A survey of Occupational Health Service organizations of

1. Occupational Health Services in eleven countries – who are they?* Contribution to Health for All?* Contribution to business development? *Contribution to an inclusive working life?* Problems ? A survey of Occupational Health Service organizations of Austria, Czech Republic, Denmark, Japan, Finland, France, Germany, Netherlands, Norway, Sweden, UK and UK/Scotland Special Issue of ”Policy and Practice in Health and Safety” Chief Editor: David Walters Guest Editor: Peter Westerholm

2. Occupational Health Services in UK (Lawrence Waterman) • Problem – 8 % of private sector companies use some form of OH support. 2.5 mill. people on incapacity benefit in 2005. • OH preventive services a patchwork quilt of public and private providers with widely varying approaches and service quality • NHS tasks diagnosis and treatment – not prevention • Strong professional bodies of OH safety and health advisers (occupational medicine, occupational hygiene etc) • Indications of traditional approaches in OH being largely ineffective. More of the same not likely to improve situation • In 2000 key documents of HSC intentions – ”Revitalizing health and safety” and ”Securing health together” demonstrating OH issues of central importance and providing basis for broad-based, multi-skilled team approach in addressing issues such as risk assessment, fitness for work and the rehabilitation and return to work of workers in ill health • In 2001 establishment of Programme Action Group to follow up ”Revitalizing” targets • Birth of the OH Support model to be described as Workplace Health Connect by the HSE

3. UK (Lawrence Waterman) - Workplace Health Connect –programme (HSE 2005) • A confidential service designed to give free,practical advice on workplace health, safety and return to work issues to smaller businesses in England and Wales • An adviceline and supporting website – giving tailored practical advice to callers, both managers and workers, on workplace health, safety and return to work issues • A service that aims to transfer of knowledge and skills directly to managers and workers enabling them to tackle and solve issues themselves • Set up in partnership with HSE and based around Adviceline/website and problem solving services available locally • Bottom line messages - OH too important to leave to doctors - Health is not divisible – healthcare is at its best holistic - To prevent harm is good, to promote wellbeing is even better

4. Developments in professional OH - UK /Scotland(Ewan B. Macdonald & Gabe Docherty) • Taking the UK government programme ”Work, Health & Wellbeing – caring for our future” one step further • Scope of OH professionals work tasks widened beyond traditional workplace perspective to cover all population of working ages • National OH Director appointed to implement Work, Health and Wellbeing strategies • Center for Healthy Working Lives established for coordination of OH activities • Healthy Working Lives action plans to be implemented on a large scale • NHS/Scotland to support development of free advisory OH services to SME:s in industry • Free Workplace visit, confidential Risk Assessment, WPHP needs assessment,

5. OHS/The Netherlands – development from a professional to a market market regime (André Weel & Nico Plomp) • First period 1920 – 1980 – Medical OH services. Drive from large industrial corporations and government to arrange medical services for workers • Second period 1980 – 1994 – Multidisciplinary OH services. Services became advisory bodies with an enlarged scope of tasks. Legal and economic experts on boards of management. Occupational physicians, occupational hygienists, safety engineers and organizational advisers on service teams. • Third period 1994 – 1999 Commercial services. Service units transformed into business organizations. New commercial OH providers emerging and sharp competition on health market. Insurance companies and private investors enter stage as owners • Fourth period 1999 – 2006 Lost monopolies Incentives to invest in rehabilitation and prevention strengthened. Return to work programmes and sickness absence management in demand by client companies.

6. OHS France – on the rails from occupational medicine towards occupational health (Gabriel Paillereau) • Arrangement of access to OHS services at compulsory for employers (who pay the costs) • Dominant role of OH physician as advisor in all OH matters and adaptation or development of working conditions. • Heavy load of annual medical examinations of all employees for assessment of work ability • Cardinal changes following a Government decree of July 2004: - medical examinations reduced to examinations every second year - OccupPhysicians dominance challenged in introducing a new professional category – ”occupational hazard prevention operative” - Occupational Health Plan 2005-2009 implying strengthening of surveillance and monitoring functions and establishing new administrative central and regional structures for these tasks - Planning of regional multidisciplinary research centres • Transformation has caused and is still causing a good deal of heat

7. OHS Finland (Matti Lamberg, Kaj Husman & Timo Leino)- the cornerstones • Government development strategy for OHS during 2002 – 2015 • OHS objectives to promote health and work capacity, to increase attractiveness of working life, to prevent and treat social exclusion and to provide functioning services and reasonable income security • Employers obligation to organise and pay for preventive services for all workers. This may be done in different ways • Employers are reimbursed for up to 50 % of approved OH service costs from sickness reimbursement funds • OHS main tasks to prevent work-related illnesses and accidents, to raise level of health and safety at work, to improve health, working ability and functional capacity of employees at all stages of their work careers, to promote the functioning of the work community • Legislative regulation of management and surveillance of national plan and subsidiary plans addressing vocational training, competence development matters and research • Finnish OH system based on firm political determined commitment

