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Behind the lines of Irish occupational medicine

As long-standing issues around resourcing and recognition deepen during the pandemic, specialists in occupational medicine warn of a ‘tipping point’. Catherine Reilly reports

Occupational health departments are the ‘engine rooms’ of healthcare – or as one observer described, the ‘thin line protecting the frontline’.

From pre-placement assessments to blood exposure management, immunisations to health surveillance, they are paramount to healthcare workers’ health and safety.

But what if the ‘engine room’ overheats?

Several specialists in occupational medicine spoke to the Medical Independent (MI) about key concerns for their specialty: Resourcing; workload; burnout; governance structure; morale; recognition. They were worried for the health of colleagues. “It is not just the doctors, it is our nursing staff, they are drained and burned out as well,” one noted. “I am concerned for them and I am concerned for us.”

The workload has exploded “20-fold” due to Covid-19, one specialist said. Services were already stretched pre-pandemic and little extra resourcing has materialised, MI was informed.

Departments are undertaking Covid-19 contact tracing in healthcare; arranging staff testing; guiding and supporting contacts or those diagnosed (including ‘long Covid’ cases); assessing and advising at-risk staff; and monitoring staff derogated by management. The work of occupational health is often led by one specialist physician, with nursing and administrative support. They cover acute and community sites with thousands of staff.

There are 16 whole-time equivalent physicians in the public system and one vacancy, according to the HSE. In early October, a specialist told MI departments were at “a tipping point”.

“When you take the extra pre-placements; the seasonal influenza vaccinations; the high-risk and very high-risk assessments for Covid and fitness for duty; the contact tracing piece; management of healthcare workers who are positive; the healthcare workers who have ‘long Covid’ symptoms and rehabilitating them, on top of the normal workload, and managing the team you have been given and trying to do it in a safe manner, it is a colossal challenge.

“I wouldn’t want healthcare workers to think we are not going to meet their requirements,” they added carefully. “But I don’t know at what personal cost to ourselves.”

‘Soul destroying’

Another specialist told MI, “right now, most of our normal work is suspended.” This situation was “testing” local relationships with managers.

“Because naturally managers need people at work, they need guidance, they need reports. We are not able to do anything in a timely manner …it is soul destroying, it is dire.”

“We are getting a huge number of referrals,” they continued. “One of the biggest workloads is at-risk workers …it varies between people who may not fit into a risk group and people who are very, very high risk. The issue is there are hundreds of people not at work until [assessments] get done. We cannot get through them all, and we are getting loads, and we are still getting them.”

Dr Lynda Sisson

In spring, redeployed staff were assigned to work in contact tracing; these staff had since been taken back, they said. There was no weekend or out-of-hours nursing or administrative support.

“There is no software for healthcare worker contact tracing, we haven’t been provided with any contact tracers. It is a very serious situation and very misleading I think, in the sense, the public and other healthcare workers… I presume assume things are not like this.

“The consequences are you could have possibly people going into work who shouldn’t be at work; you have people not being swabbed who need to be swabbed

“[The situation] is inhuman and no sign of any assistance from anywhere…”
The HSE Winter Plan promises more resourcing for occupational health. The details are currently being finalised, stated the HSE.

The plan anticipates increased absenteeism and doubling of referrals to occupational health “due to staff exhaustion, and post-Covid-19 fatigue”; doubling of influenza vaccination clinics; sustained and increased levels of contact tracing (estimated at c. 2,000 staff cases per month, for assessment, testing and contact tracing); and increased need for pre-employment assessment and training.

Doctors emphasise that departments need to be properly resourced for an increase in pre-placement assessments – new staff must be cleared by occupational health.

“It is not a paper screen, a pre-placement encompasses providing the healthcare workers with vaccines to protect themselves, such as hepatitis B; varicella-zoster virus; measles, mumps, rubella; pertussis; seasonal influenza; and that is multiple visits.”

Some staff recruited from overseas require tuberculosis clearance involving a chest x-ray, and a blood test.

