational exposures, it might not.
On the other hand, Dame Carol Black, in a report to the United Kingdom Government, looked at the problem from a different perspective, that work can be good for health, which it undoubtedly is.2
The three objectives underlying her vision “working for a healthier tomorrow”, were prevention of illness; promotion of health and well-being; early intervention for those who develop a health condition; and an improvement in the health of those out of work. Proofs which, one supposes, should be self evident.
Medical practitioners need to be involved in health at work, with, arguably, occupational medicine taking the lead. The discipline has always had a strong profile in New Zealand. Academically, a postgraduate Diploma in Industrial Health has been taught for at least 30 years.3 A number of research centres and groups, including the group who wrote this paper, have been, and are, very active. There are initiatives to increase academic networking4 and also to translate that evidence into action.5
In view of changing priorities it is often useful, as a profession, to participate in a little critical reflection. As a reflective framework I therefore propose to examine where we have been, where we are now, where we need to be and how to get there.
In 2003, Bill Glass, a senior member of our profession, wrote about Dr Thomas Ownsworth Garland as “the father of occupational health in New Zealand”.6 Tom Garland was trained in Public Health, and in 1932 commenced his industrial career as “factory doctor” to the tobacco manufacturer Carreras. He then emigrated to New Zealand, and in 1947 was appointed as “Industrial Hygienist” within the Department of Health. At the time, we were an agricultural economy with many small industries employing less than 10 employees. During the 11-month period after his appointment he visited and inspected no less than 220 factories, this work having a significant impact upon our development as a profession.
For the next 40 odd years the home of industrial medicine was within the Department of Health. Doctors also developed their skills part-time within industry, many being general practitioners. In 1984, the Australasian College of Occupational Medicine was formed, a significant step in raising the standing of the “industrial doctor” to the registered specialist level.
The tension between advisory and enforcement roles between the Departments of Health and Labour, along with the piecemeal nature of the legislation, led to statutory change through the Health and Safety in Employment Act 1992. The Department of Labour (DoL) took over responsibility for the medical role, appointing Departmental Medical Practitioners (DMPs). Which is largely where we are today as a small-employer, agriculturally-driven economy. At a strategic medical level we have part-time, 2 hours-a-week DMPs available in major centres to give advice to employers, employees and the public.
The major Government agency now either employing or contracting specialist occupational physicians is the Accident Insurance and Compensation Corporation (ACC). Some District Health Boards (DHBs) also do so. Many independent specialists and general practitioners with appropriate training provide a service, on either an ad-hoc basis or to a specific employer.
In my view where we need to be is, like Dr Garland, in the workplace, using our professional strengths to gain influence. The “factory doctor” has always had a fascinating role, the “double agent” responsibilities to both employer and “patient” requiring careful positioning, the ethical issues, being, at times, challenging. This is where negotiating and political skills are developed, where leadership qualities are nurtured and where influence is born. The problem is that training posts in occupational medicine, by and large, have to be created by trainees themselves. The largest consumer of services is ACC, which is where they end up trying to learn their specialist skills.. With the best will in the world, compensation medicine does not provide an ideal training environment, there is not enough workplace contact .
Dame Carol recognised where we need to be going. In the United Kingdom, occupational health had become detached from mainstream healthcare. The professional bodies also recognised that the major barrier to extending the scope of practice was a historical exclusion of occupational medicine from the “open access” National Health Service. The need was for “working-age health”, approached by a multidisciplinary team, to be brought back into the mainstream of health care.
The other challenges identified for occupational health were a limited remit (in terms of helping only those in employment); an uneven provision of services; inconsistent quality; a diminishing workforce; the shrinking academic base; a lack of good quality data and a poor “image and perception” of occupational medicine as an single minded agency focussed on the needs of the employer.
These barriers need to be breached, we need a sense of direction and we all have our roles.
In 2004, Professor David Coggon, a leading occupational physician in the UK, wrote about “occupational medicine at a turning point”. He argued that occupational research strategies needed to change, because “...much of the illness and disability which currently is attributed to injurious occupational exposures does not arise from underlying disease with detectable organic pathology, but rather is a psychologically mediated response to an external trigger that is conditioned by a combination of individual characteristics and cultural circumstances”.7 A provocative statement, but a theory endorsed by Dame Carol through promotion of the “biopsychosocial” model of health, the biological (health condition), psychological (impact or perceived impact on wellbeing) and the social (wider determinants of health, including work, home and family).
We are striving to understand this model, but more active research collaboration and a change of focus from the “exposure” model to something more inclusive is sorely needed.
We then need to get there by putting the evidence into practice, and it is the executive function that is missing. Unless we can persuade employers and government about our potential to contribute we will never gain real traction. In the words used in the Black Report “Improving the health of the working age population is critically important for everyone, in order to secure both higher economic growth and increased social justice”. This idea is important and it is imperative that we act upon it.
We need an occupational medicine training scheme strongly grounded in both public health and clinical medicine, with a focus on the workplace and available to small employers. Training within outward-looking DHBs could fulfil that function, were funding available to facilitate it.
Occupational medicine is like this venerable journal, it has to move on to survive. I would therefore commend, along with the other initiatives that are being promoted, personal action by us all, specialist or generalist occupational medicine practitioner alike. We simply cannot do this vicariously: like Dr Garland our presence in the workplace is sorely needed.
Competing interests: None.
Author information: David McBride, Senior Lecturer in Occupational Health, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin
Correspondence: David McBride, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 4797298; email: firstname.lastname@example.org
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