Occup. Med. 1992;42:61-63
Viewpoint '92
An occupational health service in primary care Simon Pickvance Sheffield Occupational Health Project, Sheffield, UK
In the United Kingdom we are desperately short of hard information on the prevalence of work-related ill-health. Such information is essential if we are to assess the adequacy of existing occupational health services. Past dependence on Department of Social Security statistics for compensation under the Industrial Injuries Scheme has left us vulnerable to changes in the qualifying conditions for these benefits. Four such changes have occurred in the last 12 years making trends and levels difficult to assess1. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985, have, despite wide publicity, failed to become a routine part of medical practice1. The Health and Safety Executive trailer to the 1990 Labour Force Survey will give us information on self-attributed work-related ill-health. Meanwhile one option is to use evidence from research carried out in other industrialized countries. ESTIMATES A number of studies in different countries have produced estimates of a similar order of magnitude. An Australian survey of male hospital admissions suggests an excess attributable to occupation of 24.9 per cent2. In the NIOSH pilot study carried out on a stratified sample of workplaces in Washington State, 28.4 per cent of shopfloor workers had diseases classified as probably occupational3. In a survey of disabled people in the USA, 16 per cent attributed their disability to work4. Studies on particular diseases are again consistent in showing a substantial proportion to be workrelated5"7. All these studies suggest that work may be a major contributor to ill health, however defined2'4"7 and that a substantial proportion of workers may suffer from it3. WHO IS SERVED BY EXISTING OCCUPATIONAL HEALTH SERVICES? If work-related ill-health is common, how do the occupational health services in the UK meet the need for identification and prevention of occupational diseases? Workplace based services continue to feel the pressure Requests for reprints should be addressed to: Simon Pickvance, Sheffield Occupational Health Project, Mudford's Building, 37 Exchange Street, Sheffield S2 5TR, UK.
© 1992 Butterworth-Heinemann for SOM 0962-7480/92/020061 -03
of change in the structure of employment and the economy and have never been able to provide a comprehensive preventive service8. Workers in small firms, in casual or sub-contract employment, the selfemployed, trainees, part timers, shift workers, homeworkers and workers whose first language is not English are all to a greater or lesser extent disadvantaged. They are all unlikely to have access to adequate information on health and safety and to workplacebased occupational health services. On the other hand workers in large firms with active trade unions and negotiating machinery were the great beneficiaries of the 1974 Health and Safety at Work Act. It was the recognition that many workers had benefited much less that led to the setting up of the Sheffield Occupational Health Project. At the time it was set up figures suggested that only 17 per cent of workplaces had trade union safety representatives. In 1987 this figure had dropped to 9 per cent9. A decline in health and safety representation has been accompanied by an increase in fatal and major accidents over the same period.
A PRIMARY CARE SERVICE Most people go to their GPs for primary health care. The majority visit their GP at least once a year. General practice seemed to us the obvious place to set up an occupational health service accessible to all10. The World Health Organisation noted the advantages of such a service; its perceived independence, its links to the NHS, and the possibility of making links within the community; as well as the related disadvantages. The emphasis of our service is prevention and a working assumption is that much occupational disease is hidden from those collating statistics; reflected only in the morbidity and mortality differences between social classes. A second precept is that the most effective agents of change are, as in health promotion work around lifestyle risk factors, those at risk of or currently suffering from disease. Every patient visiting their GP should have an occupational history in their notes. Project workers take histories and take the opportunity of offering relevant medical surveillance; audiometry and spirometry for example, and relevant information on health hazards from a variety of sources; trade union and labour
62
Occup. Med. 1992. Vol. 42, No 2
movement publications, Health and Safety Executive guidance, compact disc databases and microfiche. Occupational health workers do not make diagnoses or carry out treatment; the interview and screening results provide information to assist other primary care workers in this function. One of the great advantages of working within the NHS is the scope for this teamwork. The project has from the outset adopted a multi-disciplinary approach to prevention. Information and health monitoring by themselves are insufficient for patients to bring about change at work: motivation and organization lie at the core of the problem. Key members of the team have experience as workers' safety representatives, to complement the scientific and research skills of others. This involvement of workers with shopfloor experience of local workplaces and a post-entry training in occupational health, parallels developments in other European countries. In Italy and Denmark for example, workers have statutory involvement in the management of local occupational disease prevention initiatives. Sheffield Occupational Health Project is now 12 years old. It serves practices with 80000 patients in the Sheffield area from 20 surgery bases and from outreach work in community advice centres. Funding is from general practitioners and the Sheffield Family Health Service Authority, with additional grants from the local authority and Healthy Sheffield 2000. Similar projects exist in London, Liverpool and Bradford. In Sheffield we see roughly 10000 patients each year. About one third receive advice on hazards in their current job. Unemployed and retired workers consult their GP disproportionately often. They make up half of all adults consulting in some practices. Many of them have occupational health problems which remain unidentified or for which they have never received advice on compensation. Often the only source of this advice is in primary care. Emphasis is placed on support for groups of workers with specific needs. Frequently an individual may have workmates who suffer similar problems to his or her own. A number of initiatives have arisen from surgery work. Work with ethnic minority communities Men from North and South Yemen, Pakistan and Bangladesh were employed in many of the more dangerous jobs in the steel industry from the mid 1950s till the recession in the early 1980s. The vast majority have occupational deafness and have now received compensation for it. Many also have occupational lung diseases and serious injuries. We are currently translating leaflets to help identify these problems11.
