Observations on Occupational Health Services in Europe and Japan

Introduction

This article focuses on selected observations in the draft texts being currently edited, and some general comments have been added on a few salient issues. As a general observation it was noted that there is considerable variation in the approaches and practices of OHS in the countries examined. This is interesting, as the working conditions in the countries sampled are subject to largely similar impact factors, such as the rapid globalization of national economies, technical, social and economic changes, and demographic developments, all of which carry profound implications. These changes affect the health, work life and quality of life of millions of people. The approaches and solutions regarding the roles and tasks of occupational health professionals in these change processes chosen by the countries differ significantly, although the occupational health challenges in many of these countries are quite similar as regards important issues. Initially it had seemed reasonable to anticipate similarities between the OHS systems, or, at least converging trends, considering e.g., the intentions expressed in the European Framework Directive 89/391/EEC (1989) on Safety and Health at European Workplaces. One important conclusion is therefore that these differences need to be scrutinized when seeking shared policies and joint ways for the future development of OHS systems.

Legal basis

In most countries employers are obligated by law to organize OHS for their employees. This obligation is strictly enforced in Finland, France, Germany, and at the present time also in the Netherlands. It applies partially, implying exemptions for companies of a certain size or in specified sectors, in Austria, Japan, Norway and the Czech Republic. There is no corresponding legal requirement in the UK. In Sweden there is a requirement with the character of a recommendation, leaving it to the employer's discretion to provide OHS. In Denmark a legal obligation was enforced in the industrial sector with a plan adopted for extending the employer's obligation to apply also in other branches of industry and in the service sector. However, this was cancelled in 2005 after a political change bringing a new government into office.

Coverage

The countries that strictly enforce the provision of OHS can, for obvious reasons, demonstrate high rates of coverage of the workforce, approaching 90 - 100 %. In some countries the assessment is uncertain due to unreliable statistical sources. In Japan, Austria, Sweden and the Czech Republic, the estimates are therefore uncertain, especially as regards the situation in small and medium-sized enterprises (SME). This applies also to the UK.

Financing

In most of the countries covered in the study, the funding of OHS is arranged by the client companies and the market. This applies also to countries where OHS is legally stipulated (i.e., the Netherlands, the Czech Republic, Norway). In France the main funding comes from Regional Social Security Funds, contributed initially by employers' levies. In Finland the costs of OHS are basically funded by client companies, but there is a significant refund of roughly 50% of company costs through a collective insurance scheme under the surveillance of the Government through the Ministry of Social Affairs and Health. The bottom line seems to be that the funding of OHS is derived from the production of industry and services. The ordinary tax-payer is not a major stakeholder so far as funding is concerned.

Multidisciplinarity

In most countries there are intentions to develop the competence of OHS professionals and raise the level of multidisciplinarity or, rather, multiprofessionalism, which may be the preferred term here. Presently, however, the medical professions are predominant. In Denmark, the primary task of the multidisciplinary OHS units has earlier been preventive action, and it has been most consistently implemented. But now this OHS component of the Danish system is in the process of being dismantled.

Quality systems

The quality approaches adopted in the studied countries display a broad range of variation. There are standard systems of quality assurance specific to OHS developed and applied on a voluntary basis (Sweden). In some countries quality assurance systems are enforced by legal statutes as an instrument in authorization (the Netherlands), whereas other countries lean heavily on good practice guidelines in OHS (Finland, the Netherlands and Norway). In some countries professional guidelines are combined with the enforcement of regulations concerning the quality of OH services (Germany). In Denmark the official quality system set earlier for OHS no longer applies. In the UK quality guidelines for OH services are followed in the NHS (National Health Service) and guidelines on professional occupational health practice are issued by professional organizations, such as the Faculty of Occupational Medicine of the Royal College of Physicians.