“So, complex pre-placement health assessments which are not conducive to box ticking exercises.”

As winter approached, this specialist said a “perfect storm” was brewing.

Clarity

The pandemic has placed unprecedented demands on occupational health It has also deepened pre-existing challenges and concerns. The governance structure is a source of discontent among some specialists. A lack of clarity around the structure is cited. One specialist said occupational medicine has been “gerrymandered by the HR fraternity”.

Many occupational health physicians report to Dr Lynda Sisson, Clinical Lead of the HSE Workplace Health and Wellbeing Unit, which is in the HR Division. Dr Sisson is also a HSE Deputy Director of Human Resources and the current Dean of the Faculty of Occupational Medicine. Speaking to MI, Dr Sisson said she has “line management responsibility for many of the occupational health physicians, but we work very well in collaboration with each other”.

The unit allocates and appoints to physician roles. Dr Sisson said this “would be done in consultation with the services”.

Dr Sisson said the HSE had taken a number of steps to assist occupational health departments, including outsourcing some pre-placements and expanding access routes to influenza vaccination.

“We have a plan in place to develop a contact tracing system that will remove the everyday contact tracing from the occupational health departments in a matter of months,” she said (see panel).

“We are looking at every possible avenue to assist occupational health to focus on the key core competencies for the occupational health teams.”
Dr Sisson said she is currently in contact with departments in regard to Winter Plan and budget funding. She praised the work of the teams amid the pandemic pressures.

“It has been very challenging, not least because we are a very small group of people and we have had a huge amount of demands placed on us.”

Consultant status

The ongoing denial of consultant status is a festering sore, which will challenge the retention of trainees. Higher specialist training in occupational medicine is a four-year programme, funded by the HSE and managed by the Faculty. Doctors can obtain specialist registration with the Medical Council after completing training. However, they do not get a consultant contract in the public health service (they are recognised as consultants in the NHS).

The 2010 report by management consulting firm the Hay Group recommended consultant status for occupational medicine specialists. Recently, Ernst and Young has been engaged by the HSE to “review” services (the HSE said the cost of this exercise was commercially sensitive).

“Nobody else is getting reviews, and in the middle of a pandemic they want to do a review of what we are doing,” a specialist told MI. “Obviously as you can imagine we are not best happy about this.”

“We are beginning to think there is pattern here where ‘we want another investigation into what you are doing, what you are not doing…’.”

According to the HSE, it commissioned the review as the services had “changed and expanded over the years”.

The HSE said consultant status “is the subject of ongoing deliberations with wider stakeholders”.

“Our specialty is always about keeping our heads below the parapet, always being in the background,” said one doctor. “You would see colleagues in your department; you don’t go to the consultant room because you are always the ‘physician for healthcare workers’, in some aspects.”

But lack of official recognition eats away. “There is a bit of an imposter syndrome, to be honest, when you are dealing with respiratory physicians, microbiology consultants, infectious diseases consultants, and you are sitting there and you are not recognised….”

It is not just about a group ‘wanting more’, stated this doctor. There are more far-reaching implications.

“If we don’t sort out the terms and conditions we are going to leak people to the private sector the whole time, then we are left with non-specialists in our departments. Healthcare is probably the trickiest occupational healthcare service to provide, where you have got biological exposures; labs; fitters; maintenance; you’ve got people driving, absolutely everything in the Health Service Executive.”

IMO Industrial Relations Director Mr Anthony Owens said: “We had pursued it [consultant status]. There is an added impetus to it now because of the huge pressures the pandemic has caused on the delivery of occupational medicine, occupational health services…. We are looking for serious engagement with the HSE and Department of Health to get this sorted out.”

What contracts have specialists been given?

“Here is the peculiar thing, they are on a range of contracts which incorporate many of the elements of the consultants contract, but not all of them,” said Mr Owens.

“Salary is certainly a part of it but there is other stuff in the contract they don’t get, such as the rest days and so on, and the guarantee of support of teams as set out in the contract, which again, I would say is nearly as important.”