Chronic lung disease Chronic lung disease is common amongst older steelworkers. Sheffield Occupational Health Project is currently trying to get bronchitis and emphysema
prescribed for steelworkers under the Industrial Injuries Scheme, and to gain wider recognition of the need for control of air contaminants from steel production. We have produced a report reviewing the scientific literature on steelworkers' lung diseases12.
Hard metal disease Hard metal disease in the UK was until recently regarded as a rare disease resulting from pre-war levels of dust exposure. In the early 1980s we found substantial numbers of individuals currently or recently employed in hard metal producer and user industries suffering from chronic lung disease. Improvements in industrial hygiene have followed.
Noise-induced hearing loss Over 10 per cent of adult patients in general practices in working class areas of Sheffield suffer from noiseinduced hearing loss. Mass audiometric testing has lead to an increased awareness of the noise hazard, large numbers of common law compensation claims for deafness, and improved identification of patients requiring hearing aids.
Repetitive strain injury A local self-help group for repetitive strain injury sufferers has been organized. Repetitive Strain Injury clinics are run by a physiotherapist employed by the project, and qualify as health promotion clinics under the new GP contract.
CONCLUSIONS Changes in employment practice; trends towards smaller workplaces and increased sub-contracting; weakening of employment protection laws and a continuing failure to fund the enforcing authorities adequately have left increasing numbers of workers without defence against poor workplace conditions. As many as half of all patients visiting their GP may have work-related ill-health. Sheffield Occupational Health Project provides a service to these patients and to others at risk. This service is popular with patients and their GPs and forms an essential part of local prevention services.
REFERENCES 1. Employment Gazette. Occasional Supplement No. 1 Health and Safety Statistics 1988-1989. London: Department of Employment, 98. 11 November 1990. 2. Waddell VP, Holman CDJ, Armstrong BK, McNulry JC, Psaila-Savana P. Variation in hospital morbidity in the male workforce of Western Australia. Brit J Ind Med 1988; 45: 139-47. 3. Discher DP, Kleinman GD, Foster FJ. Pilot study for the
S. Pickvance: An occupational health service primary care 63
4. 5. 6. 7. 8.
development of an occupational disease surveillance method. HEWPublNo (NIOSH) 75-162. Washington DC: US Government Printing Office, May 1975. US Department of Labour. An interim report to Congress on Occupational Diseases. Washington DC, 1980. Olsen O, Kristensen TS. Impact of work environment on cardiovascular diseases in Denmark. JEpidemiol Community Health 1991; 45: 4-10. Doll R, Peto J. The Causes of Cancer. Quantitative Estimates of Avoidable Risks of Cancer in the United States Today. Oxford: Oxford University Press, 1981. Blanc P. Occupational Asthma in a National Disability Survey. Chest 1987; 92.4: 613-7. House of Lords Select Committee on Science and Technology. Occupational Health and Hygiene Services,
HLP 28, London: HMSO, 1983. 9. Walters D, Gourlay S. Statutory employee involvement in health and safety at the workplace; a report of the implementation and effectiveness of the Safety Representatives and Safety Committees Regulations 1977. HSE Contract Research Report 20. Health and Safety Executive, 1990. 10. Occupational Health as a Component of Primary Care. Environmental Health Series No 12, World Health Organisation, Copenhagen.. 11. Black and Ethnic Minority Occupational Health Initiative, Annual Report 1990, Sheffield Occupational Health Project 1991. 12. Steelworkers' Lung Diseases, a review and hazards guide. Sheffield Occupational Health Project 1989.