Special features

Concluding remarks

Due to the lack of space, numerous issues can not be dealt with in detail here. Readers are therefore referred to the issue of "Policy and Practice in Health and Safety" containing the forthcoming article series on OHS, to be published at the end of 2006. Reference is made to a few selected major issues confronting professionals working in the area of OHS. The first question concerns the role of OHS. Is OHS, as service organization, to be seen as an agent of public health, implying an instrument or tool of the State, or as an entrepreneur in a health market providing service commodities on demand to companies, organizations and other paying customers? Or is it to be both? In countries where OH services are available as commodities on the health market, there is usually competition with other agents providing the same kind of services.

A general observation is that OHS organizations in many countries assume roles lying somewhere between the role of an agent of public health and that of a provider of expert occupational health services – sometimes including curative services – to companies. In some countries the OHS system combines these roles.

This dual role may lead to differing expectations among the consumers of OH services and other stakeholders. There are customers and clients who request curative services only. Others prefer health promotion and periodic health examinations. There are, in contrast, also customers and clients or client systems with highly developed awareness of the health aspects of work, and they request OHS to contribute to programmatic approaches of considerable scope. This leads to widely differing expectations, and it also has implications for the assessment of quality and for the strategies to be selected for improving service quality. Clearly, health service organizations which primarily have public health agendas need to create a profile of professional competence that differs from commercial health organizations operating on the market The key question concerns the commitment of the State. If the OHS is understood to contribute to public health in an important way, as may be inferred from policies adopted by governments in Finland, France and Germany, the logical next step is to extend the availability of services to the entire work force. This is commonly achieved through legislative action or public regulation, i.e., by requiring companies to organize OH services. In countries where OHS is rather seen as a market commodity, as for instance in Sweden, the OHS is market-based and thus dependent for its existence on customer demand.

So, to sum up, some tough questions pertinent to the development of OHS in Europe, as well as globally, concern:

- The commitment of the State with regard to the organization, tasks, professional competencies, and funding of OHS?

- The roles of OHS organizations, either as agents of public health, or as commercially based agents providing services on the health market?

- The required competencies of OHS organizations in meeting both the expectations of the State, on the one hand, and those of the client companies on the other hand?

- The conception of service quality and its development in the field of OHS? Whose quality is it to be? The quality of services as perceived by customers/clients to satisfy their needs or demands? Quality as understood by health professionals? Quality implying cost-effectiveness or cost-efficiency of services?

- Competing or conflicting objectives in national OHS systems, such as work force coverage vs. competence/quality of service performance, and quality vs. competitiveness of OHS organizations on the market?

- The strategies for evaluating the effectiveness and health impact of OHS?

The essential question that remains to be tackled is: How should the competencies of occupational health professionals be developed, and how could their expertise be best channelled to provide a worthwhile contribution to the sustainable development of healthy societies? It is a perplexing observation that highly developed countries display such fundamental differences in organising OHS despite the fact that they share most of the major features of workplace health hazards and have access to similar occupational health expertise and professional competence. It is a sobering observation to see that the European Framework Directive on safety at European Workplaces clearly accommodates countries exhibiting widely differing practices. It is reasonable to assume that a large part of the differences may be explained by differences in the structure of the health care systems and in pertinent legislation or national cultures. The possibility of important inter-country differences in policies and the assessment of the needs of occupational health expertise should not be overlooked. The question of whether a convergence of organizations and occupational health practice – including the roles to be assumed by occupational health professionals – is feasible or even desirable is of a complex nature. It is quite possible that such convergence could be beneficial to companies, to the labour market and, indeed, to whole societies. It nevertheless seems important that efforts aiming at such convergence be based on international discourse and deep-going investigation of the factors underlying inter-country differences. In the field of safety and health, as in other important societal fields, our fundamental assumption must be that all governments do good things for their citizens. It is therefore reasonable to believe that this applies also in the field of occupational health. However, when we find differences in aspects which we hold to be important, we regard it as an elementary step to achieve a shared understanding of the factors that cause the differences before we take steps to move further towards the vision and state of affaires which we commonly refer to as convergence.

So, we have much to learn from each other. Our common goal is strengthening of the international discourse on OHS, highlighting the differences in our strategies, approaches and experiences. It seems natural to see the International Commission on Occupational Health as one important arena for such a communicative process, which will eventually bring rewards for all who accept this challenge.