8. OHS Denmark – Rise and fall of preventive services (Anders Kabel, Peter Hasle and Hans-Jörgen Limborg) • Before 2001, OHS organisations/units provided services oriented towards OH needs of prevention. Basis: Employers legal obligation. Structure: Bipartite management of service units. Requirements of competencies and a quality system with programme for evaluations • After 2001, consequent to post-election change of government : - obligation of employers to organise OHS affiliation annulled - OH surveillance to be enforced by Labour Inspectorate issueing notice for improvement. - Notices for improvement may include referral to OH service units for assistance in complying with requirements of Labour Insp. - Companies with a Danish certificate on work environment or British OHSAS 1800 are exempt from inspections • Earlier OHS units may be authorised to provide consulting services on Working Environment issues. On market also others offering similar type of services. • Consequences: Significant decrease of OHS service units in market and availability of OH professionals

9. OHS Sweden - Example of OHS unit Programme Document- Chief Occup. Physician Johnny Johnsson, StoraEnso Inc. Forss, Sweden) • Prevention of work-related disease and illness • Promotion and restitution of health • Development of the working environment • Improvement of work capacity, motivation and performance of staff Supplement – jontly with company Safety Dept • Support of business activities and strategies for Human Resource Management • Client orientation and generation of added value for the company in general

10. OHS in European countries – an ETUC view (Laurent Vogel) • OHS systems of Europe display wide differences in legislation and practices • From trade union point of view many OHS systems do not deliver services matching expectations placed on them. Situation sometimes described as a Crisis of Confidence • Coverage patchy - in most countries well below 60 % - excepting countries with legislative requirement for full or almost full coverage (Ex. Netherlands, Belgium, France, Finland, Luxembourg) • Large groups not provided OHS : SME´s, workers in insecure jobs, unorganized labour etc • Multidisciplinarity - only modestly developed. Nordics, UK + Spain • Quality of OH preventive services often uncertain. Its surveillance inadequate • Reservations regarding OHS professional independence • Reservations regarding professional competence of external consultants and expertise in Occupational Health subject matter • Reservations regarding collaboration and contacts between workers and preventive services

11. OHS Professionalism – regardless of setting • To have a Health agenda • To be evidence-based or, at least, evidence-informed, in action and in all assessments • To be aware of stakeholder expectations • To help solve practical problems • To communicate on OH issues with management, employees and trade unions and with other OH professionalsas appropriate • To act in alignment to principles of Occupational Health ethics • To take all opportunities in contacts to a life-long learning process • To be transparent in all action and asessments

12. The Doctor’s Leadership Paradox • A physician does not really need a boss at all • If there should happen to be a boss anyhow, it must be another physician • “Bosses” only do un-important, administrative things • Colleagues who become “bosses” are no longer real physicians • However, all physicians want to be bosses and have a highly developed sense of hierarchy…. Source: Chief Physician Carola Lemne MD Hospital Manager of Danderyds University Hospital Karolinska Institutet, Stockholm

13. PW_IOSH_Cardiff May 2007 ”A handshake should not go beyond the elbow” African proverb – Quoted by Godfrey B Tangwa, Yaounde University, Cameroon

14. OHS – some features with implications for professionalism • OHS actor in a welfare system of considerable complexity with high dependence on other actors in concerted efforts • Multiple stakeholder scenario in which no individual stakeholder is a priori regarded as most important of all • Challenges on evidence based or research based knowledge and insights • The three common models of guiding and managing human activity – hierarchy, market and professional networks - exist in parallel • Three domaines in co-existence – OH professionals, management – including management of OHS organisations – and the domain of industrial relations. The demarcations of accountability and responsibility may become blurred all too easy. • OHS work carried out in an ethically complex and demanding context • Health professions globally involved in re-negociation of their societal and market targeted contracts • Well trained graduates of universities pouring out and entering all sectors of labour market - including the health sector

15. Some determinants of OHS future • Commitment and governance of the state with regard to OHS? • Role models of OHS organisations. Agents of public health?, Commercially based organisations in a health market? • Required competencies of OHS organisations in meeting expectations of the state or those of clients in the market? • Conception of service quality and its development in OHS. Whose quality? Quality of customers/clients ? Quality as understood by health professionals? Quality implying cost-efficiency ? • Implications of market mechanisms in OHS organizations operating as market actors? • Strategies for evaluating the effectiveness and health impact of OHS?

16. Professionalism is to be visible and to inspire trust

17. This is it Thank you for your attention !!! Peter Westerholm