Viewpoint '92
An occupational health service in primary care Simon Pickvance Sheffield Occupational Health Project, Sheffield, UK
In the United Kingdom we are desperately short of hard information on the prevalence of work-related ill-health. Such information is essential if we are to assess the adequacy of existing occupational health services. Past dependence on Department of Social Security statistics for compensation under the Industrial Injuries Scheme has left us vulnerable to changes in the qualifying conditions for these benefits. Four such changes have occurred in the last 12 years making trends and levels difficult to assess1. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985, have, despite wide publicity, failed to become a routine part of medical practice1. The Health and Safety Executive trailer to the 1990 Labour Force Survey will give us information on self-attributed work-related ill-health. Meanwhile one option is to use evidence from research carried out in other industrialized countries. ESTIMATES A number of studies in different countries have produced estimates of a similar order of magnitude. An Australian survey of male hospital admissions suggests an excess attributable to occupation of 24.9 per cent2. In the NIOSH pilot study carried out on a stratified sample of workplaces in Washington State, 28.4 per cent of shopfloor workers had diseases classified as probably occupational3. In a survey of disabled people in the USA, 16 per cent attributed their disability to work4. Studies on particular diseases are again consistent in showing a substantial proportion to be workrelated5"7. All these studies suggest that work may be a major contributor to ill health, however defined2'4"7 and that a substantial proportion of workers may suffer from it3. WHO IS SERVED BY EXISTING OCCUPATIONAL HEALTH SERVICES? If work-related ill-health is common, how do the occupational health services in the UK meet the need for identification and prevention of occupational diseases? Workplace based services continue to feel the pressure Requests for reprints should be addressed to: Simon Pickvance, Sheffield Occupational Health Project, Mudford's Building, 37 Exchange Street, Sheffield S2 5TR, UK.
© 1992 Butterworth-Heinemann for SOM 0962-7480/92/020061 -03
of change in the structure of employment and the economy and have never been able to provide a comprehensive preventive service8. Workers in small firms, in casual or sub-contract employment, the selfemployed, trainees, part timers, shift workers, homeworkers and workers whose first language is not English are all to a greater or lesser extent disadvantaged. They are all unlikely to have access to adequate information on health and safety and to workplacebased occupational health services. On the other hand workers in large firms with active trade unions and negotiating machinery were the great beneficiaries of the 1974 Health and Safety at Work Act. It was the recognition that many workers had benefited much less that led to the setting up of the Sheffield Occupational Health Project. At the time it was set up figures suggested that only 17 per cent of workplaces had trade union safety representatives. In 1987 this figure had dropped to 9 per cent9. A decline in health and safety representation has been accompanied by an increase in fatal and major accidents over the same period.
A PRIMARY CARE SERVICE Most people go to their GPs for primary health care. The majority visit their GP at least once a year. General practice seemed to us the obvious place to set up an occupational health service accessible to all10. The World Health Organisation noted the advantages of such a service; its perceived independence, its links to the NHS, and the possibility of making links within the community; as well as the related disadvantages. The emphasis of our service is prevention and a working assumption is that much occupational disease is hidden from those collating statistics; reflected only in the morbidity and mortality differences between social classes. A second precept is that the most effective agents of change are, as in health promotion work around lifestyle risk factors, those at risk of or currently suffering from disease. Every patient visiting their GP should have an occupational history in their notes. Project workers take histories and take the opportunity of offering relevant medical surveillance; audiometry and spirometry for example, and relevant information on health hazards from a variety of sources; trade union and labour
62
Occup. Med. 1992. Vol. 42, No 2
movement publications, Health and Safety Executive guidance, compact disc databases and microfiche. Occupational health workers do not make diagnoses or carry out treatment; the interview and screening results provide information to assist other primary care workers in this function. One of the great advantages of working within the NHS is the scope for this teamwork. The project has from the outset adopted a multi-disciplinary approach to prevention. Information and health monitoring by themselves are insufficient for patients to bring about change at work: motivation and organization lie at the core of the problem. Key members of the team have experience as workers' safety representatives, to complement the scientific and research skills of others. This involvement of workers with shopfloor experience of local workplaces and a post-entry training in occupational health, parallels developments in other European countries. In Italy and Denmark for example, workers have statutory involvement in the management of local occupational disease prevention initiatives. Sheffield Occupational Health Project is now 12 years old. It serves practices with 80000 patients in the Sheffield area from 20 surgery bases and from outreach work in community advice centres. Funding is from general practitioners and the Sheffield Family Health Service Authority, with additional grants from the local authority and Healthy Sheffield 2000. Similar projects exist in London, Liverpool and Bradford. In Sheffield we see roughly 10000 patients each year. About one third receive advice on hazards in their current job. Unemployed and retired workers consult their GP disproportionately often. They make up half of all adults consulting in some practices. Many of them have occupational health problems which remain unidentified or for which they have never received advice on compensation. Often the only source of this advice is in primary care. Emphasis is placed on support for groups of workers with specific needs. Frequently an individual may have workmates who suffer similar problems to his or her own. A number of initiatives have arisen from surgery work. Work with ethnic minority communities Men from North and South Yemen, Pakistan and Bangladesh were employed in many of the more dangerous jobs in the steel industry from the mid 1950s till the recession in the early 1980s. The vast majority have occupational deafness and have now received compensation for it. Many also have occupational lung diseases and serious injuries. We are currently translating leaflets to help identify these problems11.
