Why do we, occupational health professionals, exist, and will we still be around in 10 years’ time?
Over the past 15 years, I have watched OH changing with great satisfaction as the world of work has been drastically transformed. I have always been a believer that occupational health should really be about employee wellbeing. As recently as five years ago, to mention the ‘W’ word would have brought a big shutter down in the eyes of some of my colleagues – but now even the government and the Faculty of Occupational Medicine are using it.
Look at your own world of work and compare it with, say, the typical London commuter. I regularly travel to London – I leave around 6am, so have to skip breakfast, drive my car to the station, stand on a platform and then sit down for 90 minutes on the train. I feel annoyed and under pressure when the train is late. The first walking I do is the 500 metres from the tube to the office where I sit down nearly all day. I intoxicate myself with caffeine and eat snack and convenience foods. I have lunch at my desk and the only time I get out of breath is if I am late for a meeting and have to rush. Later, I struggle home following the same routine and arrive home at 8pm, shattered, too tired to go to the gym, and have a late meal late, which disturbs my natural body clock.
Stuck in a rut
For some people, this cycle is repeated day after day. They arrive at work with presenteeism, the word for people who are present in the workplace but not engaged in their work. The average office worker is TATT, or Tired All The Time – and no wonder. Add to this childcare, eldercare and household chores, and you can forget about any kind of work-life balance.
I termed the phrase ‘workstyle health’ some years ago to describe the unhealthy worker effect. The demands and pressure we place on ourselves cause negative health behaviours – a tendency to eat a poor diet, smoke, drink too much, not get enough exercise, put on weight and sleep poorly, and so increase the risk of heart disease, diabetes, and cancer. The obesity epidemic, for example, is rampant.
The world is speeding up and the quality time we all need is disappearing. Why are we less happy than 50 years ago?
Traditional OH services have changed considerably in the past 10 years, partly as a result of the success of modern health and safety practices, which have reduced and eliminated exposure to harmful agents at work, be they physical, chemical or biological. As we all know, musculoskeletal disorders and common mental health problems now dominate work-related ill health, and common mental health problems generally appear to have increased.
OH professionals must continue to change in line with the new world of work and look to the future. As technology continues to advance at a pace, we may well end up being just a brain in a bottle in a couple of million years. We have already started to avoid talking, and instead rely on e-mail and the internet.
What sort of models will help prepare the OH professional for the future? I believe we must combine a health and wellbeing model with the traditional OH model so that, initially, both work together. Ultimately, we must transfer health spend from the casualty treatment/illness management end of the scale to the preventative, health and wellbeing improvement end, over a period of five to 10 years.
What is employee health and wellbeing? I have always used a variation of the World Health Organisation definition of health1.
All of these areas need to be in balance – if any part is not, wellbeing is compromised. A health and wellbeing programme includes a means of addressing these physical, psychological, social, economic, and environmental factors, which affect wellbeing both at work and, increasingly, away from work.
Simple definitions are:
- Physical: The health of our body systems, for example heart and cardiovascular, endocrine, gastrointestinal, immune and musculoskeletal systems
- Psychological: Our mental health status, behaviour, emotions and happiness
- Social: Interactions and relationships with other people
- Environment: Where we live and work
- Economic: Disposable income.
Employee health models must incor-porate traditional risk-based core OH services to ensure management of work-related illnesses and injuries, legal compliance and business reputation and risk protection.
This model takes the five hazards and combines a workplace risk assessment and individual total health risk assessment to give an overview.
This defines what health assessments, if any, are needed which might be either:
- health/medical surveillance, for example, hand-arm vibration syndrome, noise, respiratory asthmagens
- job-related, for example working at heights, vocational driving.
To understand workplace wellbeing we should remember the basics of traditional OH, defined universally as the effects of work on health and the effects of health on work-capability and performance. We can then combine the models (see table below).
OH services must evolve within the changing world of work, by internal and external audits, to ensure OH provision matches the real needs of an organisation.
Employers have started to recognise the role of OH as an integral part of the HR jigsaw, and to develop a health and wellbeing strategic plan.
This is where OH professionals must be involved.
Our health and safety colleagues are trying hard to move into this area. The traditional health and safety practitioner’s role in the wellbeing model is currently limited to ensuring a safe and healthy working environment – protecting employees from harm. However, any health and wellbeing strategic model must include specific programmes to address the two major causes of work-related ill health – stress and musculoskeletal disorders.
An example of a large organisation that has embraced the wellbeing strategic model is Scottish Power, a large multi-utility organisation in the UK. The company includes defined roles in wellbeing for HR, OH and health and safety.
Other organisations are developing a split-team approach – a wellbeing team and an OH team using different players with different expertise.
A key area is absence, or attendance, management. Line managers must take responsibility for this but there should be a much higher level of support from OH practitioners than there is now.
This role will increasingly become part of the OH adviser’s remit with the introduction of the “biopsychosocial model” – which is already replacing the medical model in rehabilitation following incapacity. This model was proposed by the psychiatrist George Engel and draws a distinction between the actual processes that cause disease, and the patient’s perception of their health2.
The key to effective absence management is early intervention, while rehabilitation programmes must be designed to break down the barriers that delay recovery and returning to work. Among larger employers, this will inevitably include the private health sector with increasing use of private medical insurance to fund early referral for investigation and treatment.
Another solution employers will increasingly turn to, given the shortage of OH practitioners and the huge costs of sickness absence, is the use of remote call centre services using high-tech databases and first-day intervention with immediately available sickness absence information for line managers.
