1. Connecting health and labour
The integration of occupational health practices into primary curative health care
By Jeanette Hemke
In The Netherlands, primary health care and occupational health care are two totally
separate systems. For a century now, the general practitioners in Europe have been told that
they had to provide a statement in writing if a client was too ill to work. In all other
European countries, it is still the GP who writes this sick note for the employer. Only in
Holland were the doctors strong, stubborn and superior enough to refuse to do this. Thus,
we are the only country in Europe where the company doctor -- instead de GP -- assesses
the employee’s ability to function.
Anyone can visit a general practitioner: the physician who functions as the gatekeeper for
secondary health care. General health care in The Netherlands is financed by health
insurance and nationally regulated by health laws. A company doctor is hired and paid by an
employer. When comparing both health systems, we see that the funding and the medical
education program -- as well as the patient records -- are completely separated. This has
many advantages, but also some disadvantages.
Advantages and disadvantages of the Dutch system
One of the advantages of separate systems is that the GP will not be placed in a
difficult position if a patient needs him/her to write him a note that he is unable to work.
The trust relationship between patient and GP could come under pressure if the request
cannot be honored.
In case of problems during work, the employer provides a specialized doctor who has
knowledge of work-related diseases. A company doctor is aware of the working conditions
and relationships within a company. The company doctor, therefore, is well able to judge
whether or not the client is able to work in certain specific working conditions in regard to
disease or limitations.
Moreover, if a client is not able to do his own job, the company doctor is aware of
other job opportunities within the company and takes into account the possibilities that the
client still has.
In larger companies, where occupational health care is properly regulated, the
company doctor is often easily approachable and accessible.
In case of problems arising during work -- due to illness or social issues -- the
company doctor can function as a mediator between employer and client. He can also
accompany the client and can coordinate the care provided. The GP, on the other hand, can
lose sight of the client once he/she is referred to secondary care. Moreover, health care
shouldn’t just promote health and welfare, it should also influence functioning and behavior
in a positive manner.
An effective cooperation between the company doctor and the employer plays an
important role, especially when adjustments or changes in work conditions are needed in
order to allow the client to continue to function. Recognizing problems within a company,
signaling these problems and advising management staff gives the company doctor added
value.
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2. One disadvantage might be, for example, that the primary curative caregivers do not
link work situation and related issues to the client’s health problems, which can result in
overlooking basic causes of complaints and illness. This can be followed by an intervention
by the GP, focusing more on the recovery of health and wellbeing, and less on functioning,
behavior or coping mechanisms with respect to work situations.
The client may be faced with different -- or even contradictory -- opinions from the
curative health sector and labor sector. Alternatively, the client could pit the doctors against
each other.
There could even be a double diagnosis or dual interventions, partly because, due to
lack of time, little or even no consultation between curative health sector and labor sector
takes place.
Because the company doctor is paid by the employer, the image is formed that the
company doctor is an extension of the company itself. This may create the idea that the
company doctor is unable to act independently, without interference from the employer.
Also, there is a clear difference of opinion. In the eyes of the labor sector, rest is a
negative state; in the eyes of the curative sector, rest heals. A GP might choose for a “wait
and see” approach, while the occupational health sector is more inclined to apply
interventions more quickly for certain disorders. This intervention is often quite simple: for
example, stimulating people with mental health problems to become active so the
progression of the disease can be prevented in an early stage, or, in another situation,
keeping someone with personal problems from thinking about them by providing work. This
is not only beneficial for the employer, but even more so for the employee who then
remains active and can find some distraction. Often, changes in work or working hours are
needed, which can be quickly and easily achieved by the company doctor because of
sufficient cooperation with the employer.
Another disadvantage of the current system is that only that client who is employed
and has consent of the employer has access to the occupational health services.
Developments in The Netherlands
That brings me to a number of changes and developments in recent years. With
regard to health policy, until 2005 all employers were obliged to join an occupational health
service. All employees had the right to visit their company doctor, to receive information
about work-related issues, functioning at work and health problems that could affect
functioning. This was done not only for those unable to work due to illness, but in the
context of disease and accident prevention, as well.
Since 2005, employers can regulate health policy themselves. The employer is
required to call in a company doctor if an employee fails to show up for work for 6 weeks.
This liberalization places the responsibility for health care and the quality of care in the
hands of the employer. This usually goes well and, especially within the larger companies,
the occupational health services are often well organized. Moreover, employees may also
contact the company doctor for advice about disease and accident prevention.
For a large number of the Small and Medium-sized Enterprises (SME’s), the safety and health
care is still reasonably good, although not optimal. The company doctor is only contacted
when the client has failed work for five to six weeks, which makes a quick intervention
impossible. Prevention has become an issue among many SME's, because employees must
often ask permission to visit the company doctor.
