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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Comment — Medicine for doctors

DAVID BLACK laments the decline of occupational medicine and the wider occupational health system, and proposes ways to get it back on track.

In the 1950s New Zealand started to get it right. The post-war emphasis on public health spilled over into the workplace where the Department of Health was proactive. A specialist occupational physician, Dr Tom Garland, was recruited from the UK and specialised occupational health centres were established throughout the country – 27 of them!

New Zealanders such as Dr Bill Glass returned from London with postgraduate qualifications. The University of Otago set up a substantial academic programme. Good expertise was available, with specialised laboratories in the main centres providing a resource to industry and to the labour inspectorate.

By the early 1990s there was a worldwide move to tripartite regulation, and this was adopted in a draft bill. At last, it looked as though we were on the right track to a balanced regime. Sadly in 1992 much of this progress was effectively scrapped. The incoming government replaced the tripartite approach with a poorly crafted, blunt and inadequate instrument, the HSE Act. There was little attempt to integrate this with the ACC scheme. Extraordinarily, occupational medicine was dislocated from the rest of public health and placed within the Department of Labour. Most of the health clinics were closed or sold off. The DoH staff were redeployed, often in ways which undervalued and ultimately lost their health-based experience. The careful records built up by the DoH over 30 years (such as audiograms taken in industry) were largely destroyed.

The untested principle was that employers would take over the responsibilities previously managed by the regulators. The Minister of Labour of the day repeatedly talked of a carrot and stick approach, where the carrot was lower ACC levies and employers were the donkey.

The outcome? Occupational medicine as a speciality became isolated and its workforce, trained to provide care for workers, was largely captured by the insurance industry. There was a clear agenda to allow privatisation of some aspects of ACC.

Doctors practising occupational medicine were excluded from the public health system, other than a few to look after the staff. All public medical occupational services were withdrawn. University courses were continued but broadened into safety and with less focus on medicine. In 2007 the University of Auckland abandoned teaching occupational medicine altogether. Qualified health professionals had fewer opportunities to work independently in workplaces, while professionally and technically qualified people were often marginalised, made redundant and replaced with redeployed civil servants from other areas.

The idea was to enable employers to provide health protection for workers. There were some successes but many difficulties, the worst of which was that employers were often sold “products” that had little to do with health protection at work. The no fault ACC system gave birth to a “fault industry” because of the new requirement to establish if an injury was work-related, and the specialist doctors went to work for the insurers to conduct these arguments.

Twenty years on, as a result of Pike River, the H&S regime which since 1992 had been built on a flawed foundation was officially and rightly declared not fit for purpose. New legislation is proposed. New experts have once again been recruited from overseas. There have been some changes in safety, but in occupational medicine nothing obvious has altered. AFOEM has a good training scheme and category of vocational registration but there are very few occupational physicians working in industry to provide health protection for workers. There is no publicly accessible consulting service in occupational medicine available for patients who lack substantial means or private insurance. The only way in which matters can be raised is to start an argument, usually by lodging an ACC claim – not the most objective environment to decide diagnosis or management.

There are some obvious solutions. Occupational medicine needs to come back into the public health system. The health and safety regulator has grappled with health but has not proven to be an adequate custodian of this branch of medicine, and in any case it is absurd that it should remain dislocated from the rest of the profession.

The medical schools need to improve their level of teaching in occupational medicine at undergraduate and postgraduate level. This goal would fit in well with the introduction of occupational medicine clinics in the public hospitals. Such clinics need not and should not be concerned with matters of compensation or insurance.

The regulator should look hard at the purported occupational health measures taken by employers and ask for the redeployment of sometimes scarce employer resources from “wellness” programmes and other “busy work” to properly audited surveillance of matters more relevant to the nature of the work.

The thirty-year cycle has come round again. As in the 1950s and in the 1980s, we have a third opportunity to get it right.

Dr David Black is a retired occupational physician and senior lecturer in occupational medicine. He is a Fellow of the Faculty of Occupational and Environmental Medicine of the Royal Australasian College of Physicians.

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