What occupational medicine offers to primary care

INTRODUCTION

The health of patients who work is important to UK GPs — almost 32 million people work — and about a half of a GP’s patients work.¹ Recent government publications highlight a lack of practical support to help people who are off sick stay connected to and get back to work,² and that there should be easier and earlier access to health care for people in work, with GPs recognising when early referral might prevent someone leaving work permanently.³

THE BURDEN OF WORK–RELATED ILLNESS

There is a significant health burden and cost if employers do not ‘get it right’. Accidents and work-related illness through exposures to toxic or pathogenic materials, stress, and ergonomic problems challenge health care and the economy. An estimated 25.9 million working days were lost due to work-related illness and 4.5 million due to workplace injuries in 2015–2016 in Great Britain alone, costing an estimated £14.1 billion a year.⁴

In fact, 1.3 million people who worked during the last year self-reported a work-related illness, including 500 000 new conditions presenting that year.⁴ Another 0.8 million people who worked over a year previously have reported a work-related illness,⁵ with the costs extending to society, individuals, and their family members. Around a quarter of the cost is to the state, through benefits paid and tax lost (∼80%) and NHS treatment (∼20%).⁶

OCCUPATIONAL HEALTH SERVICES

Reducing the incidence of work-related illness requires support by multidisciplinary occupational health services (OHS) staffed by specially trained professionals who possess unique and complementary skills, that is, occupational physicians (OPs), occupational health nurses, physiotherapists, counsellors, and occupational health technicians. NHS OHS may provide access to occupational psychologists, occupational therapists, and liaison psychiatrists. Typically, OHS do not provide treatment (except in an emergency) or specialist referral. Surveys indicate that 13% of British employers provide access to some form of OHS⁷ and only 3% to a comprehensive OHS.⁸ Because a minority of the workforce can access OHS, working patients may turn to their GPs and other healthcare professionals for support for work-related illnesses.

OCCUPATIONAL PHYSICIANS

OPs originate from a range of medical specialties.⁹ Specialty training starts at ST3 level and takes 4 years, with trainees often having first gained MRCGP. Membership of the Faculty of Occupational Medicine (MFOM) is conferred upon completing specialty training. Associateship (AFOM) offers a professional pathway for doctors who work in occupational medicine but not in an approved training post. A diploma exists for those such as GPs with an interest in the field.

Much of the practice involves clinical assessment and analysis. An OP is ‘neutral’ and regularly provides objective opinions to workers, employers, and other bodies. This may be for many medical, organisational, and legal reasons, for example, to convey screening findings to GPs, to provide opinions about medical fitness to work to employers, pension schemes, or statutory bodies.

WHAT OCCUPATIONAL MEDICINE OFFERS TO PRIMARY CARE — SOME OF THE EVIDENCE

Occupational health intervention studies are difficult to locate in databases because of diverse study types, few cost-effectiveness analyses, and poor methodologies; however, a new report from the Society of Occupational Medicine synthesises the evidence, mainly from systematic reviews.¹⁰ Some findings may inform the care of working patients, even in busy GP surgeries:

• Workplace ergonomic interventions are very effective in the prevention and management of work-related musculoskeletal disorders (WRMSDs) — ask a patient you suspect may have a WRMSD if their employer has performed a recent risk assessment, for example, manual handling, display screen equipment, or a general ergonomic risk assessment. The GP can recommend this is done on a fit note.

• Suspected work-related stress — cognitive behavioural therapy (CBT) is effective, particularly for workers who have control over their job demands — but employers must address the causes. CBT may be directly accessible via GP referral or self-referral. An employer may provide access to counselling/CBT, for example, via employee assistance programmes.

• Return to work interventions are among the most effective interventions — GPs should ask patients if they can access OHS to assess their needs and facilitate reasonable accommodation and adjustments for health conditions or disability.

• OHS are mainly available in larger organisations. Smaller employers and workers can access free work and health advice service through the Fit for Work service.

• Early detection and intervention is better. For example, for occupational asthma, be sure to ask any adult with new-onset or recurrent asthma or rhinitis about their job and what they are exposed to at work. Advise the patient to report this to OHS, if there is one, and their employer if not. Specialist referral is recommended whether or not an OHS exists — to ensure early diagnosis and management. Previous exposure to asbestos, even decades before, should raise suspicion of work-related respiratory illness.

COMMUNICATION

Care of the patient is the first concern for all doctors — working collaboratively is key to ensuring best patient outcomes, as is communication with the patient’s informed consent. GPs should be assured of the neutrality of OHS, whoever employs them: as with any doctor, OPs have a professional duty of care to patients. Confidentiality remains important, as does following the General Medical Council’s Good Medical Practice, for example, where there is endangerment to the public in a worker in a safety critical role.

‘FIT NOTES’

Where the patient cannot access OHS the Statement of Fitness for Work (fit note) is the main currency of communication between GP, patients, and employers. Although over 60% of GPs agree, or somewhat agree, that the fit note has improved the quality of return to work discussions with patients, and over 90% agree that helping patients to stay in or return to work was an important part of their role,¹¹ the fit note is not fully achieving what it set out to do.² The government will review the operation of the fit note, including whether certification should be extended to other healthcare professionals.³ The busy GP can provide information on fit notes to help employers or Jobcentre Plus work coaches support return to work — potentially shortening absence and reducing the need for repeat fit notes.² Information should be objective and evidence based, but no one should expect GPs to operate outside of their expertise. Updated guidance on completing fit notes is available on the Department for Work and Pensions website.¹²

FIT FOR WORK

Where a patient is expected to be off sick for more than 4 weeks the GP can refer the patient to the Fit for Work service using an online referral form at http://fitforwork.org and https://fitforworkscotland.scot/. Fit for Work can offer a biopsychosocial assessment, identify barriers preventing return to work, and, where appropriate, offer a return to work plan. Fit for Work can help GPs by reducing demands for assessments, fit notes, and detailed work-related advice.³

It is worthwhile remembering that maintaining contact with and involvement in work during the illness is a key factor in successfully retaining employment and returning to work after an illness.¹⁰

Bearing this in mind, a simple reminder may assist the busy primary care consultation when workplace health issues are suspected. It may help to ask, listen, and record from the patient the following:

• what they do day to day in their job and of any exposures to hazards at work. Remember that occupation or job title alone reveal little, and sometimes nothing, about what people do and the hazards and risks involved;

• other activities and exposures to hazards, for example, hobbies and second jobs; domestic stressors that may be the main underlying cause;

• risk assessments and training undertaken at work or due;

• key concerns — prognosis, job security, income while off sick, and other sources of stress. Such information can help with the primary care management, and communications with OHS or employers, to assist all parties, in particular the patient, in effectively managing workplace health risks and concerns; and

• support — consider with the patient what support services are available from the GP practice, the employer, OHS, Fit for Work, Access to Work, and the voluntary sector. The patient’s wellbeing and livelihood may be at greater risk if help is not available.

Provenance

Commissioned; externally peer reviewed.