Some new entrants were put on a defunct pay scale, which Mr Owens described as “an egregious abuse” of these doctors. “This is a defunct pay scale that applies to nobody else, it is not in the Department of Health consolidated pay scales, all 100-odd pages of it. It was plucked off a shelf and applied to new entrants into occupational medicine.”

Stranger still, Mr Owens said the HSE has also advertised and appointed other specialists in occupational medicine onto the recognised consultant contract salary scale, even while applying a defunct scale in other situations.

Faculty

MI understands the issue of consultant status was raised recently with the Faculty of Occupational Medicine by trainees seeking its support. This request is “under discussion at the moment, it is on the agenda of the board”, Dr Sisson told MI.

She also said a HSE business case on consultant status is with the Department of Health. Asked if the issue affects trainee recruitment, she said: “I certainly think it doesn’t help.”

Some new entrants were put on a defunct pay scale, which Mr Owens described as ‘an egregious abuse’ of these doctors

Asked if her roles in the HSE meant she was precluded from making certain comments as Dean, such as on the consultant contract issue, Dr Sisson said: “There is a conflict of interest policy in the RCPI. As a matter of fact, at every board meeting, all members are asked to declare if they have a conflict of interest with a particular agenda item, and if they do they would step away from this item. That would be the same for everybody.”

Disillusioned

Currently, the mood among trainees is downcast. “Our SpRs are incredibly disillusioned”, a specialist told MI.

“Most of them were not aware they weren’t going to be getting a consultant post at the end of their training.”

Another specialist said: “When you are a trainee and you see ‘specialist training in occupational medicine’ the last thing you’d expect at the end of your training is that you don’t get the same recognition as every other trainee.”

There were 13 trainees in occupational medicine in 2019/2020 and an approved first year intake of three, according to HSE data. A minimum requirement of 18 training places was required by 2022 to meet health service needs, according to a HSE workforce paper titled The Future Requirements For Occupational Health Physicians in the Health Service (Workplace Health and Wellbeing Unit, 2017).

Private practice

Trainees in occupational medicine rotate to private companies during their training to acquire a range of industry-specific experience. According to the HSE workforce paper, “a number of graduates from the training programme are recruited to the private/independent sector.”

The services of private companies are also contracted by some public hospitals. The level of agency/outsourced provision stood at 25 per cent in 2017, according to the HSE workforce paper.

It said “a number” of privately contracted physicians were not specialists, but held Licentiateship of the Faculty of Occupational Medicine (LFOM). Approximately two of these doctors were working toward Membership of the Faculty (MFOM) and specialist registration with the Medical Council in any three-year period.

“This is an area that has been identified as an area of potential growth as a career pathway as an alternative career.”

Within public occupational medicine, there is a view that awarding of consultant status would be disadvantageous to private companies, as it would lead to enhanced terms and conditions in the field. MI contacted one of the leading occupational health providers, Medmark, for feedback on its position. Medmark also provides services to the public health service.

Dr Paul Gueret, founding partner of the company, told MI: “I, both as a specialist occupational physician and an occupational physician with Medmark, as a national provider of occupational health services, can state without hesitation, that we as individual physicians and as an organisation support the demands of our specialist colleagues within the HSE to be granted consultant status.”

Dr Gueret said he was “not aware” of the perception that granting consultant status in the HSE would be disadvantageous to the private sector. Dr Gueret added that “perhaps more importantly I do not believe it is pertinent to the debate on consultant status for our colleagues in the HSE.”

Dr Gueret, a former Dean of the Faculty of Occupational Medicine, noted that hospitals had historically been set up with a hierarchical structure, which recognised the seniority of the consultant.

“With this long-established structure in place, those doctors who do not have consultant status may find themselves lower down the hierarchy and with a lesser degree of influence on medical matters as a consequence.