Employee and manager OH helplines are already being introduced for skilled OH professionals to give appropriate advice. Perhaps we will all end up as call centre operators using video conferencing in case management.
OH advisers have strived to drop ‘nurse’ from their title as they become increasingly involved in employee health management. Their role in health assessments will move to a supervisory one as OH technicians take over this aspect of occupational health assessments. This will enable the OH adviser to become more active in strategy development, case management and rehabilitation. But will OH professionals be happy to lose this personal, preventative, patient contact, which for many was the reason they entered the medical profession?
Some occupational physicians presently work as a ‘doc in a box’ – they sit in a room seeing endless employees with mainly psycho-social wellbeing issues. They are fed coffee and biscuits, allowed to go to the toilet and, after writing reports, are released from the ‘box’.
OH nurse advisers are increasingly taking on this role in attendance case management. Maybe they will become the ‘nurse in a box’, which calls into question what the role of OH physicians will be in 10 years’ time.
HR departments also have a major role to play in organisational wellbeing. Fair performance and appraisal systems, linked to reward and recognition, as well as dignity and diversity at work policies, are key to developing a culture and climate that enhances wellbeing.
The introduction of flexible employee benefits encourages employees to commit themselves to personal wellbeing by opting for private medical insurance and health and fitness benefits.
Healthcare services are generally described as primary, secondary and tertiary but in future those responsible for employee health will want to increase primary interventions, which are about assessing risk and preventing ill health.
Secondary interventions involve training, awareness and educating managers and employees, while tertiary interventions require a means of treating people who have developed a health problem.
For example, primary interventions for managing pressure are risk-assessment based and recommended by the Health and Safety Executive stress management standards (www.hse.gov.uk/stress/standards/). They involve a stress risk assessment using validated questionnaires to recognise the sources of pressure and its effects on the individual and the organisation. Targeted solutions can then be introduced to deal with the identified work-related stressors. This ‘demedicalises’ stress at work and encourages managerial and individual ownership of the issues.
Secondary stress interventions, however, include awareness training and sometimes stress workshops (now being called wellbeing workshops). Tertiary interventions include employee assistance programmes (EAPs) and access to counsellors and even psychologists.
As poor psychological wellbeing is increasing, more large companies are employing psychologists for the early diagnosis and treatment of common mental health problems, often using cognitive behaviour therapy . However, the continuation of this trend is in question due to concerns about the number of available psychologists. Does this mean OH practitioners should train in this area?
Similarly for musculoskeletal disorders (MSDs), usually primary prevention includes ergonomic advice to ‘engineer out’ work-related MSDs. Musculoskeletal mapping questionnaires are also used to identify which parts of an organisation have the highest prevalence of MSDs and target appropriate ergonomic and treatment interventions at them.
Secondary interventions involve training (for example, manual handling) education and early symptom reporting. Tertiary interventions include early, active physical therapy (physiotherapists, chiropractors or osteopaths), available in the workplace or locally.
The delay in treatment by the NHS for both psychological and musculoskeletal disorders results in delayed treatment and recovery. Employers are resorting to private healthcare for early investigation and treatment of these conditions, which will continue to increase in future.
Doctors’ current training does not prepare them for dealing with workplace health issues. They are trained to diagnose using set diagnostic steps – history, examination, investigation, diagnosis and treatment. The problem is that patients now often present a multitude of non-specific complaints, which makes it difficult to diagnose. Hence the general term ‘stress’ is often written on sick notes.
Managed rehabilitation programmes should include a multi-disciplinary approach. In future, occupational therapists may work more closely with OH practitioners as roles become similar in case management, while physiotherapists, psychologists and fitness coaches will all become more actively engaged in employee wellbeing.
Wellbeing centres incorporating traditional OH departments but including physiotherapists, counsellors and psychologists, dentistry and a fitness centre are already in existence in some large organisations, such as Pfizer.
The workplace is where we spend a large percentage of our time and OH should use this time to help employees understand and take control of their personal wellbeing – if they want to.
But how do you help someone take the first step? That is the hard bit, and the reason why company health and wellbeing strategic plans are not short term. OH must persuade employers to invest in a health and wellbeing strategy now.
Within the next 10 years we should be able to measure the link between health and wellbeing and productivity, performance and engagement at work.
OH professionals must undertake preventative lifestyle health screening, offer behaviour change programmes to increase physical activity and support weight management. They must also give personal advice to encourage individuals to make informed changes in their behaviour to reduce their health risks.
If nothing else, the need for daily physical activity is so important in the sedentary workplace, but not all companies can afford to have a gym that all employees can use. However, new developments such as the company ‘Virtual Health Club’ allow a cost-effective solution using the internet with online and face-to-face personal trainers and wellbeing programmes without the need for a company gym.
In this new world of employee managed wellbeing it is essential to have a means of health data collection and analysis for activities related to wellbeing to be monitored and measured. This will enable cost-effective, comprehensive and integrated programmes to be evaluated and ultimately demonstrate a bottom line pay back for the investment made.
Will OH still be here in 10 years time? If we start to consider population health management (the managed health and wellbeing of all employees), we will be able to say we are here to improve employees’ performance, productivity and engagement at work and enable them to work for as long as they want to.
And what about not getting enough sleep and feeling tired all the time? How can we manage that? Now that’s another article.
Dr Les Smith is head of clinical governance for First Assist and he specialises in designing bespoke modern employee health and wellbeing solutions for corporate clients. He was also the chief medical officer of Scottish Power Group and the head of employee health services for the pharmaceutical giant Pfizer.
1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p.100) and entered into force on 7 April 1948
2 Engel, George L. The need for a new medical model, Science, 196:129-136, 1977