Health is often seen as complicated and difficult to quantify in the workplace. As Prof David Fishwick explains, sustainable, modern, multi-disciplinary approaches are vital to achieving long-term occupational health gains. Interview by Nick Warburton.
Professor David Fishwick spends half of his week working as a respiratory consultant in the NHS. With alarming frequency, he witnesses the ‘human fallout’ caused by occupational ill health, so it’s not surprising that he is passionate about protecting workers and preventing ill health before treatment is necessary.
“I see people in clinics who have been made ill by the work environment in many ways,” he reflects.
“I cast my mind back in each case as to how things might have been done differently, and if someone had attended to the health needs as well as the safety needs at work.”
As Prof Fishwick will explain at this year’s conference, many employers may not fully deal with the growing impact of health at work, and health issues tend to be left in the “margins of a busy workplace life”. For small-to-medium sized enterprises (SMEs), in particular, it is often hard to take the time to understand what should, and can, be put in place to protect workers’ health.
But preventing ill health is very much Prof Fishwick’s passion and lies behind his commitment to ensure it gains equal parity with safety in the modern work environment. When he took up his role in the NHS in 1997, the job also included the position of chief medical officer at the Health & Safety Laboratory (HSL).
As he recalls, the NHS position advertised specifically for a respiratory physician who would also work part-time at the UK’s premier workplace research centre, the idea being that he would “add medical input into the organisation”.
Arguably, this joint posting, together with his honorary professorship at the University of Sheffield and his place on the multi-disciplinary HSE Asthma Board, has enabled him to take a more holistic view than others on the UK’s occupational health challenge, and the interventions needed to overcome it.
Health partnership
The main thrust of his presentation at IOSH 2015 is that the UK needs a multi-disciplinary partnership approach to workplace health if it is to successfully manage what is becoming a burgeoning burden on business, the wider community, and ultimately our health system.
From his work on the NHS frontline, Prof Fishwick believes the national institution is already ahead of the game in this respect. He explains how it has transformed patient care over the past ten years by bringing together professionals from diverse backgrounds to define the most appropriate treatment.
HSL’s chief medical officer points out that while many forward thinking businesses and trade associations have developed strategic frameworks to better inform senior managers about health and occupational hygiene issues in the workplace, more often than not, they miss the bottom-up worker developed inputs that are so important for a successful delivery.
The opposite is also true. “You can have a fantastic union-led initiative on health, but if the workplace is not signed up to it, the line manager does not subscribe to it or the CEO does not think it is important, it will fail,” he says.
Even so, he argues passionately that long-term health gains will only happen if managers and workers, working with health and safety representatives, occupational health professionals and a range of other disciplines, join forces to find long-term solutions.
His thinking on how to achieve health improvements rests on a very simple principle – that humans are the most critically important resource for any organisation.
“It’s easy in modern times, when you are looking at raw materials and bottom lines in a board room meeting, to forget that humans make your organisation work,” he argues.
“I work in a busy hospital and if you took the humans out, the infrastructure is worth millions and yet it would have zero function without humans in it.”
An unwanted distraction
Prof Fishwick’s moral compass tells him that health is a single entity and therefore anyone who can influence an individual’s health positively should step up and deliver.
Even so, in a profession where safety often rules supreme, and practitioners have yet to achieve legal compliance across the board in this critical area, taking on the workplace health challenge could be perceived as an unwanted distraction.
Because of its complicated nature, and the difficulty in quantifying health, there is understandably resistance from some quarters, especially when it comes to these ‘softer issues’, such as diet and obesity, which many commentators argue is a significant, contributory factor to musculoskeletal disorders.
And what about the more difficult work-related issues like stress, anxiety, depression and other mental health problems, which are very hard to quantify in terms of numbers and impact?
Prof Fishwick acknowledges that legal compliance must remain the priority, whether that is for safety or health.
“First rule, you have to legally comply and there is very clear advice on the Health and Safety Executive website around how a duty holder and employer should be approaching legal compliance,” he says.
“Other exposures that cause, for example, skin disease or breathing problems must have a risk-based approach with appropriate risk assessments, and after that you must decide whether or not you need to carry out periodic health checks to ensure compliance.
However, he also firmly believes that employers need to see the bigger picture because in doing so, there are greater health, and therefore productivity, gains to be made. Not only that, but the world of work is changing, shifting from a physical workplace economy to a knowledge-based economy in which employers need to do more to retain highly skilled workers.
“What you’ve got after [the legal compliance] are slightly more difficult issues – sedentary behaviour, diet, smoking, recreational drugs, all of these things that maybe workplaces don’t consider to be their responsibility. However, I suspect that if they did, in the long run they would get a better engaged workforce,” he points out.