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3. Unfortunately, there are many smaller companies (where working conditions are
often unsatisfactory) that do not call in a company doctor, even for longer-term absences.
Some employees are even prohibited from visiting a company doctor. This means that these
employees must contact their GP about their problems. The GP, however, has no experience
in work-related problems, has not been informed about working conditions and relations
and has no advisory function with respect to the employer. Therefore, the GP is generally
not able to bring about an optimal solution when the problems are work-related or affect
the functioning of the employee.
Due to a number of other social developments, health centers must now deal with
occupational health issues and work or labor problems much more often.
We see, for example, the increasing rise of the freelancer/self employed people. In
Holland, we know that there are currently about 700.000 freelancers, who often lack full
insurance, have arranged no occupational care and do not even know a company doctor. It is
a large, high-risk group because of their enthusiasm, the work pressure and the current
economic uncertainty.
This also applies to many small businessmen, who also have not arranged proper
occupational health care for themselves.
Volunteer healthcare workers, who provide care to those who need it and are unable
to get it from the social care system (mostly elderly and people with chronic diseases), are
often heavily burdened, especially if they also have paid employment. If this volunteer
caregiver drops out, the costs will be high, not only for the employer, but also for the council
and /or health insurer. The person cared for by the volunteer will then have to be cared for
by the system. This group is not in a position to visit the company doctor. Moreover, even if
they have an employer, they don’t realize they can go there to ask advice.
And then we have those people who have been receiving welfare or unemployment
benefits for a long period of time, with or without restrictions and limitations, or senior
citizens at the age of 50 -65 years old. The pressure to return to work is increasing, but
because they have no employment, they cannot turn to a company doctor for advice and
guidance. The catch here is that, to find suitable employment, this visit to the company
doctor is sometimes necessary.
Employees are now expected to work for a longer period of time. Moreover, early
retirement is discouraged and the retirement age is rising. In the case of unskilled laborers
with moderate to heavy physical work and poor working conditions, proper occupational
health guidance is necessary to adjust work in time and to prevent permanent damage,
making sure these employees can do their jobs properly until they reach retirement age.
Such employees often have little knowledge of their rights and obligations and they are
generally barely able to stand up for themselves. Unfortunately, in practice, many small
enterprises do not provide an occupational health and safety service for these employees, or
even take preventive measures to enable employees to work as long as possible in good
health.
Importance of the company doctor as a primary caregiver
Thus, as you see, there are many reasons why we think a company doctor acting as a
“primary caregiver” has major social importance and is of great value to the health and
income insurer.
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4. The presence of a company doctor creates awareness in the other staff at the
primary health center for the importance of paying attention to work and functioning.
It can also prevent contradictory opinions from being given, double diagnoses or
unnecessary referrals from being made. It can stimulate, where necessary, rapid
interventions including placing the focus on functioning and behavior.
To prevent that psychological or social complaints become medical problems, the
basic causes must be identified so intervention can be done in time. The company doctor
can focus on addressing underlying issues (working conditions and employee relations,
workload and personal problems), and has the knowledge and skills to deal with them within
the primary health care sector.
It is now possible, if there are uncertainties about work, health, functioning and
participation, to contact an expert in that area -- one who is close to home, in familiar
surroundings and easily accessible -- without the fear that the recommendations are
influenced by the employer or insurance company.
This does not replace the regular occupational health services, since counseling,
coaching and signalizing management is not possible in this setting. It could be a good and
decent safety net for those who are unable to use the regular occupational health services.
These could include freelancers and small business owners, volunteer caregivers, people
receiving welfare benefits, employees who are not given permission from their employer to
visit the regular company doctor, and also students and volunteers.
The added value of a company doctor in primary care is not restricted by knowledge
of work and functioning. The present problem could also be analyzed in another way.
The GP looks at a person’s health problems and tries to solve them; the company doctor
looks at the implications regarding functioning, the client’s remaining possibilities, behavior
and coping style.
Thus, we augment each other beautifully: we can increase the quality of health care,
we can expand the knowledge and skills within primary care and we will be able to reduce
costs, as well.
Experience as a company doctor within the primary care
Over the past years, some of the patients have simply come in for advice, with
questions regarding laws and regulations, rights and obligations. Currently, the largest group
of clients visiting the primary company doctor has psychological problems. These clients
have gained a bit of insight and knowledge into their own possibilities and are stimulated to
pick things up and to tackle the underlying issues and problems. This will result in
acceptance and implementation of recommendations solely because they have their own
solutions, which also makes the recommendations sustainable. Clients learned to analyze
and, subsequently, to solve their problems themselves.
The company doctor works with the GP’s patient records and is part of a healthcare
chain that deals with clients with mental health problems within the health center.
