Cancer survivorship and work

About 5 per cent of the overall UK cancer burden can be attributed to occupational exposures. However, occupational physicians in clinical practice are most likely to be called upon to support and advise employed patients with non-occupational cancers. Support services in the UK are being reconfigured to help the growing population of cancer survivors to live full and active lives for extended periods. Returning to the workplace is a part of this goal, and occupational physicians are likely to see increasing numbers of adults seeking still to work after treatment for conditions that in the past would have led to ill health-related retirement. Set against these improvements in clinical outcome, and the increasing emphasis on support for patients who achieve long-term survival, is evidence that many working-age adults treated for the common cancers subsequently encounter financial and occupational difficulties. People with cancer often experience a loss in income as a result of their condition. Thus, although most working adults diagnosed with primary cancer return to work, a significant minority do not. Cancer is increasingly seen as an illness that can be effectively treated, but functional outcomes vary considerably. Cancer survivorship is considered to encompass people who are undergoing primary treatment, in remission following treatment, show no symptoms of the disease following treatment, or are living with active or advanced cancer. Occupational physicians may be requested to assess work capability and provide advice on workplace support for cancer survivors in any of the survivorship states. In the UK, 98 per cent of public sector and 30 per cent of private sector employers have access to occupational health services. Employers will normally seek guidance from these services on how to manage employees who have developed a serious illness such as cancer. This means that occupational physicians can be in a key position to coordinate the vocational rehabilitation of cancer survivors. This chapter offers an overview of the evidence on work capability, rehabilitation, and occupational risk assessment that may apply to adults diagnosed with a range of cancers.

Health and transport safety: fitness to drive

Fitness to work in all modes of transport, where this may put members of the public or other workers at risk, has long been an area of public concern. Because inadequate performance may endanger fellow workers or the public and put expensive assets at risk, frameworks for statutory regulation have been developed. This chapter uses fitness to drive, the area of widest interest, as an example, but each mode of transport has its own pattern of performance requirements and hence fitness standards, although they have much in common. Separate appendices cover fitness to work in the rail industry, as a seafarer, and in aviation. The risks to the safety of others posed by performance deficits or incapacitation has meant that decisions on fitness are frequently taken not for the benefit of the person examined but to safeguard those at risk as a consequence of their actions. Hence hard decisions often have to be taken and for this reason standards for medical aspects of fitness are usually formal and often published. They are usually applied by physicians acting on behalf of regulatory authorities and have associated review or appeal mechanisms available to those who have been failed or restricted. Standards are necessarily based on the balance between public risk and potential loss of employment, with the former predominating. The evidence base for current standards is of variable quality and this is often a cause of contention. Patient groups and equal opportunities organizations may find it difficult to accept the concept of standards based on epidemiological evidence of risk. They may cite equality legislation to encourage applicants to demand individual assessment of risk and job adaptations to allow employment, often in situations where this is impossible. In addition to long-term health problems that are handled by reference to such formal standards, transport workers may also have short-term decrements in performance from injury, minor illness, or medication. In some areas, e.g. aviation, even short-term decreases in medical fitness are subject to national or international regulation.

Ill health retirement

Doctors who give advice to pension scheme trustees or administrators should be aware of the eligibility criteria for that scheme and the meaning of terms used in the regulations, the statutory guidance, or explanatory notes published by the scheme. Most schemes require that the doctors who act as their medical advisors have a qualification in occupational medicine. The evaluation of evidence in support of an application for IHR should be robust but fair and care should be taken to avoid conflicts of interest for doctors involved in the treatment of the patient. The medical standards to which doctors work in making these judgements should be explicit and they should audit their rate of IHR against national data, if equitable decisions are to be made and confidence in the process is to be maintained.

Drugs and alcohol in the workplace

Drug and alcohol misuse is present at all levels of society and throughout the world although the patterns of use, the substances involved, and the prevailing attitudes vary widely. However it presents, drug and alcohol misuse is a particularly challenging issue for employers, managers, and occupational physicians. These include the effects of drugs and alcohol on health and well-being and the direct and indirect effects on output, performance, and behaviour at work. There are legal implications if employees are under the influence of alcohol or drugs or in possession of illegal drugs where there may be a degree of vicarious liability for the employer. Management may have limited tolerance towards such individuals and there may be significant issues regarding public confidence towards those involved in safety critical industries. Whilst attitudes towards alcohol in society and the workplace appears to be hardening, the distinction between what is acceptable drinking and problem drinking is often blurred.

Respiratory disorders

Respiratory illnesses commonly cause sickness absence, unemployment, medical attendance, illness, and handicap.1 Collectively these disorders cause 19 million days/year of certified sickness absence in men and 9 million days/year in women (with substantial additional lost time from self-certified illness) and, among adults of working age, a general practitioner consultation rate of 48.5 per 100/year with more than 240 000 hospital admissions/year. Prescriptions for bronchodilator inhalers run at some 24 million/year, and mortality from respiratory disease causes an estimated loss of 164 000 working years by age 64 and an estimated annual production loss of £1.6 billion (at prices in 2000). Respiratory disease may be caused, and pre-existing disease may be exacerbated, by the occupational environment. More commonly, respiratory disease limits work capacity and the ability to undertake particular duties. Finally, individual respiratory fitness in ‘safety critical’ jobs can have implications for work colleagues and the public. Within this broad picture, different clinical illnesses pose different problems. For example, acute respiratory illness commonly causes short-term sickness absence, whereas chronic respiratory disease has a greater impact on long-term absence and work limitation; and the fitness implications of respiratory sensitization at work are very different from non-specific asthma aggravated by workplace irritants. Occupational causes of respiratory disease represent a small proportion of the burden, except in some specialized work settings where particular exposures give rise to particular disease excesses. The corollary is that the common fitness decisions on placement, return to work, and rehabilitation more often involve non-occupational illnesses than occupational ones. By contrast, statutory programmes of health surveillance focus on specific occupational risks (e.g. baking) and specific occupational health outcomes (e.g. occupational asthma). In assessing the individual it is important to remember that respiratory problems are often aggravated by other illnesses, particularly disorders of the cardiovascular and musculoskeletal systems.

