Q What do you think is the role of the Faculty of Occupational Medicine (FOM) today and how has it changed from the past?
A The FOM serves the public by promoting best practice in occupational health. Historically OH practitioners focused principally on protecting people in the workplace through the identification, assessment and management of health risks and the prevention of accidents. But over the past 50 years our role has progressively evolved.
It used to be that work was regarded as a necessary evil – it was the curse of Adam that you had to go out and earn your crust of bread by the sweat of your brow. But we now recognise that ‘good’ work can have positive benefits for health and wellbeing, in that it not only provides people with income but also with social contacts, and often with a feeling of worth and ‘belonging’.
Occupational health practitioners these days are more and more involved in enabling people to benefit from work, while at the same time ensuring that they do not put themselves or others at unreasonable risk. So there’s a major element of balancing risks and benefits, which has to be done fairly and based on best available scientific evidence.
Q How have you responded to the Black Review of the health of the working age population, which will report early this year?
A Dame Carol Black’s review of the health of working age people is a major opportunity for us, and we are contributing actively. We need to work effectively with others who share our objectives, and the aims of the review coincide substantially with our own.
One of the things Dame Carol will be thinking about is just what sort of OH provision is now appropriate in the UK, how it should be delivered, and who should be paying for it. That’s very much a question on which the FOM wishes to give a lead. Of course, services will only be funded if they are perceived as cost-effective by whoever is paying for them.
An important change over the past 20 years has been the major transition from in-house OH departments to the contracted delivery of occupational health care by large independent external providers. We have suggested to Dame Carol that there is a need to develop standards for OH providers, and this is another area in which I think the FOM should give a lead.
Q What are your views on standards for OH practitioners and providers?
A Until now the main focus of the faculty has been on professional standards for individual practitioners. However, there is a case that we should be extending beyond that to look at standards for OH providers, perhaps leading to an accreditation scheme. Of course, such an initiative would not just be about the work of doctors, and so it would have to be developed in collaboration with other stakeholders including other professional groups, the Health and Safety Executive, NHS Plus and the Department for Work and Pensions.
Furthermore, any system that emerged would need to be cost-effective. A danger with accreditation schemes is that you end up with a time-consuming form-filling exercise that assesses parameters which are easy to measure, but which don’t necessarily tell you whether a service is a good one. So I don’t think it’s an easy task, but it’s worth exploring.
Q What is your view on how specialists and GPs should be trained in occupational medicine?
A With regard to specialist training, I am particularly concerned that in our efforts to respond constructively to the Postgraduate Medical Education and Training Board, we don’t compromise the good things that are already in place. That means less revolution and more evolution.
Then there are two classes of GP that we need to consider: a minority who provide OH services on a part-time basis, and the large majority who don’t work in occupational health, but who nevertheless encounter OH problems fairly frequently in their day-to-day practice. For the first group the faculty established some years ago a Diploma in Occupational Medicine, which I think works well, and for which no changes are currently planned. In addition, many part-timers get useful continuing education through membership of the Society of Occupational Medicine (SOM).
For the majority of GPs who don’t work in occupational medicine I think there is a real need for a better understanding of OH. The FOM has an important responsibility to address this need, working with others like the Royal College of General Practitioners (RCGP), and this is another of the points that the faculty has made in its response to Carol Black’s review.
There are various ways in which the problem can be tackled. One is through educational pieces in journals and periodicals read by GPs. Another, if the RCGP agrees, would be to build more occupational health into training for GPs. Input at that stage is likely to be more effective than at undergraduate level because by the time doctors are GP trainees, they’ve had to face problems relating to health and work and, therefore, are more interested in trying to find the answers. Moreover, if you develop the knowledge and understanding of GP trainees, some of the messages are likely to filter through to other GPs as well.
The trust between the patient and GP is very important and it is not appropriate to compromise that relationship by asking GPs to act as policemen for the social services, but what’s lacking at the moment is a full understanding among GPs of the benefits of work for health and wellbeing. Unnecessary sickness absence should be avoided, and following a spell of sickness absence, timely return to work is an important part of rehabilitation.
Achieving these goals sometimes requires communication with the employer, and if the employer has an OH service then that is the natural point of contact. There’s still a lack of understanding among many GPs about the role of OH services, and a fear that medically confidential information may be passed on to employers inappropriately. In fact, the occupational physician’s duty of confidentiality is the same as that of the GP.
