Occupational health services do not exist as an end in themselves but as a means to an end. They are created to prevent an unnecessary interference with the primary mission of the organization, whether that mission is to create wealth, to provide a needed service, or to protect the interests of a community of people. Organizations as disparate as small business, corporations, government agencies, and the military have similar needs for effective occupational health services. Occupational health care is a process, not an outcome, and the success and quality of a service providing such care is measured by the absence of problems rather than by a specific end point. It therefore follows that a commitment to sound occupational health practices must be on-going and not limited to a specific problem-solving exercise. This fundamental principle must be accepted by the decision-makers within an organization or by a proprietor of a small business before a commitment to provide occupational health services begins to make sense and the value of such services becomes apparent.
The term "occupational health service" is used in writing and speech in either of two senses. When singular, the term usually refers to a facility or a department or other administative unit charged with responsibility for occupational health and usually safety as well. This use of the term is analogous to a "service" in a hospital. When plural or when specified as one of several opportunities, the term usually means an activity, program, or function in the sense of a service to be provided. The meaning should be clear from the context but both senses are in common use and both are used in this book, in order to parallel current actual use of the terms by professionals.
The role of the occupational health service is to provide assistance both to management and the employee so that the employee is not harmed in the course of work. To fulfill this role, the service must be and also must be perceived to be objective and impartial, whether it is part of the management structure or an external health care provider. The operational responsibility for sound occupational health and safety practice lies with the people who do and supervise the work, the employee, operating personnel, and managers. The occupational health service exists to serve them; it can assist but it cannot be in all places at all times. Its role is that of consultant, troubleshooter, teacher, auditor, and advocate. It cannot function as a policeman, personnel officer, or scapegoat and remain effective.
The objectives of an occupational health service within this role can be summarized as follows:
Philosophically, the occupational health service helps to create a fair balance between the employee's and the employer's rights and obligations. It exists to protect the employee from harm and to try to ensure that if the employee is harmed, despite the best efforts of the employer, the care given will be adequate and the compensation for the injury just. At the same time, it must ensure that the employer is not held responsible unfairly for situations beyond its control. Like the fulcrum of a seesaw, the occupational health service must weigh the legitimate interests of both employee and employer, but also like a fulcrum it often experiences pressure from both sides. To do its job, the stresses felt by the service cannot be too one-sided. In practice this means that the service must be given a certain degree of independence from management in both administrative structure and policy.
When the occupational health service is an outside physician or organization providing care on a contract or fee-for-service basis, there is often an inherent conflict between a desire to please the employer, in order to maintain the relationship, and a desire to please the worker, in order to attract private patients from among the employees. When this natural desire to accomodate the expectations and wishes of the two groups leads the physician or organization to be more responsive to their needs, it can be a good influence resulting in better service, closer attention to details, and an incentive to keep up with changing conditions. Indeed, responsiveness to the legitimate needs of both employers and employees is the essence of marketing for facilities providing services to many employers. The line between legitimate responsiveness and introducing bias into medical decisions and communications must be sharply drawn, however.
When the occupational health service is an in-plant facility, the pressures tend to be more one-sided favoring management. An enlightened employer sees the long-range benefit - and ethical imperative - of treating employees fairly and providing for their health care. The most enlightened will extend this same logic to promoting the health of their employees and ensuring that preventable hazards on the job are controlled to the degree feasible current technology and appropriate to the magnitude of the hazard to health - regardless of regulatory requirements specifying the legally acceptable minimum. Those employers who do not subscribe to this philosophy have often had bad experiences involving repeated abuse of the workers' compensation system, union-management conflicts over issues perceived by management as frivolous, or citation for failure to comply with occupational health and safety regulations that management does not accept as valid. From the manager's point of view, such experiences (first-hand or reported) justify a cynical view of occupational health services. Yet, the experiences of more employee-responsive employers are no worse and are usually much better. One suspects that there is often a process of action-reaction going on, in which constrained management policies are met with hostility on the part of employees expressed in many ways, including abuse of the occupational health system. When this occurs, it is usually up to management to take the first step toward reducing tensions and it almost invariably follows that some of the pent-up frustrations on the part of employees lead to an initially disappointing result. Yet, the transition to a mutually supportive relationship between labor and management can be made even with a smokescreen of rhetoric questioning management's motives. In such situations the occupational health service should be an oasis of fairness and mutual respect, despite the pressures on it.