“The importance of hospital consultant status is not just because specialist occupational physicians working in the health service deserve it, because I believe that they do, but because it is necessary to have this status for occupational health matters in the health service to be given appropriate attention.

“The Covid pandemic has thrust hospital occupational health services forward to the frontline and demonstrated their importance in maintaining the health service staff in work, without whom there would be no health service.

“These issues, however, did not begin with Covid, nor will they end when the pandemic is over. For people’s health at work in the health service to be given its necessary relevance, consultant status is not just fully deserved but necessary.”

LFOM

Asked about the role of LFOM-qualified doctors in Medmark, Dr Gueret said the company has a large team of physicians. He said the majority are on the Council’s specialist register for occupational medicine.

“We ask that all doctors working within the practice aspire to this and we support their journey through the various examinations, training and qualifications that are ultimately required to achieve specialist recognition.

“The LFOM offers a valuable initial academic qualification, which can then be built upon by further study, and the MFOM. For me, the important requirement is that they work exclusively within occupational medicine and do so supported by a team of colleagues both specialist and non-specialist, in an environment where they have access to supervision, training and mentoring from senior colleagues.

“In my opinion this immersive professional experience allows them to gain the necessary skills to manage the complex caseload that they are often presented with. From the perspective of Medmark we are not certain that this can be achieved by those who work predominantly within a different specialty but engage part-time in the practice of occupational medicine.”

Dr Gueret also stated SpR salaries in the private sector “are funded solely by the private sector for their duration in the private sector”.

Are public occupational health services edging towards greater private provision?

“I think our time for action is short,” Mr Owens of the IMO told MI. “If one thinks about Sláintecare for a moment, the trajectory of Sláintecare would seem to be the provision of more and more services within the public realm, so I would think that occupational medicine would be one of those services that is built up and bolstered in the public realm.

“There is absolutely a place, I appreciate, for the contractors as well, but that is not what I am talking about here, I am talking about [building up] the public side.”

‘Grave concern’ about impact of HSE derogation policy

Health sector trade unions “remain gravely concerned” about the operation of the HSE Covid-19 derogation policy, authored by the Workplace Health and Wellbeing Unit. Local managers are derogating “significant numbers of staff to return to work” amid shortages and pressurised services.

The HSE policy permits derogations for healthcare workers who are restricting their movements (eg, as a close contact) if deemed “essential to critical service needs”. The policy does not apply to close contacts of a suspected or confirmed case in their home, due to the higher risk of transmission; or those with a positive Covid-19 test.

Derogations are decided by management, who must notify the occupational health department. Management must complete a risk assessment and send a copy to occupational health, when a healthcare worker is derogated.

According to the policy, healthcare workers will be actively monitored twice daily by their line manager/designate. Occupational health must be informed of those requiring active monitoring. “Daily active monitoring will also be carried out by occupational health for these HCWs [healthcare workers], usually via daily text message system.”

An occupational medicine specialist told MI the position of occupational health is that close contacts should be stood down from work. In early October, the health unions informed the HSE there were “several questions” outstanding after a meeting with the Executive.

These questions related to the “negative impact” of the policy on the ability to provide a safe working environment; the ability to ensure asymptomatic healthcare workers were not infectious; the “absence” of a testing policy to balance this policy; the “absence” of any measurement of related infections among other staff or patients following the managerial decision to derogate under this policy.

At the meeting, the health unions had asked how many derogations were granted, the location and grade. They also asked if any derogations were linked to subsequent case(s).

According to the unions’ correspondence, Clinical Lead of the Workplace Health and Wellbeing Unit, Dr Lynda Sisson, told the meeting that derogations were granted by local management and no records were held at national level on the number, location or grade. There was no national surveillance on the potential impact of derogations on spread of the virus.

In light of the rate of healthcare worker infection, the derogation policy should be reviewed and amended urgently, according to the unions. In the interim, they said a national oversight process must be put in place.