Chronic lung disease Chronic lung disease is common amongst older steelworkers. Sheffield Occupational Health Project is currently trying to get bronchitis and emphysema
prescribed for steelworkers under the Industrial Injuries Scheme, and to gain wider recognition of the need for control of air contaminants from steel production. We have produced a report reviewing the scientific literature on steelworkers' lung diseases12.
Hard metal disease Hard metal disease in the UK was until recently regarded as a rare disease resulting from pre-war levels of dust exposure. In the early 1980s we found substantial numbers of individuals currently or recently employed in hard metal producer and user industries suffering from chronic lung disease. Improvements in industrial hygiene have followed.
Noise-induced hearing loss Over 10 per cent of adult patients in general practices in working class areas of Sheffield suffer from noiseinduced hearing loss. Mass audiometric testing has lead to an increased awareness of the noise hazard, large numbers of common law compensation claims for deafness, and improved identification of patients requiring hearing aids.
Repetitive strain injury A local self-help group for repetitive strain injury sufferers has been organized. Repetitive Strain Injury clinics are run by a physiotherapist employed by the project, and qualify as health promotion clinics under the new GP contract.
CONCLUSIONS Changes in employment practice; trends towards smaller workplaces and increased sub-contracting; weakening of employment protection laws and a continuing failure to fund the enforcing authorities adequately have left increasing numbers of workers without defence against poor workplace conditions. As many as half of all patients visiting their GP may have work-related ill-health. Sheffield Occupational Health Project provides a service to these patients and to others at risk. This service is popular with patients and their GPs and forms an essential part of local prevention services.
REFERENCES 1. Employment Gazette. Occasional Supplement No. 1 Health and Safety Statistics 1988-1989. London: Department of Employment, 98. 11 November 1990. 2. Waddell VP, Holman CDJ, Armstrong BK, McNulry JC, Psaila-Savana P. Variation in hospital morbidity in the male workforce of Western Australia. Brit J Ind Med 1988; 45: 139-47. 3. Discher DP, Kleinman GD, Foster FJ. Pilot study for the
S. Pickvance: An occupational health service primary care 63
4. 5. 6. 7. 8.
development of an occupational disease surveillance method. HEWPublNo (NIOSH) 75-162. Washington DC: US Government Printing Office, May 1975. US Department of Labour. An interim report to Congress on Occupational Diseases. Washington DC, 1980. Olsen O, Kristensen TS. Impact of work environment on cardiovascular diseases in Denmark. JEpidemiol Community Health 1991; 45: 4-10. Doll R, Peto J. The Causes of Cancer. Quantitative Estimates of Avoidable Risks of Cancer in the United States Today. Oxford: Oxford University Press, 1981. Blanc P. Occupational Asthma in a National Disability Survey. Chest 1987; 92.4: 613-7. House of Lords Select Committee on Science and Technology. Occupational Health and Hygiene Services,
HLP 28, London: HMSO, 1983. 9. Walters D, Gourlay S. Statutory employee involvement in health and safety at the workplace; a report of the implementation and effectiveness of the Safety Representatives and Safety Committees Regulations 1977. HSE Contract Research Report 20. Health and Safety Executive, 1990. 10. Occupational Health as a Component of Primary Care. Environmental Health Series No 12, World Health Organisation, Copenhagen.. 11. Black and Ethnic Minority Occupational Health Initiative, Annual Report 1990, Sheffield Occupational Health Project 1991. 12. Steelworkers' Lung Diseases, a review and hazards guide. Sheffield Occupational Health Project 1989.
