presentation by dr. Richard Roberts, president of the World Organisation of Family Doctors (Wonca) at the WHO/TNO/Dutchgovernment Congres 'Connecting Health and Labour' 29 - 1 December 2012

1. The role of primary care
workers in occupational health
Connecting Health and Labour: What
Role for Occupational Health in
Primary Health Care?
WHO-TNO-Government of the Netherlands
The Hague, Netherlands
29 November 2011
Richard G. Roberts, MD, JD
Wonca President 2010-2013
Professor of Family Medicine, University of Wisconsin
TEL: +1 608 263 3598 Email: richard.roberts@fammed.wisc.edu

2. Primary Care & Health Care
• The best health systems are based
on primary care.
• Most health care – including
occupational health – can, should
and does happen in primary care.
• Primary care is especially concerned
with knowing the person and
context.
• People do best when primary care
and occupational health care
professionals work well together.

3. The best health systems are
based on primary care.

4. “A world that is greatly out of
balance in matters of health is
neither stable nor secure. . . “
“Primary health care brings
balance back to health care,
and puts families and
communities at the hub of
the health system. “
“Primary health care also offers the best way of
coping with the ills of life in the 21st century: the
globalization of unhealthy lifestyles, rapid unplanned
urbanization, and the ageing of populations.”
Dr Margaret Chan, Director General, WHO - 2008

5. Primary Care Score vs. Health
Care Expenditures, 1997
2 UK
DK
Primary Care Score
NTH
1.5 FIN
SP
CAN
AUS
1
SWE
JAP
0.5 GER US
BEL FR
0
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures

6. Relationship between Strength of Primary
Care and Combined Outcomes
12 USA
GER
Primary Care Rank*
10
BEL
8 AUS
SWE CAN
6
SP
4
NTH
FIN
2 DK
UK
0
*1=best 0 1 2 3 4 5 6 7 8 9
11=worst
Outcomes Indicators (Rank)

7. Primary Care Strength and Premature
Mortality in 18 OECD Countries
10000
PYLL
Low PC Countries*
5000
High PC Countries*
0
1970 1980 1990 2000
Year
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled
for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R 2(within)=0.77.
Source: Macinko et al, Health Serv Res 2003; 38:831-65.

8. Most health care – including
occupational health – can,
should, and does happen in
primary care.

9. Family Doctors
• Doctors of first & last resort – e.g., cancer
• Continuous & comprehensive care
• Responsible for total health needs
• 75% of complaints are self-limited
– 80% < 65 years; 40% > 65 years
• Time and relationship as diagnostic and
therapeutic tools

10. Healthcare services
U.S., 2005
Physician office visits 963,617,000
Emergency dept visits 115,223,000
Hospital outpatient dept visits 90,393,000
Hospital discharges 34,667,000
Source: National Ambulatory Medical Care Survey, 2005
http://www.cdc.gov/nchs/data/ad/ad387.pdf

11. U.S. Physician Office Visits 20051
512 Million 451 Million
600
500
400
53% 47%
216 Million
300 168 Million
129 Million
200
100 22% 17% 13%
0
Fam Med-GP Internal Medicine Pediatrics All Primary Care Other Specialists
1Excludes anesthesiology, pathology & radiology.
Source: http://www.cdc.gov/nchs/data/ad/ad387.pdf

12. Visit rates by setting type:
United States, 1995 and 2005
197
200 % change
180 162 +22%
Visits per 100 persons
160 1995
140 2005
120
100
69
80 65
56
+23% 48 +35%
60 37 40
31
40 26 +8%
+19%
20
0
Primary Care Surgical Medical Hospital Emergency
Office Specialist Specialist Outpatient Department
Office Office Department
Sources: National Ambulatory Medical Care Survey and National Hospital
Ambulatory Care Survey. http://www.cdc.gov/nchs/data/ad/ad388.pdf

13. Primary care is especially
concerned with knowing the
person and context.

14. Aims & Assets
of Primary Health Care
• Continuity
• Comprehensive

15. More important
than knowing the disease
is knowing the person
with the dis-ease.

16. It’s the
RELATIONSHIP!

17. People do best when
primary care and
occupational health care
professionals work well
together.

18. What should primary health
care professionals …
• Know about the workplace? AMAP
• Do for work-related problems? AMAP
• Do for work-related health risks? AMAP
AMAP = As much as possible

19. What are the barriers?
• Culture
• Communication
• Time
• Complexity

20. Time Requirements
• 10.6 hrs/day – chronic conditions1, 2
• 7.4 hrs/day – preventive services3
• Patient agenda?
• Acute care?
• Administrative issues?
1. Østbye T. Ann Famed Med 2005; 3:209-214.
2. Tsai et al. Am J Man Care 2005;11:478-88.
3. Yarnall KHS. AJPH 2003;43:635-641.
4. Bodenheimer T. NEJM 2006:355:861-864.

21. Complexity
• Average visit: 1.4 – 8 problems
• Diagnoses:
 “ologist”: top 5 = 90%
 family doctor: top 25 = 60% total
Stange KC, et al. J Fam Pract 1998;46(5):363-8.

22. It’s going to get harder . . .
• Change in work: agriculture to
manufacturing to service
• Change in worker: family duties, older,
mental health issues, multiple morbidities