To date, over 9,700 healthcare workers (described as people who work in health facilities) have had a confirmed diagnosis of Covid-19. This represents over 20 per cent of all confirmed cases. According to the Health Protection Surveillance Centre, there have been 340 healthcare workers hospitalised, and eight have died. The national public health emergency team is considering serial testing requirements for asymptomatic people who work in healthcare settings.

IMO Director of Industrial Relations Mr Anthony Owens told MI the level of healthcare worker infection was “concerning and something we are monitoring”. He said there are questions around “ongoing capacity shortages” and “how that is going to impact on members as services reopen”.

Director of Industrial Relations at the Irish Nurses and Midwives Organisation, Mr Tony Fitzpatrick, said local managers have been “derogating left, right and centre, because they don’t have staff, or they cannot get replacement staff”.

This situation presented a “significant risk to patients but also to colleagues working within those services”.

He added that healthcare worker infection was an “issue we are raising constantly with the HSE”.

Of members who have had Covid-19 infection, “there is a cohort, and we are getting more and more contact from them, who have been adversely affected” in the form of ‘post-Covid’ syndrome.

“We have members with myocarditis, with tachycardia, ongoing breathing
problems, ongoing lethargy, circulatory problems in regard to pains in their legs, and not being able to get back to work,” he said.

Mr Kevin Figgis, Organiser for the Allied Health Professionals Sector, SIPTU, said it appeared derogations were conceded on an “‘we will leave it up to yourself locally’ basis”.

“What is the template, what is the barometer you use of ‘these are the risks of bringing the person back, versus the benefits; and the benefits outweigh the risks’? Or is it just the case that someone comes in and applies pressure?”

He also highlighted the “high level of infection among healthcare workers” as worrying. Mr Figgis emphasised that the pandemic is exacting its toll on the health workforce. He said healthcare workers who need to be absent from work, due to Covid-19, must be fully supported and not lose out financially – and provided examples where this has not occurred.

“These are people who every day go to work to help the sickest of the sick and protect all of us. That is really what they are trying to do, and they do it in the face of the infection.

“I don’t think, sometimes, people totally remember that they don’t have a day off from this; they have fought this since the middle of March when the first call of emergency was made. They have fought it from day one; there has been no reprieve.”

Dr Sisson told MI that data is now being collected, while an international review of the literature has been requested. The derogation guidance is currently with the pandemic infection control team for ongoing review.

“We do believe, however, derogations are necessary in some cases, so derogation guidance will continue. What we will be doing in the next few weeks is monitoring it much more closely than we have been able to so far.”

Is the policy overused?

“We just don’t know that as yet. But we will be looking to see that it is used judiciously and appropriately.”

HSE plan ‘centre of excellence’ for healthcare contact tracing

A contact tracing in healthcare pilot initiative is being developed by the HSE. But there are doubts over how helpful this could prove. According to the HSE, the contact tracing pilot is “a HSE initiative under the test trace strategy”. The plan is to develop “a centre of excellence for contact tracing for all healthcare workers”.

“You will have seen all the public health specialists saying contact tracing teams don’t replace the public health expertise when it comes to contact tracing and we would probably have a similar opinion, in that local knowledge is very important,” said an occupational medicine specialist.

“A contact tracing team based in Cork don’t know the ins and outs of a particular unit up in Dublin, the nuances around it, that kind of thing. Now, if it does work it will be fantastic, but it remains to be seen if it will help us or not.

“In the meantime, we have to cover weekends and we are trying to put contingency in place. We are worried… It is going to be a very long winter and we barely made it through the first wave unscathed.”

Obtaining the contacts list from managers is not always a smooth exercise, according to another specialist.

“In this area, there are hundreds and hundreds of managers, like any other area. Some managers will do their best. Some won’t. Some are not skilled sufficiently. Some are not even there at the weekends or they might be on a day off. It is extremely variable and I wouldn’t say that is a reliable way of doing things.”

Clinical Lead of the Workplace Health and Wellbeing Unit Dr Lynda Sisson told MI the contact tracing initiative would facilitate specialist input.

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