“If employers don’t think about workers’ health proactively, they will leave and go somewhere else and you will lose that precious resource.”
Of course, Prof Fishwick recognises that it is not always so straightforward. In many cases, and usually in SMEs, large numbers of manual workers are holding down low-paid jobs in areas of high unemployment. Exposed to very poor conditions, with limited financial alternatives, moving on is simply not an option.
“If you are trapped in a job where effectively you are disengaged from your line manager, I can’t imagine much worse, particularly if you are working as the bread winner, your partner is not working, and there is a reliance on you to bring money in but you hate your job,” he reflects.
“I would estimate those things could be prevented with time, using the right multi-disciplinary approaches because if workplaces disengage their workforce, it is very hard to regain that engagement.”
At the sharp end
Prof Fishwick does appreciate the challenges faced by these hard-to-reach groups because the HSL has a long history of undertaking research work at the ‘sharp end’. Also, over the years, he has been involved in a myriad of community-focused projects, both in the UK and overseas, including two sabbaticals to study occupational lung disease.
Having trained in medicine at Manchester University in the early 1980s, his first major research project brought him into contact with Professor Tony Pickering at Wythenshawe Hospital on the city’s outskirts.
“He was a massive world figure in relation to occupational lung disease, particularly cotton workers,” he says. “At the time, Tony was looking for a research fellow and I leaped at the opportunity to do two years in the cotton mills.”
The research, which led to an MD thesis on the epidemiology of respiratory symptoms, bronchial responsiveness and hygiene measurements in those exposed to organic dusts, brought him into contact with a very different side of life than what he’d seen growing up.
“Up until then, I had been a very protected person and I’d never had anyone be particularly unhelpful or nasty to me but you grow up very quickly trying to enrol workers into ‘real world’ research,” he recounts.
“At the time, it was a very strong community in the cotton mills, and it was sometimes difficult to get workers to agree to help with the research.
“However, gradually, the work team got to know the researchers and we ended up with a very, very good working relationship. It taught me that you can get health messages over to all different sorts of people if you use the appropriate language.”
New Zealand research
Over the next decade, he worked across a number of NHS hospitals helping individuals who were suffering from respiratory illnesses, and completed his final training in Newcastle upon Tyne in the transplant unit at the Freeman Hospital in 1995. However, before taking up his current posting, Prof Fishwick took a second two-year sabbatical to New Zealand where he had also spent three months as a medical student in 1984.
Working under the auspices of Professor Beasley at the Wellington Asthma Research Group, his research wasn’t that dissimilar to the work he’d undertaken with Professor Pickering, only this time the focus was on welding.
“We had to persuade Pacific Island welders to take part in studies,” he recalls. “We did a lot of research with this population and I’m still involved in much of it now.”
This prompts him to discuss his current HSL work where he’s heavily involved in two of its four strategic work programmes. One of its priority areas is the health of silica-exposed workers, foundry workers and wood workers.
Prof Fishwick explains that these groups have been chosen because they employ large numbers of people, they are accessible for study and each group is at risk of a long-latency illness, primarily asthma, chronic obstructive pulmonary disease and silicosis.
As part of the research, the team ask the workers about their health, take measurements, and most importantly, he adds, discuss these issues with their employers and line managers. HSL also provides training days at its Buxton site for line managers so that they can better grasp the risks associated with health.
At the same time, HSL psychologists have been involved to investigate what type of interventions might work, what has previously been tried by the employer and hasn’t worked and to formulate education packages and/or training that could be rolled out to all work sites. The idea, he says, is that when HSL involvement ends improvements can be sustained in a multidisciplinary way.
“What these interventions have got to be is cost effective and they’ve got to be sustainable when the research team leaves,” he insists. “These have got to work in real workplaces.”
Harm index
In order to prioritise research activity HSE has used a number of measures, including the harm index, to stratify finite resources and determine priorities for research. The index looks at the number of workers that potentially could be affected by a particular health outcome and then factors in the severity of the outcome.
“When HSE had done this previously, what had come out as being important are some of the respiratory end points, the breathing problems – asthma, chronic obstructive pulmonary disease, the asbestos-related problems because they have a massive impact on the individual and the potential number of people affected if workplace exposures are not controlled is very high,” he says.
“I would tend to back the long latency and medium-to-long latency diseases that cause very significant personal impact.”
Looking to the future, Prof Fishwick argues that one of the biggest challenges is to ensure that what we know should be done is done properly in workplaces.
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