Epilepsy

Epilepsy is a common condition that affects large numbers of working people. In about one-third, epilepsy is the only condition, and in others there are additional neurological, intellectual, or psychological problems. Uncontrolled epileptic seizures can lead to injury and may impact on education and employment, but antiepileptic drug (AED) treatment is effective in approximately 70 per cent of people with epilepsy. Many people do not disclose a history of epileptic seizures when applying for a job or during a routine examination at the workplace. This may cause major problems for the individual and the employer and, on occasions, inadvertently contravene the HSW Act or invalidate insurance cover. However, the disability provisions of the Equality Act 2010 now confer some protection on those with epilepsy. The unenlightened attitudes of some employers have led to secrecy or denial by those affected. The possibility of dangerous situations arising at work, or dismissal without recourse to appeal, may be the consequence. A competent occupational health service, trusted by both shop-floor and management, can be invaluable in resolving conflicts and giving advice. Responsibility for the employment and placement of a person with epilepsy rests with the employer and they should take appropriate medical advice. Each case must be judged on its merits in light of the available information, which must include a sound and complete understanding of the requirements of the job. Employees with epilepsy must be regularly reviewed. The development of good rapport and mutual trust will encourage employees to report any changes in their condition or treatment that have arisen.

Neurological disorders

This chapter deals mainly with common acute and chronic neurological problems, particularly as they affect employees and job applicants. The complications of occupational exposure to neurotoxins and putative neurotoxins will also be covered in so far as they relate to the fitness of an exposed employee to continue working. In addition to a few well-known and common conditions, many uncommon but distinct neurological disorders may present at work or affect work capacity. Fitness for work in these disorders will be determined by the person’s functional abilities, any comorbid illness, the efficacy or side effects of the treatment, and psychological and social factors, rather than by the precise diagnosis. This will also need to be put into the context of the job in question, as the basic requirements for a manual labouring job may be completely different from something more intellectually demanding. Indeed, even an apparently precise diagnostic label such as multiple sclerosis (MS) can encompass a complete spectrum of disability, from someone who is entirely asymptomatic to another who is totally incapacitated. Similarly, the job title ‘production operative’ may be applied to someone who is sedentary or who undertakes heavy manual handling. Furthermore, reports by general practitioners, neurologists, or neurosurgeons may describe the symptoms, signs, and investigations in detail, but without analysing functional abilities. These colleagues may also fail to appreciate the workplace hazards, the responsibilities of the employer, or what scope exists for adaptations to the job or workplace.

Legal aspects of fitness for work

The English legal system is based on the common law. The common law system in England and Wales developed from the decisions of judges whose rulings over the centuries have created precedents for other courts to follow and these decisions were based on the ‘custom and practice of the Realm’. The system of binding precedent means that any decision of the Supreme Court—the new name for the former House of Lords (the highest court in the UK)—will bind all the lower courts, unless the lower courts are able to distinguish the facts of the current case and argue that the previous binding decision cannot apply, because of differences in the facts of the two cases. However, since the UK joined the European Union (EU), the decisions of the European Court of Justice (ECJ) now supersede any decisions of the domestic courts and require the English national courts to follow its decisions. (Scotland has a system based on Dutch Roman law, and some procedural differences although no fundamental differences in relation to employment law.) The Human Rights Act 1998 became law in England and Wales in 2000 (and in Scotland in 1998) in order to incorporate the provisions of the European Convention on Human Rights into UK law. The two most important Articles applicable to employment law are Article 8(1), the right to respect for privacy, family life, and correspondence, and Article 6, the right to a fair trial.

A general framework for assessing fitness for work

This introductory chapter deals mainly with the principles underlying medical assessment of fitness for work, contacts between medical practitioners and the workplace, and confidentiality of medical information. Medical fitness is relevant where illnesses or injuries reduce performance, or affect health and safety in the workplace. It may also be specifically relevant to certain onerous or hazardous tasks for which medical standards exist. Medical fitness should always be judged in relation to the work, and not simply the pension scheme. It has limited relevance in most employment situations: many medical conditions, and virtually all minor health problems, have minimal implications for work and should not debar from employment. Medical fitness for employment is not an end in itself. It must be maintained.

Health promotion in the workplace

This chapter aims to provide a summary of the development of modern approaches to health promotion in the workplace, illustrated by a number of case studies from UK businesses active in this area. The workplace is an effective forum for health promoting activities and the examples highlight that careful planning and targeting may increase the likelihood of success. Many employers expect such programmes to have high cost, or be difficult to organiseize, but the increasing resources available from third -sector and public health programmes may be accessed by partnership approaches to deliver high- quality programmes, with minimal cost. Comprehensive occupational health should encompass prevention and health promotion, within the continuum ranging from pro-active health support to more reactive intervention to address injury or illness.