Whether a plant, company, or agency is unionized or not becomes important to the role of the occupational health service, but it is difficult to generalize how interaction with a union affects day-to-day operations. When employees are organized in a plant, the union may negotiate for improved working conditions and occupational health services as part of collective bargaining. In some cases, the occupational health service is mistrusted as an unwarranted benefit for employees and may be seen as a beneficent gesture, demonstrating the employer's good will and responsiveness; this is not necessarily ideal as it can degenerate quickly into a patronizing and paternalistic attitude that turns into sour resentment at the slightest problem or conflict. In general, occupational health services that are the direct product of collective bargaining are vulnerable to abrupt changes in policy, financial cutbacks, and to being used as a pawn or distraction in contract negotiations. It takes real effort to preserve the occupational health service as neutral ground in such circumstances and requires a commitment from both sides. This commitment can only come from a mutual understanding of the occupational health service and its actual role in the workplace, regardless of what either party would like it to be for their own purposes. In unionized plants, the local often intervenes in individual claims as well as by advocating changes in the workplace and acting as a conduit for complaints regarding working conditions. The union representative may assist the employee in filing a claim, arguing an appeal, or researching the background to a complex problem. Unless allowed by a clause in the collective bargaining agreement, the union representative is not entitled to personal medical information (other than fitness to work) any more than the representative of the employer but the employee is free to release medical information to whomever one wishes and almost always will do so if the union is taking up the case. A collective bargaining agreement, on the other hand, is a contract binding on all parties union signing - until it expires. If the contract stipulates that specific information is to be or can be released, that constitutes valid authority to do so.
The occupational health service in or serving an organization without union representation has a different set of problems and opportunities. As a creation of the employer without the watchdog of the union, it often commands greater support from management but it is sometimes subjected to considerable unopposed pressure to see things management's way. Communication with employees is often more difficult because there may be no organized representation and no vehicle for conveying information other than through supervisors, who have their own agendas and may distort the message. In this situation, full use must be made of joint worksite health and safety committees (required by law in some jurisdictions), quality circles, recreation associations, newsletters, and other means to communicate directly with employees and - equally important - to learn of their concerns. Unions tend to promote improved but not ideal working conditions in most industries, in part because the process of collective bargaining makes it hard to focus attention on this one issue when wages, hours, and benefits are on the table. By contrast, non-union plants often tend to fall in either extreme; the lack of representation may lead to unacceptable conditions in one plant but in another the management may provide excellent benefits and working conditions in an effort to ensure employee satisfaction in order to prevent the establishment of a union. The occupational health service can serve as a meeting point, where employee's concerns are heard and transmitted to management and management's policies are explained to the employee. It should not attempt to do more than this outside of occupational health matters, however, or it will risk overstepping the bounds of neutrality and compromising its ability to provide fair and responsive care.
Although occupational hazards have been recognized since ancient times, organized occupational health services are a comparatively recent innovation.
In modern times, occupational health services have several models after which to pattern themselves. The plant dispensary with a nurse and perhaps a part-time physician who works with a safety officer from another department traditionally has been the norm but this model is inadequate for larger organizations or those with needs beyond the most basic services. It also depends too heavily on a single person (the nurse) who must be exceptional indeed to be effective in the face of considerable demands. The largest employers can afford a full-time staff and many choose to integrate medical, safety, and occupational hygiene services into a single department with a professionally qualified director. This approach has considerable merit but it is not practical for smaller organizations. In Britain and particularly in the US, private medical groups have developed to serve several employers in a given area, providing each with convenient services that none could afford in-house. In Quebec and Sweden community-based government-sponsored clinics have been organized along similar lines. Although attractive as models, both types of clinics appear to have difficulty providing specific technical occupational health services because their roots are in general medical practice and little provision is made (except in Sweden) for preventive and occupational hygiene services coordinated with the management of the client employers. The provision of the full scope of occupational health services to small employers remains one of the most difficult problems in occupational health practice.