Moreover, every morning there is the opportunity to consult with each staff member. Thus,
there is a very well organized consultation system surrounding the client.
In the future, the primary company doctor’s task could be expanded to include treating
clients suffering from musculoskeletal diseases heart and lung problems, diabetes mellitus
and other chronic diseases such as rheumatism or, for example, pregnancy or skin diseases
caused by contact allergies, and so on.
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5. At this point, our project to integrate occupational health care into the primary
health care system is unique in The Netherlands. There have been many attempts at creating
a better collaboration between occupational and primary care and even to integrate
occupational care into primary care. Until now, we have not been very successful.
We could achieve an improvement in healthcare -- as well as in cost effectiveness --
for a great number of different parties. Nevertheless, it has been extremely difficult to find a
party prepared to take this project to the next level. The problem seems to be: everybody’s
interest, but nobody’s concern.
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6. A few examples of referrals
Referral from Practical nurse practitioner-Public Mental Health Association:
Ms. X is the wife of a small businessman, contributing to a rapidly growing company. She
presented with rather severe burnout symptoms combined with symptoms of depression
due to prolonged work overload. A few years ago, she was a part-time administrative
assistant, now she is working over 50 hours a week. There was no time left for hobbies or
other leisure pursuits. She is a woman who tends towards perfectionism and has a great
sense of responsibility and loyalty.
We started by helping her find out where the biggest problems were. Working together with
us, she, for example, changed her workplace so she would not be constantly interrupted by
customers with all sorts of questions. She wrote up a job description, a new administrative
assistant was hired and certain tasks were allocated to others. A second car was bought so
the woman was no longer dependent on her husband’s working hours. She resumed her
hobbies and went to the gym once a week to get some exercise. She and her husband had
not done anything but work and talk about the company for a long time. They decided to do
some relaxing things together again. The woman kept working, even though she temporarily
worked fewer hours than she normally would have and probably at a lower level than
previously. The recovery took almost a year and 11 appointments with the company doctor.
Afterwards, she not only felt well again and was functioning much better, but also, the social
problems between her and her husband had been largely resolved.
As a company doctor, I tried to provide this woman with an understanding and awareness of
her current – personal and business – problems. By asking her questions and giving her
homework assignments, I could help the woman to think about what exactly the problems
were, what needed to change and how that was possible within this company in order to
create a healthy working environment. It was she who proposed the solutions and how to
implement them. This is called empowerment and it occurs when people gain back control
by gaining awareness and insight into their problems. This not only means that the solutions
are almost always successful because they are accepted by the client, it also means that the
recovery is sustainable, both during work and in private situations. One positive aspect here
is that, by counseling her, a great number of things changed within the company itself, as
well. Her husband and his partner have also taken on a few of the recommendations and
have changed a few aspects of their work methods.
Referral from the physiotherapist:
This client presented with recurrent complaints of the right arm, despite apparently
successful treatment. During the consultation, it appeared that the client had an incorrect
posture when working at home. After only one consultation, during which she received
advice, the complaints were finally resolved by the physiotherapist. Moreover, this advice
was also passed onto physiotherapists, making them more alert to such causal factors.
Referral by the GP:
An older woman presented with extreme hypertension which did not respond to medical
therapy. She was feeling quite emotional and had a few other stress-related complaints,
such as difficulty sleeping, and troubled thoughts. It turned out that she has a son who had
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7. had a CVA 6 years ago. He was still struggling with some physical limitations. He was
unemployed, divorced, and took care of his daughter every other week. Over time, his house
and garden had become a total chaos and financially he was a complete mess. He had now
borrowed for over 7000 Euros from his mother. This son was the cause of her stress.
We were able to temporarily register the son in this practice, even though he lived in The
Hague. He has now been referred for a neuropsychological examination at an institute in
Amsterdam specializing in labour and reintegration. The expectation is that there will both
neuropsychological and psychosocial issues. A study will be made to see which job
opportunities are possible, and whether additional therapy is useful. He will probably be
given a recommendation to join a council program for training or retraining and to sign up
for job-coaching. Because of speech problems, a job interview always seemed to turn into a
big disappointment. In this case, a job-coach can be of great value and can aid in the
solution. This process is ongoing.
Meanwhile, the mother is already feeling much better simply because she has the idea that
someone with knowledge of the possibilities is counseling her son. The attention that he is
getting makes the son more active, because he now realizes that something really has to be
-- and can be – done in his situation.
My personal statement is:
“Work is a wonderful medicine, but it should, like the medicine, be safe,
appropriate and well-dosed.”
More information/ contact:
Jeanette Hemkes, company doctor
e-mail: Jeanette.Hemke@achmea.nl
Achmea Vitale
P.O. Box 182
2270 AD Voorburg
The Netherlands
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