key: cord-0683786-gbogtzfy
authors: Nicholson, Paul J
title: COVID-19: opportunity to learn from necessity
date: 2020-05-02
journal: Occup Med (Lond)
DOI: 10.1093/occmed/kqaa054
sha: ee06f7f08ff209ce3483d34d31b8066a4cb85e11
doc_id: 683786
cord_uid: gbogtzfy

nan

Some things have been a long time coming; not least of all the next pandemic. In 2008, the UK government published its first National Risk Register as the initial step in providing advice on how people and employers could better prepare for civil emergencies [1] . The relative likelihood of pandemic influenza was judged to be higher than that of flooding, roughly equal to severe weather but less likely than attacks on transport or in crowded places. However, the relative impact of pandemic influenza was judged to be the greatest of all risks facing the UK. The World Health Organization cautioned that in the first two decades of this century major epidemics were spreading further and faster than ever [2] . The apparent lack of preparedness for Coronavirus Disease 2019 (COVID-19) such as the lack of sufficient personal protective equipment for health and social care workers is a matter for after-action analysis during the recovery phase when the risk to life has subsided. That is also when it is important to look for opportunities to 'build back better'; a concept which refers to measures to make communities more resilient to future disasters, for example, by designing buildings to withstand earthquakes. However, it is as important to ensure that infrastructure and societal systems such as healthcare are better able to deal with the next crisis [3] . This is especially the case when the most foreseeable risks include communicable disease outbreaks [4] .

Another thing which has been a long time coming is for the occupational health specialty to build a robust evidence base to demonstrate conclusively the broad value it offers to employees, employers and society. In May 2017, the Society of Occupational Medicine (SOM) launched a report Occupational health: the value proposition [5] which its Patron Lord Blunkett noted had arrived 'at a critical time for the policy agenda for work and health, and the challenge of the productivity gap'. Three years since that report was published there has been little high-quality research to build the evidence base. This is alarming considering that in the UK, more than a half of occupational health nurses are aged over 50 years [6] and about two-thirds of occupational physicians are aged over 50 years, with the number of training positions at half the long-run average [7] .

It was suggested in 2004 that the specialty must improve capabilities to expand worker access to occupational health support; this requiring a strategic shift to apply resources differently, including to use telemedicine and information technology [8] . In 2006, the Mayo Clinic ran a pilot study of telemedicine in an occupational medicine clinic and reported that patients and providers were comfortable with the technology and satisfied with the outcomes [9] . In Canada, where similarly the majority of workers lack access to an occupational health service (OHS), a case study demonstrated the potential for telehealth to deliver high quality OHS when combined with face-to-face field service teams [10] . In Germany, occupational dermatologists opine that while teledermatology has prospects to contribute to earlier prevention and notification of occupational dermatoses it unlikely to address the decrease in dermatological services [11] . A salient caution for occupational health.

A report from the Royal College of Physicians noted that with the unrelenting demand for National Health Service (NHS) hospital outpatient care patients and doctors recognize the benefit of alternatives to face-to-face consultations such as telephone or videoconferencing, which can trigger a face-to-face consultation when clinical or patient need arises [12] . The benefits include reduced disruption to patient lives and reduced need for hospital infrastructure. During the 2018 snow storms NHS Scotland was able to deliver almost all of its outpatient appointments using telemedicine clinics [12] . Patients are said to be embracing new technology and increasingly expect their care to be supported by it [12] .

Undoubtedly, this is influenced by more people shopping and accessing other services online. Recognizing the increased use of telemedicine, the General Medical Council which regulates doctors in the UK published ethical guidelines to help doctors manage potential patient safety risks associated with remote consulting [13] .

If telemedicine has so far been slow to win more general appeal it might be that the COVID-19 pandemic provides the stimulus for transformative development, including in occupational health. Disruptive innovation produces cheaper, simpler, more convenient services that revolutionize existing ways of working and meeting customer needs [14] . In recent years, primary care practitioners have been turning to increased use of telephone consultations to manage ever-increasing workload, but there has been little use of video consultation. Because of COVID-19, more of the NHS is exploiting remote consultations so as to minimize the risk of infection for staff and patients and to cope with large numbers of NHS staff who have had to self-isolate because of symptoms of COVID-19 in themselves or in close contacts. In early March 2020, NHS England's medical director for primary care recommended telephone or video triage to avoid patients coming into primary care surgeries [15] . Within weeks a new consultation service was developed and 80% of practices were using it. Consequently, many NHS primary care physicians who were previously sceptical about video consultations have become proponents [15] .

As just-in time support for health professionals the BMJ has published a practice guide to help primary care physicians to conduct a remote assessment of COVID-19 patients, most of whom can be managed by providing telephone-delivered advice [16] . Where additional visual cues and therapeutic input are desirable there are many easy-to-set-up tools for video consulting [16] . If it is feasible for primary care physicians to manage COVID-19 patients and for hospital consultants to provide outpatient care by virtual consultations, then it is viable for occupational health professionals to expand the use of telephone and video consultations, particularly for interventions such as sickness absence reviews which do not need any tests to be performed.

The COVID-19 pandemic is challenging all types of health service, occupational health included. Many routine appointments have had to be postponed, such as for health surveillance while there is unprecedented need to provide advice to businesses regarding measures necessary to protect employee health while meeting the operational needs of the business. But once the dust or perhaps fomites have settled the specialty would miss huge opportunities if it did not systematically review and learn from these unprecedented times to discover the opportunities that otherwise might not so obviously be staring us in the face.

First and foremost is the opportunity to learn how OHS can better support and add value for its customers. The most imminent need is to help employers plan better either for the next phase of this pandemic or for the next pandemic, for example not just by replenishing stocks of personal protective equipment but by ordering and holding appropriate amounts. We should also work with employers to examine the extent of and necessity for business travel. As well as being a risk factor for communicable disease and costly for businesses such travel is often a habit driven by preference as much as genuine business need. Considering that travel will be curtailed for many months and business will continue regardless this is a good time to encourage wider adoption of virtual meetings. For those working in international OHS it is an opportunity to discuss with leadership the location of new operations in developing countries and how local employees and expatriates and their families can access quality healthcare. As a consequence of COVID-19 it is likely that managers will be more reluctant to be relocated, as part of career progression, to an emerging country with poor healthcare infrastructure.

Focussing internally on OHS, we should reflect on practices during the crisis. What services were dropped and did it make any difference? OHS should identify services which have always been offered and yet, perhaps with hindsight, add little or no value; services which could be stopped permanently. We should also identify what OHS started to do and what worked well for wider adoption. Finally, there are services which need to be continued but might be performed more efficiently. Such opportunities are sometimes only obvious in times of adversity. Improved and more efficient ways of working should not be construed as intellectual property which provides one OHS with a competitive edge over another. To serve the wider public interest, OHS should gather and share examples of disruptive innovation for wide reapplication. This will facilitate efficiency across OHS provision leading to service resilience and an improved value proposition. 16 North Block, County Hall Apartments, London SE1 7PJ, UK e-mail: pjnicholson@doctors.org.uk

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