The decision by management to develop or to contract for an occupational health service and how the arrangement shall be structured must reflect the realities both within the organization and the community of which the organization is a part. Among the considerations are the following:
Nonmedical functions, such as safety and occupational hygiene, may be organized as separate departments within an organization or incorporated into the management structure in an integrated occupational health unit. Sometimes specific non-medical services are obtained by contractural agreement from an outside supplier. Regardless of what form of organization is selected, it is essential that there be clear lines of communication and a close working relationship between the essential non-medical functions and the medical. Otherwise, efficient prevention and problem-solving is impossible and solutions to problems are often postponed or resisted because of personal or political agendas.
Occupational medical services may take four basic forms:
External services serving a single employer are common, in the form of individual physicians or consultants who do part-time work, usually on an as-needed basis, for a particular company or public agency. Usually, this activity supplements a private practice but it can be part of a physician's retirement activities or the result of a special relationship or prior experience with the agency or company or a specialized industry, such as aviation, with particular needs. Such arrangements are highly individualized and usually specific to the people involved; they do not transfer easily and tend to fall apart with changes in management. Often, they are short-term, temporary assignments to resolve a particular problem or case. One hazard of extending such arrangements over long periods is that cozy and perhaps prejudicial relationships may develop between the physician and the employer.
Internal occupational health services serving one employer are typical of large corporations, large single plants, and public agencies of cities and higher levels of government. There are of two general types, the in-plant health service and the corporate medical department. The in-plant health service often goes by the name of the infirmary, dispensary, or clinic; it is a facility where medical care above basic first aid can be rendered to ill or injured employees and where programs of a medical nature for prevention and health promotion are organized and implemented. It may be supervised by a suitably trained nurse or by a physician and is often staffed by both with the physician available by contract at designated times during the week. The in-plant health service is the first level of care, providing initial treatment and evaluation for fitness to work but rarely managing complex or difficult cases, which are usually sent outside to local practitioners. Unless a plant presents an unusual or particularly serious hazard, such as a shipyard might, or it is in an unusually isolated location, it is generally unwise for the in-plant health service to provide specialized or major surgical care because of legal liability and the cost of maintaining adequately equipped facilities. The corporate medical department is a unit within the management structure that reports at a high level and participates in policy formation and decision-making. The corporate medical department is always headed by a physician, usually with an executive title and position, who directs and reviews the provision of health care within the organization, including its plants and other worksites, the headquarters staff, and the medical aspects of the benefits packaged for employees. At the corporate level, direct medical services may be provided to local or headquarters staff or in the evaluation of individual problem cases, but this function is secondary to that of coordinating and advising on health-related matters within the organization.
External services serving multiple employers predominate in the occupational health care system. They include individual hysicians, group practices, hospitals, and clinics that accept patients from several of local employers on a contract or fee-for-service basis. Because they are outside the employer's organization, these providers are often seen by employees as neutral or at least not unduly influenced by management; they are, however, vulnerable to the conflicting pressures from employees and employers described in the last chapter. Increasing competition among health care providers for patients has increased this vulnerability, since there may be many acceptable alternatives for employers to send injured or ill employees. Occupational health services serving many employers are in a relatively poor position to influence management and are at a disadvantage (and are rarely motivated, except for marketing or academic purposes) in providing services in prevention or control of hazards. This is probably the only practical model for providing services to small businesses, however, given the high overhead costs of maintaining internal services for small numbers of employees.
Internal programs providing services to multiple employers are of three general types: 1) in-plant services open to subsidiaries and affiliates of a larger company (essentially an extended form of the internal-single employer approach), 2) in-plant services open on a contract or fee-for-service basis to other small local companies (a variant of the external-multiple employer approach), and 3) contractual arrangements by which an occupational health performs provides limited in-plant services for several employers at the same time. The first two are more common in other countries where the health care systems are not well developed or where "polyclinics" (health care centres serving the needs of a particular population) are organized by industry or employment, as in Eastern Europe. The most common situation of contractual arrangements serving multiple employers with in-plant services is when a physician works part-time in more than one plant. Occassionally, systems have been devised by which a contractor (usually a physician) places hired nurses in in-plant facilities and provides them with back-up and supervision, for a fee. Given the limited role of in-plant services and the ready availability of medical consultation in most areas, it is predictable that such arrangements usually end with the company hiring the nurse directly to save money.
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