Where employers don’t have an OH service, the GP may need to make direct contact with the employer, and by asking the patient, they can find out who would be the most appropriate person to approach. There may be scope, for example, for modified duties or for a graduated return to normal work.
Q As an academic, what is the best way for practitioners to make use of the evidence base for occupational health?
A The difficulty we have these days is that with such an enormous medical literature you can’t expect individual practitioners to check the scientific evidence bearing on every problem that they face. Having someone summarise the literature and compile guidelines, at least for the more common problems, makes life easier.
When you put together guidelines it often becomes apparent that evidence is lacking on important questions, and that there is a need for primary research to address the gaps in knowledge. Unfortunately, because of a decline in academic occupational health in the UK, we lack the resource at the moment to carry out all the primary research that is required. And the need for occupational health research is not just to underpin clinical practice. For example, much of the work in which I’ve been involved, concerns the management of risk, either in the workplace or associated with products of industry. Here the applications often lie in legislative controls.
If the decline in academic occupational health isn’t reversed, there is a real danger that in 20 years’ time we won’t have people with the ability to analyse and interpret research evidence, or institutions capable of training them to do so. We have shared our concerns with Patrick McDonald, chief scientist at the HSE, and I’m hopeful that working with him and others we’ll be able to do something about it before it is too late.
Q What are your views on the degree to which OH practitioners should look beyond work-related health risks and at other factors that influence employees’ health, including social ones?
A Occupational physicians are concerned with all aspects of health that impact on capacity to work, whether or not they are work-related. But even when you look at work-related illness, the problems that now dominate, especially non-specific musculoskeletal disorders and common mental health complaints attributed to occupational stress, have a very strong psychosocial component and are not a simple response to a noxious exposures in the workplace.
If you take back pain, for example, there is a higher risk in people who undertake heavy lifting, bending and twisting, and that’s been a very consistent finding in epidemiological studies. But that risk seems to depend importantly on people’s psychological state and probably on their health beliefs and expectations.
With regard to mental health problems, people’s unhappiness because of stresses in the workplace will depend not only on the nature and severity of the stresses but also on the individual’s expectations. And that means that you don’t manage them by the same paradigm as you manage asbestos. The emphasis needs to be on maximising the positive psychological benefits of work. Part of that may involve reducing unnecessary stressors but it’s other things as well.
Q How is the role of OH doctors and nurses going to change in future?
A A first principle is that all tasks undertaken by OH professionals should be useful and cost-effective. So, for example, we don’t want doctors or nurses carrying out over-elaborate pre-employment assessment that would be a waste of anybody’s time. And going beyond that, whoever undertakes a role in OH should be competent to do so.
Their professional background may be relevant to this, but it’s not the only thing that determines competence. For example, some OH departments are led by doctors, but I know of others that have been managed by a nurse with a doctor coming in to work part-time, where the nurse was clearly better qualified as a manager than the doctor. We don’t have to have rigid professional boundaries.
There are, however, some tasks for which doctors will normally be better equipped than nurses because of their medical training. One example would be the management of medication for unusual clinical problems in workers who are travelling overseas.
The Faculty of Occupational Medicine was founded in 1978 and is responsible for standards, training and qualifications in occupational medicine.
CV: Professor David Coggon
1972 BA in Mathematics and Medical Sciences, Cambridge University
n 1976 BM Oxford University followed by Senior House Officer and Registrar experience in general medicine at Nottingham City Hospital
1980 Joins MRC Environmental Epidemiology Unit in Southampton, and trains as a specialist in occupational medicine
1984 PhD on occupational causes of cancer
1993 DM on epidemiology of stomach cancer
2007 President of Faculty of Occupational Medicine
Main research interests: epidemiology that informs the management of occupational and environmental hazards to health. Also has a major interest in the translation of research into regulatory policy.
Current and past appointments include: chair of the government’s Advisory Committee on Pesticides and of the Deleted Uranium Oversight Board member of the Committee on Toxity, Independent Expert Group on Mobile Phones (Stewart Committee), and of the Expert Panel on Air Quality Standards and expert adviser to the World Health Organization and the International Agency for Research on Cancer.