Devil’s Advocate: Time to put the evidence into practice

The two health issues we face most frequently at work are common mental health problems and musculoskeletal disorders. Occupational health clinics are filled with patients reporting aching backs and limbs and stress, and often both. Our services are geared up to offer support, and workers are reassured by the legal duties that employers have to manage associated risks.

Naturally, considerable effort has been invested in researching these issues and their potential remedies. There are now good reviews of the evidence that should be guiding clinical practice but, as in many areas, there remains a large theory-practice gap.

Let us first consider ‘stress’. The British Occupational Health Research Foundation (BOHRF) produced a systematic review of the research evidence in 2005. Among its conclusions, the BOHRF noted that the “extent to which any [stress management interventions] prevent common mental health problems remains unclear”, and that there was “limited evidence that changing the work environment can be effective in reducing common mental health problems”. It also noted that while individual therapy is effective, this is the case “whether delivered face-to-face or via computer-aided software”.

The implications of the BOHRF review are very clear. There is no persuasive evidence that intervention using the stress risk assessment and management process that the Health and Safety Executive (HSE) requires of employers is of any benefit whatsoever. Furthermore, the increasing numbers of counsellors in workplaces has no greater benefit than the provision of cognitive behavioural therapy software. But despite these, the counselling and stress risk assessment tsunami is getting ever bigger as it sweeps through workplaces.

So what about manual handling? It is uncommon for occupational health papers to be published in the ‘Big Four’ medical journals, but one on this very subject was published recently. This systematic review concluded: “There is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain or consequent disability. The findings challenge the current widespread practice of advising workers on correct lifting technique.” In short, manual handling has no value in the prevention or management of back pain.

Again, the implications are clear. There is no evidence that intervention in the workplace using the manual handling risk assessment and management process promoted by the HSE is of any benefit whatsoever. There is no evidence to support the widespread provision of training. Despite the absence of evidence, there are legions of manual handling assessors, advisers and trainers in UK workplaces. In the NHS, an organisation that embraces evidence-based practice, manual handling training is “mandatory”.

Some might argue that the absence of evidence is different to the evidence of an absence of benefit. However, where is the dramatic improvement in musculoskeletal health that should be expected from meaningful manual handling legislation? Even the HSE has acknowledged that this has not been achieved. Nor have I seen evidence that mental ill health rates are falling, and I’m not surprised. We have growing evidence that existing approaches are ineffective.

Legislation and expected practice continue to force employers to misdirect limited resources into valueless interventions. It is time for our speciality to put the evidence into practice, stop wasting energy on ineffective interventions, and to apply pressure to amend poorly founded regulations.

Dr Richard Preece is a consultant occupational health physician


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