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Occupational health services—standards need to be underpinned by better research on effectiveness
  1. Malcolm R Sim

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The Faculty of Occupational Medicine (FOM) of the Royal College of Physicians has recently released a set of standards for accreditation of occupational health services in the UK.1 This is a welcome development and very timely, given the high profile of recent debate about service provision in other areas of the health sector in many countries, such as the USA and Australia. The FOM standards articulate the expectations of a safe, effective, quality occupational health service. It does this by outlining minimum requirements in six important areas of occupational health service provision; business probity, information governance, people, facilities and equipment, relationships with purchasers and relationships with workers. The recommended assessment process for accreditation is to include suitable evidence that eligibility criteria are met, based on customer satisfaction, an on-site assessment visit and self assessment.

The release of these standards by the FOM brings into the spotlight questions regarding the effectiveness of the provision of worker healthcare and prevention activities by occupational health services; as raised in the 2008 review of the health of Britain's working age population by Dame Carol Black.2 Such services should aim to prevent workplace disease and injury, effectively treat and manage workers who develop such conditions and facilitate return to work for injured workers. While many of the activities undertaken by occupational health services are likely to meet the aim of improving worker health and reducing the impact of injury, illness and disability, there are lingering questions about the research evidence for the effectiveness of some programs provided under the umbrella of occupational health services.

While it is important that occupational health services engage in a wide range of activities and programs to improve worker health, it is essential that the design and implementation of such programs have a sound evidence base. This is important to ensure that scarce occupational health resources are utilised in the most effective way, but unfortunately research into occupational health service provision is often seen as the poor relation in the occupational health field. A review of evaluation research in occupational health services has found that most of the published studies at that time were descriptive, rather than evaluative, and methodological quality was not high.3 This review also found that at that time some areas of occupational health services, such as occupational rehabilitation, were hardly studied, while there was a lack of evidence for the effectiveness of the pre-employment examination. Subsequent research has found little difference between different methods of pre-employment examinations for non-hazardous occupations, whether by questionnaire or involving assessment by a medical practitioner.4

Another example of where good evidence of effectiveness is lacking is hearing loss protection programs aimed at reducing the impact of noise induced hearing loss (NIHL), a longstanding occupational disease thought to be well controlled in developed countries. However, there is increasing evidence that despite decades of NIHL control, compensation claims are increasing, suggesting that past and current strategies to address this problem are not effective, inadequately implemented, or both.5 This conclusion is supported by a recent Cochrane review of interventions to prevent occupational NIHL, which concluded that there is contradictory evidence that workplace hearing loss protection programs are effective in the long term.6 While the prevention of NIHL is dependent on appropriate and enforced legislation and the suitable use of engineering controls, occupational health services are in the front line regarding the implementation of hearing loss prevention programs, including audiometric monitoring, and as concluded by the Cochrane review, there is a pressing need for better quality research into the long term effectiveness of such programs for this long established occupational disease.

Similar questions have been raised regarding the effectiveness of many other activities which may be undertaken by occupational health services. One published example of involved genetic screening to detect those thought to be at increased risk of work-related disorders. The case of genetic testing of 20 railway workers in the USA who submitted compensation claims for carpal tunnel syndrome highlighted many of the ethical, legal and scientific pitfalls when such testing is used inappropriately and isn't based on a rigorous scientific evaluation of the screening tests.7 With the rise in the incidence of chronic non-communicable disease in the general community, such as diabetes and cardiovascular disease, workplace health promotion programs are becoming increasingly common activities for occupational health services. While modest benefits have been found in a recent systematic review of dietary behaviours, further research on workplace health promotion should be directed at interventions at multiple levels of the worksite environment.8

Another important aspect of the evaluation of occupational health services is consumer satisfaction, as they are different in several respects from other types of health services, such as the perception of independence of occupational physicians and other OHS staff and visits often not being prompted by the workers themselves, but required by the workplace. Interestingly, this is an aspect of occupational health service provision highlighted by the newly released FOM standards as one of the important criteria for accreditation, but this will require valid ways to measure such satisfaction of occupational health services, as it has been shown that satisfaction levels can vary widely, depending on the methods used.9

Since occupational health services are not available to at least 80% of workers worldwide, a major challenge is to undertake research to identify the most effective way to increase coverage and quality of such services. There are some particular challenges with occupational health service provision in newly industrialising countries, but there have been international developments to provide Basic Occupational Health Services (BOHS), based on different models of care from occupational health services operating in developed countries.10 Research to evaluate the effectiveness of BOHS is needed and a recent prospective study in China has indicated that BOHS integrated into the primary healthcare system can increase the coverage of occupational health services, such as health surveillance and awareness of occupational health hazards.11

Unfortunately, despite these documented needs for research into the effectiveness of the activities of occupational health services, the quality of such studies is often poorer and has traditionally had a lower profile than other areas of occupational health research, such as aetiological or intervention research. In addition, there will be important future challenges in the provision of effective care to workers due to the ageing of the workforce and the rise in precarious employment. The release of the FOM standards for occupational health services, which addresses one of the recommendations of the Black Review, should help to raise the profile of this important aspect of occupational health practice and encourage the research community to design better studies to help evaluate occupational health services and to provide the data to underpin standards and accreditation.



  • Competing interests None.